♪ Bob and Brad, the two most famous ♪ ♪ physical therapists on the internet ♪ – Welcome my friends to
the Bob and Brad Podcast, produced by Bob and Brad, the two most famous physical therapists on the internet, in our opinion. I am Bob, exactly one half
of the Bob and Brad team. And I am going to be the host today. I'm joined by Chris the pharmacist. It's my great pleasure to have him again. One of the smartest guys I know. I definitely have you in my top five, that's for sure. – That's a scary five. (both laugh) – So today's topic is going
to be anxiety medications. We're going to talk about the SSRIs, and we'll explain to you what that is. You know, what do you do? How do you choose one? We're going to go through all that. And he has a plethora
of knowledge on this. So, you want to start by talking
about what the SSRIs are? – Yeah, I mean, basically what an SSRI is, it stands for selective
serotonin re-uptake inhibitors.
So it's kind of a mouthful.
– That's what I thought. – So it's definitely
kind of hard to process, but there's several
drugs in that category. I mean, you can go with, you know, Celexa which would be citalopram, there's Lexapro, which is escitalopram, there's Zoloft, which is sertraline, and there's Prozac, which is fluoxetine, and Paxil is paroxetine. So those are the main ones
that are in that family. – The big thing it's trying to do is, the big question I have is, what is it exactly doing? It's improving your serotonin levels? – Yeah, so basically what happens is, to understand when we're treating anxiety, basically, when we put people on these types of medications, is it's communication
between two nerve cells.
And so what serotonin
does it kind of carries signal A to signal B. And when we have anxiety, some of those nerves are hyper polarized and you're not getting
real good transmission. And serotonin is kind of looked at as kind of a feel good or a relaxing type of neurotransmitter. And when that message is interrupted, or maybe just not sent properly, it's going off into the other areas of the brain and
bloodstream, what have you, you're finding that these
cells are hyper charged and you're getting
things known as anxiety. When we take medications, like the aforementioned SSRIs, what it does, it helps to, it doesn't give your body to make more, but what it does, it
blocks the uptake of it. So it's a selective serotonin
re-uptake inhibitor. So inhibit think of it as blocking. And so it's going to allow more serotonins to kind of bathe that cell gap, so that it transmits
more of that information to hopefully help you to
feel a little bit more calm.
– So when you go off the
medication, eventually, is that going to affect
your body's ability to produce the serotonin, or,
do you know what I mean? – Yeah, it's kinda, it's
an interesting question. And it's a debatable. So basically, you know, it's interesting. I mean, we know for a fact that anxiety is a
biochemical driven condition. Is it brought on by life circumstance? Is it bought on by, you know, I mean, there's a lot of mitigating factors that lead to it.
– Sure. – And there's different forms of anxiety within that group as well. When we decide, when a doctor says, it's you and your doctor are part of this team to determine when it's ready for you to go off of these
types of medications, you have that discussion and
you'll want to taper off, because if you go off of
these medications abruptly, you're going to have some
very serious problems. And it's not so much that
you're physically addicted to the medication, but you can have, kind of this, withdrawal
syndrome kind of thing, where you kind of go off the medication and you feel yucky, you
get rebound anxiety, Which is…
– Can't you get like electrical shocks? – Yeah, they kind of, yeah. Basically the term that
kind of floats around in my circle is brains zaps. – Yeah, that's it.
– And so, so basically when people, they just feel, like just little electrical
stimulation kind of going through the brain, they can't stay focused they feel agitated. They don't sleep well. They can be short with
their tempers, feel achy. I mean, it's actually, it's
a multitude of side effects that are associated with that. And even just one of the
things that's very important in my arena, as well as
adherence to the drug. So meaning you have to
take it consistently. Drugs don't work if you
don't use them consistently. In these it's paramount that you take them on a daily basis as your doctor directs. – So, let's bring up this question.
What if you miss a dose? – Well, that's a very good
question, actually, Bob. And so what we do when you miss a dose, we try and tell the patient, it kind of depends on the time of the day that you recognize it.
– When you recognize it. – But if it's, kind of
use the kind of half a day so if it's within 12 hours, take it for sure right
away when you remember it. If you're getting to let's
say it's the next morning, and you're like, "Oh my gosh, I forgot my dose yesterday. No wonder, I felt horrible." We don't want you to double up. You just take your normal scheduled dose,
– Sure. – and get back on track. – And you'll obviously
feel maybe a little bit of the effects of that.
– Yeah. – Because you're going to
have the half-life of it. Right? – You're gonna notice that.
And really with the exception of the drug fluoxetine or Prozac, that's the only one
that people can kind of get away with skipping. All the other ones have shorter half-lifes and you know it when you skip a dose. – Sure. – All of a sudden, let's say you just take your normal
dose at six in the morning every morning after you have breakfast. All of a sudden it's noon, and you're like, "I just don't feel right. I can't focus. I'm kind of ornery." And you're like, "Oh, I
forgot my medication." – Sure. – So, and then at that
point it's like, man. – That probably creates
some anxiety in itself. – Sure, and it can, so, I mean at that point we'd instruct you, if it's possible, I mean, if you're in the
middle of your work day I dunno if you can just leave work and go back home and take your medication, or somebody can bring it to you.
But I mean, you know, we want to try and come up with some sort of solution because it will definitely
affect the remainder of your day. – Sure, now you talked about, a lot of people out there are questioning whether or not they should be on drugs. – Sure, – And they don't want to be, because people don't like to take drugs if they don't have to. – I mean, you know, when
we talk about the stigma… – And you talked about the
three things that are important.
– Yeah, so, with anxiety,
I mean to understand it, I mean, there's, the mainstays of therapy are really, it's going to
either medicine, or chemical. And then also then therapy. So cognitive behavioral
therapy are really the big two, and you're a big proponent of that. – Yeah. – And across the board,
when doctors are choosing what's best for the patient, the patient is driving
the bus in this case, because if somebody is not saying, "Oh gosh, I don't know
that I feel comfortable going to counseling.
You know, I just, I don't have
the time I can't leave work." – Imagine this stigma. – There sometimes can
be considered a stigma, which is the absolute
wrong thing we need to we have to crash. We have to smash that stigma, because it's not a stigma. – Right.
– I mean, it's, you're talking about 50
million people, one in five. – You also mentioned when we were talking about this at one point that you said that you've seen more this year, then- – Yeah, you know. – It's been stressful year.
– 2020, thank goodness this is the last day of the year. – Yeah, kicking it off. – You know, it's one
of these things where, it has been rough. And as a pharmacist, when
I dispensed the medications that doctors are prescribing I've seen a tremendous
increase in both the SSRIs, and other drugs used for anxiety as well. So it's definitely there. It's definitely prevalent, and again it's so important to
just kind of circle back that the patient kind of drives
the bus for the treatment. You know, if you think,
"Well, I can take a tablet every day and it's going to work for me." And you're going to make it work. I think it's important that
that's probably your choice. And your doctor will go through a series of questions that are
going to determine maybe what's the best choice for you, and ask would you be amenable to considering counseling, you know cognitive behavioral therapies. – So yeah, you had
mentioned the five drugs and these are the main five? – Yep. Correct, and some of them have been around a lot longer than others.
And so they have a long history of them and how they affect people. – Yep. – And so they can feel comfortable with what you can propose
the side effects are. – Absolutely. Absolutely, and actually all
of these drugs now are old. I mean, I've been a
pharmacist for over 25 years. These drugs are all well into-
– Oh, they are. So they're older medications. – Probably don't need to make a choice based upon that. – No, but it's just kind of
from a scientific standpoint it's kind of interesting
that with brain imaging we're seeing that these drugs, they work. And if you think of a stream, actually when we take the
SSRI drugs as a class, there's a lot of things going on upstream probably that are much more significant as far as what we're seeing
with brain chemistry. And then using the
medication certainly helps, but it's kind of more downstream meaning the things that
are probably to come with medicinal science are probably going to be much improved therapies as they become, they learn
which systems to trigger or what trigger points
that we need to hit. So there's other things
going on above stream.
So I think, I don't want to say it's
crude or rudimentary, because they're excellent medications that safely help people to manage anxiety conditions every day. But I think there's things
that we can do better. And I think that's the wonderful thing about science is we're
always pushing that envelope. We're always trying to learn, we're always trying to go forward.
– It's a miracle what
they're able to do now, even, if you ask me. – Yeah. Oh, the doctors are very, very adept at helping patients these days. I mean, and it's not even always drugs, like I said. I mean therapy for some people is a wonderful opportunity. – Now, the side effects, you had mentioned that they are fairly
similar, but among the five. – Yeah, they really are. And it's kind of interesting that all of the drugs have a
different chemical structure but they act on the same area, which is the serotonin re-uptake. And they're just really in that synapse. So from that standpoint,
it kind of comes down to the clinician's ability
to select something for your needs, you know,
maybe your body type, and they might even ask some
questions about family members.
– Right. – Do you have any family? Cause you know, genetics play a big part in all of the things that we drive and they do kind of drive the bus. So let's say, you know, your mother your father, aunt, uncle, brother, sister took something like, hey,
that drug worked well. Well, you know what, why don't we try, maybe sertraline is
gonna be the best choice for you or maybe fluoxetine
is the best choice for him. Or maybe paroxetine is
the best choice for me. It just kind of depends on
what your clinician decides. And keeping in mind, these
drugs do take time to work. So it's not quick. It's a four to six week
endeavor to start to get relief, which is frustrating. – That's the thing, right. Because if you have anxiety
that seems like for a lifetime. – Yeah, I mean, it is, it is a lifetime. Cause I mean, that's, you
know, an understanding – You're counting off the days. So we understand that this is something if you're considering it, you probably want to get
it started, because…
– You want to get started. You know, just even the definition of anxiety is kind of
interesting, but you know they want you to, most days of the week you should have a thought that's just not sitting well
with you for six months. I mean, that's kind of
DSM five guidelines. – To put up with for six months. – I mean, it's like when you have it, if you have anxiety, you
want it gone yesterday. – Yes. – It is an awful feeling. It's an overwhelming sense of dread, and it's just something that
we really don't want to delve into because it's just such an
awful uncomfortable feeling. – Right. – And you know, and until
you've been in those shoes, it's really hard to
understand that perspective. And again, it's just like, well I don't know why he feels that way. He seemed just fine yesterday. – Right, right. – It doesn't work like that at all. And so when you tell… – They can't understand it. – And that's the other thing, as a pharmacist and I'm sure as a doctor, if we had one sitting here, too, and you tell a patient, it's going to take about four to six weeks while before this is going
to help you feel better.
I mean, you're like what? – What, yeah, exactly. And I mean, it just,
it's somewhat deflating but you know, the thing is, is that we get your body used to it. We minimize the side effects. We keep you on track. – You ramp up slowly. – We do ramp up slowly because if I give you too much too fast, in all likelihood, you're
going to feel yucky. You can feel yucky. You can have an upset stomach. You can be nauseated. Your appetite can be shot. You don't sleep well. – It's gonna compound. – So we start basically baby steps and the appropriate dose based on body type weight,
again, genetic factors what have you, other
medications that you take. So your clinician is going to look at a lot of different things
that go into the prescribing of the choice that they provide. – Are the doses fairly
similar for the five? – No, I mean, you look, let's
see, we'll pick on citalopram, you've got a 10 and 20
and 40 milligram tablets, sertraline got a 25 to 15, a hundred milligram tablet. Fluoxetine is a 20 milligram
and also a 40 milligram dose.
So paroxetine, it's got the
10 and the 20 and the 40. – So the typical where they end up at, those tend to be different? – They do, but it's interesting. I mean, these drugs are
also used for depression, but for anxiety, you'll
see a little bit different dosing level for each of them. Sometimes it's a little bit higher. – For anxiety? – Yeah, it can be. So yeah, it's, it's, it's
kind of funny how that works. And even within the classes themselves, Paroxetine tends to have
a little bit higher dose for OCD, obsessive compulsive disorder, and things like that, or
other types of anxiety. So, and then whether you're using it for social phobia or agoraphobia, I mean there's other anxiety conditions under that big umbrella too.
– Sure
– So it just kind of depends. Your doctor is going to
drive the bus on that. And really what they do is
like we were talking about, you start slow and you gradually build up. They're going to ask you, you're going to come back for an appointment about four weeks. And then there's either
going to be a phone call or another appointment after that discussing how well you're tolerating… – That brings up the point. So you have five drugs here. What can you see as a difference between, let's say the best performing one and the worst performing one for you? Could you have one that
this does nothing for you? No, I mean, well you can, and that's why these other choices exist. I mean, way back when Prozac came out on the market, I mean, it was just, and then all of a sudden
Zoloft was number two. I mean, it's kind of, I think
the drug industry itself, they see something, and Prozac at the time when it came out, I mean,
there was a book Prozac nation. I mean, there's a lot of things out there that came out when these
drugs were first available and they all, I guess the
fondest form of flattery is imitation, right? – Sure.
– So they come up with drugs, you know and they think, well, hey,
is the manufacturer of Zoloft and I'm gonna one up, you
know, the manufacturer of you know, then that's
not necessarily true, but they come up with a way
to get into that market, and they do want to constantly improve. I mean, when you look at the molecules, they all look functionally different.
And so let's say we started you on something that didn't work well, we have other options available for you. And so that's why it's… – How soon would you know that? – You're going to know… – In a couple of weeks? – I would say you're going
to have a solid answer probably within four weeks. And that's why that first appointment back to the doctor is so critically important.
And they are going to
ask you those questions. How are you doing today? You know, Bill or Bob or Gene. – So is that common, that you might not have any help from it? – I wouldn't call it common,
but it can certainly happen. And so that's why it's
important to keep that next appointment with your provider, because they have to gauge
how well you're performing. I mean, if we're giving you
a drug that doesn't work or you're not buying into the fact that you have to take it every day, we've got some serious issues that, as a pharmacist, we want to
make sure that you stay adherent on the medication and that
you're tolerating it well, and you're not experiencing
the side effects that could create problems for you. And so, you know, we always
say, please give us a call. We'll try and help you out any way we can. And so oftentimes I spend a
lot of phone conversations with patients just saying,
well, and we actually the other thing that we do
with the company that I worked for is we make what we
call adherence calls.
So we'll call you in
about five or six days – Ah, nice. – To make sure that
you're actually doing well and comfortable on the medication. – See, that's what I was wondering because doctors have a feedback loop. They're seeing the patient
and they come back. And I wasn't sure if that you had that. So apparently you do. – Yeah, we do. – You have a good sense of what all of these drugs
work and what side effects.
– Exactly, and it really
does make a difference. And I think patients really
like to hear from us too. – Oh, absolutely. – It's like, Oh, really,
thanks for calling. And to me, it's very gratifying. It's worthwhile. And if, heck, if I can even
just help somebody an inkling I feel like it's definitely
made a difference, and I'm hoping we can
keep things going forward so that they can continue to
get the help that they need. – You know, when you're
ramping somebody up, now let's say they end up being at 100 milligrams
or something like that.
They're not going to feel the full effect of that until they're at the hundred and for another four
weeks after that, right? – It can be because there
is a change, you know? So you got the first four weeks where I guess honeymoon period
is probably the wrong word. – You're at 25 to 50 maybe. – Yeah, and I mean just
if we pick on sertraline for instance, you know, a
lot of times we'll recommend start at 25 milligrams because side effects, GI are most common. So it can cause nausea it can cause, you know, loose stool, pain. So, I mean, we want to try and avoid that. So to say a little food first. – Those will go away? – Those will go away. And usually within about five
to seven days, they're gone. And then at that point, depending on your clinician's wishes, that might be the point where
we jump you up a little bit. And then we kind of have you sit there until that four week appointment. And then we see how you, and your doctor will determine
how you're tolerating it.
And if it's beginning to see the benefits. So, in this case since
we're talking about anxiety, to say are you feeling
a little bit more calm a little bit more relaxed? Are you sleeping a little bit better? Are things a little bit better
through your day-to-day? And hopefully the answer will be, yes. I think things are getting better. And then at that point,
or if it's, you know if the answer is no,
they're not doing well, I still feel like garbage. Well, do you feel like
you've gained some benefit? Yeah. Well then maybe we are going to ramp you up to the next level though. So on certaline let's say we were at 50 milligrams for four weeks. Maybe we're going to try at 75 even a hundred milligrams to see that.
And then we're going to re-engage in about a month to see how
you're doing at that point. – How long does someone
typically stay on the drug? And if they have the idea
they'd like to get off. – Yeah, and that's an
interesting question, Bob. So I, there's not a simple answer. When these drugs all first came out they were thought you
just needed to take them for six months and
everything was all was well. We've found that over the
years, that is not the case. I mean, there are people that
have been taking it for years. So a lot of it, you get to a point, too, where sometimes the drug
just kind of runs its course and it doesn't seem to be as
effective as it used to be. Or you just feel like, I'm
in a really good place. I think it's time for me to
have an engaging conversation with my physician and see if
it's time for me to taper off. And maybe that'd be…
– Would that be six months minimum? – Well, I would tell you it's probably going to be longer. I mean, most, and the
problem is when we come off of these medications too quickly you get kind of almost a rebound effect. So you have to taper
off of them very slowly. And even if we come up too soon, oftentimes you end up back on 'em three, four months after you're off of it because you've rebounded
back to the same situation. – Sure. – So when you look at it, at least in prescribing circles, pharmacy circles, we kind of look at, people are on these
things for the long haul. And I would say a year plus, and maybe even longer yet,
depending upon your tolerance. – It might even be the time of year. – It can be, there's… – Like, you'd probably rather go off in Spring in Minnesota or Wisconsin, you know what I mean? – There are people that do benefit from short courses like that. So there's seasonal effective disorder. So I mean, and it depends on,
you know, and there's lots of other ways that you
can treat with that.
– Go back on that time of year. – It can, and the holidays
can be tough for people. COVID has not made it easy for people. So we're going back earlier. I mean, I'm just seeing a lot more of these drugs being prescribed for anxiety than ever before. – All right. How are these drugs stored? Are they stored any differently? – It's just a cool dry place in the house. So basically the worst two
places storing any medication. If you're keeping score at home, guys. Don't keep them in the kitchen. Don't keep them in the bathroom.
Moisture destabilizes these
medications rather quickly. And so, you're spending good
money on these medications. We want to make sure
that they work for you. So, a bedroom, a drawer away from, out of reach of children, obviously, you want to use your safety caps if you have small kids
or pets around the house. So keep it high, like on a shelf or just somewhere where kids can't reach, or maybe even out of eye sight, but where you know
you're going to remember to be able to get at it every day.
– Can you become dependent on these drugs? – Not physically dependent,
but there is, you know… – You've talked about tapering off. – Yeah, you taper off, but it's not like an addiction per se, that you're going to be like you're shooting heroin and
you need to get your next fix. – Yeah, yeah, yeah. – It's nothing like that. But if you skip a dose,
your body, like we talked about a little bit earlier,
your body lets you know so there is a bit of a physical dependency just because your body is used to, and I always liken it when patients go, why does that happen? It's kinda like if you
were standing on a rug, Bob and I just pulled the rug
out from underneath your feet and you fell, that's an awful feeling. And it's much the same thing clinically. We accidentally skip a dose, your body lets you know, it's a bad time. It's a bad day and you definitely don't feel like it's effective and things are going sideways on ya. – Do you want to just talk
about, we'll finish up with this.
Maybe, do you want to talk about some of the side-effects that
are common that you see? – Yeah, and you know, – Especially, they list a
lot of common side effects. – They list if any consumer
were to look at what I read on a daily basis or what a
physician reads on a daily basis most people would probably
be less inclined to take some medications that they do. And a lot of the studies
that are done and I guess, to compare like with the
vaccines out in warp speed, I mean we've done some
really quick research. The research that went into these drugs is always ever evolving. Doctors are constantly publishing studies about what is safe, you
know, is it okay to use during pregnancies, is it okay
to use in pediatric patients? Is it okay long-term short term with certain different medications. So we'll come back to, we'll circle back to side effects. And so it's like what's best tolerated? Across the board, these drugs all have kind of the same side effect profile.
And so it can be usually it's GI's the first thing most people discover. So we want you to take it with food. – Short term. – Short term, although, you know – I mean you should take
it with food all the time. – Yeah, I mean it is. But sometimes it's just kind of, a lot of the serotonins in your gut. So it stimulates those receptors first. And so as a result, why
you get tummy side effects.
So food, then drug
helps to eliminate that. So that's the primary
one that I always discuss with patients, but kind
of an odd one that happens is in about 10% of the patients almost across the board with
these drugs particularly, is some people can actually get tired. So there's one in 10 that's just like, man, I am just dragging tail. And so you feel like, man I need five cups of coffee
just to get through my morning. And all of a sudden I
took five cups of coffee. Now I'm more anxious than ever. Well, that's not the way we want to go. So that one in 10, we actually
want you to take at bedtime. So because for some of us it's somewhat, you'll sleep through that side effect. And then by morning, everything's right you kind of get your
dose patterns established and it seems to work a little bit better. But for some people, you know that 90% of us that
take these medications, you can get kind of an activating effect. And so it's not so much like
you had a cup of coffee, but it's just got a little bit of a spark to kind of get you moving.
And so it's something that
obviously could interrupt sleep. And one of the side effects
is of course insomnia. So we don't want to be promoting something that's going to keep you up all night when sleep is so paramount
with actually treating anxiety. And that's again, we could
probably almost do another video on all non-drug things
to use, to treat anxiety. – Well, I think we'll cut
off there since we're at a quite a long time here and
we'll pick up this topic with another video where we're actually going to tell you a drug you can take to kind of help you make it through that four to six week period. – Yeah, there's a couple out
there that definitely work in addition to this and
again, up to the doctor but I think there's a, there's a lot of good things that we can do
to help people with anxiety.
– Thanks for watching. – Have a great day..
I once read a story about a woman who adopted a
stray dog that she found wandering the highway. He was a sweet mutt. He was good with kids, he was
well behaved, and he didn't make messes in the house. The only downside was that every time
they got into the car he would get worked up into a tizzy, he would run back and forth across
the back seat frantically panting with anxiety, and if that wasn't bad enough he would then
throw up all over the back seat. This happened every time they got into the car. Now you can
imagine the dog owner was about at her wit's end. In desperation she decided to take
the dog to a trainer and ask for help. The trainer taught the woman to teach the dog to
be calm by having the dog lay down in the car.
She explained that when the dog's body is in a calm
position it sends messages to the brain that he's safe and triggers him to relax. The woman started
working with the dog every day putting him in the car, gently making him lay down, and before long
he stopped throwing up in her car. Problem solved. In previous videos in this course we learned
that our emotional reactions are much deeper than our thoughts, they show up in the body and are
powered by the fight-flight-freeze response in our limbic system. Now we're going to talk about
how to soothe anxiety in your nervous system through the skill of self-regulation. Basically
this means calming down your nervous system and creating the physiological response
of feeling safe when we are actually safe. This video is sponsored by Take 2 Minutes. Take 2 Minutes is a non-profit dedicated to helping improve your happiness. They use text messages to
send you a positive message every day and you can just text them to get sent a custom activity
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Their service is free. Sign up now. Just go to their website at take2minutes.org, or text the number on
the screen to start getting positive messages and activities today. Is it possible to have an anxiety
disorder or ptsd if your body is calm? I've worked with many professional trauma educators who say
that you cannot have ptsd or anxiety disorders in a relaxed body. Anxiety and ptsd are the
outward symptoms of having your nervous system stuck in high alert, when when your amygdala is
sending the message that you're in danger and it's triggering that fight-flight-freeze response.
So this is why anxiety is something that you feel in your stomach, or ptsd locks you into hyper
vigilance, you know, jumping at the slightest threat. This is because your nervous system gets
stuck in that sympathetic response. People often feel helpless to change their stress response
and it can feel impossible because this fight-flight-freeze response is an autonomic
reaction, but we have more influence than we realize.
So for example, when stressed, our muscles
get tense without us consciously thinking about it, however, we can control our muscles when we think
about it, or when we feel nervous, our breathing gets shorter and shallower, but if we consciously
take a deep breath, we can slow down our breathing. These are two autonomic reactions that we can
influence. We can change how stressed our body feels by doing simple techniques. The coolest
thing about this is not only does your brain send a message to your body about whether to be
stressed or calm, but your body sends a message to your brain about whether to be stressed or
whether to be calm. So when we choose to breathe deeply or slowly, we choose to turn on that
parasympathetic response, which fosters calm.
So in this video I'm going to teach you a half
dozen ways to regulate your nervous system and turn on that parasympathetic response. When
you practice this, you can transform your nervous system from being dominated by the stress response
to being dominated by the rest and digest response. Now a quick side note, many people are familiar
with relaxation skills. With relaxation skills we stop doing a task, we step away, and we engage
in an activity that takes a lot of our attention. So for example, watching tv right? Relaxation skills
really are important, but again they are hard to practice daily, I mean the healthy ones are hard
to practice daily, obviously watching tv is really easy, but um they can be a form of avoidance that
leads to problems in the future. So we sometimes have this idea that if we're working, we also have
to be stressed right? If we're working- we have to be stressed- these are fused, and that the
only way to be relaxed is to be away from work. Seeing a situation this way creates a dependence
on avoidance and if you remember back in section 4, avoidance makes us anxious.
When we think of
situations as the cause of our stress, we create helplessness around our stress levels. So if you
have the belief that 'I'm stressed because of my job', then you may feel like the only way to escape
that stress is to quit your job or just grate your way through it. Now there's another way to think
and act, we can train our minds and our bodies to separate the situation from the response. So let
me give you an example, if instead you recognize- 'I'm stressed because I constantly believe that I'm
in danger when I get feedback at my job', this can help you reduce that stress response at work. Now
we're going to talk a lot more about this, this way we think about danger, in the sections on Perceived
Danger and Creating Safety, but when we acknowledge that it's the belief that we're in danger, when
we're actually safe, that's making us anxious, then that opens up a little space to change how you see
your job.
So if you have a massive stress response in the face of your job evaluation, you could
change your thinking by reminding yourself- 'this is not a threat to my physical safety,
I don't need to fight off a tiger right now, I'm safe.' So in this way, relaxation skills can
sometimes backfire, they're helpful and important, but self-regulation skills are things we can
do while we're still at work and while we're changing our thinking right? Unlike relaxation
skills, self-regulation skills are things we do while performing a task to keep our nervous system
balanced. We can practice them throughout the day and while doing almost any activity. They keep our
nervous system calm while active, and they decrease stress and exhaustion. So basically the goal of
self-regulation is to pair the type of thinking that says 'I am safe right now', with a relaxed
body which keeps us calm, clear-headed, and focused. So when we're calm, we're better able to make
value-based decisions instead of being reactive, and practicing this creates relaxed vigilance.
Let
me tell you a story about how I learned this right. I used to work at a treatment center for teenage
girls. I really liked the job, it was very rewarding, but for me it was also really stressful. Each of
these girls faced many challenges and I cared a lot about them. I always wanted to do my very best
to help them. One of the most stressful parts of my job was parent weekends, when the parents of these
girls would fly out and visit for three days and we would cram as many individual family and group
therapy sessions into the weekend as was humanly possible.
For my first two years working there
these weekends were times where at work I felt like I was sprinting right, I didn't sleep well, I
was high strung, I was stressed out, I was trying to almost frantically cram as much intensity into
my day as possible. I didn't know any other way. I thought that in order to perform under
pressure, I had to be worked up and wound tight. That if I cared about my work it was natural
that I was going to be stressed and that the only alternative was to choose a job that was boring or
not important.
I really didn't know any other way. So I just kept going through this like stress
and exhaustion cycle. Then one January, I attended a conference on treating trauma that changed my
perspective. Using many of the activities that I'm going to teach you in this chapter, the facilitator
trained us to foster a calm body while engaging in an intense activity.
As I practiced these
skills, I developed the ability to facilitate a parent weekend without having to be completely
stressed out. I still cared, I still brought my A-game, and I was excited to be there, and we
still did a million sessions in a weekend, but by monitoring and relaxing my body's stress
response, I was able to stay more regulated in my body, I was able to think more clearly, and I was
able to go home at the end of the day feeling more energetic and less exhausted. It was still hard
work, but it became enjoyable and sustainable again.
The ability to be busy, engaged, even vigilant,
without our nervous system freaking out, is a skill that can be learned. Eric Gentry, who trained
me in this, he trains ER doctors and Policemen and Special Ops and Soldiers with ptsd, and he teaches
them how to be active, how to actually create safety, this experience, this felt sense of safety,
even in genuinely life-threatening experiences. How to do it without being
dominated by the stress response? We create this state by pairing the belief that
we're safe- 'okay, I know that no one is killing me right now', with mindful awareness and physical
self-regulation, and when we do this we perform the same tasks that we previously found to be you
know, exhausting and stressful, we do this instead while keeping a calm body.
Now in a previous video
I taught you four skills that send a message from your body to your brain to calm down. They are deep
belly breathing, the valsalva maneuver, peripheral vision, softening your gaze, and the yawn. And in
my last video I taught you the shake it off skill. Many of these are simple things you can do
throughout your day to regulate your stress even when you're facing stressful tasks.
I think
it's pretty cool that your phone or your smart watch can also remind you throughout the day to
take a deep breath or to pause or to go for a walk. Now all these skills can help your nervous system
calm down, and it's like they're strengthening your calm muscle. The more you practice, the better
you'll get at getting calm. Now there are lots of other activities that help stimulate
the vagus nerve and its calming effects, so I'm gonna teach you four more right now.
So go ahead and write down your anxiety level right now on a scale from zero to ten. This
first skill is an interesting one, it's called the emotional freedom technique or tapping. So
go ahead and just gently tap on your forehead seven times, and now do that
again right here next to your eye, and then right here under your eye, right here above your lip, below your lip- one two three four
five six seven, your collarbone, right here under your arm, and then right here on the karate chop
area- one two three four five six seven.
Okay, now that the activity is over, write down your
anxiety level again on a scale from zero to ten. Now for most people, their
anxiety goes down a little bit. Now here's the thing about this technique,
there is no scientific evidence to back this up. Proponents of tapping say that you're doing work
with your energy or your meridians or your chi, but there's really no research to back this up.
What we do know is that it tends to take the anxiety level down a notch for most people. In my
opinion, almost anything we can do to get grounded in the body can help the body remind the brain
that you are safe right now, so that's why I think this works for some people. Just look around your
room right now, open your eyes, look beyond to the screen you're looking at right now and just notice
you're safe in this room.
You're okay right now. This is how we calm the brain and the body.
Okay, number two is a lot more fun. Laughter triggers that parasympathetic response. Have you
ever noticed how when someone has a near miss, like they nearly get hit by a car or something,
they have this instinctive laugh? That's the body's way of relieving that pressure, that built
up fear response. So when you can, take the time to laugh throughout your day. Another way to do this
is getting upside down, getting inverted right? So you could do a headstand or you could use
an inversion table. What this does is this sends blood to the heart, it slows down its beats, and
that can trigger a relaxation response. Another way to trigger that parasympathetic response is
washing your face in cold water.
This triggers the dive response which slows heart rate and breathing.
There's a couple of other really good ways to um foster that balanced nervous system, one of them
is monotasking right? I mean just do one thing at a time. The reason this is important is because
your brain perceives multitasking as a threat, so whenever possible just do one thing at a time.
Another thing that's helpful is mindfulness, this is a big word for saying- be where you're at,
be present doing what you're doing, and that's because 99.9% of the time, we're actually safe, we're
physically safe.
We're going to talk more about this in the next video, but we have the perception
of danger when we don't notice where we're at. Something else that's helpful in triggering
that parasympathetic response is just doing one slow thing a day, so stop to pet a dog, sit and
drink cold water without doing anything else, just one slow thing a day. You know what else
is good for the parasympathetic response sex. Sex takes you through these natural cycles
of the parasympathetic response, and then the sympathetic response for orgasm, and then the
parasympathetic system rebounds afterwards. So sex can take you through these healthy cycles
of nervous system activation and relaxation. If you want to foster a healthy nervous system
it's also important to pay attention to your biorhythms.
That means eat when you're hungry, sleep
when you're tired, you know exercise when you feel that need inside of your body. Here's another
really great way to trigger that parasympathetic response- hug someone you care about. So hugs
send a sense of safety to the brain, which then releases oxytocin, which lowers blood pressure
and heart rate, and turns down that stress response. And stretching can also turn down that stress
response, so when we release muscle tension it sends a message to our brain to calm down.
So go ahead and try one of these right now.
I'm gonna just do a quick stretch, my shoulders
get really tight, and if I do this little (exhale).. let's do the other arm (slow breaths)- ahh. Now, I hope you're
feeling a little bit better. Please remember from skill number five that if we try to
force, control, suppress, or avoid our emotions, these attempts tend to backfire. If you're feeling
anxious and you try to force yourself to calm down, it can make you feel more anxious. So instead,
practice willingness, allow yourself to feel your emotions and then expand your awareness to the
calm and content areas that are already in your body. Gently lean into these sensations of calmness
instead of trying to force your anxiety to go away.
You should have plenty of opportunities
throughout your day to feel a little tense, notice it, and actively work to soften while still
doing your activity, your work or whatever it is. Practice this act of self-regulation every day, it
takes almost no extra time, just a little bit of awareness. We should be doing self-regulation
every couple of minutes throughout the day. So this practice of checking in, regulating
your muscles and your response, it just takes a second or two to do, but if you can
if you do it consistently throughout your day, this can completely change your
nervous system to be dominated by calm. In the next video you're going to learn how to
soothe your mind and create that felt sense of safety. You're going to learn about perceived
danger and actual safety. Thank you for watching and take care. This video is one skill from my
30 skill course- How To Process Your Emotions, where I teach 30 of the most essential skills for
resolving depression, anxiety, and improving mental health. Emotion processing is an essential skill
for working through intense emotions, but most people have never been taught how to do it.
I'm
putting every single main video lesson on youtube for the world to access for free. You watching
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