hpcsa – Effects of Anxiety

Anxiety Disorders in the DSM 5 TR | Symptoms and Diagnosis

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.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 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.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 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 may not be stressful for them when they are at home or when they’re.At school, 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 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 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 more anxiety.You would expect that, but even the 31 percent that it was before 2020 seems to be higher than what is identified in the 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 appears in children first, so separation, anxiety, and disorder appear first, and generalized anxiety.The disorder is down a little way, whereas you might expect 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 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 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 disturbance, I want you to think about it. Anxiety is part of the fight or flight response, so we would expect somebody to experience 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, so we would expect all of these symptoms or any of these symptoms. When the fight or flight system is engaged, the body is not focused on higher order, processing, memory, or concentration it’s focused on self-preservation protection the person 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 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 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 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 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 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 the diagnostic features of generalized anxiety disorder.Well, 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 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 the coming 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 punctuality.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, except for disaster, a lot of these worries revolve around the primary life areas or functions of the person.You know: kids, are, n’t worried about paying bills or or maintaining or parenting, or some of the things that that adults worry about associated symptoms.Well, let me talk about disaster. 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, the prevalence and likelihood of things.So when there is a disaster such as you know, we’ve had several 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 chance of it happening again.Do 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 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 you know how 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, and other somatic symptoms that are not 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 isn’t specifically indicated in diagnostic criteria, but we know it happens when that fight or flight response is kicked off the prevalence.Remember I said if you start adding 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 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 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 has a much later onset than other disorders, which I did find to be somewhat interesting.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 anxiety about separation from major attachment figures.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 separation anxiety.It actually can have an adult onset, so that is something to remember: symptoms, three or more distress due to or in anticipation of separation from home or from major attachment figures, anxiety about losing a major attachment figure, or possible harm to them.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 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 to be cut 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, fear of or reluctance to be 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 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, whether that be their significant other, their parent, or 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 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 to rank a diagnosis.Although the symptoms often develop in childhood, they can be expressed throughout adulthood.It can be diagnosed in adults in the absence of a history of childhood separation, anxiety, or 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 and examples.It’s a pretty straightforward diagnosis in terms of development and, 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 through the 20s, 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 an interesting associated feature.Now these are not diagnostic criteria.These are features that are associated 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, 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 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.A lot of children who don’t have separation, anxiety, or disorder, experience homesickness 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 provoke anxiety, anger, and 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 there and by turning on the light.So there are 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 they are in adults, and we want to make sure we don’t mislabel that as something related to a psychotic disorder, children with separation, Anxiety tends 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, and anxiety, 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 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 adolescents and adults, it ranges from one to two percent. In the culture section, the DSM talked about the importance of differentiating separation, and 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 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 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 the threat that persists for guess what six months or more and causes clinically significant distress – and I have this bold 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 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 cause me to have to alter my life to get around it? No, so it doesn’t rise to the level of a specific phobia. A lot of people have fears that may not have a um basis 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 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.In the end, the diagnostic features again for specific phobias were pretty much a restatement of the diagnostic criteria-associated features.Interestingly enough, 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 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 hers.Wasn’t phobia-related, but when she would get startled 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 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 usually develops before age, 10 or after a trauma, and the presence of phobias is a risk factor for neurocognitive 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 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 and social anxiety disorder in social anxiety disorder.There’s a marked fear of social situations when in which one might be judged.So you’ve got generalized anxiety, which is anxiety about a lot of things over at least six months.We have a specific phobia, which is 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 by children. The symptoms have 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 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 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, a level of social anxiety, because they fear not saying the right thing because they fear being canceled.Social situations almost always trigger 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.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.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 persist again for six months or more causing clinically significant distress 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, or anything like that, 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 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 a social anxiety disorder who are highly controlling of situations, and they may try to control the conversation and control other people in the situation to avoid feeling out of control.Use of substances, substance, use, misuse or abuse is often associated with people with social anxiety disorder, and I have parenthetically heard liquid courage is 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.So using alcohol before a social situation may 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 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, a question mark that’s not identified in the DSM 5t. However, we know that hyperactivation of the hpa axis contributes to ultimately development of systemic inflammation and the 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 compared 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? What’s different in the United States? That is contributing to significantly higher rates of social anxiety fear of being judged and fear of offending people.Just saying additionally, social anxiety disorder does tend to be highest in non-Hispanic whites.So what is unique about nonhispanic? Whites in 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 peak within minutes and has a and accompanying 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 an expected panic attack 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 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, 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, in which things just don’t feel real.You feel like you’re kind of a dream or depersonalization.You don’t feel, like you, ‘re part of your own body, anymore, with fear of losing control or going crazy and fear of dying.Now I’ll mention it, even though it’s pretty obvious.Many of these symptoms are also symptoms of a heart attack.It is important 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 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 of panic may include tinnitus or ringing in the ear and 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. Additionally, at least one of the attacks – unexpected attacks has been followed by one 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 attack avoidance of situations where You think they might happen again or ritualized, or superstitious behavior or extreme behavior, like changing your diet completely or doing something extreme to try to prevent the attack, so the unexpected attack happens and then for the next month or more.Both of those persistent concerns about it happening again and significant 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 attacks, there were no specifiers, but in the diagnostic features, it did note that panic attacks can be full meaning four or more symptoms or limited symptoms, so it doesn’t meet all of them.Doesn’t meet four symptoms or more, but the person’s having a panic response.If the person has never had a full-blown panic attack, uh, four or more symptoms, 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, 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 had a panic disorder at some point, they probably will have another panic attack at another point.Remember that expected 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 diagnostic issues, a 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’s associated features. People who have panic attacks.Panic disorder may also cause 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 you once makes sense that you would be a little bit more hypersensitive to it happening again.They may have increased anxiety about their ability to tolerate daily stress there.A lot of times this may stem from the fear that if they experience too much stress it, ‘ll trigger another panic attack 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 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 us and 32 worldwide. So that is a little bit divergent.You know the prevalence, and the number of people that experience it worldwide are pretty comparable, but the median age for panic disorder is much younger in us than in other countries.Additionally, they speculate that older adults may attribute symptoms to medical conditions, so they may be underrepresented in the 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 in general.Anxiety disorders often develop afterlife stress.This could be a death, a severe illness, a disaster, a big move becoming a parent adverse childhood experiences, or aces that’s just to name a few that those aren’t all of the causes, 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 considered in the past as a risk factor for the development of anxiety disorders.People who’ve been bullied have an increased risk of developing anxiety disorders.The heritability of anxiety disorders ranges between 30 and 75 percent. I found that interesting, but they didn’t explain 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 experience the same psychosocial, and environmental stressors.Both of them are so.I don’t know what the actual data is on that person with negative affectivity.They tend to be more brooding, more depressed, more irritable people who are more self-conscious.People who ruminate more also all of these kinds 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 shows that people with 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 are, threats in the environment, and anxiety disorders by and large – tend to be much more frequent in women than in men. 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 shaping and behavioral training and more about a physiological response.But additionally – and these last two were not in the DSM.However, I did a PubMed search for risk factors for anxiety disorders and those who have a more external locus of control.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 of anxiety and depressive disorders, and again not in the DSM, but in the 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.Anxiety itself increases the 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 to increased risk, but people with specific 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 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 attempts and suicidal ideation, if you have somebody with a 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 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, 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 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 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.As I mentioned earlier, people with anger, and anxiety disorders, have higher rates of autoimmune issues.Continuous or excessive levels of stress hormones contribute to systemic inflammation, which will trigger depression 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 exhausted.From being stressed out, all the time may not have a lot of energy to do.Other stuff tends 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, a disorder 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 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.I give the example of an MRI that 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, anxiety is about being judged negatively, and illness anxiety and this illness anxiety.Falls under somatic disorders but illness anxiety. The worry is about the illness, not separation, judgment, or being away from your safe place, so that’s a differential diagnosis of your basic anxiety disorders in terms of other disorders because there’s that criteria not better explained by another mental health or medical disorder.In psychotic disorders, people who have hallucinations and delusions may also have anxiety, but their worry or fear surrounds hallucinations or delusions 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 does. n’t help them feel more comfortable if they turn on the light to eliminate the shadows that don’t make them feel more comfortable, and the hallucinations are not due to psychotic disorders.The hallucinations are not due to something present in eating disorders avoidance behavior is only related to food and food-related cues.According to the DSM, however, one of the main criteria for your eating disorders is an 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 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 they start developing a fear of getting germs on their hands, so the fear becomes the object of their obsessions.Their obsessions turn to cause what they’re.Thinking about becoming a fear in the autism spectrum, the person lacks sufficient age, appropriate relationships, and social communication capacity in anxiety disorders. The person often has sufficient age-appropriate relationships and can communicate socially, and socially understand others, just fine.What we’re, looking at in anxiety, is fear of being judged 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 are due to not wanting to be told what to do.Thank you very much 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 attachment figure.If somebody has a 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 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 occurs, 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, but you can’t.Have somebody who develops 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 reluctance to leave home, but this is due to a lack of motivation and energy to engage and apathy.It’s not due to fear of something out there.They just don’t care or they don’t have an energy personality.A person with a dependent personality relies too much on others.It’s not that they fear 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, and related disorders, not in the DSM I’m. Bringing up for differential diagnosis.Anxiety 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 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 sweating and agitation in people, so we want to differentially diagnose.I believe I read a study that more than 25 of Americans are pre-diabetic and don’t know it.Co-morbidity and 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, 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 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 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, 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 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 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.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 of anxiety.Symptoms include cardiovascular issues, pots, or diabetes.100 Hot BooksComputers LaptopsExplaindio Agency Edition FREE Training How to Create Explainer Videos & SELL or RENT them! Join this FREE webinar | Work Less & Earn More With Explaindio AGENCY EDITION

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Neurobiological Impact of Psychological Trauma on the HPA Axis

Unlimited CEUs for $59 are available at AllCEUs.com/Trauma-CEU this episode was pre-recorded as part of a live continuing education webinar. CEUs are still available at AllCEUs.com/Trauma-CEU welcome to today’s presentation on the neurobiological impact of psychological trauma on the HPA axis we’re going to define and explain the HPA axis which we’ve talked about before is a response system so it’s not anything to get to you know overly concerned about that it’s going to be super dry well identify the impact of trauma on this axis and on basically your whole nervous system in your brain identify the impact of chronic stress and cumulative trauma on the HPA axis because a lot of times when we talk about PTSD we think only about some particular acute event and that’s not necessarily true there are a lot of people with PTSD who have basically what I call cumulative trauma and they were exposed to extensive child neglect they were in domestically violent relationships they were in a situation where they were exposed to trauma over and above what a normal person would think lawfully think of law enforcement military personnel think first responders I mean they see stuff that no human should have to see and they see it not only once but you know once a week or once a month depending on kind of where you are so it’s important to understand well one thing may not be so traumatic to create post-traumatic stress we’re going to look at some of the reasons that PTSD symptoms may develop as a cumulative sort of thing which I found this to be interesting anyway we’ll identify symptoms of dysfunction and we’ll talk about some interventions that are useful for this population now my guess is none of you are prescribing physicians so when we’re going through this you’re going to be going yeah that’s all well and good what’s the exact point of thinking about exactly what this information is telling me on each slide show used to be the hat to help my clients who have been annoyed by trauma and have not yet developed any sort of PTSD symptoms or who have PTSD symptoms and how can I use this information to better tailor my treatment plan to help them become more effective in managing their symptoms this is kind of a unique presentation because it was based on only one article this was a meta-analysis so it’s a long article and it’s a really good article that I would strongly suggest looking at it in your resources section in the class it lays out the many changes and/or conditions that are seamed in the brain and nervous system of people with PTSD so they really looked at a lot of research longitudinally to see what we know and what we don’t know as clinicians awareness that these changes can help us educate patients about their symptoms why do you feel this way and find ways of adapting to improve quality of life so neurobiological abnormalities in PTSD overlap with features found in traumatic brain injury so that started making a lot of researchers go hmm you know traumatic brain injury there is something or again of course hurting part of the brain so why are the symptoms similar in PTSD you’re going to find out pretty soon is that PTSD does cause damage actual physical damage in the brain the response of an individual to trauma depends not only on the stressor characteristics but also on factors specific to the individual so somebody can see a trauma and not be as traumatized if you will as someone else and part of these factors and there was a study done by Pi Newson Nader back I believe the early 80s looked at triage factors for PTSD and some of the factors that they found why certain traumas may be more traumatic than certain people versus others have to do with this particular trauma, you’re experiencing it close to one of your safe zones where you live where you work somewhere where you’re not where you’re supposed to be feel safe and if so then it’s probably going to be perceived as more traumatic now again think about the survival capacity or the survival function of this behavior when your brain says this is supposed to be a safe zone and it’s not so I need to respond in kind you’re trying to protect yourself make sense the similarity to the victim if it could happen to her if it could happen to him they’re like me it could happen to me that makes me feel scared because we like to categorize the world in terms of using them bad things happen to those people not to us people but if you’re looking at a victim who’s liked you and you say well I am and us people then you’re going to have more difficulty separating it and feeling safe and going well that couldn’t happen to me and the degree of helplessness you know if you saw something and you were just like there was nothing I could do there’s a greater sense of helplessness and horror then if you didn’t have that necessarily that same experience so those are a couple of things as far as the prestress or perception that we want to consider when we’re talking to our patients even if you’re not a therapist that works with the trauma specifically some people refer out for that some people are working with an EMDR therapist and you know cool but as important to understand and if you happen to go down this road with your clients help them understand why they perceived that particular stressor so intensely versus some other stressor that they think may have good English there oh well sorry they think should have stretched them out more so their perception of the stressor prior traumatic experiences and we’re going to learn that prior traumas do cause changes in the brain to prepare you basically Therese bond more quickly when there’s a threat so prior traumatic experiences can send you from zero to 100 a lot faster which means it’s going to be or could be more traumatic the amount of stress in the preceding months if you’re already worn down and your body has already said I can’t fight anymore it’s not doing any good then when it encounters PTSD and when it encounters a trauma the body might be going I just can’t take another thing please just I can’t do it which is why we see in people with PTSD chronic stress burnout and chronic fatigue this inability to tolerate stress because the body’s just already waived them that white flag going I can’t do it current mental health or addiction issues again that’s your body’s way of saying something in the neurotransmitter something in the system is a little bit wonky and that means I’m not going to be able to respond a hundred percent healthy and functionally to whatever’s going on and the availability of social support now a lot of the research especially with emergency service personnel points to the availability of social support within 24 hours of the trauma so when there’s an officer-involved shooting when there’s something that they encounter on the duty that’s trauma the ability to have social support within that first 24 hours preferably first two-hour period to at least touch base with a social positive social support is vital to helping somebody process the memories instead of just kind of them disappearing into never-never land and getting solidified in an unhelpful way for the vast majority of the population though psychological trauma is limited to an acute transient disturbance you see something that’s traumatic you’re like oh my gosh Wow it is devastating and yeah is going to affect you for a little while but in a week or two you’re kind of feeling like you got your land legs again so there’s this subpopulation of the population there’s a small group that ends up developing PTSD the signs and symptoms of PTSD reflect a persistent adaptation of the neurobiological symptoms to witnessed trauma and I crossed out abnormal in the article it says abnormal and I look at it as a perfectly normal adaptation because the body is either going with the reserves I have right now I can’t deal or you know whatever it’s doing it’s trying to protect itself now it may not be helpful but from a survival perspective it generally makes sense so I try when I’m working with clients to help them see the functional nature of their symptoms given the knowledge they had or the state they were in at the time so now to the HPA axis the The hypothalamic-pituitary-adrenal axis aka your threat response system controls reactions to stress and regulates many body processes including digestion the immune system mood and emotions sexuality energy storage and expenditure so let’s think about this real quick when you’re under stress, your body feels threatened I needs to survive so it sends out excitatory neurotransmitters that get you wired up which kind of makes your digestion speed up it can cause some cramping in the abdominal area your immune system is not really important right now threat we’re not worried about the flu mood and emotions you tend to be hyper-vigilant and more easily startled threat means fight or flee which means anger or anxiety so you’ve got some stress emotions and I don’t want to say dysfunctional because they’re very functional your body perceives a threat and it’s saying you need to do something sexually well if there’s a threat this is no time to procreate so your body says let’s turn off those sex hormones right now, because we need to use us for fighting and fleeing not procreating which is all well and good but when we have reduced sex hormones it also reduces our serotonin availability which serotonin is one of those calming chemicals which help us calm down the excitatory neurons so without them, you stay revved up which brings us to energy storage and expenditure you’re revved up you’re on high alert you’re staying up here and your body says you know what if I’m going to survive this fight or flight I need fuel which means you need to eat preferably high-fat high-sugar foods that give us instant energy and sustained energy we want calorie defense stuff now thinking about it from that perspective you can see how when you’re under chronic stress or a big stressor you know some of your symptoms make sense why do you want to go eat chocolate or do whatever you do that’s my go-to pizza and chocolate when I’m stressed is generally what I crave not what I need but what I crave so we want to help people understand that there’s a reason it makes sense now we just have to figure out how to deal with it differently the ultimate result of HPA axis activation is to increase levels of cortisol in the blood during times of stress now cortisol is the hormone that goes out and sets off kind of this whole well there are a couple before it but it sets off this whole event cortisol is your stress hormone cortisol is the one who says no sex hormones right now you know and it monkeys with all your different hormones to make sure and your energy storage to make sure that you’re ready for this fight or flee its main role is to release glucose into the bloodstream in order to facilitate the fight or flight now glucose is sugar is raising your blood sugar so you’ve got energy now we’re going to talk regularly about glucocorticoids which are glucose hormones that make your body release glucose which is mainly cortisol and that term is going to become important later I’m just kind of throwing it out there right now cortisol also suppresses and modulates the immune system digestive system and reproductive system so again cortisol is saying we’ve got this energy we’ve got this threat let me figure out how to sort of dole out our resources right now for survival in the now it’s cortisol is very present focused it’s not looking at you know the long-term and going well this will pass cortisol is very right now HPA axis dysfunction the body reduces HPA axis activation when it appears further fight-or-flight may not be beneficial and they call this hypo cortisol ism so basically a threat response system is you know warning the alarm in my dorm when I was in college used to have these really annoying blinking lights I because why I do this all the time sorry the hypercritical ism is your body’s response to going if I keep fighting I am just throwing good energy after bad there is no sense in surrendering so it turns down the system and it stops producing as much cortisol that way it has cortisol your stress hormone for when there is a bigger more threatening threat well what does that mean well we need cortisol is what helps us get up in the morning our cortisol goes up and down throughout the day which helps us have the energy to get up go to work do those sorts of things it’s a normal hormone when it’s in the right balance hypo cortical cortisol ISM seen in stress-related disorders such as chronic fatigue syndrome burnout and PTSD is actually a protective mechanism designed to conserve energy during threats that are beyond the organism with us ability to cope so dysfunction in the axis causes abnormal immune system activation so you have increased inflammation and allergic reactions cortisol is also related to cortisone your body does not release its natural antihistamines when you are pardon me under stress which is why your allergies seem to bother you more which when your allergies bother you more you’re probably not sleeping as well at night and we know that not sleeping as well at night keeps your HPA axis activated so you’re fighting this battle you’re trying to squeeze blood out of a turnip basically because your body said we’re not releasing any more cortisol I don’t care what you say but everything else you’re not sleeping as well you’re still kind of revved up you’re fatigued and your body is going but there’s a threat and back in your brain they’re going yep but it’s not a big enough threat yet so you can see where this cascade you’re fighting inside your own body and all your systems are kind of arguing irritable bowel syndrome such as constipation and diarrhea because cortisol speeds things up and if you don’t have enough cortisol you know what might happen reduce tolerance to physical and mental stresses including pain remember I said that sex hormones go down which means that the availability of serotonin goes down we know that serotonin is not only involved somehow in mood it’s involved with some level of anxiety reduction but we also know it’s involved in pain perception so when serotonin goes down we perceive pain more acutely and altered levels of sex hormones so fatigue and you’re like where did that come from well the HPA axis is activated see how many times I can say that without tripping on my tongue when it’s activated it sends out these you know excitatory neurotransmitters when you’re excited for too long you get fatigued well interesting little caveat or thing here fatigue is actually an emotion generated in the brain you know we’ve learned to label it which prevents damage to the body when the brain perceives that further exertion could be harmful sounds similar to hypo cortisol ISM it is so what do we know from athletes we know that fatigue and sports is largely independent of the state of the muscles themselves so fatigued you know your muscles usually only work up to about 60% of their ability to work and then fatigue starts to set in so there was still a big margin that you could work before your muscles finally gave out and said hold no more I’ve got jelly legs but your muscles quit you start feeling tired you start feeling exhausted so this is a protective mechanism the body’s gone we need to conserve a little bit of energy because you have to get home and shower and you know prepare to run in case the tiger chases you but what factors is your body paying attention to but tells it OK whoa we need to stop so we’ve got enough reserve in the event of a problem core temperature, you’re working out your core temperature goes up at a certain point it goes that’s high enough your glycogen your blood sugar levels your oxygen levels in the brain how thirsty you are whether you’re sleep-deprived, to begin with, it’s going to mean that you fatigue a lot easier and the level of muscle soreness and fatigue going into that exercise session the brain kind of takes all these factors into effect and goes okay I can unless you work out this much and then I’m going to shut you down I’m wrong it’s off what they have found though is we can override this so when clients come into our office, they’re fatigued they are they’re off they’re just like I’m exhausted I’m agitated I’m irritable I’m not sleeping well I just uh okay so with athletes, we know that psychological factors can be used to reduce fatigue such as their emotional state if they go in in a positive emotional state or a hyped up energized emotional state if they’re listening to really energizing music it can help them push past that fatigue point a little bit if they know the endpoint maybe they know they’re doing three sets of ten reps they’re going to push through faster or more effectively than if they’re working with the coach and they have no idea how many sets they’ve got or how many reps they’ve got to do they’re just like are you going to make a stop to other competitors that service motivation they’re looking around they’re seeing other people doing it they’re going okay I got this and in the case of athletes visual feedback you know they’re seeing growth in their muscles they’re seeing positive changes so they can push through that fatigue a little bit more they’re like okay this is worth it so fatigue is one sign that the body is getting ready to down-regulate that HPA axis and go conservation in practice and counseling practice how can we help reduce mental fatigue and help clients restore their age PA access functioning and one of the things I would challenge you to think about is how can we increase their self-efficacy and their high ductless if you will in their the emotional state that a can-do attitude increases their hardiness and resilience you know we talk about those, a lot man make sure they know their endpoint where are they going what does their what do their symptoms look like what is it going to look like in three weeks in three months and what can we reasonably think will change you know let’s give them some tangible goals that they can look at other competitors or motivational group therapy can be very helpful in dealing with some of this stuff obviously, you’re not going to do a lot of trauma work in the group most of the time but having other people around knowing that there are other people who are dealing with PTSD and having support groups can be really helpful because they can cheer each other on and go come on John you got this you just need to push I know this is a really tough week for you and that can help people push through that fatigue and feedback now in the case of psychological issues we’re not talking about visual feedback but we’re talking about looking at that treatment plan or looking at their symptoms and being able to say you know what I have made progress I’m not having nightmares as much as I actually slept through the night last night who knew and finding those things that they can latch on to and go things are getting better you know they’re not going to get exponentially better overnight likely but they are getting better and I can see this incremental progress and in doing that we can help people get a sense increase that those dopamine levels increase that learning and go okay I can do this we want to make sure that we are considering their fatigue level though and not putting too much on them at once let’s look at really small steps and then solidifying those steps not taking one step after another but taking one step and then taking a breather for some of our clients helping them identify how they’re feeling and be aware of their own fatigue level low cortisol has been found to relate to more severe PTSD hyperarousal symptoms and you’re like yeah it took me quite a while to wrap my head around this whole concept but it makes sense now so when you have low cortisol your body is conserving all its energy can in case it needs to respond to an extreme threat the sensitized negative feedback loop in veterans diagnosed with PTSD have they’ve shown that they’ve got greater ludic corticoid responsiveness now remember I talked about cortisol being a glue to co-corticoids and there’s just no nice way to talk about this without using really obnoxiously clinical terms anyhow which means that the body is holding on and it’s going you’re not going to have cortisol to just get irritable or happy or excited about just anything but if there’s a threat I’ll let you have it unfortunately in patients with cortisol ISM when there’s a threat they have an exaggerated response thank hyper-vigilance and I call it the flatter the Furious so their mood is either kind of flat and they’re not really responsive too much but when there is something that startles them or their body perceives as a threat all of a sudden their body dumps cortisol and dumps glucose into the system which floods the system and if you’ve ever flooded your engine you know what happens doesn’t respond quite as well but there are even more problems with this so evidence says that the role of trauma experienced in sensitizing the HPA axis regulation is independent of PTSD development okay so what does that mean that means even if somebody doesn’t develop PTSD clinical diagnosis if they’ve had trauma HPA access is going to sensitize them a little bit and hold them back a little bit more cortisol and be a little bit more reactive when there is trauma which means successive traumas could produce success successively significant reactions in those with prior trauma maybe more at risk of PTSD for later traumas so again as a clinician what does this mean for me this means that if I’m working with a client who comes from a troubled childhood there were adverse childhood events or you know whatever you want to label it they had chronic stress they had trauma in their childhood even in the prenatal period they found I wanted to educate them about the the fact that they are at a greater risk of developing PTSD if they’re exposed to more trauma so they can learn how to keep their stress levels under control because it’s more important for them according to this research because of some persistent brain changes that we’re going to see core endocrine factors of PTSD include abnormal regulation of cortisol and thyroid hormones okay so we’ve already talked about cortisol our stress hormone and you’re probably familiar with thyroid hormones being sort of your metabolism hormone but what happens when cortisol goes down in the body starting to rein in the energy thyroid hormones also go down hypo cortisol ism and PTSD occurs due to increased negative feedback sensitivity of the HPA axis okay studies suggest that low cortisol levels at the time of exposure to trauma may predict the development of PTSD so if their cortisol levels were already low they were already suffering if you will from hypercortisolism and remember we’ve seen hypercortisolism in burnout and you know regular old burnout chronic fatigue syndrome as well as PTSD so we’re not just talking about veterans here if the cortisol levels are already abnormally low and the body’s already started conserving cortisol when they’re exposed to a trauma we can with more certainty predict which people are going to develop PTSD symptoms back to those gluteal corticoids they interfere with the retrieval of traumatic memories an effect that may independently prevent or reduce symptoms of PTSD so when cortisol is in the system and it’s causing all the blood sugar to develop we’re not forming lots of memories right now we’re just surviving which they hypothesize could prevent or reduce the symptoms if those memories aren’t consolidated and they go away, or it could contribute to difficulty in treating PTSD why well let’s think about it if people who’ve been exposed to trauma you know hypercortisolism they respond to threats by increasing the amount of cortisol and political corticoids exponentially have an exaggerated response than when they’re in our off and we’re talking to them about their trauma, and they start to get upset they start to get excited there the body’s going to start dumping all these gluten coke or turquoise and guess what it’s going to make it more difficult for them to retrieve those memories potentially so it’s kind of an interesting thing to look at because a lot of clients that I worked with PTSD have been like I can’t remember why can I not remember and my very general response because they don’t want to know about all this stuff generally is it’s your brain’s way of protecting you it’s your brain’s way of saying there’s a threat right now and you need to protect yourself from the threat we don’t need to be worrying about all those memories back there so we do some you know relaxation activities and those sorts of things to help them you know get back down to baseline so we’re not continuing to fight against those gluten Co corticoids and thus cortisol because when you fight with that what happens the client generally gets progressively frustrated progressively upset and progressively unable to think clearly and access those memories neurochemical factors corner or chemical factors of PTSD include abnormal regulation of catecholamines serotonin amino acid peptide and opioid neurotransmitters each of which is found in brain circuits that regulate and integrate the stress and fear response now again if you’re thinking I’m never going to remember this for the quiz don’t get too stressed out about it because I want you to take home the overarching concepts I’m not going to ask you really nitpicky questions about stuff that you have absolutely no control over or at least that’s what I tried to do that being said I want I think it’s important that you know that all of these neurochemicals including opioids are involved in the regulation and integration of stress and fear responses it’s not just serotonin or two dopamine the catecholamine family including dopamine and norepinephrine are derived from the amino acid tyrosine now it’s not really all that important but an interesting little aside is that norepinephrine is made from the breakdown of dopamine so your focus and get up and go chemical is made from your pleasure chemical interesting little concept there when a stressor is perceived the HPA axis releases corticotropin-releasing hormone which interacts with norepinephrine to increase fear conditioning and encoding of emotional memories enhance arousal and vigilant vigilance and increase endocrine and autonomic responses to stress so when the threat response system is turned on it releases cortisol which interacts with norepinephrine the stress hormone and they get up and go hormone say there’s some really bad mojo brewing here which increases fear conditioning because the heart rates go in and everything and the response is stress there’s an abundance of evidence that norepinephrine accounts for certain classic aspects of PTSD including hyperarousal heightened startle and increased encoding of fear memories so what about serotonin you know that’s supposed to be one of our calming chemicals it where did it go poor serotonin transmission and PTSD maybe may cause impulsivity hostility aggression depression and suicidality remember you’ve got the downregulation of the sex hormones so less availability of serotonin and there are other things that cause the serotonin to not be as available but they found that serotonin binding to 5h t1a receptors and this is just a little soapbox I’m going to go on don’t differ between patients with PTSD and controls so what does that tell us that’s the only way we can really To figure out what’s going on in the brain in a live subject look at PET scans what we have figured out or they’ve hypothesized is the fact that the serotonin may not transmit as effectively as it may be a really weak connection it’s connecting but it’s you know it’s kind of like having a rabbit ears you got to twist it to get the signal to come in correctly all right this is another one just a concept I want you to think about all they’re looking at in the research is the 5-hit 1a receptor there are a ton of 5-ht serotonin 5-ht receptors and each one of these receptors is involved in some aspect of addiction anxiety mood sexual behavior mood sleep so when we’re talking about why SSRIs don’t work well SSRIs only bind to certain receptors and if we’re not picking the right receptor if it is the serotonin at all then we’re probably barking up the wrong tree I educate my patients about this if they decide they need to go on antidepressants just so they don’t get frustrated as easily I mean it’s still frustrating but so they don’t feel hopeless if the first medication they start taking doesn’t seem to work or makes it worse we talked about why that might be because there are so many different receptors for each one of the neurotransmitters there is a really cool table if you’re into this stuff it’s actually on Wikipedia and it talks also about not only what these receptors do but also what chemicals and medicines act on these receptors and how Food for Thought GABA has profound anxiolytic effects in part by inhibiting the cortisol norepinephrine circuits so it turns down the excitatory circuits patients with PTSD exhibit decreased peripheral benzodiazepine binding sites well we know that when the body secretes a neurotransmitter goes to the other end and it binds like a lock-and-key if you will or it knocks on the door and the door gets opened and it goes through however you want to think about it basically what they found is in patients with PTSD the Kem GABA goes through and the GABA levels are okay but then it knocks on the door to get let in or it tries to put its key in the lock and there’s something wrong at the binding sites or the binding sites you know somebody’s super glued them shut and they’re just not there which is why patients with PTSD tend to have a harder time de-escalating when their anxiety and stuff gets up because the GABA is there but it’s got no doors to go through no locks to bind with however you want to whatever metaphor you want to use this may indicate the usefulness of emotion regulation and distress tolerance skills due to the potential emotional dysregulation of these clients so remember we talked about them having a more exaggerated get-up-and-go response to a perceived threat and they also have a harder time calming down which is basically one of your primary tenants of emotional dysregulation so one thing clinicians can do is help patients learn that okay their body responds differently to stress than other people at least for right now so it’s important for them to understand what emotional dysregulation is emotional regulation strategies as well as distress tolerance skills to help them until they can calm down to baseline because it sometimes takes them longer than other people as clinicians we also can help reduce excitotoxin in order to reduce stress improve stress tolerance and enable the acquisition of new skills when the brain gets really going when the cortisol is out there and the glucocorticoids are in there it’s actually toxic and starts causing neurons to disappear which we’re going to talk about in a second it’s kind of scary NMDA receptors have been implicated in synaptic plasticity.

Which means the brain’s ability to adjust and adapt as well as learning and memory so these are good receptors I like them glutamate binds with these receptors and high levels of glutamate are secreted during high levels of stress glutamate remember is what GABA is made from but high levels of glutamate it’s an excitatory neural net in the brain and overexposure of neurons to this glutamate can be excited toxic and may contribute to the loss of neurons in the hippocampus of patients with PTSD so we’re actually seeing brain volume decrease as a result of exposure to certain chemicals elevated gluten core glucocorticoid and yeah glucocorticoids increases the sensitivity of these receptors so you’ve got a bunch of glutamate being dumped and you’ve got a bunch of glucocorticoid you’ve got cortisol in there making these receptors more sensitive so it’s got they’re more sensitive and they’ve got more coming in which makes it a whole lot easier to become toxic and start causing neuronal degradation what does that mean why do we care it may take clients with PTSD more time to master new skills because of emotional reactivity but also because some of their synaptic plasticity may be damaged so it may take them a little bit longer to actually acquire and integrate these new skills it’s not saying they’re stupid they can remember it just fine however when they’re an emotionally charged state and helping their brain learn that okay this isn’t a threat that’s one of those sort of subconscious things that has to happen that can take longer if the brain becomes excited toxic during stress inhibited learning and memory then it becomes excited toxic during stress which inhibits learning and memory so it’s under stress things are excited toxic neurons are starting to disappear so I’m wondering and I’m just hypothesizing here I don’t know the answers obviously or I wouldn’t be practicing it but what happens during the exposure therapies because that’s exactly what we’re doing is we are flooding the brain with all of these chemicals and creating basically an excitotoxin now they found some evidence that exposure therapies can be helpful according to the DOJ website but or not the DOJ I can’t even think of it right now the VA website but you know I’m wondering long-term what the impact is endogenous opioids natural painkillers act upon the same receptors activated by exogenous opioids like morphine and heroin exerts an inhibitory influence on the HPA axis well we know that people take opiates and it has depressant effects on them it slows them down and calms them down alterations in our natural opioids may be involved in certain PTSD symptoms such as numbing stress-induced analgesia and dissociation again think of any clients you’ve had who have been abused or even taken and not like the side effects of opiates are what opiates do to some people make them feel more relaxed stress induced and analgesia they don’t have as much physical pain sometimes they just it’s there I don’t care pill another interesting factor is now truck zone which is used to oppose opiate appears to be effective in treating symptoms of dissociation flashbacks in traumatized persons so basically, they’re saying if we undo the endogenous opioids we can treat these symptoms it highlights the risk of opiate abuse for persons with PTSD though because if endogenous opioids produce some of these numbing symptoms and dissociative symptoms so they can get away from the pain and the flashbacks then if they add to that you know oral opioids it could prove to be a very tempting cocktail we do want to as clinicians figure out how we can assist them with their physical and emotional distress tolerance so they don’t feel the need to numb and escape and you know I can’t imagine what some people have seen have gone through and I’m not trying to take that away from them, I’m trying to help them figure out how they can stay present and learn to integrate it changes question marks in brain structure and one of the questions that’s come up in the research is because there aren’t any longitudinal studies that looked at it was the hippocampal volume as low to begin with which created a predisposition for PTSD or did PTSD create the smaller hippocampal volume interesting hippocampus is implicated in the control of stress responses memory and contextual aspects of fear conditioning so it helps you to find these triggers in the environment that help you become aware with your senses about when there might be a trauma prolonged exposure to stress and high levels of glucocorticoids damage the hippocampus we’ve talked about that hippocampal volume reduction in PTSD may reflect the accumulated toxic effects of repeated exposure to increased cortisol levels what I called earlier the flatter the Furious having you know your body holding on to cortisol for this extreme stress and then when it perceives stress it’s either nothing or it’s extreme there are no kind sort of mild stressors out there that decrease hippocampal volumes might also be a pre-existing vulnerability factor for developing PTSD the amygdala yet another brain structure is the Olympic structure involved in the emotional process and it’s critical for the acquisition of fear responses functional imaging of studies has revealed hyper responsiveness and PTSD during the presentation of stressful script cues or trauma reminders but also patients show increased amygdala responses to general emotional stimuli that are not trauma associated such as emotional faces so they show an increased responsivity to things they see on the TV that aren’t trauma-related to people crying to people showing anger’s going to have a stronger emotional amygdala response than people without PTSD so clients with PTSD may be more emotionally responsive across the board leading to more emotional dysregulation again an area that we can help provide them with tools for early adverse experiences including prenatal stress and stress throughout childhood has profound and long-lasting effects on the development of neurobiological symptoms the brain is developing and if is exposed to a lot of stress and some of these excited toxic situations how does that differ in the amount of damage caused versus a brain that’s already kind of pretty much-formed programming may change for subsequent stress reactivity and vulnerability to develop PTSD so if these happen during childhood or at any time the brain can basically reprogram and go that it’s a really dangerous place out there so I need to hold on to cortisol and I need to hold on to these stress hormones because every time I turn around it seems like there’s a threat so I am going to be hyper-vigilant and respond in an exaggerated way to protect you from the outside world adult women with childhood trauma histories have been shown to exhibit sensitization of both neuroendocrine and Audino stress responses so basically they’re showing hypo cortisol ISM a variety of changes take place in the brains and nervous systems of people with PTSD and we talked about a lot of those the key take-home point is stress can actually get toxic in the brain and cause physical changes not just thought changes in the brain preexisting issues causing hypo cortisol ism where the brain has already downregulated whether it’s due to chronic illness or chronic psychological stress increases the likelihood of the development of PTSD this points to the importance of prevention and early intervention of adverse childhood experiences we really need to get in there and help these people develop distress tolerance skills understanding of vulnerabilities so they’re not going from flat to furious all the time and so that they can understand why their body kind of responds and why they respond differently than others and you know as we talk about this and of course I’m regularly bringing up DBT buzzwords if you will think about your clients if you’ve worked with any who’ve had borderline personality disorder what kind of history do they have did they have just a great childhood no we know that people with BPD generally had pretty chaotic childhoods so this research is also kind of underscoring why they may react and act the way they do that flat to furious people with hypo cortical ism may or may not have PTSD so we don’t want to say well you’re fine if you don’t have PTSD symptoms we do know that every trauma potentially can cause the body to down-regulate and I kind of look at it as conserving a little bit more of the energy that it needs each time so instead of conserving 60% now it’s conserving 65 and 66 each time it encounters a stressor in order to prepare for potential ongoing threats in the environment hypercortisolism sets the stage for the flattened the furious leading to toxic levels of glutamate upon exposure to stressors which can cause the theorized reduction in hippocampal volume and persistent negative brain changes now I always say the brain can you know rebalance itself and all well that’s part of the plasticity that is the really cool thing about our brain however as far as regenerating those neurons I haven’t found any evidence in the research that we found a way to help people regenerate once we’ve already those neurons are gone they’ve been killed off the brain has to find a workaround so it does take time but I do believe people can minimize some of the impact of the trauma they may have experienced people with PTSD are more reactive to emotional stimuli even stimuli unrelated to trauma again think about some of your clients especially if you work in a residential situation where you’re around on 24/7, you know for 30 or 60 days, and you may see some clients that seem to get upset over everything and you’re like ah such a drama queen or such a drama king and to yourself not to anybody else but when you think about it from this perspective it gives you a different perspective and you might say oh maybe their body responds differently they’ve got more emotional dysregulation because of prior trauma they’re not trying to overreact this is their body’s response because it’s perceived threat so many times it gives me a different approach to working with that client hypercortisolism results when the brain perceives that continued effort is futile feelings of fatigue set in akin to reduced stress tolerance so think about you know when you’ve had a really long stressful period you know weeks or months maybe you’re dealing with an ailing family member or something it’s just a lot of stress and you start getting really tired and when you’re really tired and you’re worn down and somebody gives you one more thing it’s that one more thing normally wouldn’t bother you but right now you just can’t take it so we can see how there’s a reduced stress tolerance when somebody’s already at this stage reducing fatigue in our clients can be accomplished in part with psychological factors including motivation or knowledge of other people who are dealing with similar things support groups feedback about their and making sure they have frequent successes not once a week but I want to have them keep a journal every day of something good that happened or something positive that may indicate they’re moving forward in their treatment goals and knowledge of an endpoint.

Where are we going with this when is the treatment going to end I don’t want most clients don’t want to be with us forever no matter how lovable we are do you want to feel better and be done with us so having to help them see that there is an endpoint we’re going to accomplish this goal this month and then we can reassess 46% of people in the US are exposed to adverse childhood experiences so like I said this is a huge area for early intervention where we can prevent people from developing PTSD later in life how awesome would that be instruction and skills to handle emotional dysregulation including mindfulness vulnerability prevention and awareness emotion regulation distress tolerance and problem-solving could be wonderful additions to health curriculums anything any skills groups you do with children or adolescents or even adults I mean just because they’re adults doesn’t mean that they’re safe from PTSD or that they’ve crossed any threshold where they’re too old to learn we’re never too old to learn of those exposed to trauma education about and normalization of their heightened emotional reactivity and susceptibility to PTSD in the future may be helpful in increasing their motivation for their current treatment protocol whatever it is but it also just normalizes things so they don’t feel like they’re overreacting or they don’t feel guilty for being so tired or whatever they’re experiencing right now are there any questions I know I went through a lot of really complicated stuff but I thought it was really interesting not only the way our brain reacts in order to protect us but how cross-cutting a lot of this stuff was it not just PTSD we’re talking about necessarily but a lot of this information applies to our clients with chronic fatigue burnout and chronic stress and we can see that those people also are at risk at higher risk of PTSD should they be exposed to trauma and none of us is immune I mean there are tornadoes there are hurricanes there are you know things that happen that really stink so the more we can help clients be aware of things develop skills and tools to prevent as much harm as possible I think the more effective we are as clinicians depending on the client and I can do some more research on the VA website because they’re really into medications for PTSD I know ketamine which is a horse tranquilizer has been shown to be effective in people with PTSD and there have been some others that have kind of given me pause ketamine is a hypnotic you know most of the drugs they’re trying out right now are really in my opinion they’re powerful drugs but a lot of them all of them that I know of have pretty high addictive potentials too so they make me nervous but you know when you’re weighing the when you’re going from a harm reduction model that’s not necessarily not necessarily such the be-all-end-all I guess that’s interesting that you use ketamine in the ER it’s definitely powerful effective stuff and like I said earlier some of the stuff that some of my clients and some people have seen done experienced I couldn’t even imagine and you know sometimes for them to actually survive we may need to look at some of these more intense more powerful drugs PTSD and veteran trauma is not are not my focus right now and yes marijuana is being experimented with or looked at used whatever however you want to look at it for PTSD treatment with veterans there’s pretty much not a drug out there they haven’t tried to throw at it to see well what will this do I believe they were even using LSD experimentally for a little while too you the VA I mean if you’re interested in this topic let me see if I could pull that down into here, we go to the National Center for PTSD US Department of Veterans Affairs has a lot of information if you go for professionals, it has a ton more information if you can get on get some of your SI CEUs on demand they do have some free CEUs for PTSD here I’ve never taken any of them but what I’ve looked at when I’ve looked at like the PowerPoints the presentations and stuff I’m sure they’re good so if you’re you do focus a lot on PTSD and you can get on-demand CEUs then this might be a place to get some good free ones aside from DBT are there any other evidence-based practices for therapy that you’ve seen work best in combination with the medications cognitive processing therapy when you’re working specifically with veterans and there is a free course on that too and this one I have gone through and it’s really awesome CPT dot must seed and here I’ll just put it into that education and this is a free course oops and here’s the other one ah golly everyone and embryo does have a lot of research effectiveness with people with PTSD too so yes I would definitely encourage people to explore all options alrighty everybody I really appreciate you coming today and sticking with me through this topic and I will see you on Thursday if you have any questions please feel free to email me or you can always also send it to support that all CEUs com either way I get it and otherwise I will see you on Tuesday thanks a bunch if you enjoy this podcast please like and subscribe either in your podcast player or on YouTube you can attend and participate in our live webinars with Doctor Snipes by subscribing at all CEUs comm slash counselor toolbox this episode has been brought to you in part by all CEUs com providing 24/7 multimedia continuing education and pre-certification training to counselors therapists and nurses since 2006 used coupon code consular toolbox to get a 20% discount on your order this monthAs found on YouTube15 Modules Of Intimate Video Training With Dr. Joe Vitale – You’re getting simple and proven steps to unlock the Awakened Millionaire Mindset: giving you a path to MORE money, …

Best Practices for Anxiety Treatment | Cognitive Behavioral Therapy

This episode was pre-recorded As part of a live continuing education webinar on-demand CEUs are still available for this presentation AllCEUs.com/Anxiety-CEU I’d like to welcome everybody to today’s presentation on best practices for the treatment of anxiety I am your host, Dr. Dawn Elise Snipes now not too long ago we did a presentation on strengths-based biopsychosocial approaches to addressing anxiety while Those are wonderful you know I thought maybe we ought to look at you know what’s some of the current research so I went into PubMed which is I don’t know it’s a playground for me it’s where You find a lot of journal articles and you can sort I sorted by articles that were done and meta-analyses that were done within the past five years so that gives us an idea About current research I mean there’s a lot of stuff that is still the same like some of The medications that were known to work ten years ago are still known to be you know good first-line treatments but there are also some newcomers that we’ll talk about and there are also some changes that we’re going to talk about so we’re going to explore some common causes for anxiety symptoms in order to treat it, we really need to and of course, this does play into the biopsychosocial aspect we really need to understand kind of what causes it because anxiety that’s caused by for example somebody having a racing heart may be different than anxiety that’s caused for somebody who has abandonment issues so we’re…

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…It can be incorporated in a lot of various places again where they’re not applying it or ingesting it in any way all they’re doing is smelling it they’ve used it in defusing aromatherapy in hospital emergency rooms and they found that it reduces stress and irritability the people in emergency rooms and I’ve been to enough emergency rooms over the course of the years to know that People who are in emergency rooms typically are not in the best mood so if it can help those people then It’s probably going to have some sort of an effect so psychologically helping clients realize that their body thinks there’s a threat for some reason that’s why it triggered the threat response system which is what they call anxiety, so they need to figure out why is there really a threat You know sometimes it’s like the fire alarm going off in my house it just means that the windows are open and there’s a strong breeze there is no fire there is no problem there’s just a malfunction It’s a false alarm A lot of times clients get this threat reaction they get this stress reaction and it’s not a big deal right now so they can start modifying what their brain responds to and again, those basic fears that a lot of people worry about failure rejection loss of control the unknown and death and loss distress tolerance is one of those cognitive interventions that has taken center stage in anxiety research and it isn’t about controlling your anxiety you know helping people recognize their anxiety acknowledge it and say okay I’m anxious it is what it is How can I improve the next moment instead of saying I’m anxious I shouldn’t be anxious I hate being anxious and slang with that anxiety let it go just accept it is what it is have the client learn to start saying I am feeling anxious okay so distracted don’t react because I explain to them The whole notion of feelings comes in crest and go out in about 20 minutes It’s like a wave so once they acknowledge their feeling if they can distract themselves for twenty or thirty minutes you know Obviously, they figured out there’s no real threat if they can distract themselves for twenty or thirty minutes those emotions can go down and then they can deal with it in their wise mind and encourage them to use distancing techniques instead of saying I am anxious, or I am terrified or whatever Have them say I am having the thought that this is the worst thing in the world I am having the thought that I could not handle this because thoughts come and go and that comes from acceptance and commitment therapy functional analysis makes it possible to specify where and when with what frequency with what intensity and under what circumstances the anxious response is triggered so it’s important that we help clients develop the ability to do functional analyses on their own so when they start feeling anxious, they can stop and say okay where am I what’s going on how intense Is it what are the circumstances, and they start really trying to figure out what causes this for them so they can identify any common themes from their psychoeducation about cognitive distortions and techniques to prevent those circumstances or mitigate them can be provided so if the client knows that they get anxious before they go into a meeting with their boss and it’s usually a high intensity of anxiety okay so we can educate them and help them identify what fears that may be related to techniques to slow their breathing calm their stress reaction and help them figure out times in the past when they’ve handled going in and talking to their boss and it really wasn’t the end of the world you know there’s lots of different things we can do there for them there but the first key and it gives them a lot of a huge sense of empowerment to start becoming detectives in their own life and going okay now under what situations does this happen positive Writing this was another really cool study each day for 30 days the experimental group and this was high school-aged youth in China but you know the experimental group engaged in 20 minutes of writing about positive emotions they felt that day so they’re writing about anything positive that make them happy that made them enthusiastic give them hope whatever long-term expressive writing positive emotions so after 30 days it appeared to help reduce test anxiety by helping them develop insight and use positive emotion words so it got them out of the habit of using the destruction and doom words and encouraged them to get in the habit of looking at the positive things and being more optimistic it’s a really cool activity that clients can try it’s…

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Best Practices for Anxiety Treatment | Cognitive Behavioral Therapy

this episode was pre-recorded as part of a live continuing education webinar on-demand CEUs are still available for this presentation AllCEUs.com/Anxiety-CEU I’d like to welcome everybody to today’s presentation on best practices for the treatment of anxiety I am your host, Dr. Dawn Elise Snipes now not too long ago we did a presentation on strengths-based biopsychosocial approaches to addressing anxiety while those are wonderful you know I thought maybe we ought to look at you know what’s some of the current research so I went into PubMed which is I don’t know it’s a playground for me it’s where you find a lot of journal articles and you can sort I sorted by articles that were done and meta-analyses that were done within the past five years so that gives us an idea about current research I mean there’s a lot of stuff that is still the same like some of the medications that were known to work ten years ago are still known to be you know good first-line treatments but there are also some newcomers that we’ll talk about and there are also some changes that we’re going to talk about so we’re going to explore some common causes for anxiety symptoms to treat, we need to and of course, this does play into the biopsychosocial aspect we need to understand kind of what causes it because anxiety that’s caused by for example somebody having a racing heart may be different than anxiety that’s caused for somebody who has abandonment issues so we’re gonna treat the two things differently so we want to look at some of the common causes we’re gonna look at some common triggers for anxiety Do you know what are some of these common themes that we see in practice I will ask you to share some of the themes that you see that underline or underlie a lot of your client’s anxiety and identify current best practices for anxiety management including counseling interventions medications physical interventions and supportive treatments so we care because anxiety can be debilitating and a lot of our clients have anxiety a lot of our clients have anxiety comorbid with depression and they’re looking at us going how can I feel anxious and stressed out and like I can’t sit still and be depressed at the same time you know when you’re depressed you’re supposed to want to sleep well a lot of times people who have both issues want to sleep but they can’t so I want to help clients understand that also sometimes anxiety when people are anxious for long enough the body starts kind of holding on to the cortisol the body recognizes at a certain point this is a losing battle I’m not going to put energy into this anymore so it starts withdrawing some of its excitatory neurotransmitters so to speak and people will start to feel depressed the brain has already said this is hopeless this is you’re helpless to change the situation so then people start feeling hopeless and helpless which is sort of the definition if you will of depression low-grade chronic stress and anxiety arose energy and people’s ability to concentrate so if we’re going to help them become their uber selves we need to help them figure out how to address anxiety not just generalized overwhelming debilitating anxiety but also panic social anxiety and those minor anxiety triggers that come along that may not meet the threshold for diagnosis anxiety is a major trigger for addiction relapse if you have a client who is self-medicated before or had an addiction for some reason anxiety is a major trigger increased physical pain when anxiety goes up people tend to tense their muscles when they tense their muscles they tend to feel more pain I mean think about when you’re stressed you tend to have more pain like in your neck your back and things that already hurt may hurt more why because serotonin which is one of our major anti-anxiety neurotransmitters is also one of our major pain modulators so when serotonin levels are too low because anxiety is high then our pain perception is going to be more acute and people can have sleep problems if they’re stressed out your body thinks there’s a threat you’re not going to be able to get into that deep restful sleep you may have you may sleep you may sleep a lot but it’s probably not quality sleep which means your neurotransmitters may get out of whack your hormones make it out of whack and your body is going to start perceiving yourself in a persistent state of stress when you’re exhausted the body knows that we may be the weakest link in the herd so it continues to secrete cortisol to keep you on alert a little bit so you may again you may be resting kind of like when you have a new baby at home those first couple of months that my children were home from the hospital I slept but I didn’t sleep well I mean the slightest little noise and I was awake and I was looking around and you know I felt it I felt exhausted and a lot of new parents do so triggers for anxiety abandonment and rejection and we’re going to talk about ways we might want to deal with these things but some of the underlying themes that I’ve seen in a lot of clients and when I do the research and a lot of what themes that come out include low self-esteem if someone has low self-esteem they’re looking to be externally validated oftentimes they’re looking for somebody else to tell them you’re lovable you’re okay so that can lead to anxiety about not having people to tell them you’re okay which makes their relationships tenuous and can make them dysfunctional irrational thoughts and cognitive distortions may lead people to believe that if I’m not perfect for example I am not lovable so we’re going to look at some irrational thoughts and cognitive distortions unhealthy social supports and relationships when you’re in a relationship it takes two to tango and even if your client is relatively mentally and physically healthy if they are in a dysfunctional relationship they can fear abandonment and rejection if that other person is always saying if you don’t do X I’m going to leave you or if that other person is always cheating on them or whatever so relationships can trigger abandonment anxiety and ineffective interpersonal skills can lead to relationship turmoil and social exile if our clients are in relationships even if they’re not completely dysfunctional if our clients are not able to ask for what they need and set appropriate boundaries and manage conflict effectively because conflict happens in every relationship then they may start to argue more which may lead to fearing may lead to relationships ending in the past and them going well every relationship I get into ends which means I must not be lovable so they start fearing abandonment and rejection these are four areas that we can look at one more assessing clients another issue is the unknown and loss of control a lot of times negative self-talk and cognitive distortions can contribute to that if I don’t have control of everything then it’s all going to be a disaster negative others when clients hang out or when people hang out with negative people it kind of wears on you after a while you notice that people who tend to be more negative pessimistic conspiracy-minded tend to hang out with people who are also negatively pessimistic and conspiracy-minded so if you’re hanging out with somebody who tends to be anxious then the anxiety can be palpable and it can kind of permeate physical complaints can lead people to be anxious because they don’t know what’s causing it like I said earlier sometimes if your heart starts to race if you don’t know what’s causing it you can start thinking I’m having a heart attack or I’m gonna die when people have panic attacks for the example they truly think they’re having a heart attack and it’s I’ve had them they are very very unpleasant experiences but when people start having physical complaints and it can be you know they have a weird rash that they can’t get to go away or whatever but when they don’t know what it is and they can’t control it they can’t make it go away they start thinking about all the worst-case scenarios and going online and getting on WebMD which usually gives you all the worst-case scenarios um so physical complaints are important we need to normalize the fact that nobody’s pain-free all the time and you know the fact that you may have an ache or a pain or a lump or a bump or you know a cough most likely you know when we look at probability the probability of it being something significant is pretty small now do you want to get it checked out probably but you know the probability that is anything to be worried about is relatively small and a sense of powerlessness can trigger fear of the unknown and loss of control for somebody who doesn’t feel like they have any agency in their life if they have an external locus of control or if they felt victimized all of their life then they may fear not being in control they may be holding on and saying okay this is the one area of my life I can control when I grew up you know I grew up in a very chaotic environment I had no control I was bounced around in the foster system yadda yadda yadda now that I’m an adult you know I can control these things and I am going to hold on with white knuckles and if I can’t control everything then that terrifies me to death and loss are other triggers for anxiety and it can be people or pets and pets are important I don’t want to minimize pets because you know they are little parts of a lot of our families so making sure we check that my daughter’s dog for example is it’s getting old she’s getting older she’s 14 now I think and you know she’s in decent health we took her to the vet and the vet said yeah she’s got a little heart murmur but that’s expected for a 14-year-old dog and but when she goes out if she doesn’t come back when I call her I have this rush of anxiety for a second oh my gosh I hope this wasn’t the day so anxious around losing people and you know if she when she crosses the bridge she will and you know I’m okay with that I’m I have a harder time dealing with my daughter’s emotional turmoil when that happens and because she’s grown up with this dog so you know those are the types of things that we want to talk about with our clients what things are weighing on you that you may not even be thinking about because I know in the back of my mind there’s always that worry about one of our donkeys and her dog jobs and promotions can trigger anxiety if people are afraid they’re gonna lose their job if they’re always afraid that you know they’re gonna walk in and get a pink slip or get fired you know we want to help them look at how realistic they are you doing what you need to do to achieve and keep your job and sometimes it’s not easy to answer I mean the first thought that a lot of us have is well you know if you’re doing the right thing so just do it but there are those bosses out there and I’ve had some amazing bosses a lot of them and I’ve had two horrendous bosses and those two bosses I could never I never felt like I was able to do anything right and so going to those jobs there was always this anxiety about what I’m what am I going to get in trouble for today so you want to talk with people about does your job cause anxiety what can you do to moderate that anxiety the same thing with promotions people may get anxious about whether they’re going to get promoted to safety and security you know when you lose safety and security you can feel anxious so if there’s a break-in at the house next door or shooting down the road or you start watching the news you can feel very unsafe and insecure quickly so we want to help people figure out how safe and secure are you really and a lot of it goes back to really looking at facts when people lose their dreams and hopes or fear that they’re going to lose their dreams and hopes they can start to get anxious you know they have this dream that they’re going to be a doctor or I just finished the presentation on helping high school students transition to college and a lot of high school students for example start college with these wide eyes and hopes to save the world and they want to be doctors and engineers and this and that and they get into it and they realize that it’s a lot harder then they thought or they realize that you know what I don’t like this but I’ve already committed to it so what do I do I want to help people but I can’t I can’t cut it doing this you know for me I figured out in my second year that I wasn’t going to medical school because I wasn’t going to pass calculus and that caused a lot of anxiety it was like okay what am I gonna do now Do you know what career should I choose to help people figure out do they have dreams that have maybe kind of crashed and burned and you have to find new ones you know okay that one we’ve got to accept it figure out that it’s not going to be and what can you do now people may also have dreams about relationships, they get into relationships and see themselves with this person forever and then this relationship ends and or starts to get rocky and they’re like but that’s my dream what happens if that’s got to happen because it’s my dream I don’t know how to function if that goes away we want to help people be able to rewrite their narrative and then sickness spiders and other phobias kind of go in with death a lot of times when people get sick they start getting anxious that oh my gosh what if this is terminal oh my gosh what if this is you know incurable if I get bit by a spider it’s gonna kill me and which is rare you know there are very few spiders that is that poisonous same thing with snakes going over bridges I’ve shared with you all that is not one of my irrational fears you know I am just terrified that you know something’s going to happen and I’m going to get pushed off the side of the bridge which is completely irrational but we need to help people look at those and identify the thoughts that they’re telling themself about those phobias and dealing with that anxiety failure is another trigger for anxiety especially in this culture our culture American culture is in large part puts a high premium on success and perfectionism so when people realize that they’re not perfect they may start to get anxious because they feel like if I’m not perfect then I’m a failure you know those cognitive distortions of all-or-nothing thinking and they start with that negative self-talk you know you can’t do anything right so those are some of the issues that you know we often see in counseling sessions so what do we do you know somebody comes in and is like I can’t live this way doc anxiety depression and substance disorders as well as a range of physical disorders are often comorbid so this is the first the thing we need to realize is that we’re very rarely dealing with a very simple diagnosis you know when somebody comes in we need to figure out you know if they come in and they’re presenting with depression all right let’s talk about that and then we start realizing that there depression started to occur after a long period of being anxious okay so we need to deal with that but we also need to help them with their sense of hopelessness and helplessness we need to develop that sense of empowerment and then substance disorders we know that substance use is often a way of self-medicating but we also know that it monkeys with the neurochemicals in the brain and can contribute to anxiety and depression the same thing to physical issues pain from physical disorders anxiety about having physical disorders medications you’re taking for physical disorders can all contribute to anxiety so we need to look at the person as a whole and go what are all the things that are contributing to the anxiety and what are all the things that the anxiety is contributing to so we have started having this big list of stuff that needs to be addressed and then we can start figuring out okay where we start so knowing that these things are comorbid helps researchers explore pathways to mental disorders so they can start figuring out you know what little string can we pull to unravel this blanket of anxiety so it doesn’t suffocate somebody and for us as clinicians it provides us key opportunities to intervene in you know sometimes clients will come in and start talking about their anxiety and their physical issues you know maybe their anxieties about you know heart palpitations and because that’s a common one we may want to encourage them to go see the doctor to get that ruled out you know rule out anything that has to do with hormone imbalances or you know heart conditions or anything else that might be contributing to it which can help them address it and if they do have physical disorders let’s go with hormone imbalances that are contributing to the heart palpitations then they can start to treat that if they don’t start to treat that then no amount of talk therapy we do is going to get them to the quality of life that they’re looking for because they’re still gonna feel those so we want to make sure that we’re addressing them holistically anxiety disorders should be treated with psychological therapy pharmacy therapy or a combination of both and what they found and this is no surprise this is kind of old news is that counseling Plus pharmacotherapy tends to have the best outcomes but separating the two have similar outcomes in many cases but that’s just looking at and I hate to call it simple anxiety but we’re just looking at anxiety symptoms here we’re not looking at the full quality of life and we want to make sure that we’re also including any medical issues behavioral therapy is regarded as the psychotherapy with the highest level of evidence, there are a variety of cognitive behavioral approaches ranging from acceptance and commitment therapy to dialectical behavior therapy to CBT to debt you know any of those that deal with the thoughts and the cognitions that fall in that realm and it is effective in the current conceptualization of the etiology of anxiety disorders includes an interaction of psychosocial factors such as childhood adversity or stressful events and a genetic vulnerability so the psychosocial factors and these are other things when we do our assessment we want to pay attention to because our approach to treatment is going to be different for people for example who have trauma-related brain changes maybe then for somebody who doesn’t so, we want to look at childhood adversity and stressful events that it may have caused basically what I tell clients is like rewiring of the brain there are trauma-related brain changes in soldiers and especially in children or in people who’ve been exposed to extreme trauma that is designed to protect them but it also can cause complications kind of later on in dealing with anxiety coping skills that were learned that are ineffective you know sometimes people grow up in a household or an environment or a situation where they don’t learn effective coping skills so we need to kind of help them unlearn those and learn new ones build on their strengths and trauma issues that may still need to be dealt with such as domestic violence you know if they grew up a lot around a lot of domestic violence they may think you know I’m out of that situation it’s over I don’t want to think about it it’s not bothering me anymore or a parental absence and I put absence because it can be death it can be a parent that just packed up and left it could be a child that got put up for adoption whatever put the child in a position of feeling like they were rejected by a parent can be very traumatic and bullying among other things but there are a lot of trauma issues that people once they’re out of that situation often say you know I’m out of it it’s not a big deal I dealt with it let’s move on and they don’t realize the full ramifications and how that’s contributing to their current anxiety and their current self-talk and cognitions of current stressors if somebody has a lot of current stressors that’s also going to impact whether they develop generalized anxiety you know we’re kind of stacking the deck here and the current availability of social support if they don’t have effective current social support then they’re gonna have difficulty bearing the weight of everything on their shoulders so we want to look at all these psychosocial factors when we do our assessment now going back to the trauma issues if you’ve taken the trauma courses at all CEUs you know that some people are not ready to acknowledge that the trauma is still bothering them or work on the trauma and that’s okay we can educate them that it might be an issue and then let them choose how to address it but we want to bear in mind the fact that you know this could be sort of an underlying force motivating some of the current cognitions and genetic vulnerability so you take any three people and you put them or 300 people and you put them through roughly the same psychosocial situations they’re all probably going to react a little bit differently based on their prior experiences but also because of their genetic makeup there are certain permutations and they found four we’ll talk about later that make the brain more or less responsive to stress and more or less responsive to serotonin which is your calming chemical so brains that are less responsive to serotonin isn’t going to you know send out as much or send out serotonin as easily so people can stay kind of tensed and wired that’s an oversimplified explanation but that’s all you need for right now so genetic vulnerability impacts people’s susceptibility to the effects and development of dependence on certain substances which can increase anxiety when people are detoxing from alcohol when they’re detoxing from benzos when they’re detoxing from opiates they can feel high levels of anxiety when they take opiates some people find that opiates have wonderful anti-anxiety properties not that I am advocating for the use of opiates I’m just client experiences have shown that that can be true so some people are going to be more susceptible to the anti-anxiety effects of certain substances and some people are going to be Cerrone to become dependent on substances where others may not and that part of that is genetic vulnerability and they estimate about 30% the predictability of the development of anxiety disorders is genetic and genetics also impact which medications are effective if you have genetic makeup then SSRIs might be helpful then atypical antipsychotics may be more effective and SSRIs might not do anything which is why a lot of our clients get so frustrated because they know there’s no way to figure out exactly what I guess there is now that there’s genetic testing out there but up until then it was harder to figure out which medications to start with and most physicians matter of fact I don’t know of a single physician that starts by saying well let’s do a genetic profile to see what med to start you out with most we’ll start with events as with an SSRI or some other anti-anxiety medication some sort of Benzo that’s been my experience so we may want to encourage clients to consider genetic testing if they’re having difficulty finding a medication regime that works for them and they are feeling like they have to have medication genetic vulnerability also affects what’s going to make somebody more vulnerable now than all of you in class today you know thinking about sleep you know sleep may not be a big deal for some of you I know people who can go days or weeks with four or five hours of sleep and they feel fine it’s not a big deal, not me I need eight or nine hours of sleep so genetically for whatever reason I am programmed to need a lot of sleep so when I don’t get that much sleep I tend to be it tends to be harder for me to deal with life on life’s terms and I know that that makes me more vulnerable to being irritable so genetic vulnerability affects who can become addicted and affects what medications work best and affects what situations are going to tend to make somebody more vulnerable to anxiety so our medications and I know the type on here is small but we’re going to go through the first-line drugs are the SSRIs selective serotonin reuptake inhibitors and SNRs is selective norepinephrine reuptake inhibitors now the names are a little bit deceptive because selective norepinephrine reuptake inhibitors also increase available serotonin but the mechanism of action is different the mechanism of action for each SSRI is a little bit different as well which is why you can put somebody on Prozac and they have an awful experience and you can put them on Zoloft and they have a much better experience like I said earlier a lot of the research pre five years ago had been done on medications and Zoloft paxil luvox lexapro celexa and their generics have all been found to be effective at treating anxiety in certain people no one medication works for everybody in the last five years effexor has come on the radar and it has been found effective according to the Hamilton rating scale for anxiety so that’s another one to consider if clients are not successful or getting the treatment effect that they need for on some of the other medications obviously, none of us probably are prescribers but we do need to educate clients about why the first drug or even the third drug that the doc tries may not work so they don’t start feeling helpless and hopeless like I said earlier there are at least four different genetic variations which are correlated with the development of generalized anxiety disorder and different medications are more or less effective depending on the genetic makeup of the person there’s a high mortality rate moving on to two benzos the recommendation has switched to back off from the use of benzos now for some doctors will prescribe an SSRI and for the first, four weeks while the SSRI is building up in the system they will also prescribe a Benzo to be taken as needed to moderate the anxiety and you know you could argue on either side of that, if somebody has a history of substance use or substance dependence benzos are really a bad idea because they do have a high rate of dependence but the other reasons that they are now cautioning against the use of benzodiazepines is that there’s a higher mortality rate among benzo users compared with non-users there’s an increased risk for dependence with use for more than six months and that’s a long time to be using Benzo and when we’re talking about dependence and six months we’re talking about somebody who uses it like every four hours or every eight hours depending on your Benzo every single day, not a PRN user if somebody’s using it at night to help them go to sleep or you know three or four times a week when the anxiety gets high the risk of dependence is relatively low but a lot of people with anxiety because if they find the right Benzo makes them feel so much better they may not want to be off of it and for a lot of people when that benzo reaches its half-life and starts getting out of the system even more their anxiety spikes you know they have rebound anxiety which they want to medicate with more benzos that’s gonna be an issue for them to discuss with their doctor there’s also an increased risk of dementia identified in long-term benzodiazepine users again this is for the people who use you know throughout the day every day for six months or relatively every day for six months or more and it doesn’t matter if it’s you know we’re talking about somebody who’s 65 or somebody who’s 35 who’s been using Benzos for you know six months a year two years the risk of later life dementia is greatly increased according to the research benzodiazepines also don’t treat depression okay so if you’ve got somebody who has concurrent anxiety and depression there’s a much higher suicide risk if they’re on benzodiazepines so being aware and generally that suicide risk comes from overdosing on benzodiazepines but not always other treatment options you know if the benzos aren’t something that people want to touch you know they scare the living daylights out of I SSRIs and SNRIs don’t seem to be working then tricyclic antidepressants can be tried on those your older generation antidepressant seroquel is used a lot and there are some there’s some research that shows it can be effective with anxiety like some of the antidepressants and depending on the person the benzos seroquel can make people very very very sleepy so you know it may not be the side effects of the Seroquel the weight gain and the fatigue and you know sleepiness may be an unacceptable side effect for some clients and boosts perón is the third option boost Barone works more like an anti-depressive serotonin reuptake inhibitor and that it takes you know four weeks or so to kind of build up in the system studies have shown that there’s really no long-term benefit to taking it but after six months to eighteen months of use it has been shown to be effective in talking with clients a lot of clients report that boost bar when they take it doesn’t necessarily help them stop being anxious like a benzodiazepine does but it helps them not go from zero to 200 in 2.3 seconds it kind of you know keeps them from having this gush of a freak out reaction every time something goes wrong which a lot of clients report helps because they feel more stable throughout the day after remission medication should be continued for six to twelve months and during that last six months first six months keep it as is last six months you know they say that tapering is best it’s best not to stop somebody cold turkey on any of these but it’s important for people once they’re in remission to not just suddenly go okay I feel better I don’t need any of this anymore they need to work into it and make sure they’ve developed the skills and tools that they need to deal with some of the anxiety that is going to happen in life so physical signs and symptoms of anxiety may include fatigue irritability muscle tension or muscle aches try laying feeling twitchy being easily startled trouble sleeping nausea diarrhea irritable bowel syndrome headaches so the first thing we want to do with clients when we’re talking to them well second thing first thing is say get a physical let’s rule out physiological causes of this but we can also help clients look at you know what might be causing these things that you can do to mitigate it what might be contributing to your fatigue what might be contributing to your irritability and your muscle tension or your muscle aches I mean let’s look at economics did you recently get a new bed or do you need to get a new bed what about your desk chair I know you know I get more muscle tension and muscle achy when I do a lot of mousing because I have deplorable posture being becoming aware of that helps and then I’m like okay well I know it caused unfortunately, it’s unpleasant but it’s not a big deal trembling or feeling twitchy you know that can be caused by low blood sugar that can be caused anxiety that can also be caused by early onset Parkinson’s symptoms you know there’s you know it can be worst case scenario or it can be something benign so we want to have people figure out you know when you start trembling or feeling twitchy is there something that it’s related to you know I know when my son gets excited he’s he just sits there and you can see him almost shake because he’s so excited about something so we want to have people prevent misidentification we don’t want them to jump to that worst-case scenario we don’t want them to go onto WebMD and go oh my gosh I’ve got cancer I’ve got this debilitating disease and I’m going to die in six months probabilistic Lee speaking it’s not gonna happen yes get a doctor’s opinion I’m certainly not going to tell them it’s all in your head I want them to get an evaluation but I do want to in the meantime help them think about how likely is this and other things for headaches and this is one another one of those that can be frustrating as we get older our eyesight starts to go and you know there was a period there I did fine and then after I hit 45 my eyesight just started to like steadily and kind of rapidly in my mind decline so I have to get my eyeglass prescription changed every couple of years and that can cause headaches so instead of starting to worry about oh my gosh I’ve got a headache all the time maybe I’ve got a brain tumor you know I know that it’s probably my glasses or I’m grinding my teeth so other biological interventions that have been evaluated there’s something called the floatation rest system that reduced environmental stimulation therapy reduces sensory input into the nervous system through the act of floating supine which is on your back in a pool of water saturated with Epsom salt you know I’m looking at this going sounds good and you can’t quite get the same experience in a bathtub because you’re not floating you’ve got pressure points and you’re still hearing stuff clients can sort of simulate it with you know earplugs or whatever but it’s if they can access this it’s been shown to be effective the float experience is calibrated so that sensory signals from visual auditory olfactory gustatory thermal tactile or tactile vestibular gravitational and preceptive channels are minimized which means you don’t see here taste touch smell feel anything as is most movement and speech so you want people to lay just like completely motionless and not talk which can be hard for some people with anxiety in the study the study I looked at fifty participants reported significant reductions in stress muscle tension pain depression and negative effects and it was accompanied by significant improvement in mood characterized by increases in relaxation happiness and well-being I read the study I’m like where can I sign up you know it sounds in looking at some of the research this was more effective for addressing anxiety than something like a massage Tai Chi also produced significant reductions in anxiety there was approximately a 20% treatment effect 25% treatment effect in patients with anxiety and fibromyalgia who practiced twice a week for a year now you know we want to look at the confounding things here is it the Tai Chi itself or is it learning to control the muscles and becoming more in tune with your body and learning to control your breathing helps people reduce their anxiety either way you know Tai Chi helps people do that and it was shown that after a year after the first six months, there was a significant treatment effect but after a year you know it kept growing and after a year it was about 25% so Tai Chi can be effective acupuncture at the HT 7 median Meridian can attenuate anxiety-like behavior induced by withdrawal from chronic morphine treatment through the meditation of the GABA receptor system what does that mean that means if you if the acupuncture is done in very certain places the anxiety behavior the GABA a receptor system GABA is your main calming relaxation neurochemical that is triggered and causes your body to sort of flood that receptor system and this research was done on people who were detoxing from morphine treatment but we can look at generalizing the results and I would be interested to see further studies on it pain other things we need to do to help people with anxiety when people are in chronic pain they often have anxiety that oh my gosh this is getting worse or It’s never gonna get better or I just can’t take this pain anymore or they may get anxious that they’re going to be rejected because they can’t do some of the things they used to do because they’re in so much pain so there’s a lot of guilt and anxiety that can kind of revolve around pain what can we do to help clients guided imagery is generally very helpful if we can help them imagine you know if that pain in their shoulder imagine the pain is like the color red flowing out of their arm or other focus mindfulness so you know when you think about something you know when you get a shot if I don’t think about it it doesn’t hurt near as much as if the nurse says okay now one two three and you know she’s counting down and I’m getting prepared and I’m focused on it I had another nurse one time who she was just talking to me and you know put the alcohol on my arm and just kept on talking and didn’t tell me she was getting ready to give me a shot and before I knew it she had given me a shot and she was like okay we’re done I’m like you didn’t give me a shot yet she said yes I did it’s like oh so not focusing on it and next time you have an itch for example if you’ve ever been driving on the interstate and you can reach on your foot I get those on the bottom of my foot sometimes and I’m like okay I’m not going to pull over to each my foot if you focus on something besides the itch eventually, it goes away I’m not saying the pain is gonna completely go away but the more people focus on it the more it hurts physical therapy can help so encourage them to get a referral and encourage them to do a self-evaluation if nothing else of ergonomics in their car at work where they watch TV and spend most of their time at home and they’re sleeping so those are the four places that they spend most of their time what do their ergonomics look like and that can help a lot of people mitigate a lot of pain hormones are another thing that we need to look at imbalances of estrogen and testosterone can contribute to anxiety symptoms heart palpitations fatigue irritability having people get a physical we can’t as clinicians do anything about it but doctors can rapid heart weight rate sweating palpitations are not uncommon in women in perimenopause or menopause so a lot of women start feeling like they’re developing generalized anxiety and/or something’s going wrong when they start reaching that mid-40s to mid-50s area and they start having some of these symptoms again we’re not going to diagnose it but we do want them to recognize that it may not be anything you know is catastrophic this is something that a a lot of women experience and help them figure out how to deal with that supportive care biologically now you know this isn’t gonna treat anything but we can help them minimize their vulnerabilities help them create a sleep routine so their brain and body can rebalance this can help repair any adrenal issues that may be going on and improve energy levels people with anxiety don’t sleep well so helping them figure out how to get some quality sleep is important nutrition minimizing caffeine and other stimulants are going to be a big help because those make people feel anxious and encourage them to work with a nutritionist to try to prevent spikes and drops in blood sugar which can trigger the stress response when your blood sugar goes way up or way down you can start getting kind of shaky and feel weird and that can cause people anxiety because they might think oh my gosh I’m having a stroke or a heart attack or you know I don’t know what these tremors are so it’s important that they don’t miss identify symptoms and encourage them to drink enough water dehydration can lead to toxic Ardea which is increased heart rate sunlight vitamin D deficiency is implicated in both depression and anxiety mood issues vitamin D has been found in those main areas where serotonin receptors are found vitamin D receptors are found so we know the serotonin and vitamin D have something going on sunlight prompts the skin to tell the brain to produce neurotransmitters and set circadian rhythms which impact the release of serotonin your calming neurochemical melatonin which is made from breaking down serotonin and helps you sleep and gaba so sunlight actually helps increase the release of GABA when it’s time to start calming down and going to sleep exercise studies have shown that exercise can have a relaxing effect and encourage clients to start slowly there’s not a whole lot of new research on exercise and anxiety aromatherapy has been used a lot, especially in other countries in the treatment of people with anxiety people with hospital anxiety people women who are giving birth and they have some birth anxiety there they’ve been found to be effective in a lot of those studies essential oils for anxiety include lavender rose Bedevere ylang ylang bergamot chamomile frankincense and Clary sage encourage clients to just go to a health food store and you know sniff some of these and see if it makes them feel happy and calm and content the aromatherapy molecules enter the nasal membranes and they will start triggering neurochemical reactions and so you don’t need to apply it you don’t need to ingest it all you need to do is so encourage clients if they’re open to it to think about this because aromatherapy can be integrated into their bedroom for example with an atomizer or a Mr. It can be incorporated in a lot of different places again where they’re not applying it or ingesting it in any way all they’re doing is smelling it they’ve used it in defusing aromatherapy in hospital emergency rooms and they found that it reduces stress and irritability the people in emergency rooms and I’ve been to enough emergency rooms over the years to know that people who are in ers typically are not in the best mood so if it can help those people then it’s probably going to have some sort of an effect so psychologically helping clients realize that their body thinks there’s a threat for some reason that’s why it triggered the threat response system which is what they call anxiety so they need to figure out why is there a threat you know sometimes it’s like the fire alarm going off in my house it just means that the windows are open and there’s a strong breeze there is no fire there is no problem there’s just a malfunction it’s a false alarm a lot of times clients get this threat reaction they get this stress reaction and it’s not a big deal right now so they can start modifying what their brain responds to and again those basic fears that a lot of people worry about failure rejection loss of control the unknown and death and loss distress tolerance is one of those cognitive interventions that have taken center stage in anxiety research and it isn’t about controlling your anxiety you know helping people recognize their anxiety acknowledge it and say okay I’m anxious it is what it is how can I improve the next moment instead of saying I’m anxious I shouldn’t be anxious I hate being anxious and slang with that anxiety let it go just accept it is what it is have the client learn to start saying I am feeling anxious okay so distracted don’t react because I explain to them the whole notion of feelings comes in the crest and goes out in about 20 minutes it’s like a wave so once they acknowledge their feeling if they can distract themselves for twenty or thirty minutes you know they figured out there was no real threat if they can distract themselves for twenty or thirty minutes those emotions can go down and then they can deal with it in their wise mind and encourage them to use distancing techniques instead of saying I am anxious or I am terrified or whatever have them say I am having the thought that this is the worst thing in the world I am having the thought that I cannot handle this because thoughts come and go and that comes from acceptance and commitment therapy functional analysis makes it possible to specify where and when with what frequency with what intensity and under what circumstances the anxious response is triggered so it’s important that we help clients develop the ability to do functional analyses on their own so when they start feeling anxious they can stop and say okay where am I what’s going on how intense is it what are the circumstances and they start trying to figure out what causes this for them so they can identify any common themes from their psychoeducation about cognitive distortions and techniques to prevent those circumstances or mitigate them can be provided so if the client knows that they get anxious before they go into a meeting with their boss and it’s usually a high the intensity of anxiety okay so we can educate them and help them identify what fears that may be related to techniques to slow their breathing and calm their stress reaction and help them figure out times in the past when they’ve handled going in and talking to their boss and it wasn’t the end of the world you know there’s lots of different things we can do there for them there but the first key and it gives them a lot of a huge sense of empowerment to start becoming detectives in their own life and going okay now under what situations does this happen positive writing this was another cool study each day for 30 days the experimental group and this was high school-aged youth in China but you know the experimental group engaged in 20 minutes of writing about positive emotions they felt that day so they’re writing about anything positive that make them happy that made them enthusiastic gave them hope whatever long-term expressive writing positive emotions so after 30 days it appeared to help reduce test anxiety by helping them develop insight and use positive emotion words so it got them out of the habit of using the destruction and doom words and encouraged them to get in the habit of looking at the positive things and being more optimistic it’s a cool activity that clients can try it’s not gonna hurt anything if you have them journal each day for 30 days mindfulness also came up in the research and was shown to be effective in a meta-analysis of six articles about mindfulness based stress reduction four about mindfulness-based cognitive therapy and three about fear of negative appraisal and emotion regulation were reviewed all of these showed that mindfulness was an effective strategy for the treatment of mood and anxiety disorders and is an effective in therapy protocols with different structures including virtual modalities so you know if you’re doing it via teleconference mindfulness can still be helpful mindfulness helps people start learning how to observe what’s going on and become aware of what’s going on more aware of those circumstances which will help them complete their functional analysis but it also helps them become aware of vulnerabilities and head off things in the past and if they’re taking better care of themselves that they’re living more mindfully then they may not experience as many situations that trigger their anxiety mindfulness also encourages clients to learn acceptance that radical acceptance of it is what it is I’m not gonna fight it I’m angry right now I am anxious right now however I’m feeling right now is how I feel and that’s okay it’s hard for clients to get to that but once they get a hold of that and they truly believe it and they can say all right it’s fine I’m not gonna feel this way forever I’m gonna do something else until the feeling passes it helps and that’s where the labeling and letting go comes in mindfulness can also help them identify trigger thoughts what thought were you having right before you started feeling anxious if people are mindful or let’s start back when people are not mindful they often notice or don’t notice that they’re getting anxious until they’re like super anxious when people are mindful they become more aware of subtle cues address unhelpful thoughts when they say or believe it’s a dire necessity for adults to be loved by significant others for almost everything they do always running gonna happen why is it a necessity what we can encourage them to do is concentrate on their self-respect on winning approval for practical purposes you know for promotions or whatever but it’s not about me being lovable it’s about me getting a promotion and making more money and focusing on loving rather than being loved because when we give love we generally get love back with unhelpful thought number two people feel they aren’t able to stand it if things are not the way they want them to be or are not in their control so encourage clients to focus on the parts that are in their control and other things in life which are going well and to which they’re committed number three misery is invariably externally caused and is forced on us by outside people and events just by reading that makes me feel disempowered so encouraging clients to focus on the fact that reactions such as misery or happiness are largely caused by the view that people take of the conditions so if you see it as a tragedy and devastating then it’s probably going to produce misery if you see it as an opportunity and a challenge it’s probably going to produce a different emotional reaction if something is or may be dangerous or fearsome people should be upset and endlessly upset about obsessing about it a lot of people with anxiety get stuck on this you know if I feel like it’s fearsome I need to worry about it getting on a plane for example if I fear that that’s dangerous that I need to think about it and worry about it that’s not going to do any good so encourage clients to figure out how to face it and render it harmless if possible and when that’s not possible accept the inevitable so looking at airplanes you know facing it means researching to figure out how dangerous is it really and realizing that it’s not that dangerous so that helps render it a little bit harmless in their mind it proves to them that it’s not as dangerous as it could be and when it’s not possible accepting the inevitable you know you got a fly so getting on there figuring out how you’re gonna get through it hurricanes are the same way people especially in places like Texas Louisiana Florida may obsess as soon as it starts coming to hurricane season or if a hurricane is spotted out in the Atlantic somewhere they start checking the weather every hour or more wondering what the path is going to be and you know what there’s you can’t change the path of the hurricane so all you can do is board up your house evacuate if necessary and deal with the fallout child driving is just another example I’ll give you know my children are learning how to drive and that’s kind of scary and fearsome you know what’s gonna happen when they’re out there you know you see crashes all the time well render it harmless by making sure they’ve got good training on how to drive make sure they’re good drivers and then accepting that some things are just not within my control it’s easier to avoid than face life difficulties and responsibilities Well running from fear is usually much harder in the long run so encourage clients to look back at times when they’ve avoided difficulties and responsibilities and the eventual outcome you know what happened there people believe they should be thoroughly competent in achieving in all possible respects or they will be isolated rejected and failures we need to encourage clients to accept themselves as imperfect with human limitations and flaws and focus on what makes them loveable human being what qualities like courage and intelligence and creativity and those things that can’t be taken away what inherent qualities do they have that make them awesome people because something once strongly affected people’s lives they should indefinitely fear it if you got lost you know when little kids get lost it’s terrifying when you’re grown up if you get lost you turn on the GPS and you figure out your way but some people still, you know freaked out about getting lost if they got lost once so we want to help people look back at past episodes that may be contributing to the current anxiety and compare the situation’s you know are you the same person or is this not a big deal now that you’re older wiser stronger encourage them to learn from past experiences but not be overly attached to or prejudiced by them yeah you could have maybe got lost in the past and it was a horrible experience well you were six I can see where that would be terrifying and a horrible experience but it doesn’t have to continue to impact you that way now when you’re you know 26 getting lost you know could be an opportunity to try a new restaurant or something people must have complete control over things well this doesn’t happen so encourage clients to remember that the past and the future are uncontrollable we can’t change the past it is what it is we can learn from it so it doesn’t repeat but we can’t change it and the future is largely uncontrollable I mean there are a lot of things I can do to stay moving toward a rich and meaningful life but life is going to throw me curveballs sometimes and there’s nothing I can do to plan for or control that we can control our actions in the present to stay on our preferred path and general develop general skills to deal with adversity should it arise so we want to help clients develop those general problem-solving skills and the general support system so when they are thrown a curveball you know it doesn’t knock them upside the head people have virtually no control over their emotions and cannot help feeling disturbed by things well encourage them to think about the fact that they have real control over destructive emotions if they choose to work at improving the next moment and changing inaccurate thoughts then they’re not going to experience the destructive emotions as intensely or as frequently when you feel an emotion you feel how you feel but again you don’t have to wrestle with it fight it and nurture it you can say this is how I feel how do I improve the next moment when it comes to cognitive distortions encourage them to find alternatives when they start to personalize things if somebody laughs when you walk out of the room then the and the person starts getting anxious thinking oh they were making fun of me I wonder what they thought I wonder if I had something stuck to the back of my dress and they start getting all panicked about it that doesn’t do any good encouraging them to think you know what our three alternate explanations that hadn’t but had nothing to do with you for why they laughed magnification of the worst thing you know taking something and saying if this happens then it’s going to be a catastrophe and minimization going along with that a lot of times when people magnify and see a catastrophe they minimize not only their strengths and resources but all the other stuff that they’ve got going for them all they’re seeing is this catastrophe so encouraging them to focus on the facts of what is actually happening and what is the high probability event and encourage them to get information and look at the broader picture you know yes you got into a car crash and your car is totaled and that is unfortunate you know it sucks but you know that is not going to cause you to lose your job and then become homeless and penniless and yadda-yadda it might cause your insurance to go up but okay so you don’t have a car but what are the resources that you have who can Who do you work with that might be able to give you a ride to work you know let’s look at the resources you have and work around so problem-solving helps with magnification and also focusing on you know let’s be grateful for what didn’t happen you know you could have been killed but you weren’t the car was totaled it’s replaceable all or nothing thinking again have them think about what else could have been happening like Brittney suggested finding the exceptions instead of saying she always does this look for exceptions when has she not done that what else has she done instead of this selective abstraction and filtering is when people look for the good the bad and the ugly a selective abstraction means you kind of see what you expect to see so if you expect something to be devastating you see only the devastating aspects of it which kind of goes with the magnification and minimization you filter out the stuff a lot of times when people are in a bad mood or are anxious they see the negative because that’s the state of mind they’re in so encouraging people to complete the picture alright there’s all this bad stuff now what’s the good stuff you know to encourage them to look at the good the bad and the ugly so they get a wide view of exactly what’s going on and encourage them to remember that hindsight is twenty-twenty when people have something embarrassing happens or they get anxious about something that happened they look back and they go I should have or I could have or Oh I wish I wouldn’t have when you were in that situation you did what you did and you know maybe you may have had a reason for it or you know you may have not had other options or it may have just been a bonehead thing to do but okay so you made one mistake hindsight is 2020 that’s gonna that mistake is gonna stand out just like the great big letter on the eye chart because you’re thinking back and you’re looking at it and that’s all you see but encouraging clients to remember that other people are too busy worrying about themselves to remember what they did jumping to conclusions encourages clients to remember to get all the data if your significant other male significant other comes home and is smelling like perfume don’t just jump to the conclusion that he was cheating on you maybe he went to the mall to get a new tie and walked through the perfume area and got spritzed or bought you some perfume or who knows maybe the person sitting next to him at work sprayed her perfume on the desk and some of it filtered on there are all different reasons that that might happen so encourage people to get all the data mind reading we can’t do it you know you can’t read somebody’s mind you don’t know what they’re thinking so ask them what you think about this don’t assume anything and emotional reasoning encourages people to step back from a situation and ask themselves am I feeling anxious about this because I’m feeling anxious and I’m looking for reasons that it should be scary or am I feeling anxious about this because it’s really scary for some reason there are facts support my anxiety a lot of times when we go into new situations we may feel anxious because it’s a new situation but when we step back we say you know what there’s nothing to be worried about here you know no big deal I got this and move on so instead of rolling with it and trying to figure out okay I feel anxious so there must be a reason not necessarily very likely a false alarm other psychological interventions relaxation skills encourage people to learn how to relax not only physically but mentally diaphragmatic breathing helps encourage them to breathe through their stomach and put their hand on their belly and feel their belly expand and contract slows breathing down which triggers the rest and digestion reaction in the brain which is calming meditation can be helpful for some people some people find trying to quiet their minds too frustrating because they’ve got too much monkey mind going on that can be later or maybe never for some people we don’t want to increase their anxiety with interventions cute progressive muscular relaxation also has a lot of research support and remembers with cute progressive muscular relaxation we’re Sakura getting them to attach a cue AK you word like relax or breathe with the relaxation response so they tense their muscles and then relax their muscles and as they relax their muscles they say their “querk”-word like relaxed and they work from head to toe or from toe to head tensing and relaxing different muscle groups so they become more aware of what a tense muscle feels like versus a reactive relaxed muscle there are great scripts that are online that people have already recorded that can walk people walk clients through CPM are I highly encourage it because once they get used to it then they can just think that cue they can think relax and as they exhale they will start to feel their entire body kind of relaxing because it’s trained when it hears that just like when you hear the word pop quiz when you were in high school you had a stress reaction well we want to use it in reverse and train the body so that when it hears a cue word relaxes helps them develop self-esteem because fear of failure and rejection a lot of times come from needing other people’s approval to help them develop a rational idea of their real self develops compassion self-talk instead of saying I’m an idiot or I’m stupid or I’ll never measure up to anything encourage them to talk to themself like they would talk to their child or hopefully their best friend and encourage them to spotlight strengths whenever they feel like they’ve got an imperfection to identify these three strengths that they have so they’re you know balancing out the imperfections and the strengths of cognitive restructuring reframes challenges in terms of current strengths, not past weaknesses so if you’re going to give a presentation in front of 60 people and you hate public speaking instead of thinking about you know this is terrifying because the last time I went up in front of people I forgot everything I was going to say and drop my note cards well that’s a past weakness what is your current strength you’re prepared you know the material you Jabba-dada so encourages people to look at all the strengths and resources they currently have them develop an attitude of gratitude and optimism because like I said with that the positive writing exercise when people are in a grateful optimistic frame of mind they tend to see more of the good stuff they see the bad stuff too but they can also see more of the good stuff and some of the bad stuff they see opportunistically instead of as a devastation acceptance and commitment therapy says that some of the reasons that we’re miserable are fear we get fused with our thoughts we think I am terrified well if I am terrified then I can’t I mean if I am I can’t get rid of anything I am if I’m having the thought that I’m terrified well I can get rid of a thought I can forget things easily encourage people to evaluate their experience and empower them to look at things as challenges and opportunities instead of hardships encourage them not to avoid their experiences so things that are scary gradual exposure and finding exceptions like for me bridges you know I love public speaking so that’s not a thing but when I go to a bridge you know when I Drive to the bridge you know when I’m on the bridge somebody else is driving I get used to doing that when I Drive over a bridge than when I Drive over one of those bridges that opens up I hate those bridges um I know y’all are just like oh my gosh yeah it’s an irrational fear I realize that but instead of going straight for the bridge that opens up going for the little bridges first and then thinking back over times that I’ve gone over bridges and there’s been no problem you know there are exceptions nothing happened it wasn’t a big deal Sometimes I didn’t even notice it until somebody pointed out hey look down there at that pretty water and I’m like oh we’re on a bridge so encourage people to not avoid their experiences get used to them embrace them and learn that they have the power to deal with them and stop reason giving for behavior you know use the challenging questions if something is fearsome let’s look for at the evidence for and against it instead of you know making excuses for social interventions improve their relationship with their self which goes with self-esteem improvement people are going to feel less anxious about getting their needs and wants to be met if they know what their needs and wants are so part of that is becoming mindful cuz a lot of our clients don’t know what they need and want they just want to feel better but they don’t know how they don’t know what they need to feel better so helping them identify their needs and wants to encourage them to be their own best friend you know when they get a promotion take themselves out to dinner pat themselves on the back whatever it is don’t rely onother people to do it because other people it’s not that they don’t care but other people are often very involved in thinking about their stuff and they may not notice encourage them to develop a method of internal validation so they can feel like they are all that ‘no bag of chips and they realize why they are lovable human beings and they accept the the fact that everybody is not going to like them and nobody is gonna like them all the time and that’s okay you know my kids don’t like me all the time my husband doesn’t like me all the time I’m okay with that I know I can be challenging but you know most of the time you know they like me and that’s okay and there are some people you know who don’t like me at all and okay there’s nothing I can do about that helping our clients develop an okayness with that helps relieve a lot of anxiety because a lot of people feel like they have to be liked by everybody and if somebody doesn’t like them it’s like what did I do wrong oh my gosh encourage them to develop healthy supportive relationships with good boundaries develop assertiveness skills so they can ask for help when they need it anxiety a lot of times you know that’s the body saying there’s a threat well if there’s a threat maybe you need some help you know dealing with it so people need to be willing and able to ask for help and not feel like that’s going to lead them to be rejected and allow them a certify this will allow them to say no to requests again without feeling like that’s going to result in them being fully rejected describe the ideal healthy supportive relationship and encourage them to separate the ideals from the reals you know let’s look at if you had the best relationship what would it look like okay you know Warden June Cleaver we got that now how realistic is that you know let’s look at you know rephrasing this a little bit so it’s less extreme you know warden June Cleaver never fought their kids were perfect you know all those extreme words let’s look at what’s real what happens in real relationships encourages people to identify who would be a good partner in supportive relationships I’m not meaning necessarily romantic I’m meaning friends and where they can be found you know where would you find people that you could be friends with and encourage them to play through what it means when gaming cuz a lot of times again this goes with my reading you know what it means when your friend doesn’t return your text right away what does it mean when your friend cancels dinner on Friday night what does it mean when you see where I’m going with this and a lot of times clients with anxiety and rejection issues and low self-esteem will go to the worst-case scenario so encourage them to go back to finding the exceptions what else could have been happening what else could it be that caused this and it’s not about you so anxiety is a natural emotion that serves a survival function excessive anxiety can develop from lack of sleep nutritional problems neurochemical imbalances failure to develop adequate coping skills cognitive distortions low self-esteem and a variety of other stuff recovery Ambala involves improving health behaviors making sure your body’s functioning and making the neurotransmitters it needs and you know release them as needed to identify and build on current coping strategies address cognitive distortions and develop a healthy supportive relationship with self and others if you enjoy this podcast please like and subscribe either in your podcast player or on youtube, you can attend and participate in our live webinars with Dr.

Snipes by subscribing at all CEUs comm slash counselor toolbox, this episode has been brought to you in part by all CEUs calmly provide 24/7 multimedia continuing education and pre-certification training to counselors therapists and nurses since 2006 have used coupon code consular toolbox to get a 20% discount on your order this month.As found on YouTube Brain Booster | Blue Heron Health News ⇝ I was losing my memory, focus – and mind! And then… I got it all back again. Case study:

Brian Thompson There’s nothing more terrifying than watching your brain health fail. You can feel it… but you can’t stop it. Over and over I asked myself, where is this going to end? What am I going to end up like? And nobody could tell me. Doesn’t matter now. I’m over it. Completely well. This is how I did it!

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Addressing Negative Thoughts | Cognitive Behavioral Therapy with Dawn Elise Snipes

CEUs are available at AllCEUs.com/CBT-CEU This episode was pre-recorded as part of a live continuing education webinar. On demand CEUs are still available for this presentation through ALLCEUs. ALLCEUs.com/CBT-CEU I’d like to welcome everybody today to cognitive behavioral therapy addressing negative thoughts. Now a lot of us took courses and cognitive behavioral therapy we’ve worked with CBP for many many years so some of the this is just going to be a refresher and others you know you may pick up a few new tips or tools as we go along so we’re going to define cognitive behavioral therapy and its basic principles just get a really basic refresher on what was that original CDP about well identify factors impacting people’s choices behaviors because you know they always have a choice we’ll explore causes and the impact of thinking errors whether you call them cognitive distortions irrational thoughts or when I work with my clients I try to call them unhelpful beliefs or unhelpful thoughts because distortions and irrational seems sort of pejorative to me so I try to avoid those words as much as possible and help clients see them as not incorrect necessarily but unhelpful and then we’ll identify some common thinking errors and their relationship to cognitive distortions and some of our just very basic fears why do we care well because cognitive distortions or irrational thoughts or unhelpful thoughts whatever you want to say really impacts people on a physical level a mental level and an emotional level a person who perceives the world is hostile unsafe and unpredictable will tend to be more hyper vigilant until they exhaust the stress response system so think about you know a bottle ship and you’ve got a bunch of new people on this battleship and all the sailors every time there’s the least little thing they send off the all-hands-on-deck so a big bird flies over and I mean literally a bird and they freak out found me all hands on deck and this goes on for a week or two or six months you know let’s think about our clients they don’t usually come in right away where everything is set to OFF that startle response everything sets off that fight-or-flight response the staff starts to get exhausted all the rest of the sailors that have to drop everything and run to their battle stations after a little while they’re like really no no we just we can’t even do this and it also reminds me of the boy who cried wolf anyhow I digress sticking with the battleship metaphor so eventually the captain says you know what let’s retrain on what is worth setting off the all hands on deck because everybody here is exhausted and nobody’s even really responding anymore when they come to their battle stations they’re just kind of dragging their butts in like whatever it’s probably another false alarm the same sort of thing is true with us when we’re on on high alert for too long our brain says you know what we got to conserve some energy in case some really really big threat comes along so it turns down what I call the stress response system it turns down the sensitivity so you don’t get alerted for every little thing that would cause you stress but you also don’t get alerted for those little things that would cause you happiness either anything that would cause the excitatory neurotransmitters to be secreted you’re just not getting those anymore which a lot of people kind of refer to as depression it’s just kind of like the F whatever and only the biggest most notable things actually cause an emotional effect we don’t want people to get to that point that’s no way to live so we need to help them learn how to sort of retrain their spotters to figure out what is actually stressful a person who perceives the world is generally good and believe they have the ability to deal with challenges as they arise will be able to allow their stress response system to function normally there are going to be times you have all hands on deck whether it’s a real emergency or whether it’s just a drill but it will happen and they can go they can you know do what they’re going to do they have that adrenaline rush they have the energy and the focus to do their jobs and when it’s over they go back to their quarters they can relax refresh you know just kind of chill for a while and then there’s a low where their body rebalances before the next one and this is kind of what we want in life I mean ideally we wouldn’t have super high peaks very often but we want to make sure we give our body time to rebalance after there’s a stressor and not have to stand on on edge not be hyper vigilant constantly just waiting for the next one to come along so what is the impact of these thinking errors well whenever we have that stress response system activated the body is saying we either need to fight or we need to flee so you’re dumping all kinds of adrenaline and other neuro chemicals so there’s anxiety there can be stress when people start having this reaction you know they start having muscle tension sweating heart rate increases breathing increases people will call that anxiety some will label that as anger either way they’re both sides of the same coin they need to do something but if it lasts too long then we start moving into depression and they just they don’t have to get up and go anymore there’s just not any excitatory neurotransmitters really left they need some time to rest and rebalance behaviorally think about it if you go somewhere and you are just constantly on guard are you going to keep going there or are you going to withdraw so people who have a lot of thinking errors unhelpful thoughts tend to withdraw more they may turn to addictions to kind of numb or blunt some of the inputs sleep problems and changes when you are hyper vigilant when you have this stress response going even if it’s not a full-bore if it’s still there somewhat if you’re stressed out you’re not going to sleep as well you’re going to maintain higher levels of cortisol so you’re not going to get that restful rejuvenating sleep you may kind of goes on and off eating changes you know depending on the person some people eat the self food that some people can’t eat it all but we do see that the hormones Guerlain and lets them get all out of whack not under stress but also when sleep gets out of whack when your circadian rhythms get out of whack so we’re starting to see the Cascade effect where it’s emotional and behavioral physical you’ve got stress-related illnesses that start coming up if you’re on that lunch you’ve got muscle tension for that long it starts to hurt I mean you start to get migraines your back starts to hurt wherever you store your stress so to speak it starts to come out and most people when they’re under a lot of stress for an extended period you know a day is not a big deal for most people but for an extended period become more susceptible to illnesses they start getting sick easier headaches GI distress you know some people store their stress right in their gut socially think about the last time you were stressed were you patient and tolerant and just a pleasure to be around you may have tried to be but you’re more prone to irritability and impatience and again wanting to withdraw all of these affects contribute to fatigue and a sense of hopelessness and helplessness which often intensifies thinking errors so you’ll see this negative reciprocal interaction if somebody feels stressed out and overwhelmed and that they withdrawal then they may start feeling like they have no support and they don’t and they lose all their social buffers to the stress so they feel even more stressed so they want to withdrawal even more so we’re going to talk about how to prevent that now I like this little diagram maybe because it’s got a heart in the center I don’t know but behavior feelings and thoughts this is the outside of the circle all three of these impact diecuts each other when you do something it often impacts your feelings and your thoughts about a situation when you when you’re thinking if you think positively you’re probably going to choose more positive behaviors and more have more positive feelings you’re thinking negatively obviously you may choose more of an escape behavior Protection behavior and may have more feelings of anger anxiety depression etc so these things are going on and they’re all interacting the one really cool thing is if you break this chain somewhere or this circuit then you can stop that reciprocal negative downward spiral so cognitive behavioral helps people who are willing to show up or who are willing to address their thoughts not everybody is willing to start addressing their thoughts right away maybe they want to start addressing their sleep problems in their eating problems or something that’s more physical okay that’s fine because anywhere we interrupt this circuit is going to have positive effects assuming the intervention is positive it’s going to have positive effects on the other ones so what about the triangle well yourself so you’re feeling thoughts and behavior impact you it impacts how you feel and you’re like well yeah okay just stay with me but the way you feel think and act impacts your future and it also impacts how you interact with others so you know that kind of affects things because remember social support is a big buffer for us now core beliefs and you can do this inward to outward or outward to inward but either way it comes down to core beliefs if you have positive thoughts and positive feelings and you generally engage in positive behaviors to keep that cycle going you will probably feel pretty good about yourself have good relationships have a somewhat optimistic feeling about the future and your core beliefs may be more like people are generally good I can do this you know very self affirming and other affirming positive core beliefs about yourself in the world now if your thoughts or feelings are negative then you have this negative outer circle you don’t feel so good you start questioning the goodness and Trust ability and dependable of other people you have more of a bleak look in the future so what do you think is going to happen to the core beliefs the core beliefs may change too if someone doesn’t love me I am completely unloveable they may change to being more extreme more negative and more difficult to rectify if you want to have somebody who’s happy I mean you’re not going to have somebody who’s happy who thinks the world is an unkind unpredictable scary place going it’s just wonderful roses today so we have to help people try to adjust eventually start adjusting those core beliefs and when we get into causing that behavior remember the ABCs your automatic but well your automatic thought then your and beliefs are what happened as soon as that event occurs and those you don’t think about that’s why they’re called automatic so when you have the ABCs these core beliefs are those things that pop up that we need to address so what factors affect this and whoops you know there’s a lot of stuff right here and EBP they call them vulnerabilities you know we’re just going to talk about in general different factors that affect the choices our clients make in terms of behaviors so negative emotions if they are not if they’re feeling angry if they’re feeling anxious they’re feeling depressed they’re probably not going to be really motivated to get up and engage in a whole lot of self affirming activities they’re not probably not going to be having a lot of positive self affirming thoughts they’re going to be focused on whatever is causing that distress and maybe escaping from that physically pain and illness when you don’t feel well it’s harder to be Susie sunshine I don’t think many of us are just a barrel of monkeys when we don’t feel well so if our clients have pain this is one of those if you want to put it in behaviors behavioral areas physical areas we can address and have them go see their physician have them go see their physical therapist and get recommendations so they aren’t feeling physically painful physically and distress all the time because physical distress and emotional distress both mess with sleep unfortunately sleep is the first thing to usually go and I’m not talking about quantity I know a lot of clients who when they get depressed they’re in in bed for you know days they’ll get up they’ll maybe shower and you know go back to bed and they’re sleeping a lot but it doesn’t mean it’s quality sleep so what we need to look at is what is the quality of their sleep are they getting that rejuvenation the time for their brain and neural chemicals to rebalance so they can feel happy so they can have that nice balance of all the the neurotransmitters they need to feel happy poor nutrition well no matter how much sleep they get if they don’t have the building blocks to make the neurotransmitters and the hormones that are needed to prompt the feelings the physiological sensations that we’ve labeled happiness or excitement or you know even depression and anxiety those are all caused by different neurotransmitters being secreted in different combinations if your body doesn’t have the building blocks to make those then it doesn’t matter how much sleep you get you’re not going to get any benefit from it an intoxication and this can be uppers downers anything that is psychoactive if you are messing with that neurotransmitter balance you’re going to get it out of whack and you may either use up too much of the excitatory or cause us a lot of it or you may use up too much of the depressant either way there’s usually a rebound effect which we call withdrawal so you’re not going to be in a good space either during the intoxication sometimes but definitely when you’re sobering up there’s a period where there’s going to be negative emotions negative feelings environmentally yeah your environment can even make you grumpy introduction of a new or unique situation some people love new challenges love going to new places other people not so much depending on the person taking on going somewhere new may be really stressful for them so if they’ve already got de-stress going on because of having to go to this new situation then their thoughts may be a little bit more on the anxious side about a lot of things and they may have less patience and tolerance to deal with other stuff that comes their way because they’re already kind of on edge and exposure to unpress you know going places that you just really don’t want to go maybe and one of the places I used to work we had this meeting once a month and it was literally an eight-hour meeting and we would all sit in there for eight hours and one person at a time would get up and give their staff reports or whatever but it tended to be a relatively dreadful sort of environment or eight hours and we all knew we had to be there and that was fine but it was an unprecedented were grumbling on the way in they were getting their coffee and going well I better do this because I’m not getting out for another eight hours we need to help our clients obsess what is it in your environment if anything that is making you already feel grumpy or not as happy and likewise what can you put in your environment to make you feel happier you know I keep pictures of my kids and my animals on my phone that way if I’m having a moment or not sometimes I just like looking at them I can take a look at it it makes me smile and I’m like okay life is good you know this moment may not be so wonderful but it’s just this moment then we move on to stress of a social nature peers or family who convey irrational thoughts as necessary standards for social acceptance nobody wants to associate with those people or nobody’s going to like you when you’re like this or you read if you really want to be successful then you need to change fill in the blank it’s always a something needs to change you are not okay for who you are how you are and a lack of supportive peers to buffer stress because we all have negative people in our life it happens but if you have negative supportive peers that you can call afterwards and go yeah I had just had to meet with someone so for an hour and it was just dreadful and that person can go well I’m sorry or be there make you laugh or whatever they do it helps buffer the stress if you don’t have those positive social supports then you’re left walking out of it you’re kind of feeling shell-shocked and then you also at the same time have to figure out for yourself all right what do I do next now it doesn’t mean you can’t do it you know people do it all the time but it is good it is awesome to have supportive peers to buffer your stress so when cognitive therapy clients learn to distinguish between thoughts and feelings realizing that thoughts will trigger feelings but they don’t have to cause continual feelings and behaviors and feelings can cause certain thoughts but they don’t have to you can unhook from them and you can just say this is how I’m feeling right now now where am I going to go from here and we talked about that on Tuesday with unhooking from unhooking from your thoughts and stepping back and going what is the next logical action to get me to where I want to go become aware of the ways in which the thoughts can influence feelings in ways that are sometimes not helpful being critical being jealous envious maybe you just don’t like somebody and you know there’s a whole lot of reasons for that but you don’t like everybody most people don’t like everyone and so it’s you know that’s okay but recognize how that affects your interactions with that person and your thoughts about that person learn how thoughts that seem to occur automatically affect emotions so recognize start getting down to what are these core beliefs that happen every time it’s a negative incident that make me feel angry or anxious constructively evaluate whether these automatic thoughts and assumptions are accurate or perhaps biased evaluate whether the current reactions are helpful and a good use of energy or unhelpful and a waste of energy that could be used to move toward those people and things important to the person so again back kind of to that ACP sort of thing is this a good use of your energy to help you achieve your goals and be the person you want to be and develop the skills to notice interrupt and correct these biased thoughts independently like I said you don’t always have to call somebody you can do it on your own but sometimes it’s nice to have that buffer in that middle moment so what causes these thinking errors how can we even start helping people address their thoughts and until we start thinking about well what caused them information processing shortcuts as we grow up we learn things you know when you were knee-high to a grasshopper you didn’t have a lot of experience so you learned things but things you learned when you were a kid unfortunately because you were cognitively a child are either our dichotomies they’re all or nothing it’s either this way or no way at all so things that you have things that you learn back when you were a child may not have been challenged if you heard something from your parent maybe your parents said you’re a bad girl or you’re a bad boy it’s all or nothing well I am a bad girl so I guess that means I’m not okay and if I’m not okay right now I’m never okay that can stick with a person so these outdated amis schemas can really trip somebody up once the person gets into you know middle schoolish the thoughts aren’t nearly as dichotomous there’s a lot more formal operational thought if you will but up until then I mean you’ve got a child who’s experiencing a lot of stuff and taking in like a sponge everything they hear and it gets sorted into a yes or a No pile there’s there’s no kind of middle pile that there’s no yes and so what we want to do is help people look at those thoughts now and say okay if they’re all or nothing is there a way to find both and so for example we’ll take that exam scenario I gave you earlier if a child hears you’re a bad girl when they’re young they take that to mean always everything about me is bad I’m unlovable so what is the both and compromise as an adult we can look back and go you know I’m a good person I may not make may make poor choices sometimes I may make bad choices but I’m a good person so there’s that both and you know I’m not perfect but I’m good so that it’s not all or nothing and I encourage my clients to really always look for that middle ground how can it be both or does it have to even be that negative one but most of the time there’s a little bit of something on both sides the brain’s limited information processing capacity and limited responses when children are young you know they hear something you know mom comes in and says you’re a bad girl and child hears I’m totally unlovable and it just crushes the child they don’t have experiences to go moms having a bad day she kind of tends to say things she doesn’t mean when she’s having a bad day it’s just it’s devastating to that child when you’re older if somebody says something that’s not necessarily tactful you know you can look at it and go yeah that really wasn’t nice but that person probably did not intend to be hurtful they may have something else going on children have fewer experiences so what was devastating or overwhelming as a child may not still have have to feel that way when you’re a child if your best friend moved away oh that was devastating it was the end of the world now as an adult you can go visit them you can call them and with the internet and everything you can email them you can still stay in touch so there are ways to do it yeah you can’t go out and swing swing on swings together all the time but it doesn’t have to mean the end of the end of time things will change and there’s a little process of grieving that has to go along with that but to an adult a friend moving away is less devastating than say to a six-year-old your parent being angry with you if you grew up in an alcoholic or addicted household you learn don’t talk don’t trust don’t feel when the parent came in if the parent was angry with you you could have been in a lot of hurt you know there could have been some actual danger to your physical or emotional person so it was scary as a 26 year old or however old your client is is it that threatening you know if your parent gets angry with you you don’t depend on them for food and shelter anymore you don’t have to be an inner household if they were violent towards you so is it as terrifying when your parent gets angry yes there’s lots of issues with wanting acceptance from your parents that’s over here there’s a whole nother issue but when your parent is angry do you have to have that person’s approval when we’re in crisis we don’t process much when you’re in crisis your body is worried about surviving if you’ve been in a car wreck if somebody has gone to the hospital whatever the case is you’re not processing all of the data in order to make it in for decision you’re processing what’s right in front of you because when we’re in crisis we generally have tunnel vision and really crappy memory so if something happened when someone was in crisis that hurt their feelings made them angry you know fill in the blank some sort of dysphoric emotion we want to say well let’s look back at that and see if there’s a pose and let’s look back at that and see if there was something that you missed that might help you understand why this person reacted that way but understanding that in crisis we just generally don’t make the most informed decisions so emotional reasoning helping clients understand that feeling or not facts and helping them learn to identify feelings and separate them from facts so if they say I’m terrified all right so you’re terrified got that about what are you terrified you know tell me what are these things that make you feel like the world is such a scary place and let’s list them on the whiteboard or a flip chart what is the evidence that those are present dangers right now that they’re actually impending threats so tell me about what the evidence is in what ways is this similar to other situations where you felt terrified and how did you deal with those situations I have a friend who actually went this morning on an airplane flight and she hates flying totally terrified of it so what is the evidence that this plane is going to crash you know what is the evidence that it is likely that this plane will crash and there really she’s flying on an american-based commercial airliner there really isn’t any when you look at the proportions so okay there’s there have been a couple of crashes over the past 20 years and in a couple of those there were some fatalities no doubt but looking at the proportions and running the numbers what’s the likelihood in what ways this is similar to other situations that you have felt terrified you know maybe there haven’t been any other situations where she’s flown and gotten through it and been like score I did that but what other situations have you had to get through that you were terrified and how did you deal with those help people develop distress tolerance skills one of the things I told her was when you’re sitting on the airplane and you know the airplane starts up don’t wait til you start getting really stressed necessarily but when we were little on the car when we’re in the car we used to find things on the drive find something that starts with a and everybody would find something that started with a and then find something that starts with B and you know so on and if you couldn’t find something that started with that letter you were out so I mean she’s going on this trip with her kids and I’m like why don’t you try doing that because there are some letters that you’re going to have to work really hard and it’s kind of like the game apples to apples you end up finding something really inane in order to get that letter and you laugh and you’re so busy focusing on that you’re not focusing on all of the things that could possibly maybe go wrong other distress tolerance skills you know you can go through the whole DBT curriculum and learn some of those the biggest thing is if you have to face the terror if you have to go through it figure out a way to not have to focus on it and fight it and go I shouldn’t be afraid I shouldn’t be because that doesn’t work if it worked we wouldn’t be talking about it and develop emotional regulation skills so prevent those vulnerabilities set yourself up so you are as prepared as you can to not feel stressed to not feel anxious she has her spouse with her who can help diffuse some of it she’s got her kids with her she downloaded some movies she’s prepared to endure the distress she’s you know trying to go into it with a positive mindset as much as possible and focusing on the destination which you know is ultimately the reason she’s getting on the plane social causes of stress and thinking errors everybody’s doing it well that’s not true there’s very real that everybody does so correcting misinformation how the client gather objective information about you know if they say well everybody else that I know has succeeded okay well let’s gather objective information about that who do you know and tell me if they’ve succeeded if I want to be liked I must do it this need for approval or low self-esteem can cause a lot of problems in thinking errors and fears of rejection so we say okay let’s look at developing some self-esteem so you don’t need to worry about if somebody likes you what would it be like if you woke up in the morning and you didn’t care if so-and-so liked you I mean we all want to have friends don’t get me wrong I’m not saying you want to be her moving out in the woods but if we’re talking about a particular so-and-so what would it be like in the morning to get up and go you know what if that person messages me today or call us me today that’s great and if not I’m okay with that how liberating would that be to get your power back and how people develop social supports that share their same values and goals at least mostly or at least can respect yours so for example when you know I work with people with co-occurring disorders and they don’t drink and they don’t use drugs so they may be around people family friends who drink if you’re going to be in that situation do you have to drink and can you be around do you have social supports that can be supportive of your choice to not drink doesn’t necessarily mean they’re it’s not going to not going to not drink in front of you but at least they’re not trying to get you to drink so the social causes of irrational thoughts if I want to be liked I must do this why can’t you be like for who you are cognitive bias negativity mental filter focus on the negatives and worry about the future most of us know some people like that most of us have had a moment where we felt like this we’ve just gotten ourselves in a tizzy and spun out of control but you can bring it back so you want to ask yourself or have your clients ask themselves what’s the benefit to focusing on the negative if you know that this is going to go south really fast what’s the benefit to just focusing on that could you focus on alternatives or Plan B’s what are the positives to the situation most people who have mood issues who present to us in counseling don’t focus on both sides yes every side you know has a little bit of negative to it if you really want to look hard enough but every side also has a silver lining if you really want to look hard enough so we need to balance the the positives and the negatives so encourage people to look for the positives in the situation yeah this really sucked but and what are all the facts what are all the things going into it sometimes people will go to work and not know or wonder if they’re going to get laid off because you know you’re not necessarily always guaranteed a job anywhere there can be layoffs but if somebody is going to work every day worried about this focusing on the negative up yep I’m definitely going to be the one that’s going to get the pink slip and they go to their mailbox each time looking for that pink slip expecting it to be there how is that going to affect their mood as opposed to alright there may be layoffs coming what can I do to make myself really valuable or and what are my options if I do get laid off let’s make a plan B and C so I don’t just feel like the rug was pulled out from under me coin toss activity if somebody tends to be stuck in negativity have them flip a coin every morning if it lands on heads they can just see their normal selves to their heart’s content if it lands on tails they need to act as if they are a happy positive optimistic maybe even a noxious ly optimistic person for the entire day you know we want them to be farting rainbows and when I say that they usually look at me and laugh and but that’s okay I’m like every time you start having a negative thought I want you to see a unicorn farting rainbows and take it from there and then have them process how they felt at the end of the day if they weren’t constantly focused on negativity and worrying and only seeing the bad stuff disqualifying or minimizing the positive if something happens when somebody says well I just got that promotion because they didn’t have anybody else to give it to okay if your best friend just got a promotion would you say that to them what is scary about accepting the positive about accepting the fact that maybe you got the promotion because you’re awesome sometimes we disqualify the positive because it fails to meet someone else’s standards so might that be true here you know maybe you got this promotion and you’re actually down deep down inside kind of proud of it but you know that your mother had always wanted you to be this over here and you’re never going to meet that expectation so you minimize it that way nobody else could say well you know better than nothing and take away your thunder egocentrism my perspective is the only perspective take different perspectives I always say three if something happens and you know maybe somebody was rude to you anyone they were rude to me okay they were rude to you what are three reasons what are some alternate perspectives why that person might have been rude maybe what you did something that triggers them maybe they were having a bad day and it’s got nothing at all to do with you you know there are options that we can look at personalization and mind-reading what are some alternate explanations for the event that didn’t involve you if you think well that person that person just really doesn’t like me and you know I’ve got to work with them every day and they hate me my question to my client would be what what’s the evidence for that and what are some alternative explanations for why that person may be behaving that way I had a staff member that a lot of my other staff members had difficulty getting along with and ultimately you know we had to sit down and look when I had some different staff meetings with people and say you know what gives you the idea that she doesn’t like you what gives you the idea that it’s about you and you know they cited all kinds of behaviors and I had to come back to well what are some alternate reasons why somebody anybody not just her might be expressing those behaviors could it be something besides you and of course they came back – yeah availability heuristic remembering what’s prominent in your mind if somebody was if you’re a supervisor for example and you’re doing evaluation for the year what are you really remembering when you’re doing that evaluation the whole year or the last three months and that’s the event fail ability heuristic so when you’re talking to somebody about their relationship with their best friend or their spouse or their kids and if somebody says well that that child has always been a problem okay let’s look at that you know the child is 18 and you’ve had a lot of problems with him lately but what about three years ago so was he always a problem or is this something that’s relatively new that something might have changed magnification people getting stuck on fearing the absolute worst so you want to ask them is this a high probability or low probability outcome if they’re magnifying something that happened like oh my gosh that is the worst thing in the world is this going to matter six months from now maybe you totaled your car and yeah that is a huge bummer and you’re safe in six months is this really going to matter that much you know there are going to be some bills and everything but the big scheme of things is at the end of the world what have you done in the past to tolerate events like these when something really really unpleasant has happened and then if they’re looking at dichotomous ways of thinking which a lot of our clients still do they’re like someone so it always does this or never does this have them look at the differences between love versus hate perfection versus failure and all good intentions versus all bad intentions because a lot of our dichotomies fall in one of these three categories this person always does this or Never or does it intentionally or you know just doesn’t care belief in a just world the fallacy of fairness encourage people to look for for good people they know that have had bad things happen attributional bearers are labeling yourself not a behavior such as saying I am stupid instead of I don’t have good math skills I am is difficult to get rid of I can’t get rid of stupidity if it’s part of me but if it’s a thought or a skill I can either get rid of it or improve it stable I am means I am right now and I probably always will be stupid verses I can change this thought or skill I can learn math and internal attributions mean it’s about me as a person versus about a skill or skill deficit or something completely unrelated so when somebody makes a global internal negative statement we want to help them challenge that global internal positive statements I’m all about but the negative ones I want to say let’s take a look at that is that true that this is about you all of the time and it means that there’s something wrong with you so we want to ask them how are these thoughts how are these ways of thinking impacting your emotions health relationships and perceptions of the world we want to increase motivation to start looking at these spanking errors because it’s a lot of work to start changing the way you automatically think because you’ve got to stop you’ve got to become mindful and then you’ve got to decide well what are the alternative thoughts because this is what I thought for so long how may have this thought has been helpful in the past most of the time thoughts we have came from somewhere and whether it was a thought we had when we were a child something we learned when we were a child that is dichotomous and not quite applicable anymore it may have been helpful in the past to help you navigate situations doesn’t mean it was wrong it means it’s not helpful in the present asking them to always ask themselves is this thought or feeling bringing you the client closer to those people and things that are important to you it’s hanging on to this negativity bringing you closer and and I like the energy philosophy if you will when you are unhappy you are letting this person have your power you are letting this person make you angry when you decide you are not going to give them your power then you may start feeling happier and I don’t always use that with clients but sometimes the power metaphor help when we talk about thinking Ayers asked them are there examples of this not being true and and or how can a statement be made less global stable and internal is it about you or is it about what you do at work is it about you or is it about your relationship with this particular person so the last couple of slides focusing on some of the irrational thoughts or unhelpful beliefs our basic fears are rejection and isolation failure loss of control the unknown and death generally the things that cause people to have this fight-or-flight reaction fall into one of those categories so some of the unhelpful beliefs that we hear a lot coming up when we do the ABCs is that mistakes are never acceptable so if I make one I am incompetent so we’ve got dichotomous thinking and we’ve got a lot of internal global labeling here rejection and isolation when somebody disagrees with me it’s a personal attack against me well sometimes it is what does that mean it’s about you we’re helping them address the rejection and isolation fears we want to ask them you know if they disagree with you were they attacking you and saying you were stupid or were they attack attacking you want to use that word or were they attacking the thought and saying they disagreed with the thought there’s a little bit of a difference it’s somewhat semantics but it’s a difference because they may have a lot of respect for you but they may disagree with what you just said if someone criticizes or rejects me there must be something wrong with me again that’s one of those internal global negative statements to feel good about myself others must approve of me we want to make sure our clients can self validate and they don’t rely on external validation because they’re setting themselves up for a world of hurt if they are not their own best friend to be content in life I must be liked by all people and thanks for a second are you liked by everybody I know I’m not liked by everybody so does that mean that I should not be content in life and what does it say to give people that power to say if you don’t like me that I can’t be content because I’ve got to be liked by everybody sometimes with clients I’ll help them look at what may be going on with the other person why that person might like them because a lot of times other people’s reactions towards you are more about their stuff than about you and helping them see how that might be true my true value as an individual depends on what others think of me so these other unhelpful beliefs pertain to those thoughts of failure and loss of control none of us likes to fail don’t get me wrong it’s not pleasant but it happens and there is a saying out there that says if you haven’t failed you haven’t tried which means we need to get beyond our safety envelope we need to push ourselves behind beyond our boundaries and when we do sometimes we’re going to stumble and fall and we pick ourselves up and we learn from it but to expect to never fail at anything is not realistic so nothing ever turns out the way you want it to how many times have you heard that from your clients I won’t try anything new unless I know I’ll be good at it I’m in total control and anything bad that happens is my fault so let’s look at this locus let’s control thing here you’re in total control so you can make it rain you know it was unpleasant today because I had to come to work and it was raining outside so that was bad it happened was it your fault pointing out and depending on your relationship for your client you’re probably going to be more or less snarky when you present some of these but a lot of times I have a semi joking relationship if you will with my clients and they’re like yeah I see your point that kind of didn’t make a lot of since other times you know if they’re more serious I’ll ask them to identify things that happened that were bad that they had nothing to do with if I feel happy about life something will go wrong or I’m always waiting for the other shoe to drop helping people stay focused in the moment with mindfulness and something’s going to go wrong down the road somewhere sometimes yeah it’s true this will happen let’s enjoy what we’ve got for right now the past always repeats itself it was if it was true then it’s true now so what was true when you were ten is true now that you’re forty always is that true it’s not my fault my life didn’t go the way I wanted everybody conspired against me and there’s no gray area so for people who feel the need to hold on to control its dichotomous it is or it isn’t it’s got to be that way there’s no gray area and it can make life be seem very uncomfortable because they’ve got to put things in one of two buckets and sometimes things don’t fit nicely in buckets what happens if we add a third bucket that both an bucket so a quick note about irrationality the origins of most beliefs were rational and helpful given the information the person had at the time and their ability to process that information because of their cognitive development so things that we identify as unhelpful or automatic beliefs now came from somewhere and they made perfect sense whenever they were formed they may not be healthy or helpful now which is why we want to look at them and either adjust them or just throw them out the door but when they were formed they were on point irrationality or unhelpful nasaw thoughts comes when those beliefs are perpetuated without examination so again we need to look at them continually look at what you’re telling yourself and go is this still accurate and continue to be held despite causing harm to the person sometimes you’re going to look at a thought an automatic thought and you’re going to go yeah that is still spot-on now is holding on to this helping me achieve my goals you know yet the world right now is kind of a scary place is holding on to this fear and terror helping me and be a happy productive yada-yada whatever kind of person you want to be or is it causing me to feel anxious and angry and scared sometimes it’s more productive for clients to think of thoughts as unhelpful instead of irrational because like I said I feel like irrationality and distortions seem very pejorative to a lot of clients so questions clients can ask themselves when they are faced with a situation what are the facts for and against this belief is this belief based on facts or feelings just because you feel scared is it a scary situation does the belief focus on just one aspect or the whole situation does the belief seem to use any of those thinking errors we talked about and if so you know what do I need to do about it what are some alternate explanations for this belief what else could have caused this to happen besides whatever I’m afraid of what would you tell your child or your best friend if they had this belief what would you took what would you want someone to tell you about this belief you could have somebody tell you something that would make you feel okay what would you want them to tell you and how is this belief moving you toward what and who is important to you remembering that beliefs are a combination of thought and fact and personal interpretation of those thoughts and facts I tend to when I talk you know you see me I kind of I’m all over the place with my arms I am a animated talker now if you are seeing me from a hundred feet away and you are seeing me talk might think I was angry because I make a lot of really big gestures because if you had grown up in a situation where there was domestic violence or something but if you had grown up in a household like I did where you had a first generation Italian first generations of ten Italian Americans talk big they talk real big with lots of gestures and sometimes loud and that doesn’t necessarily mean any anger a lot of times it’s just pure excitement so understanding that there’s thoughts in facts you know you see this going on but your personal interpretation can really affect what you get out of it or what you perceive that situation to be so we need to look at how is your personal interpretation maybe adding a negative bias and what what do we do about that it may be 100 percent accurate what do we do about it so it doesn’t keep you miserable thoughts impact behaviors and emotional and physical reactions emotional physical reactions impact thoughts and your interpretation of events irrational or unhelpful thinking patterns are often caused by cognitive distortions my two favorite words in that same sentence cognitive distortions are schemas or shortcut ideas or memories if you will which were formed based on faulty inaccurate or immature knowledge or understanding of the event you know little kids may not have quite understood what was going on they just understood that mommy and daddy were screaming identifying the thoughts the hecklers I call them those negative voices inside your head that are maintaining unhappiness helps people choose whether to accept the thoughts and say yeah you know that’s right I really am not good at that or whatever the negative thought is and change it or let the thought go are there any questions you you thank you miss Benson well thank you all if you come up with any questions you know you’re mulling it over later and you think you know that yet I’ve worked with a client and with something similar and I did this or you know you have a question about something I said feel free to email me the easiest one to remember is support at all CEUs com there’s only two others in the office so either my husband gets it err I do so it’ll get to me and I guess that’s it so I will see you all on Tuesday if you have any types of courses that you want to see added to the list please let me know I’m always interested in doing what you want to learn about not necessarily just where I pull out on my rabbit hat yes you can print the slides in the golly golly golly when you go into the class there’s a link that has a PDF of the slides that you can print if you want to print go ahead and print those out the video version of this will be up on YouTube by tomorrow morning maybe later this afternoon you okay everybody have an absolutely amazing rest of your day and weekend if you enjoy this podcast please like and subscribe either in your podcast player or on YouTube you can attend and participate in our live webinars with dr.

Schneider by subscribing at all CEUs calm / counselor toolbox this episode has been brought to you in part by all CEUs calm providing 24/7 multimedia continuing education and pre certification training to counselors therapists and nurses since 2006 use coupon code consular toolbox to get a 20% discount off your order this month.As found on YouTube SeanCooper🗯 The Shyness & Social Guy ⇝ The 3 WORST Mistakes You Must AVOID If You Want To Overcome Shyness (PLUS: 1 weird trick that targets the root biological cause of shyness so you can stop being nervous, awkward, and quiet around people…) By Sean Cooper, The Shyness & Social Anxiety Guy. The fact that you’re reading this article tells me you may have already reached a point where you feel your shyness is NOT going away on its own…

or you fear it’s getting worse and worse. And I don’t want you to waste one more day living a life where you feel left out, bored, or depressed because you don’t have the relationships which would make you happy. That’s why I’ve put together this page to help you avoid the worst mistakes that keep many people stuck with shyness for years… often giving up hope of ever improving as you watch other people have interesting “normal” lives without you. Yet this doesn’t have to happen.

Best Practices for Anxiety Treatment | Cognitive Behavioral Therapy

this episode was pre-recorded as part of a live continuing education webinar on-demand CEUs are still available for this presentation AllCEUs.com/Anxiety-CEU I’d like to welcome everybody to today’s presentation on best practices for the treatment of anxiety I am your host, Dr. Dawn Elise Snipes now not too long ago we did a presentation on strengths-based biopsychosocial approaches to addressing anxiety while those are wonderful you know I thought maybe we ought to look at you know what’re some of the current research so I went into PubMed which is I don’t know it’s a playground for me it’s where you find a lot of journal articles and you can sort I sorted by articles that were done and meta-analyses that were done within the past five years so that gives us an idea about current research I mean there’s a lot of stuff that is still the same like some of the medications that were known to work ten years ago are still known to be you know good first-line treatments but there are also some newcomers that we’ll talk about and there are also, some changes that we’re going to talk about so we’re going to explore some common causes for anxiety symptoms to treat, we need to and of course, this does play into the biopsychosocial aspect we need to understand kind of what causes it because anxiety that’s caused by for example somebody having a racing heart may be different than anxiety that’s caused for somebody who has abandonment issues so we’re gonna treat the two things differently so we want to look at some of the common causes we’re gonna look at some common triggers for anxiety Do you know what are some of these common themes that we see in practice I will ask you to share some of the themes that you see that underline or underlie a lot of your client’s anxiety and identify current best practices for anxiety management including counseling interventions medications physical interventions and supportive treatments so we care because anxiety can be debilitating and a lot of our clients have anxiety a lot of our clients have anxiety comorbid with depression and they’re looking at us going how can I feel anxious and stressed out and like I can’t sit still and be depressed at the same time you know when you’re depressed you’re supposed to want to sleep well a lot of times people who have both issues want to sleep but they can’t so I want to help clients understand that also sometimes anxiety when people are anxious for long enough the body starts kind of holding on to the cortisol the body recognizes at a certain point this is a losing battle I’m not going to put energy into this anymore so it starts withdrawing some of its excitatory neurotransmitters so to speak and people will start to feel depressed the brain has already said this is hopeless this is you’re helpless to change the situation so then people start feeling hopeless and helpless which is sort of the definition if you will of depression low-grade chronic stress and anxiety arose energy and people’s ability to concentrate so if we’re going to help them become their uber selves we need to help them figure out how to address anxiety not just generalized overwhelming debilitating anxiety but also panic social anxiety and those minor anxiety triggers that come along that may not meet the threshold for diagnosis anxiety is a major trigger for addiction relapse if you have a client who is self-medicated before or had an addiction for some reason anxiety is a major trigger increased physical pain when anxiety goes up people tend to tense their muscles when they tense their muscles they tend to feel more pain I mean think about when you’re stressed you tend to have more pain like in your neck your back and things that already hurt may hurt more why because serotonin which is one of our major anti-anxiety neurotransmitters is also one of our major pain modulators so when serotonin levels are too low because anxiety is high then our pain perception is going to be more acute and people can have sleep problems if they’re stressed out your body thinks there’s a threat you’re not going to be able to get into that deep restful sleep you may have you may sleep a lot but it’s probably not quality sleep which means your neurotransmitters may get out of whack your hormones make it out of whack and your body is going to start perceiving yourself in a persistent state of stress when you’re exhausted the body knows that we may be the weakest link in the herd so it continues to secrete cortisol to keep you on alert a little bit so you may again you may be resting kind of like when you have a new baby at home those first couple of months that my children were home from the the hospital I slept but I didn’t sleep well I mean the slightest little noise and I was awake and I was looking around and you know I felt it I felt exhausted and a lot of new parents do so triggers for anxiety abandonment and rejection and we’re going to talk about ways we might want to deal with these things but some of the underlying themes that I’ve seen in a lot of clients and when I do the research and a lot of what themes that come out include low self-esteem if someone has low self-esteem they’re looking to be externally validated oftentimes they’re looking for somebody else to tell them you’re lovable you’re okay so that can lead to anxiety about not having people to tell them you’re okay which makes their relationships tenuous and can make them dysfunctional irrational thoughts and cognitive distortions may lead people to believe that if I’m not perfect for example I am not lovable so we’re going to look at some irrational thoughts and cognitive distortions unhealthy social supports and relationships when you’re in a relationship it takes two to tango and even if your client is relatively mentally and physically healthy if they are in a dysfunctional relationship they can fear abandonment and rejection if that other person is always saying if you don’t do X I’m going to leave you or if that other person is always cheating on them or whatever so relationships can trigger abandonment anxiety and ineffective interpersonal skills can lead to relationship turmoil and social exile if our clients are in relationships even if they’re not completely dysfunctional if our clients are not able to ask for what they need and set appropriate boundaries and manage conflict effectively because conflict happens in every relationship then they may start to argue more which may lead to fearing may lead to relationships ending in the past and them going well every relationship I get into ends which means I must not be lovable so they start fearing abandonment and rejection these are four areas that we can look at one more assessing clients another issue is the unknown and loss of control a lot of times negative self-talk and cognitive distortions can contribute to that if I don’t have control of everything then it’s all going to be a disaster negative others when clients hang out or when people hang out with negative people it kind of wears on you after a while you notice that people who tend to be more negative pessimistic conspiracy-minded tend to hang out with people who are also negatively pessimistic and conspiracy-minded so if you’re hanging out with somebody who tends to be anxious then the anxiety can be palpable and it can kind of permeate physical complaints can lead people to be anxious because they don’t know what’s causing it like I said earlier sometimes if your heart starts to race if you don’t know what’s causing it for you can start thinking I’m having a heart attack or I’m gonna die when people have panic attacks for the example they truly think they’re having a heart attack and it’s I’ve had them they are very very unpleasant experiences but when people start having physical complaints and it can be you know they have a weird rash that they can’t get to go away or whatever but when they don’t know what it is and they can’t control it they can’t make it go away they start thinking about all the worst-case scenarios and going online and getting on WebMD which usually gives you all the worst-case scenarios um so physical complaints are important we need to normalize the fact that nobody’s pain-free all the time and you know the fact that you may have an ache or a pain or a lump or a bump or you know a cough most likely you know when we look at probability the probability of it being something significant is pretty small now do you want to get it checked out probably but you know the probability that is anything to be worried about is relatively small and a sense of powerlessness can trigger fear of the unknown and loss of control for somebody who doesn’t feel like they have any agency in their life if they have an external locus of control or if they felt victimized all of their life then they may fear not being in control they may be holding on and saying okay this is the one area of my life I can control when I grew up you know I grew up in a very chaotic environment I had no control I was bounced around in the foster system yadda yadda yadda now that I’m an adult you know I can control these things and I am going to hold on with white knuckles and if I can’t control everything then that terrifies me to death and loss are other triggers for anxiety and it can be people or pets and pets are important I don’t want to minimize pets because you know they are little parts of a lot of our families so making sure we check that my daughter’s dog for example is it’s getting old she’s getting older she’s 14 now I think and you know she’s in decent health we took her to the vet and the vet said yeah she’s got a little heart murmur but that’s expected for a 14-year-old dog and but when she goes out if she doesn’t come back when I call her I have this rush of anxiety for a second oh my gosh I hope this wasn’t the day so anxious around losing people and you know if she when she crosses the bridge she will and you know I’m okay with that I’m I have a harder time dealing with my daughter’s emotional turmoil when that happens and because she’s grown up with this dog so you know those are the types of things that we want to talk about with our clients what things are weighing on you that you may not even be thinking about because I know in the back of my mind there’s always that worry about one of our donkeys and her dog jobs and promotions can trigger anxiety if people are afraid they’re gonna lose their job if they’re always afraid that you know they’re gonna walk in and get a pink slip or get fired you know we want to help them look at how realistic they are you doing what you need to do to achieve and keep your job and sometimes it’s not easy to the answer I mean the first thought that a lot of us have is well you know if you’re doing the right a thing so just do it but there are those bosses out there and I’ve had some amazing bosses a lot of them and I’ve had two horrendous bosses and those two bosses I could never I never felt like I was able to do anything right and so going to those jobs there was always this anxiety about what I’m what am I going to get in trouble for today so you want to talk with people about does your job cause anxiety what can you do to moderate that anxiety the same thing with promotions people may get anxious about whether they’re going to get promoted to safety and security you know when you lose safety and security you can feel anxious so if there’s a break-in at the house next door or shooting down the road or you start watching the news you can feel very unsafe and insecure quickly so we want to help people figure out how safe and secure are you really and a lot of it goes back to looking at facts when people lose their dreams and hopes or fear that they’re going to lose their dreams and hopes they can start to get anxious you know they have this dream that they’re going to be a doctor or I just finished the presentation on helping high school students transition to college and a lot of high school students for example start college with these wide eyes and hopes to save the world and they want to be doctors and engineers and this and that and they get into it and they realize that it’s a lot harder then they thought or they realize that you know what I don’t like this but I’ve already committed to it so what do I do I want to help people but I can’t I can’t cut it doing this you know for me I figured out in my second year that I wasn’t going to medical school because I wasn’t going to pass calculus and that caused a lot of anxiety it was like okay what am I gonna do now Do you know what career should I choose to help people figure out do they have dreams that have maybe kind of crashed and burned and you have to find new ones you know okay that one we’ve got to accept it figure out that it’s not going to be and what can you do now people may also have dreams about relationships they get into relationships and see themselves with this person forever and then this relationship ends and or starts to get rocky and they’re like but that’s my dream what happens if that’s got to happen because it’s my dream I don’t know how to function if that goes away we want to help people be able to rewrite their narrative and then sickness spiders and other phobias kind of go in with death a lot of times when people get sick they start getting anxious that oh my gosh what if this is terminal oh my gosh what if this is you know incurable if I get bit by a spider it’s gonna kill me and which is rare you know there are very few spiders that is actually that poisonous same thing with snakes going over bridges I’ve shared with you all that is not one of my irrational fears you know I am just terrified that you know something’s going to happen and I’m going to get pushed off the side of the bridge which is completely irrational but we need to help people look at those and identify the thoughts that they’re telling themself about those phobias and dealing with that anxiety failure is another –trigger for anxiety especially in this culture our culture American culture is large part puts a high premium on success and perfectionism so when people realize that they’re not perfect they may start to get anxious because they feel like if I’m not perfect then I’m a failure you know those cognitive distortions of all-or-nothing thinking and they start with that negative self-talk you know you can’t do anything right so those are some of the issues that you know we often see in counseling sessions so what do we do you know somebody comes in and is like I can’t live this way doc anxiety depression and substance disorders as well as a range of physical disorders are often comorbid so this is the first the thing we need to realize is that we’re very rarely dealing with a very simple the diagnosis you know when somebody comes in we need to figure out you know if they come in and they’re presenting with depression all right let’s talk about that and then we start realizing that there depression started to occur after a long period of being anxious okay so we need to deal with that but we also need to help them with their sense of hopelessness and helplessness we need to develop that sense of empowerment and then substance disorders we know that substance use is often a way of self-medicating but we also know that it monkeys with the neurochemicals in the brain and can contribute to anxiety and depression the same thing to physical issues pain from physical disorders anxiety about having physical disorders medications you’re taking for physical disorders can all contribute to anxiety so we need to look at the person as a whole and go what are all the things that are contributing to the anxiety and what are all the things that the anxiety is contributing to so we have started having this big list of stuff that needs to be addressed and then we can start figuring out okay where we start so knowing that these things are comorbid helps researchers explore pathways to mental disorders so they can start figuring out you know what little string can we pull to unravel this blanket of anxiety so it doesn’t suffocate somebody and for us, as clinicians, it provides us key opportunities to intervene in you know sometimes clients will come in and start talking about their anxiety and their physical issues you know maybe their anxieties about you know heart palpitations and because that’s a common one we may want to encourage them to go see the doctor to get that ruled out you know rule out anything that has to do with hormone imbalances or you know heart conditions or anything else that might be contributing to it which can help them address it and if they do have physical disorders let’s go with hormone imbalances that are contributing to the heart palpitations then they can start to treat that if they don’t start to treat that then no amount of talk therapy we do is going to get them to the quality of life that they’re looking for because they’re still gonna feel those so we want to make sure that we’re addressing them holistically anxiety disorders should be treated with psychological therapy pharmacy therapy or a combination of both and what they found and this is no surprise this is kind of old news is that counseling Plus pharmacotherapy tends to have the best outcomes but separating the two have similar outcomes in many cases but that’s just looking at and I hate to call it simple anxiety but we’re just looking at anxiety symptoms here we’re not looking at the full quality of life and we want to make sure that we’re also including any medical issues behavioral therapy is regarded as the psychotherapy with the highest level of evidence, there are a variety of cognitive behavioral approaches ranging from acceptance and commitment therapy to dialectical behavior therapy to CBT to debt you know any of those that deal with the thoughts and the cognitions that fall in that realm and it is effective in the current conceptualization of the etiology of anxiety disorders includes an interaction of psychosocial factors such as childhood adversity or stressful events and a genetic vulnerability so the psychosocial factors and these are other things when we do our assessment we want to pay attention to because our approach to treatment is going to be different for people for example who have trauma-related brain changes maybe then for somebody who doesn’t so, we want to look at childhood adversity and stressful events that it may have caused basically what I tell clients is like rewiring of the brain there are trauma-related brain changes in soldiers and especially in children or in people who’ve been exposed to extreme trauma that is designed to protect them but it also can cause complications kind of later on in dealing with anxiety coping skills that were learned that are ineffective you know sometimes people grow up in a household or an environment or a situation where they don’t learn effective coping skills so we need to kind of help them unlearn those and learn new ones build on their strengths and trauma issues that may still need to be dealt with such as domestic violence you know if they grew up a lot around a lot of domestic violence they may think you know I’m out of that situation it’s over I don’t want to think about it it’s not bothering me anymore or a parental absence and I put absence because it can be death it can be a parent that just packed up and left it could be a child that got put up for adoption whatever put the child in a position of feeling like they were rejected by a parent can be very traumatic and bullying among other things but there are a lot of trauma issues that people once they’re out of that situation often say you know I’m out of it it’s not a big deal I dealt with it let’s move on and they don’t realize the full ramifications and how that’s contributing to their current anxiety and their current self-talk and cognitions of current stressors if somebody has a lot of current stressors that are also going to impact whether they develop generalized anxiety you know we’re kind of stacking the deck here and the current availability of social support if they don’t have effective current social support then they’re gonna have difficulty bearing the weight of everything on their shoulders so we want to look at all these psychosocial factors when we do our assessment now going back to the trauma issues if you’ve taken the trauma courses at all CEUs you know that some people are not ready to acknowledge that the trauma is still bothering them or work on the trauma and that’s okay we can educate them that it might be an issue and then let them choose how to address it but we want to bear in mind the fact that you know this could be sort of an underlying force motivating some of the current cognitions and genetic vulnerability so you take any three people and you put them or 300 people and you put them through roughly the same psychosocial situations they’re all probably going to react a little bit differently based on their prior experiences but also because of their genetic makeup there are certain permutations and they found four we’ll talk about later that make the brain more or less responsive to stress and more or less responsive to serotonin which is your calming chemical so brains that are less responsive to serotonin isn’t going to you know send out as much or send out serotonin as easily so people can stay kind of tensed and wired that’s an oversimplified explanation but that’s all you need for right now so genetic vulnerability impacts people’s susceptibility to the effects and development of dependence on certain substances which can increase anxiety when people are detoxing from alcohol when they’re detoxing from benzos when they’re detoxing from opiates they can feel high levels of anxiety when they take opiates some people find that opiates have wonderful anti-anxiety properties not that I am advocating for the use of opiates I’m just client experiences have shown that that can be true so some people are going to be more susceptible to the anti-anxiety effects of certain substances and some people are going to be Cerrone to become dependent on substances where others may not and that part of that is genetic vulnerability and they estimate about 30% the predictability of the development of anxiety disorders is genetic and genetics also impact which medications are effective if you have genetic makeup then SSRIs might be helpful if you have genetic makeup be then atypical antipsychotics may be more effective and SSRIs might not do anything which is why a lot of our clients get so frustrated because they know there’s no way to figure out exactly what I guess there is now that there’s genetic testing out there but up until then it was harder to figure out which medications to start with and most physicians matter of fact I don’t know of a single physician that starts by saying well let’s do a genetic profile to see what med to start you out with most we’ll start with events as with an SSRI or some other anti-anxiety medication some sort of benzo that’s been my experience so we may want to encourage clients to consider genetic testing if they’re having difficulty finding a medication regime that works for them and they are feeling like they have to have medication genetic vulnerability also affects what’s going to make somebody more vulnerable now than all of you in class today you know thinking about sleep you know sleep may not be a big deal for some of you I know people who can go days or weeks with four or five hours of sleep and they feel fine it’s not a big deal, not me I need eight or nine hours of sleep so genetically for whatever reason I am programmed to need a lot of sleep so when I don’t get that much sleep I tend to be it tends to be harder for me to deal with life on life’s terms and I know that that makes me more vulnerable to being irritable so genetic vulnerability affects who can become addicted and affects what medications work best and affects what situations are going to tend to make somebody more vulnerable to anxiety so our medications and I know the type on here is small but we’re going to go through the first-line drugs are the SSRIs selective serotonin reuptake inhibitors and SNRs is selective norepinephrine reuptake inhibitors now the names are a little bit deceptive because selective norepinephrine reuptake inhibitors also increase available serotonin but the mechanism of action is different the mechanism of action for each SSRI is a little bit different as well which is why you can put somebody on Prozac and they have an awful experience and you can put them on Zoloft and they have a much better experience like I said earlier a lot of the research pre five years ago had been done on medications and Zoloft Paxil luvox Lexapro Celexa and their generics have all been found to be effective at treating anxiety in certain people no one the medication works for everybody in the last five years Effexor has come on the radar and it has been found effective according to the hamilton rating scale for anxiety so that’s another one to consider if clients are not successful or getting the treatment effect that they need for on some of the other medications obviously, none of us probably are prescribers but we do need to educate clients about why the first drug or even the third drug that the doc tries may not work so they don’t start feeling helpless and hopeless like I said earlier there are at least four different genetic variations which are correlated with the development of generalized anxiety disorder and different medications are more or less effective depending on the genetic makeup of the person there’s a high mortality rate moving on to two benzos the recommendation has switched to back off from the use of benzos now for some doctors will prescribe an SSRI and for the first four weeks while the SSRI is building up in the system they will also prescribe a benzo to be taken as needed to moderate the anxiety and you know you could argue on either side of that, if somebody has a history of substance use or substance dependence benzos are really a bad idea because they do have a high rate of dependence but the other reasons that they are now cautioning against the use of benzodiazepines is that there’s a higher mortality rate among benzo users compared with non-users there’s an increased risk for dependence with use for more than six months and that’s a long time to be using benzo and when we’re talking about dependence and six months we’re talking about somebody who uses it like every four hours or every eight hours depending on your benzo every single day not a PRN user if somebody’s using it at night to help them go to sleep or you know three or four times a week when the anxiety gets high the risk of dependence is relatively low but a lot of people with anxiety because if they find the right benzo makes them feel so much better they may not want to be off of it and for a lot of people when that benzo reaches its half-life and starts getting out of the system even more their anxiety spikes you know they have rebound anxiety which they want to medicate with more benzos that’s gonna be an issue for them to discuss with their doctor there’s also an increased risk of dementia identified in long-term benzodiazepine users again this is for the people who use you know throughout the day every day for six months or relatively every day for six months or more and it doesn’t matter if it’s you know we’re talking about somebody who’s 65 or somebody who’s 35 who’s been using benzos for you know six months a year two years the risk of later life dementia is greatly increased according to the research benzodiazepines also don’t treat depression okay so if you’ve got somebody who has concurrent anxiety and depression there’s a much higher suicide risk if they’re on benzodiazepines so being aware and generally that suicide risk comes from overdosing on benzodiazepines but not always other treatment options you know if the benzos aren’t something that people want to touch you know they scare the living daylights out of me and SSRIs and SNRIs don’t seem to be working then tricyclic antidepressants can be tried on those your older generation antidepressant Seroquel is used a lot and there are some there’s some research that shows it can be effective with anxiety like some of the antidepressants and depending on the person the benzos Seroquel can make people very very very sleepy so you know it may not be the side effects of the Seroquel the weight gain and the fatigue and you know sleepiness may be an unacceptable side effect for some clients and boosts perón is the third option boost Barone works more like an anti-depressive serotonin reuptake inhibitor and that it takes you know four weeks or so to kind of build up in the system studies have shown that there’s really no long-term benefit to taking it but after six months to eighteen months of use it has been shown to be effective in talking with clients a lot of clients report that boost bar when they take it doesn’t necessarily help them stop being anxious like a benzodiazepine does but it helps them not go from zero to 200 in 2.3 seconds it kind of you know keeps them from having this gush of a freak out reaction every time something goes wrong which a lot of clients report helps because they feel more stable throughout the day after remission medication should be continued for six to twelve months and during that last six months first six months keep it as is last six months you know they say that tapering is best it’s best not to stop somebody cold turkey on any of these but it’s important for people once they’re in remission to not just suddenly go okay I feel better I don’t need any of this anymore they need to work into it and make sure they’ve developed the skills and tools that they need to deal with some of the anxiety that is going to happen in life so physical signs and symptoms of anxiety may include fatigue irritability muscle tension or muscle aches try laying feeling twitchy being easily startled trouble sleeping nausea diarrhea irritable bowel syndrome headaches so the first thing we want to do with clients when we’re talking to them well second thing first thing is to say get a physical to let’s rule out physiological causes of this but we can also help clients look at you know what might be causing these things that you can do to mitigate it what might be contributing to your fatigue what might be contributing to your irritability and your muscle tension or your muscle aches I mean let’s look at economics did you recently get a new bed or do you need to get a new bed what about your desk chair I know you know I get more muscle tension and muscle achy when I do a lot of mousing because I have deplorable posture being becoming aware of that helps and then I’m like okay well I know it caused unfortunately, it’s unpleasant but it’s not a big deal trembling or feeling twitchy you know that can be caused by low blood sugar that can be caused anxiety that can also be caused by early onset Parkinson’s symptoms you know there’s you know it can be worst case scenario or it can be something benign so we want to have people figure out you know when you start trembling or feeling twitchy is there something that it’s related to you know I know when my son gets excited he’s he just sits there and you can see him almost shake because he’s so excited about something so we want to have people prevent misidentification we don’t want them to jump to that worst-case scenario we don’t want them to go onto WebMD and go oh my gosh I’ve got cancer I’ve got this debilitating disease and I’m going to die in six months probabilistic Lee speaking it’s not gonna happen yes get a doctor’s opinion I’m certainly not going to tell them it’s all in your head I want them to get an evaluation but I do want to in the meantime help them think about how likely is this and other things for headaches and this is one another one of those that can be frustrating as we get older our eyesight starts to go and you know there was a period there I did fine and then after I hit 45 my eyesight just started to like steadily and kind of rapidly in my mind decline so I have to get my eyeglass prescription changed every couple of years and that can cause headaches so instead of starting to worry about oh my gosh I’ve got a headache all the time maybe I’ve got a brain tumor you know I know that it’s probably my glasses or I’m grinding my teeth so other biological interventions that have been evaluated there’s something called the floatation rest system that reduced environmental stimulation therapy reduces sensory input into the nervous system through the act of floating supine which is on your back in a pool of water saturated with Epsom salt you know I’m looking at this going sounds good and you can’t quite get the same experience in a bathtub because you’re not floating you’ve got pressure points and you’re still hearing stuff clients can sort of simulate it with you know earplugs or whatever but it’s if they can access this it’s been shown to be effective the float experience is calibrated so that sensory signals from visual auditory olfactory gustatory thermal tactile or tactile vestibular gravitational and preceptive channels are minimized which means you don’t see here taste touch smell feel nothing as is most movement and speech so you want people to lay just like completely motionless and not talk which can be hard for some people with anxiety in the study the study I looked at fifty participants reported significant reductions in stress muscle tension pain depression and negative effects and it was accompanied by significant improvement in mood characterized by increases in relaxation happiness and well-being I read the study I’m like where can I sign up you know it sounds in looking at some of the research this was more effective for addressing anxiety than something like a massage Tai Chi also produced significant reductions in anxiety there was approximately a 20% treatment effect 25% treatment effect in patients with anxiety and fibromyalgia who practiced twice a week for a year now you know we want to look at the confounding things here is it the Tai Chi itself or is it learning to control the muscles and becoming more in tune with your body and learning to control your breathing helps people reduce their anxiety either way you know Tai Chi helps people do that and it was shown that after a year after the first six months, there was a significant treatment effect but after a year you know it kept growing and after a year it was about 25% so Tai Chi can be effective acupuncture at the HT 7 median Meridian can attenuate anxiety-like behavior induced by withdrawal from chronic morphine treatment through the meditation of the GABA receptor system what does that mean that means if you if the acupuncture is done in very certain places the anxiety behavior the GABA a receptor system GABA is your main calming relaxation neurochemical that is triggered and causes your body to sort of flood that receptor system and this research was done on people who were detoxing from morphine treatment but we can look at generalizing the results and I would be interested to see further studies on it pain other things we need to do to help people with anxiety when people are in chronic pain they often have anxiety that oh my gosh this is getting worse or it’s never gonna get better or I just can’t take this pain anymore or they may get anxious that they’re going to be rejected because they can’t do some of the things they used to do because they’re in so much pain so there’s a lot of guilt and anxiety that can kind of revolve around pain what can we do to help clients guided imagery is generally very helpful if we can help them imagine you know if that pain in their shoulder imagine the pain is like the color red flowing out of their arm or other focus mindfulness so you know when you think about something you know when you get a shot if I don’t think about it it doesn’t hurt near as much as if the nurse says okay now one two three and you know she’s counting down and I’m getting prepared and I’m focused on it I had another nurse one time who she was just talking to me and you know put the alcohol on my arm and just kept on talking and didn’t tell me she was getting ready to give me a shot and before I knew it she had given me a shot and she was like okay we’re done I’m like you didn’t give me a shot yet she said yes I did it’s like oh so not focusing on it and next time you have an itch for example if you’ve ever been driving on the interstate and you can reach on your foot I get those on the bottom of my foot sometimes and I’m like okay I’m not going to pull over to each my foot if you focus on something besides the itch eventually it goes away I’m not saying the pain is gonna completely go away but the more people focus on it the more it hurts physical therapy can help so encourage them to get a referral and encourage them to do a self-evaluation if nothing else of ergonomics in their car at work where they watch TV and spend most of their time at home and they’re sleeping so those are the four places that they spend most of their time what do their ergonomics look like and that can help a lot of people mitigate a lot of pain hormones are another thing that we need to look at imbalances of estrogen and testosterone can contribute to anxiety symptoms heart palpitations fatigue irritability having people get a physical we can’t as clinicians do anything about it but doctors can rapid heart weight rate sweating palpitations are not uncommon in women in perimenopause or menopause so a lot of women start feeling like they’re developing generalized anxiety and/or something’s going wrong when they start reaching that mid-40s to mid-50s area and they start having some of these symptoms again we’re not going to diagnose it but we do want them to recognize that it may not be anything you know is catastrophic this is something that a a lot of women experience and help them figure out how to deal with that supportive care biologically now you know this isn’t gonna treat anything but we can help them minimize their vulnerabilities help them create a sleep routine so their brain and body can rebalance this can help repair any adrenal issues that may be going on and improve energy levels people with anxiety don’t sleep well so helping them figure out how to get some quality sleep is important nutrition minimizing caffeine and other stimulants are going to be a big help because those make people feel anxious and encourage them to work with a nutritionist to try to prevent spikes and drops in blood sugar which can trigger the stress response when your blood sugar goes way up or way down you can start getting kind of shaky and feel weird and that can cause people anxiety because they might think oh my gosh I’m having a stroke or a heart attack or you know I don’t know what these tremors are so it’s important that they don’t miss identify symptoms and encourage them to drink enough water dehydration can lead to toxic Ardea which is increased heart rate sunlight vitamin D deficiency is implicated in both depression and anxiety mood issues vitamin D has been found in those main areas where serotonin receptors are found vitamin D receptors are found so we know the serotonin and vitamin D have something going on sunlight prompts the skin to tell the brain to produce neurotransmitters and set circadian rhythms which impact the release of serotonin your calming neurochemical melatonin which is made from breaking down serotonin and helps you sleep and GABA so sunlight actually helps increase the release of GABA when it’s time to start calming down and going to sleep exercise studies have shown that exercise can have a relaxing effect and encourage clients to start slowly there’s not a whole lot of new research on exercise and anxiety aromatherapy has been used a lot, especially in other countries in the treatment of people with anxiety people with hospital anxiety people women who are giving birth and they have some birth anxiety there they’ve been found to be effective in a lot of those studies essential oils for anxiety include lavender rose Bedevere ylang ylang bergamot chamomile frankincense and Clary sage encourage clients to just go to a health food store and you know sniff some of these and see if it makes them feel happy and calm and content the aromatherapy molecules enter the nasal membranes and they will start triggering neurochemical reactions and so you don’t need to apply it you don’t need to ingest it all you need to do is so encourage clients if they’re open to it to think about this because aromatherapy can be integrated into their bedroom for example with an atomizer or a Mr.It can be incorporated in a lot of different places again where they’re not applying it or ingesting it in any way all they’re doing is smelling it they’ve used it in defusing aromatherapy in hospital emergency rooms and they found that it reduces stress and irritability the people in emergency rooms and I’ve been to enough emergency rooms over the years to know that people who are in ers typically are not in the best mood so if it can help those people then it’s probably going to have some sort of an effect so psychologically helping clients realize that their body thinks there’s a threat for some reason that’s why it triggered the threat response a system which is what they call anxiety so they need to figure out why is there a threat you know sometimes it’s like the fire alarm going off in my house it just means that the windows are open and there’s a strong breeze there is no fire there is no problem there’s just a malfunction it’s a false alarm a lot of times clients get this threat reaction they get this stress reaction and it’s not a big deal right now so they can start modifying what their brain responds to and again those basic fears that a lot of people worry about failure rejection loss of control the unknown and death and loss distress tolerance is one of those cognitive interventions that have taken center stage in anxiety research and it isn’t about controlling your anxiety you know helping people recognize their anxiety acknowledge it and say okay I’m anxious it is what it is how can I improve the next moment instead of saying I’m anxious I shouldn’t be anxious I hate being anxious and slang with that anxiety let it go just accept it is what it is have the client learn to start saying I am feeling anxious okay so distract don’t react because I explain to them the whole notion of feelings comes in the crest and goes out in about 20 minutes it’s like a wave so once they acknowledge their feeling if they can distract themselves for twenty or thirty minutes you know they figured out there was no real threat if they can distract themselves for twenty or thirty minutes those emotions can go down and then they can deal with it in their wise mind and encourage them to use distancing techniques instead of saying I am anxious or I am terrified or whatever have them say I am having the thought that this is the worst thing in the world I am having the thought that I cannot handle this because thoughts come and go and that comes from acceptance and commitment therapy functional analysis makes it possible to specify where and when with what frequency with what intensity and under what circumstances the anxious response is triggered so it’s important that we help clients develop the ability to do functional analyses on their own so when they start feeling anxious they can stop and say okay where am I what’s going on how intense is it what are the circumstances and they start trying to figure out what causes this for them so they can identify any common themes from their psychoeducation about cognitive distortions and techniques to prevent those circumstances or mitigate them can be provided so if the client knows that they get anxious before they go into a meeting with their boss and it’s usually a high the intensity of anxiety okay so we can educate them and help them identify what fears may be related to techniques to slow their breathing and calm their stress reaction and help them figure out times in the past when they’ve handled going in and talking to their boss and it wasn’t the end of the world you know there’s lots of different things we can do there for them there but the first key and it gives them a lot of a huge sense of empowerment to start becoming detectives in their own life and going okay now under what situations does this happen positive writing this was another cool study each day for 30 days the experimental group and this was high school-aged youth in China but you know the experimental group engaged in 20 minutes of writing about positive emotions they felt that day so they’re writing about anything positive that make them happy that made them enthusiastic gave them hope whatever long-term expressive writing positive emotions so after 30 days it appeared to help reduce test anxiety by helping they develop insight and use positive emotional words so it got them out of the habit of using the destruction and doom words and encouraged them to get in the habit of looking at the positive things and being more optimistic it’s a cool activity that clients can try it’s not gonna hurt anything if you have them journal each day for 30 days mindfulness also came up in the research and was shown to be effective in a meta-analysis of six articles about mindfulness based stress reduction four about mindfulness-based cognitive therapy and three about fear of negative appraisal and emotion regulation was reviewed all of these showed that mindfulness was an effective strategy for the treatment of mood and anxiety disorders and is an effective in therapy protocols with different structures including virtual modalities so you know if you’re doing it via teleconference mindfulness can still be helpful mindfulness helps people start learning how to observe what’s going on and become aware of what’s going on more aware of those circumstances which will help them complete their functional analysis but it also helps them become aware of vulnerabilities and head off things in the past and if they’re taking better care of themselves that they’re living more mindfully then they may not experience as many situations that trigger their anxiety mindfulness also encourages clients to learn acceptance that radical acceptance of it is what it is I’m not gonna fight it I’m angry right now I am anxious right now however I’m feeling right now is how I feel and that’s okay it’s hard for clients to get to that but once they get a hold of that and they truly believe it and they can say all right it’s fine I’m not gonna feel this way forever I’m gonna do something else until the feeling passes it helps and that’s where the labeling and letting go comes in mindfulness can also help them identify trigger thoughts what thought were you having right before you started feeling anxious if people are mindful or let’s start back when people are not mindful they often notice or don’t notice that they’re getting anxious until they’re like super anxious when people are mindful they become more aware of subtle cues address unhelpful thoughts when they say or believe it’s a dire necessity for adults to be loved by significant others for almost everything they do always running gonna happen why is it a necessity what we can encourage them to do is concentrate on their self-respect on winning approval for practical purposes you know for promotions or whatever but it’s not about me being lovable it’s about me getting a promotion and making more money and focusing on loving rather than being loved because when we give love we generally get love back with unhelpful thought number two people feel they aren’t able to stand it if things are not the way they want them to be or are not in their control so encourage clients to focus on the parts that are in their control and other things in life which are going well and to which they’re committed number three misery is invariably externally caused and is forced on us by outside people and events just by reading that makes me feel disempowered so encouraging clients to focus on the fact that reactions such as misery or happiness are largely caused by the view that people take of the conditions so if you see it as a tragedy and devastating then it’s probably going to produce misery if you see it as an opportunity and a challenge it’s probably going to produce a different emotional reaction, if something is or may be dangerous or fearsome people, should be upset and endlessly upset about obsessing about it a lot of people with anxiety get stuck on this you know if I feel like it’s fearsome I need to worry about it getting on a plane for example if I fear that that’s dangerous that I need to think about it and worry about it that’s not going to do any good so encourage clients to figure out how to face it and render it harmless if possible and when that’s not possible accept the inevitable so looking at airplanes you know facing it means researching to figure out how dangerous is it really and realizing that it’s not that dangerous so that helps render it a little bit harmless in their mind it proves to them that it’s not as dangerous as it could be and when it’s not possible accepting the inevitable you know you got a fly so getting on there figuring out how you’re gonna get through it hurricanes are the same way people especially in places like Texas Louisiana Florida may obsess as soon as it starts coming to hurricane season or if a hurricane is spotted out in the Atlantic somewhere they start checking the weather every hour or more wondering what the path is going to be and you know what there’s you can’t change the path of the hurricane so all you can do is board up your house evacuate if necessary and deal with the fallout child driving is just another example I’ll give you know my children are learning how to drive and that’s kind of scary and fearsome you know what’s gonna happen when they’re out there you know you see crashes all the time well render it harmless by making sure they’ve got good training on how to drive make sure they’re good drivers and then accepting that some things are just not within my control it’s easier to avoid than face life difficulties and responsibilities well running from fear is usually much harder in the long run so encourage clients to look back at times when they’ve avoided difficulties and responsibilities and the eventual outcome you know what happened there people believe they should be thoroughly competent in achieving in all possible respects or they will be isolated rejected and failures we need to encourage clients to accept themselves as imperfect with human limitations and flaws and focus on what makes them loveable human being what qualities like courage and intelligence and creativity and those things that can’t be taken away what inherent qualities do they have that make them awesome people because something once strongly affected people’s lives they should indefinitely fear it if you got lost you know when little kids get lost it’s terrifying when you’re grown up if you get lost you turn on the GPS and you figure out your way but some people still, you know freaked out about getting lost if they got lost once so we want to help people look back at past episodes that may be contributing to the current anxiety and compare the situation’s you know are you the same person or is this not a big deal now that you’re older wiser stronger encourage them to learn from past experiences but not be overly attached to or prejudiced by them yeah you could have maybe got lost in the past and it was a horrible experience well you were six I can see where that would be terrifying and a horrible experience but it doesn’t have to continue to impact you that way now when you’re you know 26 getting lost you know could be an opportunity to try a new restaurant or something people must have complete control over things well this doesn’t happen so encourage clients to remember that the past and the future are uncontrollable we can’t change the past it is what it is we can learn from it so it doesn’t repeat but we can’t change it and the future is largely uncontrollable I mean there are a lot of things I can do to stay moving toward a rich and meaningful life but life is going to throw me curveballs sometimes and there’s nothing I can do to plan for or control that we can control our actions in the present to stay on our preferred path and general develop general skills to deal with adversity should it arise so we want to help clients develop those general problem-solving skills and the general support system so when they are thrown a curveball you know it doesn’t knock them upside the head people have virtually no control over their emotions and cannot help feeling disturbed by things well encourage them to think about the fact that they have real control over destructive emotions if they choose to work at improving the next moment and changing inaccurate thoughts then they’re not going to experience the destructive emotions as intensely or as frequently when you feel an emotion you feel how you feel but again you don’t have to wrestle with it fight it and nurture it you can say this is how I feel how do I improve the next moment when it comes to cognitive distortions encourage them to find alternatives when they start to personalize things if somebody laughs when you walk out of the room then the and the person starts getting anxious thinking oh they were making fun of me I wonder what they thought I wonder if I had something stuck to the back of my dress and they start getting all panicked about it that doesn’t do any good encouraging them to think you know what our three alternate explanations that hadn’t but had nothing to do with you for why they laughed magnification of the worst thing you know taking something and saying if this happens then it’s going to be a catastrophe and minimization going along with that a lot of times when people magnify and see a catastrophe they minimize not only their strengths and resources but all the other stuff that they’ve got going for them all they’re seeing is this catastrophe so encouraging them to focus on the facts of what is actually happening and what is the high probability event and encourage them to get information and look at the broader picture you know yes you got into a car crash and your car is totaled and that is unfortunate you know it sucks but you know that is not going to cause you to lose your job and then become homeless and penniless and yadda-yadda it might cause your insurance to go up but okay so you don’t have a car but what are the resources that you have who can who do you work with that might be able to give you a ride to work you know let’s look at the resources you have and work around so problem-solving helps with magnification and also focusing on you know let’s be grateful for what didn’t happen you know you could have been killed but you weren’t the car was totaled it’s replaceable all or nothing thinking again have them think about what else could have been happening like Brittney suggested finding the exceptions instead of saying she always does this look for exceptions when has she not done that what else has she done instead of this selective abstraction and filtering is when people look for the good the bad and the ugly a selective abstraction means you kind of see what you expect to see so if you expect something to be devastating you see only the devastating aspects of it which kind of goes with the magnification and minimization you filter out the stuff a lot of times when people are in a bad mood or are anxious they see the negative because that’s the state of mind they’re in so encouraging people to complete the picture alright there’s all this bad stuff now what’s the good stuff you know to encourage them to look at the good the bad and the ugly so they get a wide view of exactly what’s going on and encourage them to remember that hindsight is twenty-twenty when people have something embarrassing happens or they get anxious about something that happened they look back and they go I should have or I could have or oh I wish I wouldn’t have when you were in that the situation you did what you did and you know maybe you may have had a reason for it or you know you may have not had other options or it may have just been a bonehead thing to do but okay so you made one mistake hindsight is 2020 that’s gonna that mistake is gonna stand out just like the great big letter on the eye chart because you’re thinking back and you’re looking at it and that’s all you see but encouraging clients to remember that other people are too busy worrying about themselves to remember what they did jumping to conclusions encourages clients to remember to get all the data if your significant other male significant other comes home and is smelling like perfume don’t just jump to the conclusion that he was cheating on you maybe he went to the mall to get a new tie and walked through the perfume area and got spritzed or bought you some perfume or who knows maybe the person sitting next to him at work sprayed her perfume on the desk and some of it filtered on there are all different reasons that that might happen so encourage people to get all the data mind reading we can’t do it you know you can’t read somebody’s mind you don’t know what they’re thinking so ask them what you think about this don’t assume anything and emotional reasoning encourages people to step back from a situation and ask themselves am I feeling anxious about this because I’m feeling anxious and I’m looking for reasons that it should be scary or am I feeling anxious about this because it’s really scary for some reason there are facts support my anxiety a lot of times when we go into new situations we may feel anxious because it’s a new situation but when we step back we say you know what there’s nothing to be worried about here you know no big deal I got this and move on so instead of rolling with it and trying to figure out okay I feel anxious so there must be a reason not necessarily very likely a false alarm other psychological interventions relaxation skills encourage people to learn how to relax not only physically but mentally diaphragmatic breathing helps encourage them to breathe through their stomach and put their hand on their belly and feel their belly expand and contract slows breathing down which triggers the rest and digestion reaction in the brain which is calming meditation can be helpful for some people some people find trying to quiet their minds too frustrating because they’ve got too much monkey mind going on that can be later or maybe never for some people, we don’t want to increase their anxiety with interventions cute progressive muscular relaxation also has a lot of research support and remembers with cute progressive muscular relaxation we’re Sakura get them to attach a cue AK you word like relax or breathe with the relaxation response so they tense their muscles and then relax their muscles and as they relax their muscles they say their “quack”-word like relaxed and they work from head to toe or from toe to head tensing and relaxing different muscle groups so they become more aware of what a tense muscle feels like versus a reactive relaxed muscle there are great scripts that are online that people have already recorded that can walk people walk clients through CPM are I highly encourage it because once they get used to it then they can just think that cue they can think relax and as they exhale they will start to feel their entire body kind of relaxing because it’s trained when it hears that just like when you hear the word pop quiz when you were in high school you had a stress reaction well we want to use it in reverse and train the body so that when it hears a cue word relaxes helps them develop self-esteem because fear of failure and rejection a lot of times come from needing other people’s approval to help them develop a rational idea of their real self develops compassion self-talk instead of saying I’m an idiot or I’m stupid or I’ll never measure up to anything encourage them to talk to themself like they would talk to their child or hopefully their best friend and encourage them to spotlight strengths whenever they feel like they’ve got an imperfection to identify these three strengths that they have so they’re you know balancing out the imperfections and the strengths of cognitive restructuring reframes challenges in terms of current strengths, not past weaknesses so if you’re going to give a presentation in front of 60 people and you hate public speaking instead of thinking about you know this is terrifying because the last time I went up in front of people I forgot everything I was going to say and drop my note cards well that’s a past weakness what is your current strength you’re prepared to know the material you ‘yoyo’ so encourage people to look at all the strengths and resources they currently, have them develop an attitude of gratitude and optimism because as I said with that the positive writing exercise when people are in a grateful optimistic frame of mind they tend to see more of the good stuff they see the bad stuff too but they can also see more of the good stuff and some of the bad stuff they see opportunistically instead of as a devastation acceptance and commitment therapy says that some of the reasons that we’re miserable are fear we get fused with our thoughts we think I am terrified well if I am terrified then I can’t I mean if I am I can’t get rid of anything I am if I’m having the thought that I’m terrified well I can get rid of a thought I can forget things easily encourage people to evaluate their experience and empower them to look at things as challenges and opportunities instead of hardships encourage them not to avoid their experiences so things that are scary gradual exposure and finding exceptions like for me bridges you know I love public speaking so that’s not a thing but when I go to a bridge you know when I Drive to the bridge you know when I’m on the bridge somebody else is driving I get used to doing that when I Drive over a bridge than when I Drive over one of those bridges that open up I hate those bridges um I know y’all are just like oh my gosh yeah it’s an irrational fear I realize that but instead of going straight for the bridge that opens up going for the little bridges first and then thinking back over times that I’ve gone over bridges and there’s been no problem you know there are exceptions nothing happened it wasn’t a big deal sometimes I didn’t even notice it until somebody pointed out hey look down there at that pretty water and I’m like oh we’re on a bridge so encourage people to not avoid their experiences get used to them embrace them and learn that they have the power to deal with them and stop reason giving for the behavior you know use the challenging questions if something is fearsome let’s look for at the evidence for and against it instead of you know making excuses for social interventions improve their relationship with their self which goes with self-esteem improvement people are going to feel less anxious about getting their needs and wants to be met if they know what their needs and wants are so part of that is becoming mindful cuz a lot of our clients don’t know what they need and want they just want to feel better but they don’t know how they don’t know what they need to feel better so helping them identify their needs and wants and encouraging them to be their own best friend you know when they get a promotion take themselves out to dinner pat themselves on the back whatever it is don’t rely on other people to do it because other people it’s not that they don’t care but other people are often very involved in thinking about their stuff and they may not notice encourage them to develop a method of internal validation so they can feel like they are all that ‘no bag of chips and they realize why they are lovable human beings and they accept the the fact that everybody is not going to like them and nobody is gonna like them all the time and that’s okay you know my kids don’t like me all the time my husband doesn’t like me all the time I’m okay with that I know I can be challenging but you know most of the time you know they like me and that’s okay and there are some people you know who don’t like me at all and okay there’s nothing I can do about that helping our clients develop an okayness with that helps relieve a lot of anxiety because a lot of people feel like they have to be liked by everybody and if somebody doesn’t like them it’s like what did I do wrong oh my gosh encourage them to develop healthily supportive relationships with good boundaries develop assertiveness skills so they can ask for help when they need it anxiety a lot of times you know that’s the body saying there’s a threat well if there’s a threat maybe you need some help you know dealing with it so people need to be willing and able to ask for help and not feel like that’s going to lead them to be rejected and allow them a certify this will allow them to say no to requests again without feeling like that’s going to result in them being fully rejected describe the ideal healthy supportive relationship and encourage them to separate the ideals from the reals you know let’s look at if you had the best relationship what would it look like okay you know warden June Cleaver we got that now how realistic is that you know let’s look at you know rephrasing this a little bit so it’s less extreme you know warden June Cleaver never fought their kids were perfect you know all those extreme words let’s look at what’s real what happens in real relationships encourages people to identify who would be a good partner in supportive relationships I’m not meaning necessarily romantic I’m meaning friends and where they can be found you know where would you find people that you could be friends with and encourage them to play through what it means when gaming cuz a lot of times again this goes with my reading you know what it means when your friend doesn’t return your text right away what does it mean when your friend cancels dinner on Friday night what does it mean when you see where I’m going with this and a lot of times clients with anxiety and rejection issues and low self-esteem will go to the worst-case scenario so encourage them to go back to finding the exceptions what else could have been happening what else could it be that caused this and it’s not about you so anxiety is a natural emotion that serves a survival function excessive anxiety can develop from lack of sleep nutritional problems neurochemical imbalances failure to develop adequate coping skills cognitive distortions low self-esteem and a variety of another stuff recovery Ambala involves improving health behaviors making sure your body’s functioning and making the neurotransmitters it needs and you know release them as needed to identify and build on current coping strategies address cognitive distortions and develop a healthy supportive relationship with self and others if you enjoy this podcast please like and subscribe either in your podcast player or on YouTube, you can attend and participate in our live webinars with dr.

Snipes by subscribing at all CEUs comm slash counselor toolbox, this episode has been brought to you in part by all CEUs calmly provide 24/7 multimedia continuing education and pre-certification training to counselors therapists and nurses since 2006 have used coupon code consular toolbox to get a 20% discount on your order this month.As found on YouTube Animated Video Maker – Create Amazing Explainer Videos | VidToon™ #1 Top Video Animation Software To Make Explainer, Marketing, Animated Videos Online It’s EASIER, PRODUCTIVE, FASTER Get Commercial Rights INCLUDED when you act NOW Get Vidtoon™

DBT Skills Emotion Regulation | Counselor Toolbox Podcast with Dr. Dawn-Elise Snipes

CEUs are available at AllCEUs.com this episode was pre-recorded as part of a live continuing education webinar on-demand, CEUs are still available for this presentation at AllCEUs.com/counselortoolbox I’d like to welcome everybody to today’s presentation of dialectical behavior therapy techniques emotion regulation we are going to start by reviewing the basic premises of DBT and the reason we’re doing that we’re only going to do it in this one because emotion regulation we’re starting kind of at the beginning but we want to go over what is the theory underlying a lot of what we’re going to talk about we’ll learn about the HPA axis and this isn’t something that Linehan talks about in DBT but it is important for understanding our physiological stress reactions will define emotion regulation identify why emotion regulation is important and how it can help clients ourselves staff yay and we will finally explore some emotion regulation techniques there are things besides just preventing vulnerabilities that we can provide to clients to help them regulate their emotions before moving into that distress tolerance realm of skills and activities so basic DBT premises everything is interconnected when you get up in the morning if you’re having a bad the day you know you didn’t sleep well your back hurts you’re cranky you got a lot of stuff to do it’s raining outside you know yay you’re noticing all the negatives your thoughts maybe more negative you may be more likely to notice the negative you may be more likely to have what we call commonly call a bad attitude if you start to have a better attitude what happens to what you observe and we’ll talk about that in a little while the reality is not static what is true right now in the present may not be true which is you know was the future from what the present was half a second ago so reality changes when we look at a situation when we look at an event, we’re looking at how am i reacting and what is my feeling about the situation right now you know we can learn to change where we’re at but with the information, I have right now what’s going on and a constantly evolving truth can be found by synthesizing different points of view because most of the time as humans it’s just kind of part and parcel of being humans we don’t have the whole picture and I did the best I could with these little graphics here think back if you will to some of PJ’s experiments when he was trying to demonstrate egocentrism when we’re looking at this yin and yang sort of model the girl’s stick figure what does she see if you ask her what color is this orb she would probably say black because we’re assuming she sees the black side if we ask this little thick figure model over here what color is the orb she’s seeing the white side so he’d say white now if we asked a little confused guy who is standing kind of on the third side or the south side he sees both of them so he hears the stick figure girl say it’s black he sees a stick figure boy say it’s white and he’s going well it’s kind of both you can synthesize both perspectives and figure out that this is an orb that has multiple colors even though she can’t necessarily see those colors and he can’t necessarily see those colors so BBT says let’s try to take a look and see if there are blind spots see if there are things we’re not seeing or things we didn’t observe the basic assumptions of DBT and well people do their best if we didn’t think that we probably wouldn’t be in this profession so people are doing their best with the tools they have and the knowledge they have at any given time and I added that extra part people want to get better and be happy most people don’t want to be miserable if it seems like they don’t want to get better then we need to ask ourselves what is the benefit to staying miserable why is it is scarier more threatening more awful to look at getting better or being happy and that’s one of those motivational things we’re not going to go there today but in general people are going to choose the most rewarding option when prevents presented with multiple options okay now this one area in that I kind of diverge from the official statement is clients need to work harder and be more motivated to make changes in their lives I’ve had a lot of clients who have been working their butt off but they may not have the right tools it’s like trying to unscrew something that is Phillips head with a butter knife they’re working hard but it’s not going anywhere because they can’t get any traction so I crossed out the work harder and I tend to replace it with work smarter clients need to work smarter they need to have more tools they need to have more effective tools and some of the tools they have may be awesome if we just tuned them up a little bit sharpen their oil and grease them whatever you need to do and be more motivated to make changes in their life and you’re saying well they’re in therapy they’re coming here for whatever reason there why aren’t they motivated to make changes well again let’s look back at motivation and what’s the most rewarding choice is if they tried to make changes before and it hasn’t worked out and they’ve been told that it was their fault they were being resistant or you know they were blamed in some way or they just felt disempowered what’s going to make them motivated to try to do that again please let me run the gauntlet most people don’t want to do that so we need to help clients work smarter and understand that they are working hard and they need to continue to do so and we’re going to help them get more effective tools and we need to help them get more motivated we need to help them see that this time it’s going to be different maybe a little bit different but this time we’re trying something new it may be different even if people didn’t create their problems they still must solve yep you know if you grew up in a dysfunctional household you didn’t create that problem but it is negatively impacting you today so you’re going to have to fix it if you want to be happy which is the whole goal of the lives of suicidal or addicted people are unbearable and when we’re talking about DBT we’re generally talking about people who are highly emotionally reactive and suicidal self-harm those behaviors are away at this point that they’re trying to figure out how to tolerate what seems like an unbearable situation in their head addiction is much the same way it provides some relief from something they feel they have no control over people need to learn how to skillful live skillfully in all areas of their life well yeah because every area is interconnected if you’re stressed out at work do you just leave work go home and you have not stressed out anymore no that’s not the way it works it would be great if it did but it’s just not even if you don’t take all your stresses of work home with you it has taken a toll on your energy level so when you get home you’re more vulnerable to emotional upset or just fallen asleep on the couch at 6:00 p.m. Whatever it is so we need to help people learn how to live skillfully in each area so the exhaustion or negativity or whatever it is from one area doesn’t bleed over into the other area so we need to learn how to juggle stresses in all of our areas to prevent vulnerabilities and people cannot fail in treatment when someone relapses when someone you know backslides whatever word you want to use I look at it as a learning the opportunity I say okay you made a different choice than we wanted you to make a different choice than you were hoping you would make so let’s learn from and figure out why that was the most rewarding choice than what was on your treatment plan the goal that you’re working toward why what happened what were you more vulnerable so you didn’t choose the newer behaviors because they weren’t as readily available let’s use this as a learning opportunity to figure out what’s going on it’s not a failure it’s a learning moment or a teachable moment so what is emotion regulation emotional dysregulation will start there results from a combination of high emotional vulnerability so you’ve got somebody who is kind of reactive and extended time needed to return to baseline so that when they get upset it takes them longer to de-escalate and get back to baseline and an inability to regulate or modulate one’s own emotions so I want you to think about some the time that you’ve been driving on the interstate and you’re just driving along cruising along and heaven forbid if this has happened I hope not but if it did you’re probably just late a semi comes along and runs you off the road onto the shoulder and oh my gosh you get onto the shoulder your legs just to go in like this you can’t even press the gas pedal because you are so stressed out you’re gripping your knuckles are white from gripping the steering wheel so tight your heart racing you’re breathing fast you’re in full-out fight-or-flight mode so you went from a1 on the stress meter you know kind of cruising along aware of the fact that you need to be cognizant of dangers to a5 of oh crap that could have been bad alright so you take a couple of deep breaths you your breathing goes down a little bit you get to the point where you can press the gas pedal and you pull back out onto the highway now are you returning to baseline and just like la-dee-da cutting around like you were before most likely not you’re a little bit more on edge and you’re checking your bat rearview mirror more often you’re looking back making sure nothing’s in your blood spot more awesome so you’re not returning to that same level of less stress Tunis if you will you stay a little bit elevated because your brain is gone you know I thought it was kind of a safe situation but I’m realizing now that not so much so I’m going to keep you on higher alert and it’s going to take longer for you to return to baseline because you’re looking for those threats now you’re much more aware that it could happen to people who come from invalidating environment people who are regularly chronically stressed they’re constantly looking around for anything else that is going to threaten them anything else that’s going to stress them out so they’re not going from a 1 to a 5 back down to a 1 again they’re going from a 1 to a 5 back down to a 2 and then back up to a 5 and then now we’re only going down to a 3 it’s that stress is ramping up so we need to figure out how to help people deescalate get back down to that one and realize okay I got this that was an unpleasant situation but I got this now emotional vulnerability refers to the situation in which an individual is more emotionally sensitive or reactive than others or then they normally would be you know some people this is kind of and when we’re talking about personality disorders this is pervasive when we’re talking about someone who has been under a bunch of stress for six months this may be a situational sort of thing that we need to help them figure out how to get out of but it may not be something that is completely and utterly pervasive in any event when you are stressed you know you’re already kind of on edge and something happens do you react the normal way that you normally would if you were just like sitting there and going off oh well okay let’s figure out how to handle this or does it throw you up sort of into the stratosphere and for a lot of people with emotional dysregulation when they’re their relaxation is on the brink of chaos so they’re standing there teetering and they’re going okay I cannot take one more wind or it’s going to push me over and then they call them damp they get upset and they’re kind of on freefall for a while they get their balance again but then they’re still right there on that precipice they never come down so what we want to look at is what’s going on with these people that’s making them more reactive that’s making them more alert and more hyper-vigilant to stresses and stressors some of these may be because of differences in the HPA axis which play a role in making people more vulnerable or reactive and we’re going to talk about the HPA axis in a minute environment of people who are more emotionally reactive or often invalidating and what does that mean well pick Jane Jane has had a heck of two years you know there’s just been death after death a job loss she lost her home she’s living in an apartment right now but she’s not happy and you know yeah you can just pile stuff on okay so James struggling right now she’s holding on and really trying to do the next right thing she’s trying to make ends meet trying to do what’s right by our kids just feeling stressed out and then something happens something that most of us would react with it to you know it’s annoying but it wouldn’t throw us into utter chaos well James on that precipice Jane’s already at a four maybe a four and a half depending on the day so when this happened just that too puts her on a scale of one to five puts her at a six-and-a-half which is in freefall but people may not understand that they may not understand what’s going on in Jane’s life and they’re like this is not that big of a deal why are you just overreacting which makes Jane feel guilty Phil is self-conscious and feels misunderstood so then she feels isolated and rejected and we’ve talked about basic fears being rejection isolation failure loss of control and the unknown well James kind of experiencing all of those right now and the people around her instead of being validating and going okay you were already stressed out I can see how this was just the straw that broke the camel’s back they’re going what is your the problem so she doesn’t feel like she’s got social support she’s out there on an island unto herself so we want to help Jane with emotional regulation because we know she’s up here and we know she doesn’t like going into that freefall but how do we help her emotional regulation is the ability to control or influence which emotions you have when you have them and how you experience or express them and that’s a quote straight out of Linda hands book so emotion regulation prevents unwanted emotions by reducing vulnerabilities so you can go through life you can go through the day you can experience stress but instead of feeling overwhelmed or enraged you might feel mildly irritated for a second and then choose to move on emotion regulation helps people learn how to change painful emotions once they start so you don’t get stuck nurturing that emotion or feeding into it and being angry with yourself because you got angry about something you have no control over it teaches that emotions in and of themselves are not good or bad they just are it’s your brains hardwired way of responding based on waiting for it the information that it has at this particular point in time spiders if you’re afraid of spiders that is your brain’s way you see a spider and you feel fear it’s your brain’s way of going threat spiders can be a poisonous big threat so you want to get away from it that’s your body’s way your brain’s way of going let’s survive we want to do this now you can figure out you can learn more about spiders so in the future when you encounter then you realize that they’re not you know 99% of them are not threatening to humans but right now at this moment your brain is saying warning getaway you probably want to do that so it teaches that emotions internet themselves are just prompting us to do something they are survival responses and suppressing them makes things worse telling yourself I shouldn’t feel afraid does that do any good if your kid comes to you and tells you that you know I’m having a crappy day or I hate this does it usually do any good to tell them well you shouldn’t feel that way feel better you know just be happy does that work I’ve never had an experience where that worked now it may work for some people but so we want to help people identify their emotions and not get consumed by the emotions are effective when acting on the emotion is in your best interest so sometimes it’s in your best interest expressing your emotion gets you closer to your ultimate goals sometimes expressing your emotion gets you closer to your short-term goals like making the pain stop and true pain is unpleasant however in the big scheme of things 15 minutes from now 3 hours from now is that getting you closer to the goals that you want to achieve or was it just a stopgap expressing your emotions will influence others in ways that will help you so if you want to influence others in ways that are positive and will help you then emotions can be very kinder that can be very helpful emotions are sending you an important message and we already talked about that so I’m thinking the devil’s advocate amigos well I can think of a client that goes you rage is a great emotion to express is it in my best interest yeah gets people to leave me the heck alone does it get me closer to my ultimate goals yeah it reduces my stress by getting people to leave me the heck alone will it influence others in ways that will help you, yeah it make them go away and are these emotions sending you an important message yet rage is telling me that these people like everybody are a threat to me so in the short term when you look at it that way it can be tricky to see but we want to help people get outside of this immediate threat and say where you want to be what happiness looks like to you or however you want to define that ultimate goal and then once you get into distress tolerance was your Thursday talk about how do you endure unpleasant emotions so you don’t take the stopgap route now on to our favorite HPA axis the hypothalamic-pituitary-adrenal axis is our central stress response system and doesn’t get too caught up and all the psychobiology of this I think it’s good to be cognizant of but we’re not prescribing hypothalamus place in the brain release is a compound called corticotropin-releasing factor or CRF which triggers the release of adrenocorticotropic hormone from the pituitary gland which triggers the adrenal glands to release stress hormones particularly cortisol and adrenaline now your adrenal glands are actually on your kidneys and why is that important what I want you to see or understand is there are a lot of systems involved there are a lot of hormones involved there’s a lot of stuff involved it’s not just box you know you’re releasing a bunch of chemicals in your body that are altering the neurochemicals and the other hormones to prepare you for spiders the adrenals control chemical reactions over large parts of your body including the fight-or-flight response and produce even more hormones than the pituitary gland so you’ve got these adrenals this is kind of your stress area if you will it produces steroid hormones like cortisol which is a gluteal corticoid which means it makes your body release glucose what we know is that glucose is blood sugar energy all right so it increases the availability of glucose and fats for the long-term fight-or-flight reaction it also produces sex hormones like DHEA and estrogen okay why is that important because we know that when estrogen goes up serotonin availability goes up so if there are the adrenals are busy doing something else it may cause other hormonal imbalances and it also produces stress hormones like adrenaline that is going to ramp you up they’re going to increase your respiration increase your heart rate all that kind of stuff so once you have that whole reaction we talked about and the perceived threat passes cortisol levels return to normal great this is what happens in the ideal situation but what if the threat never passes what if we’re working with a client who is constantly fearing rejection and isolation they need external validation because they don’t feel good enough as they are they don’t have social support because their emotional reactivity kind of pushes everybody away so they’re constantly feeling this threat of rejection isolation failures loss of control and the unknown they’re holding on just like you were holding on to the steering wheel after you ran off the road and you got back on you know you kept chugging because you wanted to get to your destination but you were scared witless okay so you’re chugging along what’s going on what’s going on in that body the amygdala and the hippocampus are intertwined with the stress response the amygdala modulates anger fear or fighter flight and the hippocampus helps to develop and store memories when you’re under stress and think about a time when you are under a lot of stress were you effective at learning and paying attention to the good things and the bad things or were you just trying to make the pain stop and make the threat go away from the brain of the child or adolescent is particularly vulnerable because of its high state of plasticity which is why do we see people who tend to have personality disorders much of their trauma and stuff really started early in their development and which is why it’s pervasive in every area or many areas of their life, bad things are learned emotional upset prevent learning new positive things to counterbalance it if you’re in a bad mood if you’re scared if you’re threatened you know if you’re hungry homeless put whatever stuff is there are you paying attention to the bluebirds that are flying around and singing pretty songs or are you paying attention to the fact that you got an a on a test maybe not so, we need to understand this person who lives in a chronically stressful environment may also have an overactive HPA axis so they’re already they’ve already got some adrenaline and cortisol going on they live kind of in this state of hyper-vigilance and then something happens and they’re just like through the roof kind of like when you scare a cat what happens to the brain one is a chronic threat to its safety and a constant the underlay of anxiety is constant undercurrent as it learns your brain forces synaptic connections from experience and pruned away connections that aren’t utilized by people who feel a lack of control over their environment are particularly vulnerable to excessive stimulation of the stress response now it’s not just children abuse and neglected children pop right up there but abuse and neglected adults think about a client you’ve worked with who’s been in an abusive relationship for years does she have all the happy connections or is she pretty much terrified exhausted and stressed out most of the time adults with anxiety or depressive disorders it doesn’t even have to be an abusive or neglectful situation if you have someone that forever whatever reason has clinical anxiety or depressive symptoms they are in this state of constant threat and constant of people if you will so they’re not seeing they’re not able to learn and take in as much of the good stuff so there’s more bad stuff coming in they’re paying attention to more of the bad stuff or unpleasant stuff the synaptic connections that form the foundation of people’s schema of themselves in the world become skewed towards the traumatic event at the expense of a synaptic Network-based on positive experiences and healthy relationships so we had this client here and these are her negative experiences she has a lot of them and she’s got these going through her head a lot and it’s not they don’t just go away whenever she meets somebody and she’s like well they’re going to leave me whenever something happened she feels isolated and alone she may fear so she’s got really strong connections to those memories and past experiences and when you’re in the midst of all this, there’s not a lot of happy stuff and even when she appears happy a lot of times she’s faking it she’s not seeing and remembering all the happy stuff she just wants to avoid the pain another example I could give you is thinking about a city planner now a city planner only has a the certain budget just like we only have a certain amount of energy the city planner looks and says what roads and what connections between cities get the most traffic and let’s devote our resources and strengthen those connections because we know we’ve got all kinds of traffic going over there and those roads that don’t travel those back roads we don’t need to pay much attention to them right now because we need to make sure that those roads that are used the most are strong but that’s the best analogy I can give without putting out strings and everything else but so the hyper-vigilant state active IDEs activated by the stress response that disrupts our ability to focus and learn you know we’re just trying to not die we’re trying to not be consumed by pain it impairs the ability to form new memories and recall information due to the physiologic changes in the hippocampus, it’s not time to learn and process and do all that kind of stuff have you ever tried to study for a test when you had 16 other things going on that you are stressed about how well did you remember this stuff over here sometimes people relate things to prior experience well most of the time so maybe they’ve had a lot of dysfunctional relationships and they start to get in a relationship which side is going to be triggered the negative memories are the positive memories and then you have somebody who may be attached to some positive relationships they start to get into a relationship and they remember some of the positives because there have been some really good relationships but you know they may remember the negative too but most likely they’re going to remember more strongly the positive so what’s their reaction going to be if we’re trying to help our clients develop a healthy support system we need to help them address some of those highways that are going towards the negative memories emotion regulation is transdiagnostic or useful with many disorders it helps people increase their present focused emotion awareness it says right now right here right now what are your feelings what are your physical sensations what are your thoughts and what are your urges it helps people increase cognitive flexibility because it helps the kind of step back and take a look and say okay what are my options let me step back from being intertwined with this feeling and go okay I feel angry got it what are my options here what do I usually do what I want to do when I’m on autopilot what are some other options I could do that might help me move toward where I want to go identifying and preventing patterns of emotion avoidance and emotion-driven behaviors we don’t want to get into the situation of constantly trying to avoid unpleasant emotions by lashing out by hurting ourselves or by doing things reactively when I feel this way I must smoke a cigarette I must cut myself I must fill in the blank we want to help people find alternate ways and be able to step back and say that is an option is it the option I want to choose today increasing awareness and tolerance of emotion-related physical sensations sometimes these physical sensations are just so powerful and so overwhelming and sometimes the rush of adrenaline and that foggy wibbly-wobbly feeling you get in your head when you have just adrenaline coursing through your veins is so overwhelming that people don’t know what to do with it and are afraid it won’t stop so let’s help them increase their awareness and tolerance of this helped them understand that it passes and use emotion-focused exposure procedures when they get upset help them think about things in the group sessions that get them a little bit revved up you know we don’t want to precipitate a full-scale crisis or talk about something that happened last week that got them upset and let’s apply these procedures emotional behavior is functional to change the behavior it’s necessary to identify the functions and reinforcers of the behavior so when they did it you know let’s talk about cutting because you know that is one of those behaviors that we see are self-injury it’s what is the function of that behavior cutting or self-injury is a way of inflicting physical pain where the person has control and they focus on that and they feel a sense of mastery when the stuff going on in their head feels completely uncontrollable and intolerable it diverts their attention and it also is something that they they can control how much pain they’re in so that’s how it’s functioning now is the best the response we want no but we can see why somebody might engage in that behavior and what reinforces that behavior well when they do that not only do they get a reprieve from this emotional turmoil that they don’t feel like they can touch or control or do anything with but their body also releases endorphins release natural painkillers to kill that physical pain which makes them feel a little a bit better so they’ve got kind of a double whammy on reinforcers there so we understand that now we need to find something else that they can do and help them figure out how to tolerate the turmoil emotions function to communicate to others and influence and control their behaviors and serve as an alert or an alarm to motivate one’s behaviors so let’s talk about the first one communicate to others so I’m communicating to a rat around me the people around me through my emotions what’s going on if I’m angry I’m lashing out I’m going to influence people’s behavior and they’re probably going to back off if I am sad or crying or scared that might bring them closer and in a more supportive sort of thing you know again you’ve got to look at some of the behavior self-injury can elicit a caretaking response but these emotions before somebody start acting out the behaviors the emotions serve as a cue that okay Sally is getting ready to go in free fall so they can start reacting sooner and it serves as an alert or an alarm to the person to motivate their behaviors if they know you’re on the precipice if you know you’re right on the edge of being vulnerable cranky being irritable that day can motivate your own behaviors to figure out how to reduce some of your vulnerabilities and identify obstacles to changing emotions now we can’t just say be happy and all of a sudden somebody’s like oh I don’t know why I didn’t think of that I’m just going to go ahead and be happy that’s just not how it works we want to look at organic factors do they have an organic long-standing chemical imbalance of some sort and it may not be neurochemical it may be hormonal they may have too much estrogen too much testosterone too little estrogen too little testosterone whatever let’s figure out you know have them go see their doctor and figure out if there is something fibroids or moans whatever that might be affecting their mood okay once we identify anything that we can tweak there we can’t measure neurotransmitters we’re out of luck there because they’re found in so many places in the body that there’s no way to isolate how much serotonin is actually in the brain can’t do it yes we want to look at other factors that are biological imbalances neurochemical imbalances that are caused by chronic stress that cause addiction to sleep deprivation and nutritional problems so what sort of chemical imbalances are we precipitating by keeping the stress going and keeping the adrenaline going keeping your body revved up all the time we want to look at obstacles well let me stay with biological factors here real quick the organic things if we can refer to the physician and we can figure out ways to address those that give the person one step forward so they’re not feeling as depressed or they’re not feeling as reactive people with hyperthyroid you know when their thyroid is overactive may have some anxiety issues or some other mood issues that can be addressed with medication then we Looking at situationally caused things is the ways we can help them reduce their chronic stress sometimes there are some easy right-now sort of solutions other times but chronic stress comes from issues that are so long-standing it’s going to take a while it’s not that we can’t do it but it’s going to be a process so we move on and we say okay addiction we know that when people use stimulants rev them up and then they crash and it makes them more than emotional yo-yo caused by the substances or the addictive behaviors also makes them more vulnerable to emotional reactivity sleep deprivation is all kinds of hormones out of whack and tends to make people more irritable that’s one almost everybody can look at addressing right now and nutritional problems if they’re not eating well not eating at all encourage them to see a nutritionist to make sure they’re getting something balanced that they will adhere to not something that they look at and go yeah that looks great but no way I’m eating nuts skill factors what can we help they with we can identify cognitive responses that are obstacles which as I can’t do that I won’t do that resistance in some way my response to that obstacle is set to look at it and weigh the positives and the negatives do a decisional balance exercise to address the cognitive responses and figure out why is the dysfunctional or unhelpful reaction more rewarding why is it more rewarding to be angry or scared than to look at doing things and thinking of things that will help you feel happier what’s the disconnect generally, it comes back to prior failures and fear of failure because they’ve been down that road before and it’s such a letdown when they’re feeling good for like three weeks and then they crash behavioral responses that are obstacles to changing emotions if somebody lashes out when they get upset they lash out and throw things and then they feel guilty so this behavioral response may lead to having more difficulty changing emotions because we’ve got to help them figure out how to pause before the behavioral the response so they don’t compound the situation with more negative emotions and environmental factors people places and things being in environments where you’re surrounded by people who either agon negativity or who bring out you know they’re there with you they’re talking about conspiracy theories they’re just negative about everything or they’re critical of you or remind you of situations where you’ve been criticized before so first, we want to help people identify and label emotions a lot of our clients are relatively Alex Simon you know they have a small repertoire if any of noting their emotions they just generally go from situation to reaction and label what they felt is kind of a mystery so we want to help them and doing it retrospectively is fine at first because that’s probably all you’re going to be able to get the event profiting the emotion what were your thoughts your physical sensations and your urges help me describe this in enough detail that if we were going to give it to an actor or an actress they could recreate the situation what expressive behaviors were associated with that emotion you know did you cry did you throw things did you hit the wall what were your interpretations of that event at the moment not retrospectively but at the moment what were your interpretations of what was going on what history before the event increases your vulnerability to emotional dysregulation lots of big words what happened before that that already stressed you out or had you on edge and you know we go through a whole bunch of different things and this is you know behavior chaining we’re looking at kind of what led up to the event what made you more vulnerable and what were you feeling at that time and then what were the after-effects of the emotion or the reaction on your other types of functioning so after this event and you went into freefall and you got angry and you lashed out and you screamed and you threw things how did that affect your work how did that affect your relationships with your family how did that affect your mood and just generally your sense of being in yourself for the rest of the day changing unwanted emotions okay so we started labeling them we figure out what we’re feeling we figure out that yeah when we feel that way we act in ways that you know make us feel worse afterward what do we do about it let’s change All alright we already talked about the obstacles and we’re trying to address those but in a moment check for facts ask yourself what are the facts for and against your belief if you believe that someone did something to be antagonistic towards you okay what was their motivation what is the facts for and against that also ask yourself is this emotional or factual reasoning am I making a decision based on how I felt I felt attacked therefore I must have been being attacked or facts you know I felt attacked yes but that was because this person said ABCDE and all of those were very attacking and I felt like I needed to defend myself so those are to check the facts sort of steps or you can go with problem-solving so let’s change the situation that’s called cause any unpleasant emotion like I said with spiders at the moment you may not have enough information to not feel scared but maybe your spouse loves hiking and camping and you want to go but you’re afraid of those aren’t spiders so how can you change the situation so spiders don’t trigger that same reaction increase knowledge increase exposure there are a lot of different ways but problem-solving says ok what can I do so my reaction my correct reaction is not one of threat or anger but it is one of at least mild acceptance prevent vulnerabilities which helps reduce reactivity if you are a hundred percent you know you get up and you’re like this is going to be a good day to day things that come your way are probably going to roll more like water off a duck’s back then smack you upside the face like a mud pie so we want to prevent vulnerabilities from the turn down the stress response because when you’re not when you’re not up here already then you know you can fluctuate a little bit more and they help the person be aware of and able to learn and remember positive experiences so if you turn down that vulnerability and somebody’s in a good place or a better place than they were at least they’re going to be able to notice and we’re going to want to encourage them to notice the positive experiences you know instead of thinking that all people are threatening all people are going to hurt me all people are going to leave they might notice that you know there’s Sally over here who’s worked here for 15 years with me and you know she’s there she sometimes calls in sick but then she comes back she’s generally in a good mood you know she’s not such a bad person and you start noticing some of the things that are not self-fulfilling processes building mastery through activities that build self-efficacy self-control and competence smuggle we don’t want to say you don’t want to set a goal where somebody needs to go an entire week without having an emotionally reactive response let’s say go for hours or maybe even a whole day that would be wonderful but first, we’ve got to talk about how to reduce those vulnerabilities so we set the person up for success what things can you do and well and we’re going to get down here in a minute what can you do if you wake up and you’re feeling vulnerable you know the creepy crowds are going around they cancel school for the entire week for school the county school system kids are off for an entire week because of illness right now but you wake up in the morning and you’ve got a fever and a sore the throat you’re like I don’t want to go to work and get out of bed today what can you do to prevent being grumpy and overly reactive throughout the day’s mental rehearsal and this can go for if you’re getting ready to do something scary or threatening seeing yourself do that and do it successfully and this can even be during the day just envisioning yourself getting up and eating your breakfast driving to work going through your day seeing that one person at the office that always has some sort of snarky comment to say or whatever irritates you laughing at it or dealing with it just fine going through everything in your day as you would like to see it happen envision it see see what you can do rehearse it rehearse how to handle negativity you know if you know you’re going to have to go in for your annual evaluation with your boss okay so mentally rehearse how it’s going to go how are you going to react what’s going to happen so you’re prepared for it you have your responses and it takes some of the unknown out of the situation physical body mind care pain and illness treatment and the acronym for this is please I changed one of them to laughter it used to be physical illness and that was both PNL but I like laughter anyway we’ll get there when you’re in pain or when you’re sick you’re vulnerable to being a little bit cranky you know that’s just because your body is already saying you are weak you know back in the day when you had to defend yourself against predators the sick ones and the ones that were in pain were the ones that usually got taken out first as a part of our brain that still remembers that for whatever the reason so when we’re in pain or when we’re sick our body keeps that cortisol keeps our cortisol levels higher and the stress response a little bit higher so we want to deal with those things but know if we wake up and we’re in that situation moment that was a little bit more vulnerable so we need to handle it with care and laughter you can’t be miserable and happy at the same time laughter releases endorphins laughter helps people feel a little bit better and find something to laugh at and have on my phone I keep comedy skits every once in a while I’ll just pop one in even if I’m not having a bad day pop it in because I like to laugh eat two-sport mental and physical health avoid addictive or mood-altering drugs or behaviors that are going to put you on that the up-and-down roller coaster that goes up and it goes even further down than you were when you started to get adequate quality sleep and exercise also helps increase serotonin and release endorphins which help people be in a better mood mindfulness is a judgemental observation and description of the current emotions we’re not going to go deep into this right now another class on mindfulness and you can also google it remembering that primary emotions are often adaptive and appropriate I know I said that like six times much emotional distress is a result of your secondary responses shame over having it I shouldn’t feel this way anxiety about being wrong you know maybe this is the wrong way to respond or you know what if I’m wrong about this or rage doing due to feeling judged for feeling that way I feel this way and you’re telling me I shouldn’t how dare you so mindfulness is kind of an exposure technique because it helps people identify that yes I feel that way but it helps them learn to step back and figure out how to not judge that and just go okay I feel that way better or worse whatever that’s how I feel exposure to intense emotions without negative consequences that non-judgmental acceptance just going all right is what extinguishes the secondary emotional responses of feeling guilty about it or feeling ashamed or angry at yourself for being angry so think of it this way if you can’t see this one’s the best Bruce Lee picture I could come up with scenario one is an unpleasant experience the person has an unpleasant emotion and then feels guilt shame or anger for feeling that an emotion so instead of having to deal with one emotion one-on-one now you’re having to fight for different unpleasant emotions and you start acting to try to stop the avalanche of negativity in the absence of adequate skills now Bruce Lee he was able to take out four or five at a time but most of us you know we would be beaten because all of these adversaries would be coming at us and we would be building on them in scenario two and this is where we want people to get they have an unpleasant experience which is part of life they identify unpleasant emotions again part of life is sucky but part but they can deal with one emotion they’re like okay I’m angry what do I do about it instead of I’m angry what do I do about it and I’m guilty and you see how you know she’s got this she can take that one emotion so what we’re helping people do is uncomplicated this regulation is common to many disorders people with dysregulated emotions have a stronger and longer-lasting response to stimuli yes they’re already kind of stressed out they’re already hyper-vigilant if you want to say they’re already wound up a little bit and then something happens and it amps for months now we have a scale of 1 to 5 if they’re already on a 4 and it amps them up 2 points they’ve fallen off the scale they’re in freefall so we need to understand that what we perceive as an excessive emotional reaction they may not have been starting from the same place that we were, we’re starting from a 1 if they’re starting from a 4 you know then their reaction to the same thing you seemed pretty reasonable emotional dysregulation is often punished or invalidated and increases hopelessness and isolation emotional regulation means we help people use mindfulness to be aware of and reduce their vulnerabilities so we help them take it so they’re not at a 4 there may be a 2 you know they’re in therapy for a reason we’re going to help them work on the other stuff and get them down to a 1 but right now let’s help them figure out ways, they can take down their stress response take down their just underlying anxiety, and stuff identify the function and reinforcers for current emotions when they happen was understand where they came from because they’re functional do that chaining worksheet check for facts ok now that I know how I feel I know what my reactions are I know what my thoughts are I know what my urges are let’s check the facts in the situation for and against that forces people to kind of step back which lets the urge sail out some and then problem-solves what can I do right now to improve the situation and what can I do in the future so I don’t necessarily experience this exact the same situation again how can I break that mold okay so emotion regulation doesn’t provide us with a whole lot of distress tolerance skills, emotion regulation is really about preventing vulnerabilities and helping people figure out okay here’s where I’m at how do I pause so then I can choose from my disgust distress tolerance problem-solving or interpersonal effectiveness skills but it’s a big step how awesome would it be if you could eliminate some of your vulnerabilities and think about it just for a minute or two what vulnerabilities you’ve got going on in you right now and how many of those you know could you potentially over the next week or two kinds of address sleeping and eating maybe you have 16 things going on and you could pare it down to eight there are a lot of different things that you might be able to kind of pull out of the rabbit hat if you will and what kind of a difference would it make if you’re talking to your staff and looked around at your organizational environment what vulnerabilities are there environmental vulnerabilities physical vulnerabilities my best friend’s working somewhere right now where pretty much everybody is required to work doubles because they are so short-staffed they’re going to start getting vulnerable pretty soon so look around what can you do to moderate that so they can model effective emotional regulation but they can also not be emotionally dysregulated by a client who has emotional dysregulation issues all right so that concludes our discussion today if you have any questions I would love to hear them if you want to discuss that’s awesome if you want to get on to your next client you know I totally understand that I want to wish everybody a happy Valentine’s Day for me I don’t particularly pay a lot of attention to Valentine’s Day but it is the eve before half-price chocolates and that is my kind of my kind a day you you you you if you enjoyed this podcast please like and subscribe either in your podcast player or on YouTube you can attend and participate in our live webinars with dr.

Schneider I subscribing at all CEUs comm slash counselor toolbox this episode has been brought to you in part by all CEUs calm providing 24/7 multimedia continuing education and pre-certification training for counselors therapists and nurses since 2006 have used coupon code consular toolbox to get a 20% discount on your order this month.As found on YouTube Hi, My name is James Gordon 👻🗯 I’m going to share with you the system I used to permanently cure the depression that I struggled with for over 20 years. My approach is going to teach you how to get to the root of your struggle with depression, with NO drugs and NO expensive and endless therapy sessions. If you’re ready to get on the path to finally overcome your depression, I invite you to keep reading…

Trauma Focused Cognitive Behavioral Interventions: Trauma Informed Care

this episode was pre-recorded as part of a live continuing education webinar on-demand, CEUs are still available for this presentation through all CEUs register at allceus.com/counselortoolbox I’d like to welcome everybody to today’s presentation on trauma-focused cognitive behavioral therapy part 1 treating trauma and traumatic grief in children and adolescents in this first part we’re going to define trauma-focused CBT and talk about what we’re dealing with here because trauma-focused CBT is a best practice and it is a manualized best practice so you’re going to learn about it today but you’re not going to have enough skills where you can say you are certified in TF CBT however I will provide your resources should you want to go out and pursue those so we are going to talk about TF CBT as a best practice and implementing fidelity but I’m going to also take a few detours and as I always do and talk about how this might be able be useful with adults who have a history of trauma in childhood we’ll explore the components of trauma-focused CBT and their intended functions, we’re not going to get through all of those today but we’re going to start and we’re going to explore ways to use TF CBT with adult clients so TF CBT works for children who have experienced any trauma including multiple traumas so what we’re talking about is children who come to your office who are presenting with trauma-related issues it’s effective with children from diverse backgrounds and works in as few as 12 treatment sessions so a lot can be accomplished in 12 sessions they’re not necessarily weekly sessions they can be spaced out a little bit part of it depends on the age level of the child how long ago the trauma was any concurrent developmental or mental health issues that might be present yada yada yada so it may be a little bit longer it may be a little a bit shorter in terms of calendar time but you can also extend the number of sessions because some of these things for example when they start talking about cognitive coping differentiating between thoughts and feelings, some children take a while to get the hang of the the nuance between the difference between thoughts and feelings so you might have to do two or three sessions helped them to identify feelings and use the feelings thermometer this has been used successfully in clinics schools homes foster care residential treatment facilities and inpatient settings so there’s not an environment in which it can’t be used provided that there is a supportive caregiver that can be of assistance obviously if you’re working with a 10 or 11-year-old or a little bit younger or an older adolescent but you know any child who may need some support outside of session we don’t want to be creating a crisis and then leaving them kind of defend for themselves between sessions without some sort of emotional and cognitive support so there must be a relationship that there is a bond if you will a the rapport between the clinician and the caregiver who may not be the biological parent or the caregiver and the child it does work even if there is no parent or caregiver to participate in treatment however again we need to be selective about how we’re using that so if you have a child and you’re going to use this particular approach and there’s no parent or caregiver to participate it may be safer to use it in a residential setting or an inpatient setting where there is a clinician somewhere where they can get emotional support because as you’ll see when we get into the trauma narrative gets intense TF CBT is intended for children with a trauma history whose primary symptoms or behavioral reactions are related to the trauma so if you’ve got someone who has an unfortunate childhood but you think their behaviors may be more related to the peer group maybe more related to conducting disorder or FASD or something else that may not be appropriate because what we’re going to look at with TF CBT is reducing the PTSD symptoms the hyper-vigilance avoidance behaviors etc as well as improving social skills and helping the person identify and communicate their feelings and needs traumatic stress reactions can be more than simply symptoms of PTSD and also present as difficulties with affect regulation we’ve talked before about how people who are experienced who have experienced trauma may develop a situation where they are more likely to experience emotional dysregulation the HPA axis kind of tightens up and holds on to the stress hormones hold on to the stress reaction but then when it does perceive a stressor it goes from 0 to 250 there’s no I’m going to get a little bit upset it is either nothing or it is a huge mountain there’s no mole hills there so there may be problems with affect regulation there may be problems in relationships because of difficulty trusting other people because of difficulties with their self-perception and systems of meaning which you know we’re getting to in a few minutes but the way they conceptualize the world because all of a sudden their world was turned upside down somatization feelings coming out as physical symptoms so headaches body aches more illnesses more days where they just don’t feel well and you know sometimes they just really don’t feel well however, is it because of a bacteria or a virus or is it because of a stress reaction that is kicking off all kinds of imbalances in hormones and neurotransmitters so we want to look at what the effect are these traumas having on this youth or person and if we address this trauma and if we help help them come to some sort of resolution or acceptance of the trauma and integration into their world view of why this trauma happened and making meaning from it will help improve these areas will help them reduce their hyper-vigilance etc and for many clients the answer is yes and I talked earlier about the fact that this may be useful now it was designed for children and adolescents but many of the adults I’ve worked with are very Alex thymic they are very unable to identify their emotions their very unable to express their feelings sometimes they don’t even know where their fear is coming from they’re just sort of paralyzed with fear and don’t trust the world and they’re angry at everybody and if it comes from a traumatic experience then helping them explore how that trauma is impacting them in the present can be useful in their recovery process so these issues that TF CBT may help improve aren’t just limited to children and adolescents they can present in adults who were traumatized as children and who didn’t develop the skill to effectively deal with the trauma components of CBT TF CBT psychoeducation we’re going to start by teaching them what they need to know about the trauma we’re going to talk about in depth about these so I’m not going to detail them very much here parenting skills and if you’re dealing with an adult oftentimes I will provide what I call reap Aron ting skills if your parent were here or if your parent would have responded how you would have wanted how would they have responded how can you do that for yourself now because sometimes you don’t have a significant other or a caregiver with an adult client either but we want to help them figure out how to self nurture if needed relaxation and stress management skills because some of the stuff we’re fixing to talk about is going to be extremely distressful so you have some wiggle room if you will in terms of what skills do you teach here they prescribe some but as far as relaxation and stress management affect expression and modulation DBT skills seem to fit well into this framework for helping people tolerate the distress not act on their impulses understand where the emotions are coming from and preventing vulnerabilities and all that other stuff that can help them function outside of session and when they’re not doing their homework help them feel like they’re able to focus on something besides the trauma because we’re just kind of ripping the band-aid off that wound at a certain point and they may have difficulty focusing on anything else likewise some children and adolescents will come to you when that trauma is still relatively present and all they can think about is that trauma or it regularly comes up for them and so we can help them learn skills so they can start living more of what they might consider a meaningful life that’s not dominated by memories of this trauma while we’re working through the process we want to give them a little hope that there’s relief in sight cognitive coping and processing are provided next and enhanced by illustrating the relationships among thoughts feelings and behaviors so initially cognitive coping skills are taught and then all of this is going to be applied later as soon as we get into the trauma narration helping the youth work through narrating the trauma and cope with the feelings and thoughts that come up in vivo mastery of trauma reminders so any of those triggers that are triggering flashbacks that are kicking off hyper-vigilant situations we’re going to address as they come up in the trauma narration we’re going to help the person identify what it is about certain situations that bring up this particular memory and how we master how to do we deal with it and then finally conjoint Parent Child sessions and these don’t come till the end all along the parents or the caregivers are participating in the process assuming there is a parent or caregiver and understand learning a little bit more about what’s going on but we’ll talk about what the clinician does in the parent sessions as well as what the clinician does in the child sessions as we go through each stage effects of TF CBT reduction in intrusive and upsetting memory so that’s awesome and you know if you think about what’s the function of these intrusive memories a lot of times it is because either they haven’t been integrated into the person’s schema of the world and well-being and or they still feel unsafe they have some cognitions that is telling them they need to be alert they need to be aware they’re not safe so helping them identify any cognitions and triggers that may be causing intrusive and upsetting memories and addressing those again in the in vivo desensitization avoidance helping people reduce their avoidance of certain situations and certain activities so they don’t feel like they are confined basically to their prison it helps reduce the emotional numbing of a lot of people when they go through trauma it’s so overwhelming and they’re so afraid if they feel they won’t be able to stop feeling so they numb emotionally it’s protective it makes sense and as they develop the skills to handle this and as they learn they can tolerate the distress of the memories of the trauma it empowers a lot of clients there’s a reduction in hyperarousal depression and anxiety behavior problems when you’re dealing with adolescents or children, especially ones who don’t have the ability to articulate their feelings and their thoughts that are underlying these feelings and how they relate to the trauma I don’t know many adults that can do that so children typically act out physically to either protect themselves or try to get some sort of protection comfort attention so they feel more secure so it’ll help reduce some of that as we empower the child to identify what’s going on and articulate their needs more effectively communicate with their parent and also deal with some of the stuff that’s making them still feel threatened or afraid reductions in sexualized behaviors trauma-related shame interpersonal distrust and again social skills deficits if a youth has been dealing with this trauma issue for a while, they may have avoided other people because they don’t trust other people they’re afraid of other people haven’t made sense of it so they may not have developed the social skills that other youth have developed because they have been avoidant situations that might trigger the trauma memories so who is is inappropriate for if the primary issue is defiant or conduct disordered it if you don’t believe from a clinical standpoint that this is coming from a the root of trauma history and addressing trauma is probably not going to do it now do these children who are oppositional defiant conduct disordered have traumas in their history sure probably they do but are those traumas causing the behavior or are those traumas sort of irrelevant and one thing that you’ll find is a lot of we’ll talk about it more in a minute a lot of people have multiple traumas but they may have resolved certain ones and be okay with they but others are still open wounds don’t use it if the child is suicidal homicidal or severely depressed if a child is in that particular state we don’t want to start poking the bear especially in an outpatient setting but even in residential and even residential with adults I was always extraordinarily cautious and hesitant to do any sort of trauma work in the first 30 to 60 days I had a client in residential substance abuse treatment I mean the first 30 days they’re still kind of sobering up there are a lot of impulse issues and in the next 30 days there’s usually a a lot of mood issues so I want them to feel like they’ve got a handle on things before we start ripping band-aids off open wounds if possible and if you’re obviously if you’re dealing with a a child the safety and ethics would just tell you when this might not be appropriate additionally when children remain in high-risk situations with a continuing possibility of harm such as in many cases of physical abuse or exposure to domestic violence some aspects of TF CBT may not be appropriate for example attempting to desensitize to trauma memories is contraindicated when real danger is present I took that verbatim from the TF CBT training or one of them that is cited in your booklet or your class it is important to understand that not all of these children are coming or existing living in an environment that is healthy and you may have a parent who is court-ordered or ordered by child welfare to bring the youth to counseling to address trauma issues but that child is going back to a chaotic situation so again it’s going to be an ethical decision on your part once you have all of the training and you’ve become certified and TF CBT it would be an ethical decision at that point whether or not to implement the program to fidelity and you know we want to make sure that the child is cognizant of any real and present dangerous challenges, they always come up, especially when you’re dealing with families if the carrot parent or caregiver does not agree that the trauma occurred and we’ve all dealt with this whether you deal with adults who were traumatized as children and they say nobody believed me when I was a child and I tried to get somebody to here or whether you’re dealing with a child right now who is with a caregiver or removed from a caregiver it doesn’t matter but the caregiver was present at the time and the caregiver doesn’t believe the trauma occurred it can be a huge barrier because that caregiver is not going to be able to be as supportive if the The caregiver agrees the trauma occurred but believes that it is not affecting the child significantly or thinks that addressing it will make matters worse then we can do some education here we can identify symptoms that are coming out that are present which may be caused by the trauma and we can show the research of TF CBT as well as other methods if you choose not to use TF CBT but you can show the caregiver how addressing this trauma can mediate or mitigate some of those symptoms if the parent is overwhelmed or highly distressed by his or her emotional reactions and is not able to attend to the child’s experience so if the parent feels guilty for what happened or you know such as in the cases of domestic violence the parent is dealing with their trauma because they are surviving domestic violence they may not be able to attend to the issues of the child at that point and it’s not a judgment it’s just how much energy you have and if you’re trying to survive yourself you’re probably not going to be able to devote your full attention to jr. Over here so we need to look at timing if the parent is suspicious distrustful or doesn’t believe in the value of therapy again we can do some education here rapport building and go slow if the client and I my experience has been this occurs when the client is court-ordered or ordered by child welfare the parent does not trust the system and by the fact the system referred them to you you’re part of the system so start low go slow try to be as compassionate open and honest as possible I try with all of my clients but especially with my clients who are involuntary I am very open about what’s in my records and what I write down because that could go to the court which could you know potentially reflect upon them you know we talked about what’s going in into the chart I don’t use subjective judgment everything’s objective unless we talk about something and they say yeah I’ve made progress here or I feel like I’m backsliding here and then we talk about how to how that’s going to be put in the notes I don’t lie I don’t cover-up but I do want to make them feel more comfortable with what’s being written in that magic file that gets stored away that nobody can see if the parent is facing many concrete problems such as housing but consume a great deal of energy again if it’s a domestic violence issue and they’ve moved out and they’re living in a homeless shelter or a domestic violence shelter the parents may be exhausted and just not able to fully attend to the increased emotional and psychological demands of the child during this therapy you know they’re going to be doing good to help junior through the present crisis let alone anything else or if the parent is not willing or prepared to change parenting practices even though this may be important for treatment to succeed and there are few and far between situations where this may happen one of the situations would be if you have a parent who is the biological parent and you have a boyfriend or girlfriend who is abusing the child and you know that comes out and there needs to be some change in the the way that children are introduced to new people or there may need to be some change in another situation and how to indiscipline there are a lot of variations that may come up but ultimately we need the parent’s full buy-in we need them to be willing to work with children on emotions identification and cognitive coping and all this other stuff which ultimately ends up helping them most of the time anyway because I don’t believe any of these skills can be harmful to a person at At least the initial skills of the trauma narrative if it’s done inappropriately or incorrectly can be very very harmful but we’ll get there specific strategies that can be undertaken through perseverance in establishing the therapeutic alliance reach out to contact and try not to serve as the all-knowing omniscient person but asking them what they need asking them what changed with jr. Asking them for feedback and suggestions about what helps when jr. gets like this and so you can brainstorm put the parent in the expert role of being the parent imagines that explore past negative interactions with social service agencies or therapy not that we can undo that but we can make sure not to repeat it and if they start acting disengaged we can evaluate the situation and come back and say is this reminding you of that prior situation or you know are you feeling disempowered again or whatever the case may be being fully aware that n TF CBT you have two very distinct clients plus a the third one is the family so you’ve got a lot of different things to juggle if you want to explore the parent’s concerns that may make them feel as if they’re not being understood or accepted the lead listens to or is respected and that gets a little dicey sometimes especially when we start talking about cultural sensitivity about belief about why the trauma occurred or a variety of other things that we’ll talk about it’s important to be able to hear the parent and come from a culturally sensitive and culturally informed perspective it’s also important if the parent feels guilty for some reason you know and sometimes they will be cognizant of any nonverbals or any statements that you make that might make them feel that way and if it comes out or if there’s no other way to say it you know talk about any feelings they may have that about being not believed or not respected and how can you best facilitate making them feel respected and accepted and all that stuff explore and help them to come overcome barriers to participating in treatment, if it’s transportation if it’s a job if it’s something else there may be some brainstorming that’s required and a little bit of case management and I recognize that most of us when we work in private practice or agency work don’t get any credit for billable hours for case management but it has to be done in the best interest of the client and emphasize the centrality of the caregiver’s role in the child’s recovery making sure that they understand that this can’t succeed without their help by using parent sessions to reduce parent caregiver distress and guide them through structured activities that empower them in interactions with the child so you’re going to bring them in each week and you’re going to talk to the parent independently about what’s going on what you’re covering how juniors behaving how you can help them help jr.

Etc sometimes you need to delay joint sessions until the parent or caregiver can offer the child support and sometimes that means not even starting treatment really until the parent and caregiver parent or caregiver can be on board now you can get started with psychoeducation emotions identification feelings identification and stress management and coping skills you know there were not really poking a bunch of bears so you can probably safely get started on that if it’s sometimes it’s court-ordered and they have to start treatment by April 1st or something so there are things you can do but you may need to delay the actual beginning of the trauma narrative until the parent is able to be available to educate everybody on how therapy works and instill in everyone not just the parent optima optimist that well optimism about the child’s potential for recovery you know sometimes they’ve been dealing with this child’s acting out behaviors for so long they’re just like you know we’ve already been to three other therapists I don’t know what’s going to fix it or I’ve done everything I know how to do good luck so we can talk about you know a different approach or we can talk about what they’ve done that’s worked for a short period of time and build on those strengths to instill optimism and hope and empowerment so initially, when we talk about psycho-education it’s important to provide accurate information about the trauma when children are traumatized they can be confused and not completely understand what happened they may blame themselves and they may hold on to myths because they’ve been misled and/or deliberately given incorrect information so one of the best ways we can help is to correct that information provides information about how often this happens and whether you know it’s okay to do this that or the other psychoeducation clarifies inappropriate information children may have obtained directly from the perpetrator or on their own so the perpetrator may have told them that this is how I express love or this is how you need to be disciplined because you don’t learn this is how I was disciplined whatever it is or they could have gotten it on their own they could have gotten it from school from the internet or just come up with it in their little heads trying to make sense of what happened psychoeducation also helps them identify safety issues the difference between safe situations and dangerous situations and as we get through this I really want you to get away from the notion that TF CBT and childhood trauma are only physical and sexual abuse there are so many other traumas as evidenced by the adverse childhood experiences survey that I want you to wrap your head around that and there are things they didn’t cover in the aces such as bullying and natural disasters so we want to help children whatever the trauma is the trauma made they feel unsafe so we want to identify safety issues if the trauma was a hurricane then we want to talk about what hurricanes are how often they hit what to safety plan etc so every time a the thunderstorm comes they don’t freak out and we want to use psychoeducation to provide another way to target faulty or maladaptive beliefs by helping to normalize thoughts and feelings about the traumatic experience you know it makes sense that that was scary and makes sense that you’re angry it makes sense that you feel this way and we can talk about why that makes sense and why it makes you feel that way through cycle education you’re getting the child to start talking about the specific trauma that he or she experienced in a less anxiety-provoking way by talking in Jen wrong about the type of trauma so you’re talking about natural disasters you’re talking about plane crashes you’re talking about domestic violence so they start learning about it and then eventually you’re going to move down to their experience with it so like I said there are a ton of different traumas and the ACE study even acknowledges that these are just the ten most common ones that they heard however there are many many many different traumas and types of trauma some of the biggest ones are physical and sexual abuse physical neglect emotional abuse and neglect and the Aces identified mother treated violently I would say anyone in the household treated violently it’s not just the mother’s substance misuse within the household and that can be by the parents or by siblings household mental illness parental separation or divorce and an incarcerated household member so those were aces but then like I said there’s also bullying the death of a parent or sibling is extremely traumatic hurricane tornado natural disaster and then I put the fire out separately because sometimes fire can be man-made sometimes it can be a wiring problem but sometimes it can be Jr was playing with matches now even if jr. Accidentally started the fire does that make it any less traumatic no it probably makes it more traumatic because then there’s a whole sense of guilt and responsibility but it’s still a trauma that has to be dealt with so I put a link to the adverse childhood experiences website if you want to go look more about that but we’re going to move on psycho-education involves specific information about the traumatic events the child has experienced not the child’s event we’re not going to go into police records or something, we’re just going to talk about specific information about domestic violence or whatever body awareness and sex education in cases of physical or sexual maltreatment and there are caveats for getting parental consent and permission and all that other stuff and Risk Reduction skills to decrease the risk of future traumatization now going back to those other things it’s not just about physical or sexual abuse so we want to look at what was the the risk created by you know how can you reduce your risk of being bullied how can you reduce your risk of being traumatized in a tornado you know you can’t stop the tornado from coming and they’re everywhere so what do you do and talk about a safety plan the same thing with fire information needs to be tailored to fit a child’s particularly particular experiences and level of knowledge obviously, you’re going to provide different information to a seven-year-old than you are to a 17-year-old provide caregivers with handout materials to reinforce the information discussed in session so this may help educate the parents about some of it but it lets them know what you talked about and it gets us all on the literal same page you’re providing them a handout of everything you went over with Junior and we want to encourage caregivers to discuss this information at home reinforces accurate information about how safe or unsafe they are and obviously, we’re going towards safe and reinforced accurate information and develop a safety plan so they feel confident that at home they’re going to be taken care of when you start psychoeducation you do want to get a sense of what the child already knows and you can use a question-and-answer game format in which the child gets points for answering questions which I love this suggestion so you can ask them if you know what is a hurricane or is a tornado and see if they know and see if they know how much time and much-advanced warning we have for a tornado versus a hurricane or you know whatever situation you’re talking about you see I did a lot of posts Hurricane Katrina counseling in northern Florida so that’s one of those things that comes up for I am talking with children about how likely is it that a category 5 hurricane is going to hit again but encouraging them to give your aunt’s give answers and if they give the wrong answer you know it’s great to try now you know try to coach them into a correct answer or provide them the correct one but give them credit for at least making an effort sample questions might include what is you know and put in the type of trauma what is bullying how often do you think bullying happens and why does bullying happen you know those are some questions you can ask to just open a dialogue about bullying, if this child has been a victim of bullying and is and is traumatized so cultural considerations meet the child and family where they are by presenting information in a way which they can relate it to their belief system and you may need to consult with their spiritual guidance guides leaders whether it be a pastor or you know whatever to get some guidance on how to handle certain aspects of whether it was the will of God and in the case of sexual abuse how to handle the concept of virginity and how to handle the concept of bad things happening to bad people and whatever else they think is coming from or their parents are instilling in them in a belief system we want to make sure that we’re not necessarily contradicting it and going oh mom dad and the church is wrong but we also want to help them try to integrate this in a way that can help they have strong self-esteem so reaching out to those spiritual leaders and the family asking what their belief system about certain things can be very helpful assess the general beliefs about the trauma if something happened or when something happens ask the parent or the family that’s there not necessarily the child but you want to get a sense of what the family stance is on why this happened what it means how it’s going to impact life hence foreign henceforth and forever more focus on the events they perceive as traumatic to the family but most especially the child if the child’s going back to the Aces you know maybe the parents got divorced but the child doesn’t see that as traumatic because there was domestic violence ahead of time the domestic violence was traumatic the divorce was a relief so wherever the child is with each trauma we want to be respectful of what they perceive is traumatic and tailor the information so the family can be more receptive to it as supportive as possible and sometimes you need to make sure that the language you know make sure the language is not jargony about general views of mental health and mental health treatment should also be assessed and addressed in the psychoeducation piece not only with the child but also with the family, if they are suspicious of it don’t understand it think that you’re just going to magically fix Junior we want to demystify the process and talk about what is the purpose of the assessment what is the purpose of each one of these activities and why am I doing this or why are we doing this as a team and how can it help and then we also want to provide information to D stigmatize and normalize mental health issues and seeking treatment some cultures are still resistant to seeking treatment and I use the term cultures broadly because there’s a stigma associated with it so normalizing for them how many people go to treatment how common PTSD is or whatever the situation you’re dealing with it doesn’t mean they have to like it but at At least it will give them a little bit of a nugget to understand that they’re not the only ones if they are from a cultural group a minority cultural group of some sort you might want to provide information about how common this particular issue is in their group I’ve done a lot of work with law enforcement and emergency responders and they’re kind of their little group so we talk about how common depression is among law enforcement and emergent emergency responders specifically, because they face so much so many different stressors than you know Joe Schmo over here so it D stigmatizes and normalizes a little bit now they still may not talk about it and go well hey you know 37% of us have clinical depression no that’s probably not going to happen but at least in the back of their mind, they can go you know what I’m looking around this room and I can bet that at least one other person’s on antidepressants or something and feel a little less unique and isolated in parent sessions you want to provide a rationale and overview of the treatment model educates parents about the trauma and talks about the child’s trauma-related symptoms so we’re going to go over what is hyper-vigilance what is the function it why people become hypervigilant after trauma and what might it look like in a child because it presents very differently for different children so we might want to give some ideas and say does this sound like Johnny or does this sound like Johnny and help them understand why these behaviors may be coming out we want to talk about how early treatment helps prevent long-term problems okay maybe the trauma happened three years ago but still, it’s better than waiting ten more years and you know Johnny’s still not having any Ellucian will want to talk about the importance of talking directly about the trauma to help the children cope with their experiences and not hedging and this will be on a case-by-case basis but the manual walks you through handling this discussion with the parents about exactly how much detail do I go into if Johnny brings it up at home reassure parents that children will first be taught skills to help them cope with their discomfort and that talking about the trauma will be done slowly with a great deal of support so we’re not just going to plop them down and go okay and tell me about the day that all this happened which is what the child has experienced already if it was reported to law enforcement and/or the child welfare they’ve probably had somebody sit down and say get right to the nitty-gritty at least once or twice and it’s completely dehumanizing so we want to reassure parents that we’re not going to do that to the child again will help the caregiver understand their role in the child’s treatment since this modified since this model emphasizes working together as a team so I’m not just going to be educating you it’s not going to be a parallel thing where I go in and I work with Johnny and then I tell you what I did and then I work with Johnny I’m going to work with Johnny and then we’re going to discuss what Johnny and I did in session and I’m going to get input from you and we’re going to talk about how you feel about it and then I’m going to provide you with tools so you can help Johnny outside of the session because you’re going to be with them for six-and-a-half other days that I’m not and this can’t work if it’s just one hour once a week and we want to elicit parent input questions and suggestions as much as possible because they’ve been living with their kid for you know however many years so they probably have an idea about what works and what doesn’t so we’ll start with both parents and children in their respective sessions helping them understand what control breathing is and how it helps slow the heart rate and trigger the wrist and digest sort of reaction in your body when your breathing slows your heart naturally slows because the stress reaction tells your brain you’ve got to breathe fast and the heart rates got to go fast well when you override that then you’re kind of overriding the whole system and we’ll also talk about thought stopping and this is especially helpful if the trauma is recent or and/or ever-present in the mind of the youth so they can say I am NOT going to talk about that right now I’m not going to think about that right talk about distraction techniques go back to your DBT stuff talks about improving the moment and accepts to help the child develop skills to handle and work through when those thoughts pop up replace unthawed unwanted thoughts with a pleasant one so talk about it in session when thoughts like that come up what would you prefer to think about and then really get into the Nitty Gritty the five senses what do you see smell hear taste you know help me get into that situation or that thought this teaches that thoughts even unexpected and intrusive ones can be controlled so that gives them hope and again we’re not exacerbating the thoughts right now we’re not bringing up their particular trauma and having them get into detail we are just helping them deal with what’s happening normally on a day-to-day basis so they feel like they have more control for the older kids you can have them people log about when this technique is used what they were thinking about and how effective the thought stopping was and then review it and help them tune it up if it’s not really effective and give them praise for when they use it effectively relaxation training persons of Asian or Hispanic origin tend to express stress in more somatic or physical terms so just be aware of that but that doesn’t mean that Caucasians don’t relaxation training is good for anyone and the medical school of South Carolina training recommended that relaxation is stress-free and workbook by Davis Schulman and McKay so and it is still in publication when deciding how to present relaxation techniques are creative have the child help you to integrate the elements into the technique that makes it more relevant to them so, what are you thinking about when you relax you know I know I like to go to the woods but maybe this kid likes to think about a video game or play with their dog whatever it is but helps them make it relevant to them and then have they identify other things they do to relax like drawing listening to music walking and making a list of those things so they can refer to it when you’re teaching relaxation training especially if you’re doing something like progressive muscular relaxation be sensitive to the child’s wishes if they don’t wish to close their eyes or lie down which could trigger memories of the trauma we’re not going there yet so if they feel vulnerable lying down or taking orders like that because you can imagine how being told to lie down and close their eyes might be a trigger for certain abuse survivors you know be cognizant of that and say you know get into a comfortable position or how where would you like to sit while we talk about this like I said parents can often benefit from the relaxation training as well so because they’re dealing with their issues about the trauma but they’re also dealing with trying to figure out how to help Johnny and any of them deal with any of Johnny’s misbehaviors or problematic behaviors then they move on to feelings identification so it helps the therapist judge the child’s ability to articulate feelings if you can tell me what makes you happy that’s great but if you can’t then you know we need to work on figuring out what makes you happy you also want to help the child rate the intensity of the emotion don’t let them stick with happy mad sad glad and afraid you know let’s talk about different emotions and use the emotion chart with little faces on it or you can use the emotion thermometer so is it a hot emotion or is it a cool emotion and helps the child learn how to express feelings appropriately in different situations I mean sometimes they’re going to be angry but it might not be appropriate to you know get up and stomp out of the room or whatever however they communicate it so help them figure out how to articulate that so they can be heard and supported some children have difficulty discussing or identifying their feelings so you might try stepping back and discussing the feelings of other children or characters from books or stories so you know think about Puff the Magic Dragon if they’ve read that you know that dates me a little bit there but you know how did the little boy feel and talking about things different characters and different stories where there are elements of anger and shame and loss and all of that stuff helps children identify how they experience emotions if they seem detached from the experience because sometimes they just they’ve shut it off it was just too overwhelming so we want to talk about you know when you’re happy what does that feel like or when you’re angry what happens what does your body feel like when you’re angry and they might be able to tell you they hear their heartbeat in their ears or everything gets all fuzzy or whatever but help them start tuning in to how they react and connecting that with an emotional word and then after all, that’s done they can identify feelings they can identify feeling intensity now we want to differentiate between thoughts and feelings many children describe thoughts when they’ve been asked about a feeling so if you ask them how they feel they may say I want to run away so you want to say okay well I hear that you want to run away so I’m wondering if you are bored and you you’re bored and want to get away from it or if you’re scared can you tell me a little bit more about what it means to you to want to run away during feelings identification the parent sessions normalize what is going on with their child and help the parent understand that some children may be seemingly in constant distress or detached from the trauma and that’s okay we all react differently to traumas so again we’re going to share with the parents what we’re Do let them know any specific difficulties if any juniors have encouraged the parent to praise the child for appropriate management of difficult motions and I put in parenthesis successive approximations because they’re not going to get it a hundred percent right every time so if they try to effectively manage their emotions even a little bit let’s give them praise for that and then help them figure out how to do it a little bit better the next time so instead of having a complete meltdown maybe they got up and stomped out of the room well that’s an improvement so then we want to talk about how to shape that behavior so it’s a more appropriate communication if parents have difficulty identifying their own emotions provide them with examples so continually ask them questions about how you feel when it’s a rainy day outside and how to do you feel when somebody’s supposed to call you and they don’t how do you feel when and have about 15 or 20 examples and you can have them on a piece of paper and even give it to the parent to take home for their homework if parents are overcome with their own emotions about the trauma validate their feelings and explain how children need to see that their parents can handle talking about the trauma so there the children need to see the strength and the parents which is what you’re going to work on in parent sessions to make sure that the parents have the resolve and the skills handle talking about this topic with junior TFC BT can be an effective intervention for children or adolescents whose primary presenting issue is trauma-related emotional or behavioral dysregulation TF CBT is not appropriate for clients who are actively suicidal and severely depressed or currently abusing substances we want to make sure they’re clean and sober as much as possible TF CBT starts with psychoeducation and then teaches stress management and coping skills to aid in the management of distressing feelings psycho IDI helps to clarify the inappropriate information children may have and start getting them a little a bit more comfortable talking about the topic in general before we start going deeper and feelings identification helps participants start effectively labeling and communicating their feelings so they can receive the support and nurturance they need from their caregivers and their support system if you enjoy this podcast please like and subscribe either in your podcast player or on YouTube you can attend and participate in our live webinars with dr. Snipes by subscribing to all CEUs comm slash counselor toolbox this episode has been brought to you in part by all CEUs calm providing 24/7 multimedia continuing education and pre-certification training to counselors therapists and nurses since 2006 use coupon code consular toolbox to get a 20% discount on your order this month.As found on YouTube Alzheimer’s Dementia Brain Health ➫➬ ꆛシ➫ I was losing my memory, focus – and mind! And then… I got it all back again. Case study: Brian Thompson There’s nothing more terrifying than watching your brain health fail. You can feel it… but you can’t stop it.

Triggers in Addiction and Mental Health: Strategies to Reduce Depression, Anxiety and Anger

Please click on the SUBSCRIBE link and the BELL to be notified each week when we release new videos. Sponsored by TherapyNotes.com Manage your practice securely and efficiently. Two free months of TherapyNotes with coupon code “CEU”CEUs related to this presentation are available at https://www.allceus.com/member/cart/index/product/id/465/c/Triggers are things that make you feel a certain way or want to do certain things. Negative triggers can prompt feelings of sadness, depression, anxiety or anger. Positive triggers help us feel happy, energized and increase our confidence.Also check out our other podcasts, Happiness Isn’t Brain Surgery and Addiction Counselor Exam ReviewAllCEUs provides multimedia #counseloreducation and CEUs for LPCs, LMHCs, LMFTs and LCSWs as well as #addiction counselor precertification training and continuing education for NAADAC and adacb. Live, Interactive Webinars ($5) Unlimited Counseling CEs for $59 Specialty Certificates starting at $89 including #AddictionCounselor #RecoveryCoach #PeerSupportSpecialist #TraumaInformedCare #BHT #Etherapy#AllCEUs courses are accepted in most states because we are approved as an education provider for NAADAC, the States of Florida and Texas Boards of Social Work and Mental Health/Professional Counseling, the California Consortium for Addiction Professionals and Professions, the Australian Counselling Association, National Counsel for Therapeutic Recreation Certification NCTRC, CRCC, PA Certification Board, Canadian Counselling and Psychotherapy Association and more. and more…#DrDawnEliseSnipes provides training through #allceus that are helpful for #LPCCEUs #LMHCCEUs #LCPCCEUs #LSWCEUs #LCSWCEUs #LMFTCEUs #CRCCEUs #LADCCEUs #CADCCEUs #MACCEUs #CAPCEUs #NCCCEUS #LCDCCEUs #CPRSCEUs #CTRSCEUs and more. nbcc

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