250 A Strengths Based Approach to Panic Disorder Treatment

This episode was pre-recorded as part of a live continuing education webinar. On demand CEUs are still available for this presentation through ALLCEUs. Register at ALLCEUs.com/CounselorToolbox I’d like to welcome everybody to today’s presentation. Today we’re talking about a strengths-based biopsychosocial approach to recovery from panic. We talked about anxiety yesterday. Generalized anxiety, which is ongoing worry about a lot of things. Panic is more time limited. You know, people have panic episodes and it’s not as enduring. But we’re going to talk about what may trigger those. Some of the stuff we’re going to talk about obviously it’s going to be very similar to what we talked about with anxiety but some of it may be a little bit different I know it’s a little different we’re going to define panic and examine how the fight-or-flight reaction can be corrupted to prompt panic attacks hint overgeneralization examine the cognitive emotional behavioral and biological sources of the stress reaction which may be underlying the panic situation and explore a variety of interventions that may assist people encounter conditioning the panic response so I’ll give you an example you know think about if you’re out driving and you get cut off in traffic and it’s a real close one it’s not dumb you know one of those where somebody just cuts in too close but you have to swerve maybe off the side of the road I’ve had that happen a handful of times in my years of driving but when that happens you know I have this adrenaline surge and my legs get all shaky and you know I can feel the adrenaline rush in my in my larger muscles and my heart’s beating and you know all of the symptoms that you would associate with fight or flee so thinking about how something that happens an an event could cause trigger a panic attack and for some people when they feel that anxiety they don’t know what’s causing it or they don’t know how to stop it or they just get overwhelmed and they can start feeling or thinking that they’re going to die you know I’ve worked with a lot of people at different traumatic scenes whether it’s been a car accident or a house fire or something where somebody has experienced a trauma and they’re hyperventilating they’re having a hard time catching their breath they feel nauseous they don’t really know what’s going on because they haven’t felt anxiety or panic to that level before so they’re not sure if they’re having a heart attack or if they are experiencing a panic episode panic attacks can feel very overwhelming to people they’re exhausting and can leave people feeling out of control of their own body and one of the things we’re going to talk about when we get down to interventions is looking at how to help people feel like they’re more in control recognizing what their body’s doing and just working through it when I was pregnant with both of my children but it was worse with my son because I didn’t realize what was going on I had something called super ventricular tachycardia which basically meant that when I was sitting down especially blood according to my my OB blood would kind of pool down in my in my feet and not get up to my brain and my and my heart like it was supposed to so as a result my heart would start beating a lot faster and you know it freaked me out and when that would happen everything would start to go gray and I would get tunnel vision and then after that you know I could get myself all worked up once I had that diagnosed and you know by my second OB when I had my daughter he’s like oh you know all you need to do is start moving those big muscles and get the blood flowing again and 99 times out of 100 that worked so I felt more in control the doctor was like this is the problem this is what you do bottoming and he also pointed out that the problem would resolve itself as soon as I was not pregnant anymore so and he was right so moving on to an understanding of what’s causing the problem but until you understand it can be really freaky if all of a sudden your heart starts doing flip-flops or beating really fast for no reason and or no reason that you won’t understand people can avoid things they have phobias of but panic attacks often seem to come out of the clear blue so if they’re in a situation whether a phobia triggers it and then they get worked up from there

or they just have a panic attack out of the clear blue you know we want to look at what led up to it and some people tend to be more prone to panic attacks in certain situations like large open spaces or you know like I said when I was pregnant when I was especially when I was driving because I’m sitting there and I’m really not moving much when I’m a passenger when I’m just sitting on the sofa I’m a little bit Restless you know I move around switch positions heck I even do that while we’re talking so blood doesn’t pool as much so I became more aware that if it was going to happen it was more likely to happen either during unfortunately a clinical session or when I was driving so I needed to figure out ways to deal with that people with panic attacks often restrict what they do superstitiously to avoid panic triggers if people go to the mall and they have a panic attack well then they might start avoiding the mall because they think that’s what triggered the panic attack if they have a panic attack when they’re driving they may start avoiding driving because they think that is what’s triggering the panic attack unfortunately people with panic disorder often have panic attacks and they start having them in different situations so they become less and less able to go about normal life awareness of what a panic attack is and what triggers them for each individual is crucial to recovery so people really need to understand what is it that triggers it for them another example I’m really sensitive to stimulants especially sudafed caffeine you know it’ll make my heart race like nobody’s business I know this so if I’m sick and I take you know a night dayquil or something I know that my heart’s gonna race and I just kind of work with that if I have to take something with the decongestant so what’s going on in the body of someone with panic well that primitive response system that protects us from danger we talked about the HPA axis or the threat response system whatever you want to call it it tells the body to fight flee or freeze and freeze is usually unfortunate but think about you know a rabbit out in the woods you know if it’s hopping along and it senses danger it may freeze because you know if it’s not moving it’s less likely to be noticed by a predator so freeze actually does make sense from a you know evolutionary perspective if you will so to prepare to take on a threat the body for whatever reason whether it’s a cognition they think something’s gonna go wrong a situational trigger a physiological trigger something happens and they start getting shaky or their heart starts beating too fast and they’re like oh here it comes you know I’m gonna lose control of my body and this is gonna be awful so the person starts experiencing that the increase in heart rate increase in respiration the body’s going okay this is not normal you know for you we need to take a look at it there must be a threat they may have numbness or tingling in their hands because blood is going to their core to prepare them for fight or flee sweating because an increase in temperature helps them helps their muscles stay warm and actually one of the articles I read it was kind of interesting that said sweating especially on the palms they hypothesize might actually be a evolutionary response because it’s harder to hold something that sweaty and slippery pupil dilation you may have blurred vision spots in front of your eyes or see brightness bright flashes and muscle tension now thinking about these you know again what increases heart rate well panic attacks do anxiety does stimulants do getting cut off in traffic what if if something makes you angry there are a lot of different things that can cause an increase in heart rate that don’t have anything to do with dying and may not even have anything to do with the panic attack you can have an elevated heart rate and respiration without having a panic attack there are different degrees so the minds response to panic oh crap something Bad’s gonna happen or I wouldn’t be feeling this way and in most people with panic disorder they’ve experienced it before and it is a horrible feeling and when they start feeling that way regardless of what caused it then they start anticipating the panic attack and can actually work themselves up into a full-blown panic

attack by worrying about it they start having catastrophic thinking I’m gonna pass out I’m gonna die I’m gonna throw up I’m going to lose control right here and right now and I want people when they start trying to address their panic attacks to identify what types of things they tell themselves at the first signs that they might be getting ready to have a panic attack you know that’s one of the first things to do is to address those catastrophic thoughts that they’re having you know what’s the evidence for and against the idea that you’re going to pass out die throw up what can you do you know what are some steps you can take so you feel safe and and help people walk through and develop an action plan because panic attacks aren’t going to go away right away when you know I was pregnant I would drive to work but I knew where every fire station was along the way and I always took a route that had plenty of other like convenience stores and stuff to stop off at if I needed to because I knew if I started having an episode you know I’d lose my peripheral vision I wasn’t safe to drive so I pull off once I understood what was going on when I was pregnant with Hayley I knew I just needed to start moving those muscles but I still took the conservative route just in case because that kept my anxiety low going into it so new when I was driving if there should be a problem you know I had an outlet so helping clients develop a plan helping them understand what might be causing for them and addressing catastrophic thinking are some of the first things that we can do so the panic cycle there’s an anxiety provoking situation physiologically we have the increased heart rate muscle tension sweating dizzying nausea or stomachache now sometimes yep when people do something like maybe go over and try to talk to someone of the opposite sex or try to talk to their boss they may experience these feelings and because they’re feeling anxious but feeling anxious that’s just your body going you know again there might be a problem doesn’t say there is but your body is telling you to check it out and helping clients understand what that response means it that they don’t have to hold on to it they can do something to move past it and improve the next moment is important anxiety provoking situation also causes cognitive what if I pass out what if I die what if I’m having a heart attack they start worrying about physiological symptoms and then they start worrying about the anxiety provoking situation so there’s this worry on top of worry people will have emotional reactions to whatever that is fear dread panic you know and that’ll start after they have a panic attack in a certain situation that fear dread or panic may start long before they even approach that situation think of public speaking some people really hate public speaking so if you had to go up and give a speech in front of twenty or thirty people or more you know three days before or maybe even long before that you might start dreading it and kind of getting your worried worked up frustration anger disappointment and sadness can also accompany the anxiety because it’s frustrating to feel like they can’t control their anxiety feel like they can control their own body and they can get angry with the situation with other people with themselves with other people for not understanding what’s going on so all of these things can also contribute to reduced performance due to anxiety and avoidance of a lot of situations and this is you know we start to see this in people who become a Gore phobic they start limiting themselves to where they can go and what they can do until all of a sudden they don’t feel like they can leave the house wonderful first step let’s get a handle on what’s going on so encourage clients to log their anxiety episodes not just the panic ones the anxiety episodes because a lot of times you know if somebody has an underlying level of anxiety it doesn’t take long to kind of push them into the stratosphere so we want to start thinking about what is triggering your anxiety if we can lower that then you know it’s going to take more potentially to trigger your panic so let’s get that heart rate down let’s get that respiration down quiet that HPA axis so encourage them to identify what their symptoms are

physically so we know that way when they have those symptoms at another point in time they can identify well is this a panic attack or is this just anxiety or is it low blood sugar you know there could be a variety of reasons for why they’re shaky cognitive what are your thoughts when you start having symptoms and sometimes thoughts are the first thing to happen you know they get ready to go out and do a presentation or do a performance and they don’t even have physiological symptoms yet they start talking themselves into being anxious and fearing the worst and emotionally what are your symptoms you know some people will say I was anxious beforehand other people will may say you know I wasn’t but it’s important to know identify for that particular for each situation what triggered it what triggered this anxiety was it talking to your boss driving to work being in a big crowd whatever it was because we’re gonna start going back over the log after a week or so and look for themes look for commonalities that might help us understand this trigger and better deal with it have the person speculate why did this situation trigger your anxiety my daughter has a little bit of social anxiety she doesn’t like to be in large crowds you know it’s exhausting for her she’s an introvert but it’s past that it actually really stresses her out to be in like if we go to Walmart and it’s really busy so we talk about bad anxiety and you know she knows that being in crowded places triggers her anxiety so we talk about why it triggered it and you know is that whatever she’s thinking what whatever her thoughts are are those actually accurate at this point in time identify what may have made the person more vulnerable to their triggers so you know maybe things don’t bother them too much unless they haven’t had enough sleep or unless they forget to take their medication or there’s a whole bunch of things they had a fight with their spouse sir you know there’s a lot of stuff that can make people more vulnerable to panic triggers so then once you’ve identified the triggers and what makes you more vulnerable have the person identify how they can prevent those in the future and some things are just not preventable but if we can look and say you know what it would have been probably a better step when I was going through to do this if I would have prepared ahead of time you know I’m one of those people I get really anxious before I get have to go to a presentation if I don’t have everything printed out and I did the same thing for final exams if I don’t have everything print it out and stapled and collated and ready to go two days before why two days because that gives me time if my ink cartridge runs out if my printer breaks if I have any sort of mechanical issue that gives me time to drop back and punt so I’m not up against the eleventh hour where you know I’m not going to be prepared going in that’s one of my little things but that helps me prevent a trigger for high anxiety so encouraging people to look at what are some of their triggers and how can they intervene at least mitigate them ask them what they’ve done in the past that might have helped in this situation so they were getting ready to go do something or they were in a situation they got had a panic attack okay you know you may not have had a situation exactly like this before but when you’ve had panic attacks before or when you’ve gotten anxious before what have you done that helps you deal with your anxiety start building on those things and this is where the strengths-based comes in you know if they say you know when I get anxious usually I just go out and I have a walk around the building or something okay well let’s start thinking about how you can do that a little bit more and if it’s raining what do you do and the answer is stairwells hopefully you’ve got some not always available but in a pinch you know people can go walk in stairwells if they can’t get outside and they just need to take a break for a second let’s see ask them to review their log each week to identify particular situations that might trigger panic and begin to address those and to identify times when they’re not panicky

and increase those so think about the times where they’re just blissful and you know what’s going on are they relaxing with family or they hit the gym what are they doing and let’s increase those periods and whatever triggers the panic let’s start addressing those you may not be able to eliminate them if you’ve got if you get panicky when you’re driving for example and I know a lot of people get panicking when they’re driving or when they’re flying maybe they can’t eliminate that so how can you start addressing those issues and we’re going to talk about that in a second so the question comes in I’ve had a couple people tell me that they do not have any stress or anything to be anxious about but have panic attacks how can i rephrase that to help them recognize their triggers well we want to look at you know it may not be cognitive let’s look at what else is going on we talked yesterday for example about hormones when women are in perimenopause and you know the hormones are starting to get all wonky there are times where because of the changes in estrogen levels that heart their heart can start to race and it feels really weird and it feels really scary until you realize what it is sometimes it accompanies a hot flash other times it’s kind of just a symptom that’s right out there all by itself so the first thing I would do is encourage them to look at okay what is your body trying to tell you it’s trying to tell you there’s a threat of some sort it doesn’t that you need to fight or flee from so we got to figure out what that is now it could be environmental but if the person saying they don’t have any stress and can’t identify any triggers I would certainly refer them and make sure they’ve had a good blood work done in the past you know three months or whenever the panic attacks started in order to rule out anything that could be like hyper thyroid hormone changes as I said before and the same is true to a lesser extent for testosterone so it’s not just estrogen that can make your body do kind of funky things also have them people start keeping a log of what’s going on so you can start spot-checking or not spot-checking but investigating and think about when you’re driving a car and I hate it when I’ve got an intermittent problem because you take it to the to the mechanic and you say it makes this squeaking sound and they take it out and they drive it around and they say not hearing it and then you’re like well it makes the squeaking sound some times and then the mechanic says well what are you doing when that happens and so you start keeping track of what’s going on when that happens I usually try to phrase it as an investigatory tool to have them start keeping track of things see if they can identify what trigger it see if they can look at what they were eating and if they smoke if they were smoking if they were drinking we know that alcohol has a depressant effect initially but then as it wears off the body can’t balance out the neurotransmitters quickly enough so people tend to have an anxiety reaction or any feelings of anxiety when the alcohol is getting out of their system about two hours and or two hours into it so it’s important for them to just be aware that there may be certain things that they’re sensitive to that they’re eating that they’re doing and then we can start exploring and if I’m wrong okay cool let’s mark that off that’s not what’s causing it but at least we know we’ve addressed the physiological issues and we’re starting to look biopsychosocial e at what might be triggering the panic some people may have a lot of repressed stress and anxiety if we look at PTSD and and it’s the true Carl some people will have emotional numbing they just kind of shut down and they can have panic attacks that feel like they kind of jump out of nowhere because they’re they’re emotionally numb and then all of a sudden they’re in this terror state so that’s totally true the other thing to recognize is with hypo cortisol ISM too little cortisol which can be caused by PTSD brain injury a variety of things the body is holding on to cortisol it’s saying you know what we’re not gonna get stressed about some of the mundane stuff because there’s no point we’re not winning this battle so I’m gonna get served my energy for when there’s a real

threat but then when there’s a real threat the floodgates just like open wide you know it’s kind of like opening a fire hydrant you know how they clean those out periodically and it’s just start spewing water so that could be something else that’s going on so you want to look at what’s going on for the person if they have a history of PTSD or if they may be experiencing extreme fatigue and some people will call it adrenal fatigue whatever you’re comfortable looking at but when you have hypo cortisol ISM you can have that zero to 200 reaction especially with with stressors Danyelle suggests asking people to track and log times they feel anxious or have panic attacks and make note of various situational factors that occurred prior to them feeling anxious to see if the patterns emerge so yeah any any kind of anxiety log you can have them do will help you get a better handle on if there’s something that they’re missing because when we start having a panic attack what happens we get whether it’s literally or not we tend to get tunnel vision we tend to focus on what’s going on with me right now and there’s you know all this other stuff going on out here that we need to take a look at so we want and we might not pay attention to as much we’re solely focused on my heart was racing what was causing that instead of you know what else was going on life threw panic colored colored glasses and if you’re hyper vigilant about panic triggers you’re going to find them if I get up in the morning and I look for reasons to be stressed out if I look for signs that I’m getting ready to have a panic attack guess what I’m probably gonna create a self-fulfilling prophecy so encouraging people to review their anxiety logs identify their triggers too and make a plan to deal with them identify their vulnerabilities you know poor nutrition lack of sleep lack of quality sleep drinking too much excessive stimulants etc make a plan to prevent start preventing vulnerabilities this can really help people get started on the way and remind them to really look at their cognitions because you know when something happens they need to check the facts and we’re we’re gonna get their body awareness and this is encourages physical mindfulness for people who say this panic attack came from out of the blue okay well have them go through and identify what are they experiencing what might be causing it so they can run through a list of things one of the good things about having them run through a list of things is it gets them into their cognitive mind and out of that emotional mind to give their HPA access a break for half a second so thinking about could it be blood sugar you know if they start having this shaky feeling or tightness in their chest when was the last time I ate could my blood sugar be low have I had too much coffee or stimulants did you know and you probably do if you’ve been coming to this class that most sodas most carbonated drinks like dr. pepper root beer have caffeine in them and some you know depending on the maker some makers put caffeine and root beer for example where others don’t so it’s important to be aware even if you’re not drinking coffee Coke Pepsi Mountain Dew dr. pepper all of those have caffeine in them and other things can cause that rush in addition to just caffeine you know if you look at the side of an energy drink it actually has a very limited amount of caffeine there’s more caffeine and a Starbucks Coffee but they have a bunch of other herbs in there that can also increase heart rate and blood pressure so we want to look at those things did I just have an adrenaline rush for some reason you know we all have them occasionally if you wake up and you know in the middle of the night for example I woke up when my husband was out of town and I heard a noise upstairs and for half a second I had this what in the world is that and then I realized it was the dogs getting a drink so you know I was good with it and I went back to sleep but that initial flush of oh my gosh can throw people for a loop if they have that they feel like oh no here we go again orthostatic hypotension which is we’ve all experienced it probably when you get up too fast and you get dizzy some people have it because their blood pressure is too low some people have it when they’re

pregnant there’s a lot of different reasons for it obviously want to get it checked out by an MD but this can cause dizziness and shortness of breath for just a second hormones we already talked about that people need to check and say you know are my hormones okay um an excitement or panic you know there may be something going on where the body is truly responding to some sort of stimulus with excitement or panic and excitement and panic both trigger excitatory neurons so it’s how you interpret what’s getting ready to happen that decides whether it’s anxiety or excitement so having them go through this list can be helpful they can keep a list handy you know especially once they start identifying some other things that it could be when they have a panic symptom they can start identifying well for me I know these different things cause it did any of these happen it helps them get into their cognitive mind it’s only a false alarm by mindlessly attending to panic we can help people feel the sensations and ride the wave without getting tied up in them and go oh I need to control this it’s gonna come that’s gonna go it’s gonna be okay 10 to 15 minutes it’ll crest and go out encourage them to initially focus on their breathing because the first thing a lot of people do is start hyperventilating you know when they start feeling anxious their breathing gets rapid and shallow so focus on long slow breaths you know they don’t have to take ten deep breaths most people won’t do that just have them focus on breathing in and breathing out so they can get focused on something that’s calming because when respiration slows heart rate will slow encourage them to use positive self-talk instead of I’m going to die I’ve been through this before it’ll be over in ten minutes at the most so encourage them to develop a script encourage them to then you know all this happens really quickly they feel the sensations that focus on breathing all right I got this use positive self-talk and then distract you know you don’t want to sit there and go okay now how am I feeling now how am I feeling now it’s kind of like the kid in the back of the car there’s goes there yet seventeen timesand dad’s like uh you know no we’re not there so we want to have people distract themselves and again I encourage people when they’re having a panic attack or highly anxious they’re not going to think of their options very easily because that’s not where their brain is their brain is in that fight or flee mode so having a list of things that they like to do to distract themselves whether it’s praying singing calling someone listening to music all four of those things are things I do so having them brainstorm what works for them can be really helpful and it helps them get through that ten to fifteen minute period when the body’s on high alert because it’s getting stressed signals but you’re sitting still there’s disconnect you know you’re sitting still your heart’s racing you’re breathing really fast you’re starting to get sweaty you’re feeling hot you know all the ways you feel when you’re exercising well but you’re sitting still and your brain is going okay this doesn’t make any sense here so that causes an increase in stress chemicals your body’s going hello I told you to get up off your butt and do something because there’s a threat which also make trigger catastrophic thinking so they’re like well I’m not doing anything that should make my heart rate go faster so I must be having a heart attack or I am gonna die or whatever they tell themselves so one way to get the mind and body back in sync is to move helping them provide a reasonable explanation to their brain for the increased heart rate and respiration think about times when you’ve de-escalated a client who well if you’ve worked in residential you’ve probably done this a lot when clients get really upset you know one of the first things I usually do is obviously separate them and then take them out so they can move around and move those big body muscles and then the heart rate kind of gets in sync with whatever physical activity they’re doing and it helps reduce anxiety sir size also releases serotonin so if people start to exercise when they’re feeling stressed out when they’re feeling panicky it can have a calming effect now that serotonin doesn’t kick in until you’ve been exercising for twenty or thirty minutes so it’s not a cure for a panic attack but it can help reduce underlying anxiety and we lower that

threshold or whatever you want to say lower it so people aren’t starting at the 50-yard line they’re all the way back on the on the opposing 10-yard yard line nutrition stimulants medications and certain supplements can trigger a stress response information is part of the key for clients caffeine decongestants guarana which is a common supplement in not only workout supplements but I’ve started to see it creep up in vitamins that are supposed to help you have more energy and you think well it’s a vitamin it’s not gonna have anything in it and since guarana is not technically caffeine if you look at it you’re like okay you know you’re thinking ginseng lauranna all right whatever but it can have a really strong stimulatory effect on some people hot peppers can trigger indigestion and a stress response two years ago I grew ghost peppers which are supposed to be like the hottest peppers around and of course I was being silly and I picked one I’m like I bet it’s not that bad it can’t be any worse than the habaneros I’ve been been growing so I picked it and I bit into it and initially it wasn’t too bad but once the juice got in you know it wasn’t the flesh it was the juice once the juice got in I couldn’t breathe I literally could not breathe for you know 15 or 20 seconds I was just like and it felt like my chest was tightening up and you know it was not a pleasant sensation I learned not to do that again so hot peppers can actually trigger it and if people have indigestion you know a lot of times end jes tchen is mistaken for a heart attack and heart attacks are mistaken for indigestion so when people get indigestion they can start worrying that they’re having a heart attack and work themselves up into a panic attack not to say to ignore symptoms of a heart attack definitely not but helping people become aware and you know kind of check in and go did I eat something really spicy that might be upsetting my stomach and what other symptoms am I having am I having radiating pain down my arm encourage them to look for multiple symptoms to help them feel calmer low blood sugar can also trigger Coldhands dizziness and trembling those signs indicate to your person that it might be an impending panic attack then when their blood sugar gets low they may become overly concerned and not know how to control it if they identify that it’s low blood sugar then they can do something to intervene so encourage people to keep their blood sugar steady and this is something between them and their doctor but ideally they minimize processed sugars and carbohydrates which are really hard on the blood sugar levels you know there’s a spike and then a crash and if appropriate having a protein with their carbs if you eat fiber protein fat with carbs it helps slow down the absorption of the carbohydrates so you don’t have as much of a spike encourage people to drink enough water dehydration can cause a racing heart can also cause shakiness and have them consider exploring decaffeinated green tea which is thought to have anti-anxiety effects breathing meditation and guided imagery are other things people can do mindful breathing you know combat breathing whatever you want to call it where they breathe in 4/4 and breathe out 4/4 can help slow that respiration it gives them something to count and something to focus on aware breathing is really just sitting there and being aware of your breath how does it feel coming into your nose what temperature is it feel your belly expand fill your belly contract you noticing all of the feelings and maybe even anything you’re smelling can help people again get out of that emotional mind and into something more concrete they can also do a body scan and the rain’ acronym is used for that recognize what’s happening I might be having a panic attack allow life to be just as it is it is what it is this is going to come and go there’s nothing I can do to stop it investigate inner experience with kindness so instead of looking in and getting upset because they can’t control it or because they got up and anxious about something recognize it is what it is and be compassionate and say you know I need to figure out how to deal with this maybe but right now I just need to get through this moment and N is for non identification so instead

of starting to try to focus on all the you know I’m having a heart attack or I’m gonna die or or whatever encouraging them to just let it go and be in the moment relaxation techniques and biofeedback can reduce stress symptoms by slowing the heart rate and respiration lowering blood pressure reducing activity of stress hormones increasing blood flow to major muscles you know if you’re not all knotted up the blood can get through a little bit easier reducing muscle tension and chronic pain which not only makes people irritable but can interrupt their sleep improves concentration and mood lowers fatigue it can reduce anger and frustration think about it if you’re relaxed then you can’t be angry and frustrated at the same time they’re mutually exclusive so if somebody is practicing relaxation they’re increasing their GABA and their serotonin and they’re calming hormones and those excitatory North hormones have to go down there’s just no other way and it provides a sense of control over bodily responses so how do we do biofeedback it’s not hard you know you don’t even need anything to do it where people just can focus on slowing their breathing and focusing on their breathing and they can put their hand on their belly and maybe feel their heart heartbeat they can also take their pulse if they want to I do it with a my Fitness watch you know I can breathe breathe in and breathe out and I can watch my heart rate go back down to closer to what baseline is and just practicing that getting used to being able to calm your breathing and calm your heart rate can help people feel like they’ve got more control over what’s going on physical conditions that may increase anxiety and when we have high anxiety we’re more likely to get upset and panicked over things that may not normally cause us so much consternation exhaustion diabetes especially hypoglycemia hypertension and hyperthyroid so high blood pressure and too much thyroid can cause you know symptoms of increased anxiety PMS pregnancy postpartum hormones are all over the place in all three of these situations anemia bronchitis or emphysema if the person and cardiac issues if the person’s not getting enough oxygenated blood throughout their body they could potentially have a panic reaction and side effects of medication including SSRIs so even the things that like zoloft and some of your other selective serotonin reuptake inhibitors that are supposed to help with reducing anxiety sometimes they increase anxiety so I asked you earlier what are some common issues or thoughts that may trigger panic in people now when you’re thinking about yourself your friends your clients people may say I feel like I’m gonna lose my mind if this is going on it’s going to be absolutely untenable or I’m going to embarrass myself by saying something wrong or doing something foolish when I’m in the middle of this panic episode and all of those or both of those are true if they have to do something they dread that can increase anxiety levels and panic for some people they can get really worked up think about when you took your qualifying exams you know I don’t know about you but I was a little stressed when I went in there and you know read over the questions the first time ours are qualifying exams were essays and I read I think it was the third question I read I was like I have no idea how to answer that you know thankfully it came to me later but I had this flush of panic for a second and I was like oh boy so encouraging clients to be aware of things that are going to trigger it loud noises can trigger panic for people even if they don’t have a PTSD history think about being in a situation where you hear a car crash right next to you or something that you don’t understand even

from the time you come out of the womb loud noises are startling they’re scary and your body sends out a stress reaction when they hear it so if you’re predisposed to that figuring out how to best handle those situations so challenging questions worksheet can be used for any of these so we’ll use the example if I’m going to embarrass myself the challenging questions worksheet you will have people just go through these questions again if they keep it with them on their mobile device they can look at it and they can go through it and it helps get them into their cognitive frame of mind or their thinking mind what are the facts for and against this belief what are the facts that I’m going to embarrass myself I don’t know what’s gonna happen in five minutes have I been in similar situations and embarrassed myself maybe does it mean I have to embarrass myself in the future no you know what are the facts that are telling me that this is going to happen probably not going to find a lot of those is your belief a habit or based on facts sometimes we just expect something to be awful like getting a shot you know I just expect it to be awful so my habit is getting anxious before I’ve got to go get a shot where if I look at the facts of it you know 7 out of every 10 shots I’ve had haven’t been a big deal the other three were pretty miserable but it balances out encourage people to look at what way their feelings are their belief is based on feelings rather than facts so this can be habit or feelings since they felt anxious getting ready to do this doesn’t mean it’s scary doesn’t mean it’s dangerous maybe maybe not but they need to check it out in what ways is your belief not including all of the information so if you think you’re gonna go out and embarrass yourself what’s all of the information you know you’ve got to go up in front of people true you know why do you think you’re going to embarrass yourself have other people had to do this before and gotten through it probably so let’s look at all the information you know maybe eight other people have to go up and speak to okay well those eight other people may risk embarrassing themselves as well so getting out of your own head and looking at all of the information other parts of the information if you’re getting ready to do a speech for example if you’re afraid you may embarrass yourself think about what’s the other information did I prepare do I have my note cards have I rehearsed it you know did I do everything I needed to do to be ready for this so I wouldn’t embarrass myself and if you did then cool you’re probably on the right track examine if the belief uses all or nothing extreme or exaggerated terms I am going to die if this doesn’t go well I am going to be mortified if I forget where I’m at in my speech in what ways is your belief focused on just one piece of what’s going on and some of these questions may not apply to every single situation but it encourages people to look more broadly you know I’m focused on I’m going to embarrass myself but other people may not even notice you know they don’t know exactly what’s written on the note card are you confusing something that’s possible with something that’s likely now this is true with embarrassing yourself it is possible to embarrass yourself and I’ve done some doozies in my day but is it likely you’re going to embarrass yourself probably not how does this belief protect you or help you move toward what is truly important in your life so if I’m terrified of going out to give a speech and embarrassing myself how does that protect me from embarrassing myself well if I get too scared then I may flee instead of you know go through it so my brain may be trying to say you don’t want to put yourself out there all right but is it helping me move towards what’s truly important in my life so if running away from this and avoiding it is that going to help me move toward what’s important in my life and a lot of times the answer’s no you know I I’m here because it’s something I’ve got to do in order to move closer to things that are important to me and look at how does hold on holding on to the belief keep you from doing things that are important in your life so maybe you want to be a singer and but you also are afraid of embarrassing yourself and going to tryouts well if you want to be

a singer if that’s really important then you’re gonna have to go and do tryouts so how can you address that fear of embarrassing yourself thinking patterns that increase anxiety all-or-nothing thinking you know this is gonna be the worst thing ever or I’m going to die if encouraging people to look for exceptions and not use always and never egocentric thinking the center of attention if I embarrass myself I’m never going to be able to show myself my face here again because every is gonna remember forever what I did know most people are probably gonna forget in 30 minutes but if you may hang on for a couple weeks it just depends on what you do but generally we are not that important to other people we notice a lot more what we did then you know everybody around you catastrophic thinking the world is going to end if this happens so we want to increase people’s knowledge and realistic thinking instead of thinking catastrophic ly you know what’s likely to happen and a need for approval can also increase anxiety if my goodness is a person and okayness depends on your approval then that’s going to increase anxiety because I’m always going to be afraid of rejection or or failure which may lead to rejection which means that there are a lot of situations that are going to trigger high levels of anxiety if I can learn to separate what I do from Who I am it’s hard then it becomes a little bit easier remembering that I’m a good person even if I fail at this or I’m rejected by somebody one activity you can have people do is write down five things that cause them anxiety such as annual evaluations going to the doctor going to a new place especially a big city I don’t like driving in the big city so I always put that one in there um and when I say to big city I mean Nashville and not even talk in New York you know those things are anxiety provoking identifying the underlying thoughts that trigger your anxiety in those situations and the dispute those thought patterns so when I’m getting ready to go to Nashville you know I’m worried that I’m gonna get lost I’m gonna get into a car accident because there’s lots of one-way roads and stuff that I’m gonna get pulled over well I Drive like a granny so it’s unlikely I’m gonna get pulled over I have Google on my phone so it’s unlikely I’m gonna get lost and as long as I’m careful I’m not going to turn the wrong way a one-way street so disputing those thought patterns those apprehensions that I have and then planning ahead sometimes if I’m going to a really important meeting I will drive there ahead of time like the day before to make sure I know how to get there and where to park other times I just leave with plenty of lead time and if it means I have to go you know stop by McDonald’s or something for a few minutes so be it but at least I got there in plenty of time so I wasn’t stressed that oh my gosh I’m gonna be late for this appointment emotions that increase anxiety shame and embarrassment a feeling of inadequacy a sense that you’re going crazy or even anxious anticipation if you’re getting nervous getting worked up waiting for something whether it’s a job interview or a performance or a test it can increase your anxiety exponentially so have people identify what causes that emotion what causes a sense of embarrassment and what does the emotion mean to you and encourage them to look for themes of loss of control rejection and failure so if I’m embarrassed that means you know I don’t have control about what other people are thinking about me or maybe saying behind my back so what does that mean why is that important to me why is that anxiety provoking if I’m embarrassed maybe it means I failed at something or got rejected okay so what does rejection mean and in different situations it means different things whether you’re being rejected in a relationship or for a job or you know heaven forbid you know I am NOT good at sales so you know when I had to do marketing for a clinic that I worked for I would get sick to my stomach every morning because I don’t cold call that’s just not me and when I would cold call I would always feel guilty like I was bothering people and then when they’d be terse with me because I was bothering them you know I would feel bad and feel rejection that increased my anxiety for calling the

next person because it was unpleasant which is you know one of the reasons you don’t do things that you’re not exceptionally skilled at sometimes but identifying what was causing that anxiety and then disputing it so recognizing you know when I called that person and they were terse with me it had nothing to do with me as a person it had to do with the fact that I was bothering them when I called them at work okay well that was my job so moving past it behaviors that increase panic can include poor time management when people take on too much or they procrastinate then they feel overwhelmed and when they feel overwhelmed they can get themselves all into a tizzy and and panic because there’s not enough time in the day they can’t focus they can’t get it done the less they focus the more overwhelmed they feel and it spirals out of control type-a personalities may be more prone to panic if they have because they have perfectionist tendencies so we want to explore why do you have to be perfect why do you have to be perfect at this or at everything and and what does that mean what happens if you’re not perfect weak and how many people do you know that are perfect I always try to get some perspective on it another question if you’re not perfect you know what does that mean what would it mean if your child wasn’t perfect is your child perfect you know maybe ask that question first and we all think our kids are the greatest but I wouldn’t say my children are perfect I’m not perfect so then you say well if your child’s not perfect and you love them anyway you follow that out to its conclusion the overachiever often takes on too much feels like they need to excel at multiple things or everything which again can increase panic so why do you feel you need to overachieve what does it mean if you can’t be everything to everybody all the time and you know look at why their self-esteem is wound up and that where they got those messages from start talking to that internal critic and getting to be quiet people who are overly conscientious and this kind of goes with perfectionism but if everything every eye has to be dotted and every T has to be crossed it can cause them to feel panicked when they’re coming up on a deadline or they’ve got to turn something in if they have a phobia of wasting time they need to get everything done and they don’t have a good time perspective you know they may rush through things and feel like they’re always time pressured when they there really is plenty of time to get it done and Type A personalities often have difficulty falling asleep because their mind is kind of racing because they’re worried about whatever they’re doing that they need to be perfect at and all of the different things that they need to achieve at which keeps them from falling asleep and getting good restful sleep which can increase anxiety stress and time management you can feel time stressed when you’re over committed or if you’ve procrastinated it’s important to remember that sometimes procrastination is caused by anxiety when I took philosophy you know I was always anxious about turning in my my papers because for some reason I had a mental block with it but it would come up to the eleventh hour and then I would all of a sudden have this breakthrough and write my paper but I procrastinated getting into it I had this mental block because I was afraid of beginning working on the paper so helping people identify why they procrastinate and how they can start working towards it and how they can set good boundaries and time management and manage their time better one activity we do for time management is to have people list all the things that they have to do and whatever they think they have to do start writing them on index cards separate the cards into three categories must do need to do soon or I’d like to do it you know I must pay but pay the electric bill I need to go grocery shopping sometime soon and I’d like to go to the gym you know nothing hugely horrible will have if I don’t go to the gym so separate into those categories prioritize and delegate the must deuce you know paying your bills whatever it is that has to be done or there going to be significant negative consequences delegate where you can you know some people can help simplify where possible if you can simplify paying your bills by paying them online so you don’t have to get out the the stamps and the envelopes and all

that stuff well so much the better if you can you know order in for dinner instead of making a five-course meal so much the better and combine things when possible a lot of times when I’m calling to check in with my family or my friends I will call when I’m on the road from one place to another because I spend a fair amount of time in the car going between meetings sometimes and that way you know I’m not wasting that time just kind of watching the birds and I’m accomplishing something that’s important to me fears of failure rejection and abandonment can trigger high anxiety or even panic for many people panic can be triggered if people feel like their needs are not going to be met or if they engage in mind-reading so think about relationships where one person where a relationship ends and one person says gets panicked about it and feels like they’re gonna die they can’t live with that without that other person and they are just completely overwhelmed with their anxiety and panic well why is that why can’t you live without that person what is it that they’re providing for you so encouraging people to try to figure out you know and use those challenging questions what are the facts for and against this that I can’t live without this person am i confusing high likely with am i confusing what is likely with what is probable etc have them develop effective assertiveness skills so they can state what their needs are that way they’re not afraid of not getting the met if you put them out there then it’s easier to get a met as opposed to if you hold them inside and just hope people can read your mind stop mind reading you know because a lot of times people can get themselves all worked up and in a panic because they think somebody else is thinking something it’s important to communicate and not just try to interpret stop looking for the other shoe to drop if you’re in a good relationship and things are going well you know if you’re waiting you’re keeping that person at arm’s length waiting for that other shoe to drop it can cause panic because you’re always looking for things to go wrong you’re looking for those panic clues address abandonment issues develop self-esteem and self-acceptance so if somebody else rejects you or something you do it’s not a big deal nurture supportive relationships and use the challenging questions worksheet so at the end of group you know we go through this this group and usually it takes me to group sessions to go through the panic activities I have clients look at what they’ve learned and identify three ways they could have used the information in the past week so three times they got panicky in the past week or whatever what was the situation what did they do how effective was it for them in the short term in the long term if they would have had this new information what could they have done differently how would it have changed the outcome and how can they start integrating this knowledge into their routine so they start looking at you know I didn’t really think about lack of sleep making me more prone to panic or I didn’t really think about all the different things that supplements that I take might be interacting with my meds and causing anxiety or whatever so hopefully they picked a couple nuggets out of it and that’s all I want is nuggets but I want them to pick a couple nuggets and figure out how they’re going to apply those panic is caused by the fight-or-flight reaction many things mostly benign may cause symptoms of the stress reaction so you know low blood sugars generally benign is it’s not a big deal it’s not going to kill you but it can cause shakiness for example cognitive interpretations of these symptoms can lead to a full-blown panic attack so we need to help people address those cognitions early on as soon as they’re having a symptom check for any possible explanations other than a panic attack that might be causing it encourage them to do a body scan and focus on breath awareness to help regulate their stress reaction rain and distraction may work better for others and encourage all people to eliminate vulnerabilities so they can eliminate low-grade chronic stress that can increase the likelihood of a panic attack dear clients need a little help staying on track between sessions are you looking for a great aftercare

resource look no further than Doc Snipes calm for as little as $15 per week dr Snipes provides concierge coaching services to clients through online weekly groups chat availability seven days a week and Members Only resources learn more at Doc’s nights calm