 Welcome, everybody. Today, we're going to be going over a strengths-based biopsychosocial approach to recovery from panic. Now, let's see, today is what Thursday? No, Tuesday. Last Thursday, we talked about the same thing as far as recovery from anxiety. And this one, we're going to specifically talk about panic disorder, because panic disorder can be debilitating for a lot of people. Over the next few minutes, we're going to define panic, examine how the fight-or-flight reaction can be corrupted to prompt panic attacks, examine the cognitive, emotional, behavioral, and biological sources of the stress reaction, and then explore a variety of interventions that may assist people in counter-conditioning the panic response. When you run into someone with panic disorder, they find that there are a lot of situations that will almost automatically trigger a panic attack. Think about back when you were little. If you got called to the principal's office, you know, all of a sudden, there was a panic response. Even if you didn't do anything wrong, just going to the principal's office was not good. Or maybe that's how you feel when you get called to your boss's office now, I don't know. When we work with people with panic disorder, these situations which may not warrant a panic response, we need to help them counter-condition it so they can approach situations without having that adrenaline dump seem to come from out of the blue or, you know, maybe they know where it's coming from, but it's still bothersome. Panic attacks are overwhelming. If you've ever had one, you know that it can feel just completely debilitating and overwhelming. You may feel like you're going to die. Panic attacks are exhausting and can leave people feeling control out of their own body. When you have a panic attack, your body is in this extreme fight-or-flight phase or mode, which means it is excreting all of these excitatory neurotransmitters that's telling your body to get up and go. Your body's jumping adrenaline and doing all this other kind of stuff. So yeah, you're going to feel exhausted. It's not all in your head. Your body has just burned a whole truckload of energy. So we need to help people understand that because if they're having a lot of panic attacks, they're going to feel more drained, more exhausted, more lethargic, which can compound feelings of depression, hopelessness, hopelessness, yada yada. People can avoid things they have phobias of, but panic attacks don't seem to follow that same rule. You can't just avoid everything or every situation where you've ever had a panic attack. And a lot of people may not really know what triggered their panic attack. It feels like, you know, their heart just started racing for no apparent reason. And we're going to examine some of that, but it's important to understand that it's not just a phobia. It is something that almost follows people around, like this little thing they've got on their shoulder that decides to pop up whenever it wants. People with panic attacks often restrict what they do superstitiously to avoid panic triggers. So again, I said a lot of times people don't understand what's causing their panic attacks. So it's like, okay, this happened when I was in the car. So I probably don't want to drive anymore. And that's kind of blowing it out of proportion to a certain extent. But if it happens a couple of times when you're in the car, you may get nervous before you start driving. If you get nervous, then the first sign that there may be something getting ready to happen, you can sort of think yourself into a panic attack. Awareness of what a panic attack is and what triggers them for each individual is crucial to recovery. And throughout this presentation, I'm going to use the example that I used, I think I used it last week, of when I was pregnant. And I had super ventricular tachycardia, which means that blood would pool in my extremities, pull down on my feet if I was sitting for too long. And then my heart would start to race to try to pull that blood back up from from my feet. And when that would start to happen, I wouldn't know what was going on, which would make me go start kind of thinking catastrophically and creating a situation where I may have had a panic attack when I didn't need to necessarily get that upset about it. With my daughter, it was a little bit different because the OBGYN had explained to me what was going on. And he said, when you start to feel that way, or preferably before you start to feel that way, just make sure you're tensing and releasing all those big muscles in your lower body when you're driving. So the blood doesn't pull down there. Because you've got all this extra weight in your gut sitting there, keeping the, I was like, thanks, Doc. But having something that I could do, the doctor said, this will help. Well, and theoretically, I trusted him. And that helped a lot because then I felt like I had more control over what was going to happen. And I could prevent those things from coming from out of the clear blue. We have a primitive response system that protects us from danger. It's fight, flight or freeze. And a lot of times we talk about fight or flight. And we forget to talk about freeze. Sometimes people get completely paralyzed in their own terror. And they can't get out of it when they start having a panic attack. They're frozen. They're not fighting. They're not fleeing. They're hyperventilating. To prepare to take on the threat, the body sends out excitatory signals. Your heart rate increases. Let's think about what else increases heart rate. You get cut off in traffic. That increases heart rate. You're, you know, you have something going on that causes your heart to spike for some reason. And we're going to go through some of the physical causes later in the presentation. You had too much caffeine, you know, sometimes you go to Starbucks and you chug one of those. And there's a whole lot of caffeine in Starbucks. So your heart rate may start racing. Or, you know, who knows, there could be a variety of different things that may make your heart race. Or sometimes people just have a situation where the heart kind of skips a beat. Most people have that happen occasionally. And if it happens a lot, obviously they're going to send you in for EKGs and all that kind of stuff. But if every time or if the first time that happens, it can be kind of scary, you can be like, Oh, that felt really weird. If you tend to lean toward catastrophic thinking, you may go from the heart skipping a beat to I'm having a heart attack and I'm going to die in two shakes of a lamb's tail. Numbness or increase in respiration. What causes you to start breathing heavier? If I am sitting in a chair and my office at home is in the basement and I'll sit in the chair and I will be working on the computer, not moving much for a couple of hours. And then I will get up and I'll go upstairs to get something to drink or, you know, help the kids with something. Not really thinking about it, but I go from no movement to climbing stairs. And all of a sudden I'm like out of breath. Now I run 10ks every day. So it's not like I'm out of shape, but my body is trying to catch up. It's like, wait, wait, warn us before you go up those stairs. Knowing that it's easy to understand why my respiration might be going up, why my heart rate might be going up more. And there are a lot of other things like orthostatic hypertension. You get up too fast. Sometimes your body can't adjust. It's trying to get that blood circulating again to meet the body's needs. And just like when I was pregnant and sitting down, sometimes if you stand up, blood pools in the lower extremities and the body is like trying to get the blood back up to the main core where it's needed. Numbness or tingling in hands, you know, when you're in a stress reaction, your blood goes to the core. It wants to protect, it wants to get the heart rate moving, it wants the heart rate going, it wants to get your body moving, and it wants to make sure that the brain stays alive. So your hands not as important. So you can start having numbness tingling or coldness in your hands. There are a lot of things that can cause this. Anything from carpal tunnel syndrome to just being too daggum cold. Be aware of what's going on in your situation. And we're going to talk about body scans. Sweating. This is an interesting thing that I learned. And you know, I've taught the fight or flight response for years and years and years. But one of the things that I learned when I was doing this presentation was one of the reasons that your body starts to sweat not only is to help you regulate your temperature and not get overheated, but it also makes you slippery to predators. You know, think grease pig. So I was like, Oh, well, that kind of makes sense. We sweat for a variety of reasons. You know, if you're hormonal, you may just start sweating for no reason at all. Being aware that sometimes your body temperature is just going to change. It doesn't necessarily mean there's anything majorly wrong. Pupil dilation. When your pupils dilate, it helps you see more of what's around you. This is what happens in a stress response. When it happens, you may have some blurred vision. It may feel like it's way too bright. Think, you know, if you've ever gone in for an eye exam and had your eyes dilated, if you walked out, it was like, Oh, the light. Sometimes you also may see little spots in front of your eyes. Same sort of thing is going on. Your pupils are so wide, it's taking in too much light. So people might start freaking out that they're having a stroke because they're suddenly having blurred vision and seeing spots. When in reality, they're having a stress reaction and their pupils are dilated. Muscle tension. If you're going to fight, if you're going to flee, or if you're just going to freeze up, but fighting and fleeing, both of those involve moving the muscles. So the muscles are going to be tense and prepared for action. Once people start to understand the function of the symptoms, why their body's doing it, and then we can start looking at why does your body think there's a threat. Most of the time with panic attacks, something relatively innocuous happens. You have an unexpected increase in heart rate or increase in respiration. Something scares you. You jump and it's like, oh my gosh, you lose your breath for a second. People who have a history of panic attacks can take that and be like, oh, that's going to cause me to have another panic attack. And then they cognitively basically talk themselves into one. The mind's response to panic. Oh crap. It thinks something is going wrong. The body is sending out all these stress signals. The mind is going, why is my heart rate increased? My heart rate has increased. There must be something going wrong. So I need to start figuring out what to do. A lot of times people with panic disorder kind of go straight to catastrophic thinking. I'm going to pass out. I'm going to die. I'm going to throw up. I'm not safe. I fill in the blanks. One of the things to be aware of when you're working with people who have PTSD is the fact that they may tend to be more hypervigilant naturally because in the past they haven't been safe. I don't want to take that away from them, obviously. It's important to help them work through understanding that, okay, you weren't safe back here. That's true. That happened and we can deal with it. What can make you safe now? So people can feel these catastrophic thoughts that go through their head. They need to have a counter to it so they understand that they are not going to die right now. They're not going to throw up. So the panic cycle, and I found this online. I thought it was a really interesting diagram because it shows the interactive nature physiologically. Any of these things can kind of kick off a panic attack, an increased heart rate, muscle tension, sweating and blushing, you know how you feel that warmth go up in your face, dizziness and nausea or stomach ache. Any of these symptoms might send a signal to somebody that says, oh, I'm getting ready to have a panic attack. If that's what precipitated or what they think precipitated the first panic attack. Cognitively, if somebody starts getting hung up on the what ifs. What if I'm driving and I get lost and then my heart skips a beat or what if I'm out running and I start to have a heart attack. And then if they're out running and their heart skips a beat or they start feeling chest tightness, which if you're running really hard, you're going to feel some chest tightness. They might create a panic attack. Constantly worrying about those physiological symptoms. Every time they feel something, it's like I'm going to die. One of my friends who's a physician said, best thing you can tell people, stay off WebMD because people will go on there and think, and my son does the same thing, bless his little heart. You know, every time he finds a lump, a bump, a ache, a pain, he goes on WebMD and he's convinced himself by the end of the day that he's got cancer. I'm like sweetie, you're 14. You don't have, you know, chances of that happening are very unlikely. Let's talk about what other options there are. And then worries about anxiety provoking situations. If you worry about going to something that you're worried about, you can rev your body up enough where it doesn't take much to kind of send it over the edge and to panic. Behaviorally, reduce performance due to anxiety and avoidance of things, then you're not exposing yourself to something and you can create a situation where it might not actually trigger a panic attack, but you're afraid it will. And that fear gets intensified if you have, you know, this is more towards the phobias sort of situation. If you have a fear of spiders, for example, and you don't ever get around a spider, you can convince yourself that you're way more afraid of spiders than you actually really are. And once you expose yourself to them, you can develop a greater understanding of how your body's going to react. Emotionally, fear, dread and panic. If you're panicked all the time that you're going to be panicked, you're going to be exhausted. If you wake up in the morning and you're like, okay, when am I going to have the panic attack today? Not if I'm going to have a panic attack or what can I do to prevent a panic attack? Just it's going to happen. So, you know, I might just start bracing forward the minute I get my foot out of bed, which can lead to frustration, anger, disappointment and sadness. Frustration, anger, fear, dread and panic can all cause muscle tension, increased heart rate, yada, yada, yada. All these things can cause people to think, oh, well, here comes the panic attack. Cognitive things kick in. You can see how everything sort of folds in on itself. The cool thing is, again, like, you know, we've talked about a lot of times, you can address any one of these areas and the person will likely start feeling improvement. Most of it really deals with what they're willing to work on right now. Physiological is helpful because it's education about what's going on, but then you can get into biofeedback and relaxation and all those other things. First thing, track your panic symptoms with an anxiety log, not just panic, because anxiety keeps you revved up. If you're already revved up, if you're already on edge, it doesn't take much to send you, like I said, over that edge into panic. So when you're having an anxiety episode, when you're really stressed out, what are your symptoms? When you get stressed out, what are your symptoms? Does your heart increase? Does your respiration get deeper and faster or shallow? What's going on? Do you feel tightness in your chest? Does your belly get upset? What physical symptoms do you have? And it's different for everybody. Cognitively. And for me, like I said, when I was pregnant and having those episodes, the first thing that I would notice is my ears would start to ring. And then everything, I'd start to get tunnel vision. Once I started convincing myself that that was happening, that was all she wrote. So helping people work through it. As I got used to or starting to understand what symptoms were going on, you know, that was a clue to me to do something a little bit different. Let's start tensing some muscles. I was also able to call people. I had some friends that I could call and just kind of talk me through it. Because generally for me, if I distracted myself, it worked better than focusing on what was going on because then I hyper focus. So have people identify what their physical symptoms are that they think triggers a panic attack. But also, when you get stressed, what are your physical symptoms? Cognitively, when you start getting anxious, what are your thoughts? What feeds your anxiety? Fear of failure, fear of rejection, using those all or nothing thought patterns. And then emotionally, how did you feel when you got stressed out? Did you feel helpless? Did you feel out of control? Did you feel embarrassed? You know, obviously you felt anxious. But what else did you feel? Because we rarely feel just one emotion. You felt anxious. How do you feel about feeling anxious is another way to ask them. Then say, okay, looking back to this anxiety situation, what triggered it? What caused the anxiety? Did you have to go in for your annual evaluation? Did you have to go to the dentist? Did you have to drive somewhere new? What was it that triggered that anxiety situation? And why was that triggering for you? And what may have made you more vulnerable to your triggers? It's important for them to understand that if they have anxiety issues to begin with, that points to the fact that they have some neurochemical imbalances going on. Cognitively, they can talk their body into excreting more norepinephrine and adrenaline and keep things going. Not everybody creates the biochemical imbalance, but a lot of times cognitive and behavioral symptoms of panic attacks worsen the neurochemical imbalances. If you're hyper-vigilant about panic triggers, you're going to find them. If you look around for things that are going to stress you out, you're going to find them. So let's try not to look at life from the perspective of what's going to set off my panic today. And instead, how am I going to have this wonderful great day? And oh, by the way, if I have a panic attack, what am I going to do? Easier said than done. But ideally, we want to get to that point where people aren't getting up with this dread and anticipation that they're going to have a panic attack. Review the anxiety log. Identify the triggers and make a plan to deal with them. If you know that going to your boss's office for your annual evaluation just completely flips you out, that's an issue to deal with in counseling. Why does that flip you out? How can you deal with it? Because you have to. It's not like you can just skip your annual eval. I think my boss hated doing them worse than we hated receiving them because he used to just give us our evaluations, the blank forms, and say fill this out and give it back to me. So there was very little anxiety there because you kind of knew what you were getting. Identify vulnerabilities. What things make you more likely to be edgy? To have these symptoms that may trigger a panic attack. For me personally, I said I'm a runner. Dehydration. If I get too dehydrated, I can have racing hard a little bit more. I can feel exhausted. I can have some of those symptoms. Too much caffeine. I'm already high strong enough. So having a lot of caffeine in my system is usually not beneficial. I know those are my vulnerabilities. I know having too much on my plate if I have too, not food, but too much to do. If I feel time stressed, if I feel like I am pulled in too many different directions, that's going to increase my anxiety. Those are my vulnerabilities. So I have to figure out how do I make sure that that doesn't happen so I'm not already on edge. One of the things to start out with, and this is a simple one, body scans. What am I experiencing? Just going through not defining it, not doing anything. What am I experiencing? I'm experiencing a racing heart rate. Okay. What might be causing it? Is it blood sugar? For each person, thinking for themselves. So they're not always going to this catastrophic option. And obviously, they want to go to their doctor and rule out any health causes or physical health causes and then look for other possible reasons. Low blood sugar can cause shakiness. When somebody starts to feel shaky, they may think they're getting ready to have a panic attack. Stimulants. We already talked about caffeine and adrenaline rush. If somebody slams a door behind you or a car backfires outside or whatever the case may be, if you have a startle reaction, that can actually make some people start down that path to a panic attack because they don't feel safe anymore. For whatever reason, their body's just like, oh, we're not safe. I'm going to start fight or flight. Orthostatic hypertension, like a top hypotension, like I talked about earlier. When you get up, you get up too fast, you feel kind of dizzy. Some people can take that symptom and have some faulty cognitions about what's going on. They're going to pass out, they're going to die, whatever their thought processes are. Or excitement or panic. Sometimes your heart starts to race because you're really excited about something. That's okay. You know, I want people's heart to race because they're really excited about something. When you're getting ready to go and run a 10K race, I'm hoping your heart rate is kind of up and ready and you're pumped and ready to go. That doesn't mean you're going to have a panic attack or you're going to die. It means your body's excited. Mindfully attend to the panic. Feel the feeling. You're like, okay, focus on your breathing. When people start to have panic attacks, they may start breathing more rapidly. The body's reaction is to breathe deeper and more rapidly. Some people breathe more shallowly. Either way, it's rapid. Slow it down. If your breathing is rapid, your heart rate's going to increase. If your breathing is slow, your heart rate's likely going to slow and kind of shake hands. Use positive self-talk. Help people understand what's going on, that panic attacks crest and start to dissipate within 10 to 15 minutes. So it's not five minutes. If you get to that full-out neurochemical dump, where your body's in the fight-or-flight situation, it may take 10 to 15 minutes before you start feeling better. When the body's on high alert because it's getting stress signals, but you're sitting still, there's a disconnect. If you're sitting still, and I will admit I had some very bad habits when I was in college with working out and taking pre-workout supplements, which is a nice way of saying caffeine, high levels of caffeine. So I'd be driving to the gym and all of a sudden, my heart rate would go up to 140. My heart rate's normally like 52. So that causes a disconnect. My heart starts racing and I'm like, oh, is it racing because of the stimulants? Or is it racing because I'm getting ready to have a heart attack? Because obviously, it was going to be benign or completely catastrophic. So this can cause an increase in stress chemicals. Your body is like, okay, your heart's racing and you're not doing anything. That's not okay. Your body wants to protect itself. And I give the body sort of its own persona because it is, in many ways, there's a primitive side of view that wants to protect itself, that wants to survive. One way to get the mind and body back into sync is to move. Not, you know, move to another state, but to move your body. It provides a reasonable explanation for the increased heart rate. Think about if you've had clients working in residential, we would have people periodically kind of go at each other's throats and, not literally, and we'd have to separate them. Now, I'm all of 5'4". I'm not going to be taken down some 6'2", dude. But a lot of times, if you could separate people physically and get them to walk around and get them to walk around, then all of that adrenaline and energy that they had for that fight reaction starts to dissipate because their body's like, oh, the heart rate's raised because we're going to walk. We're going to walk now. It helps people calm down. It gives their body a way to use all of that stored energy that was released for the fight or flight reaction. And exercise release is serotonin. If you remember prior presentations, serotonin and norepinephrine work sort of in tandem. When one goes up, the other one goes down. Norepinephrine is your drive and your focus. Serotonin is your calm and your chillax kind of chemical. So when you're exercising, you release serotonin, so this panic, this drive, this stress chemical has to go down. Serotonin's going to go up, so that has to go down. Nutrition, stimulants, medications, and certain supplements can trigger a stress response. We've already talked about caffeine. One thing we haven't talked about is decongestants. Decongestants are like pseudofed or proplemen or whatever it's called now, generic pseudofed. Anything that has a decongestant component to it, not antihistamine, but decongestant, will also likely have a stimulant effect to it. If people know this, then when they're sick and they take it and their heart starts racing or they feel kind of tingly, then they will understand what's going on. Gorana is an herb that is in a lot of pre-workout supplements that is high in caffeine. Being aware of what you're putting in your body. Hot peppers. Now this is an interesting one. You thought we were going to keep talking about caffeine and other stimulants. Hot peppers can trigger indigestion and a stress response. We've heard about people who've gone to the hospital thinking that they were having a heart attack and that turned out they just had indigestion. Let me tell you what, it doesn't feel good. I decided that I would grow hot peppers and I wasn't going to grow just jalapenos. No, no. I was going to grow the really, really hot ones. They're called ghost peppers. Well, my chickens impacted a couple. So I thought, well, it couldn't be too bad if the chickens are eating it. So I picked one right off the plant and I bit into it. I have never felt such intense pain in my life. Not only did I drink a lot of water and inhale a lot of air while I was trying to get my entire mouth to stop burning, but it also caused the gastric juices in my stomach to get a little bit wonky. So I had indigestion. Now it hurt. I knew exactly what it was, but it hurt. So I can see how someone who gets indigestion, maybe not quite that dramatically, it was actually hot enough it gave me hiccups. So, you know, that's hot. But I can see how somebody who gets indigestion can feel those symptoms and start freaking out that they're going, that they're having a heart attack. Low blood sugar can trigger cold hands, dizziness and trembling. Being aware of your blood sugar when the last time you ate was, sometimes it's a matter of drinking a glass of water and eating a little something. Now am I telling you to keep M&M's in your office drawer? No. You know, I'd really like to, but that's not the healthiest response to this. Eating frequent meals probably is a little bit better. Oh, eat frequent small balanced meals, drink enough water and explore green tea, which is thought to have anti-anxiety effects. There are certain chemicals in green tea that are supposed to support anti-anxiety. Green tea does have caffeine though. So be aware that you're not drinking something that's decaffeinated unless you're getting decaffeinated green tea. Some people when they start drinking green tea and they're looking for the anti-anxiety effects drink too much. Then they have that caffeine rush and they're like, well, that didn't work for me. So make sure people understand that if they drink green tea, it does have caffeine. Breathing, meditation and guided imagery. Mindful breathing. We've talked about combat breathing before. Breathe in for three, hold for three, out for three. This is one of the fastest ways to help people get through that tunnel vision and that initial adrenaline rush, which lasts anywhere from 30 seconds to a minute and a half. Aware breathing. You know, if you don't want to go to the combat breathing, just being aware of your breath. If you're breathing shallowly and rapidly, let's get into a more normal rhythm. I noticed the other night and that I was laying next to my dog because I let my dogs in the bed. That's just me and I started feeling like, you know, I couldn't catch my breath. I had synced up my breath with his. Now we breathe about 12 breaths a minute. He breathes like 20. So yeah, I was breathing a little bit too fast and I used to do that when I would snuggle with my kids too. We try to sync our breathing kind of with what we're hearing. So having people be aware of their breathing and what's going on so they can get it normalized for them. One technique for the body scan is the rain technique. Recognize what's happening. I'm having a stress reaction. Allow life to be just as it is. If you try to control it and try to stop it and try to do all this stuff, it can actually cause you to focus on it more and build it up instead of just letting it go. Investigate the inner experience with kindness. Look at what you're telling yourself or listen to those thoughts and things that you're telling yourself and just let it be. Don't be like, well, that's stupid or here you go again. You're working yourself up and you're going to cause yourself a panic attack. Just be kind. Notice those cognitions and let them go. You can work on disputing them later. And non-identification. Sometimes if you just let it be and let it, you know, flow in and flow out without having to worry about what caused it and what's going on, for some people that works better. Relaxation slows your heart rate when you relax. Your body sends out relaxing neurochemicals so it can slow, help slow your heart rate. Low is your blood pressure. Slows your breathing rate because remember the heart and the breath, go hand in hand. Reduce the activity of stress hormones. If you're reducing muscle tension and you're doing all these things, sending the signal to the brain that there's no threat, then all of those neurochemicals that are your threat neurochemicals are going to go away or at least kind of be toned down a little bit. It increases blood flow to major muscles. When your body doesn't think there's a threat, it's not going to keep all the blood in the core. It's going to send it out to your fingers and your toes. It can help you improve concentration and mood. Think about when you're really stressed and you're really tense and, you know, your hands are kind of cold and tingly and you just don't feel right. How good of a mood are you in and how functional are you at concentrating? You know, you can try to concentrate, but you may feel like you're just not getting anywhere. It lowers fatigue. Muscles, when they're tense, are using energy. Ha! Big surprise there. Even if you don't realize that you're keeping your muscles tense, if you're keeping your muscles tense, then you're using energy. So if you get rid of some of that excess tension, then your body can use that energy for other things. Reduces anger and frustration because we can get really frustrated when we're already feeling stressed out and edgy and tense and then somebody comes in and drops a new project on your desk or something and it's like, uh-huh. So relaxation can help you sort of eliminate the vulnerability. So when a new stressor comes your way, you're not already like, I can't take one more thing. It boosts your confidence to handle problems and provides a sense of control over your bodily responses. As you get used to relaxing, progressive muscular relaxation is excellent, but there are a variety of different meditation and guided imagery, different things that you can do to help you get a sense of control over your bodily responses. Because I'm a nerd, you know, it's just the way it is. And you know, when I run, I have a heart rate monitor on, but when I was, um, I had surgery and when I was in the hospital, you know, I would slow my breath and try to relax just enough to get the sensor to go off and drop my heart rate below 40. Just to say I could. Yeah, the nurses didn't like me very much, but it was, it was, I was bored. It was a game. It was not right. Don't do it. But it does provide you a sense of control when you know you can slow your own heart rate, when you know you can control what's going on. Heart rate monitors are excellent. I've had clients wear them before and have it set. So it starts to beep for them when their heart rate gets above a certain level that indicates stress, not, you know, running level. So they can understand and they can notice before they even really cognitively notice, they can notice that their body is sensing some sort of a stress reaction. Then they can start to address it. Obviously, for some clients, this wouldn't be appropriate because every time it started to beep, they would freak out and talk themselves into a panic attack. Physical conditions, and this is not an exhaustive list, but some that I found when I was doing the research for this, physical conditions that increase anxiety, exhaustion. When you're exhausted, it's hard to deal with life on life's terms. Hypoglycemia and diabetes, blood sugar wonkiness can actually increase anxiety, not only over maintaining your blood sugar levels, but also when your blood sugar levels get too low or too high, you're going to have a physiological reaction. Hypertension and hyperthyroid, both of these are hyper. Guess what? Anxiety, panic, hyper. So if you have a high blood pressure, hypertension, or if your thyroid hormone is kind of in, or thyroid gland is kind of an overdrive, that can increase anxiety, that can have you kind of revved up all the time anyway. A lot of times, hypertension is caused because you're revved up all the time anyway. So we need to look at the hypertension and go, okay, what's causing this, and how can we address it? PMS, pregnancy, and postpartum. Hormone changes, testosterone and estrogen can cause increases in anxiety levels. There are correlations between serotonin levels and GABA levels, and both of those hormones. Pregnancy, as the body changes and blood goes different places, there are a lot of different things that may trigger an anxiety reaction. There's also just inherent anxiety some people feel about becoming a parent. Being aware of that. Postpartum, one of the things that we don't talk about a lot, and this is one of my pet topics, I guess, in the postpartum phase, there is the initial trauma to the body, if you will, after childbirth. But then there's a whole other readjustment phase after the mother quits breastfeeding. For some people, that's one and the same, but for others, they may have another increase of mood instability when they stop breastfeeding, partly because of, you know, guilt or emotional issues that go with it, maybe, but also partly and largely because hormone levels are like altering at a mind-boggling rate. Helping parents, helping mothers understand what's going on and understand what may be causing it can help them get through it and understand, okay, once my body adjusts, then, you know, I'm going to feel more normal again. Anemia, bronchitis and emphysema. Bronchitis and emphysema, think about it. All of, both of those are in the lungs. They make it hard to breathe. If it's hard to breathe, then you may start to panic. If you start to panic, then you can work into a panic attack. Obviously, cardiac issues, if your heart does actually do something wonky, you can get freaked out about it and create a panic attack on top of something else. So, it's always good to get cardiac issues ruled out. In clinic, it's not possible unless you have a physician or a nurse on staff that can, you know, handle the medical part. If somebody's just in your office or in your group session and they start having a panic attack, a lot of times it is not possible to differentiate between that and a heart attack. So, you know, obviously there's clinical judgment and then there's that person's judgment about what needs to happen. And I always err on the side of caution, obviously, because I'd rather have the paramedics come out for no reason than not call them and have somebody have big problems. Side effects of medications including SSRIs. So, your normal benzos, they're not going to cause an anxiety reaction, but a lot of times SSRIs and SNRIs are prescribed for anxiety. And, you know, it's a common practice. The caveat is that if somebody already has high serotonin, if you increase their serotonin, then it may cause increased anxiety and increased panic. And SSRIs and SNRIs don't just monkey with serotonin or norepinephrine. Remember, all those neurochemicals are in a, what do I want to say, in kind of a soup. And they have to be balanced, you know. Going back to the analogy I always use of a marinara sauce, you can't, if you have one thing out of whack, you know, you have to adjust everything else to try to get it all in balance. So, anything that affects your neurotransmitters, anything that affects your hormones, you know, pregnancy, postpartum, anemia, and yes, menopause, can cause symptoms that someone may mistake for a stress reaction or a threat reaction and then start wondering, well, what's going on? Am I going to die? Or is there, you know, something going on? A lot of times, they're not looking around going, oh, this is a dangerous situation. They're just sitting in their living room going, what the heck? So, something has happened internally and their body's trying to process what's going on. Behaviors that increase panic. Poor time management. That's me taking on too much. But the other thing is procrastination. Some people, because they're anxious about whether somebody's going to approve it or, you know, a whole host of reasons, people may procrastinate even starting on something. When I was in college, I took this course that was philosophy of religion. It was a really interesting course, but we had to write these papers and I don't have a philosophical mind. My mind just, I get stuck sometimes taking those leaps. And we'd have to write these papers and for all four of them, I was not able to start on it until the night before the paper was due, which is very, very unlike me because I couldn't figure out what to say. I couldn't figure out the answer. In reality, I was, I didn't understand it and I was afraid I was going to get it wrong and I was afraid I was going to fail. So, I just kept putting it off. We need to look at the reasons people take on too much. Are they looking for external validation? Do they just have bad time management skills? Are they the type of person that wants to please everybody? If so, all three of those we can work with in counseling. You know, there are interventions. Procrastination, why do you put it off? If you don't like to do it, how can we make it more pleasurable? If you're afraid of evaluation or you're afraid you're going to fail, how can we deal with that? Type A personalities also tend to be really, really high strong. Perfectionists, overachievers, conscientious. And thinking back to that anxiety presentation we did last week, these are also three characteristics of generalized anxiety in young people. Hmm, just a thought. Phobia of wasting time or a lack of time perspective. And I'm super guilty of this. I hate sitting in three, four, five hour meetings because I'm like, you could have sent this to me in an email. We don't need to pontificate that much. There's so much more we could do. So, I'm almost always multitasking. Not that that's good. Type A personalities tend to be stressed that there's not going to be enough time to get it done or I could have gotten it done better and faster if you would have just gotten out of my way. They're mind races. They're high strong. You know, I don't want to say stressed out, but they're kind of like chomping at the bit to get stuff done all the time. And I always use the example of the chihuahua because, you know, chihuahuas seem to be really high strong little animals to me. And difficulty falling asleep because they're mind racing. You know, if you're sleeping, then you're not getting stuff done. If you have a phobia of wasting time, then guess what? It's going to be hard to fall asleep. So, these people are not getting enough rest. They've got exhaustion. They tend to be overly concerned about what people are going to think and whether they get it perfect. So, they spend a lot of time doing things over again that may not necessarily have needed to be done over again. Thinking patterns, all or nothing. I'm either perfect or I'm useless. We've talked about that with cognitive distortions. I'm not going to belabor that, but go over all of your cognitive distortions because they tend to increase anxiety, which is why, you know, so much is written and done with them. Ego-centric thinking, center of attention. Thinking that people are going to remember what you did six months from now. Likely they're not. You know, when I was working at one of the clinics in Florida, you know, this was back when everybody used to wear stockings. And I probably shouldn't tell you this, but I will. The only bathroom was up in the front lobby. And so, you know, every once in a while, you've got to go to the bathroom. I went upstairs, went into the front lobby, went to the bathroom, came out. You can see where this is going. Started walking down the hall of the residential unit. And one of the clients pulled me aside and let me know very nicely, thankfully, that my dress was tucked into the back of my stockings. And so, like, everybody in the lobby had seen my tushy. Yeah, that was not okay. I was mortified. Now, I could have used that and been like, okay, I'm not going back to work. I'm calling in sick the rest of the week. You know, no, I laughed it off. I'm like, they're not going to remember six weeks from now. Or if they do, we'll just laugh about it. But people who are worried about getting other people's approval and think that everyone notices every mistake they make, and everyone focuses on that, create a lot of stress for themself, which can lead to social anxiety and can lead to situations that prompt a panic reaction. And catastrophic thinking, going from my heart skipped a beat to I'm having a massive coronary and I'm going to die like that. Yeah, that increases anxiety and panic. Every time you have an ache or a pain, you convince yourself that you're dying. You're increasing your anxiety. So let's look at how we can deal with that. Aside from getting on WebMD because that generally makes things worse. Need for approval. And I use WebMD because that's kind of like the brand that everybody knows. But going and searching online, you can find all kinds of horrific outcomes for things when likely it's pretty whatever's going on with you is pretty benign. But also this need for approval. When everything you do is in order to get other people's approval. If you do things, you're thinking, okay, they will be happy with me if I do this. That can increase anxiety because sometimes you just can't please people. One thing you can do with your clients is have them write down five things that cause them anxiety. Annual evaluations, going to the doctor, going to a new place. It's only three, but those are my three big ones. The big city, you know, driving into Nashville like freaks me out. I'm a country girl. So, you know, I usually have somebody else drive because they can handle the one way streets and, you know, parking and all that stuff. I know that freaks me out. So, I have to plan ahead whenever I have to go into one of those situations. Helping people understand why it freaks them out, whatever their stress triggers are. Identify the underlying thoughts that trigger your anxiety. So, why is it that going to the big city causes me so much anxiety? Because what if I get lost? What if I turn down the wrong way on a one-way street? What if I, you know, I can make things catastrophic at the drop of a hat, you know? If I'm already anxious, I can usually make a mountain out of a molehill really easily. Helping people understand that once they're already anxious, that catastrophic thinking can kick in is especially helpful. And then help people dispute those thought patterns. When I have to go to Nashville, I look all the stuff up on Google Maps ahead of time. I know where I'm going to go. I know where I'm going to park. And now that we have GPSs everywhere, I'm a lot calmer because I know that Siri will just redirect me if I take a wrong turn. Easy as that. Most of what we do as clinicians is educating people about what their body is doing, having them figure out what cognitions or things they're doing that may be causing their body to do that, and then helping them figure out how to fix it. A lot of people with panic attacks are very embarrassed. There's a lot of shame about having those panic attacks and, you know, when they're driving or when they're going into public situations, or maybe they don't even know when it's going to happen. They have a panic attack and then they're like, well, I can't go back to that place now. Encouraging people to identify why they feel ashamed or embarrassed, look at, again, how many people are really going to remember six weeks from now or six months from now? What does it mean about you that you had a panic attack in the middle of the Walmart? You know, what are you telling yourself that is causing you to hold on to this negative attitude about yourself? A sense of inadequacy going crazy, all of those kind of feed in, or anxious anticipation. These are the people who they're like, okay, every time I go to Walmart, I have a panic attack. So we're going to Walmart, I just got to brace myself. Well, that pretty much sets you up for a panic attack. And you know what? If they go into Walmart 10 times and eight times, they don't have a panic attack, but two times they do, guess which two times they're going to remember? Or I guess I kind of gave it away. They're going to remember the two times that they did have the panic attack and discount the eight times they didn't. Part of our job is to help them really focus on all of the evidence. What was different the eight times that you didn't have the panic attack? Identify what causes these emotions and what the emotion means about you. Because a lot of people they're like, I'm really embarrassed. Well, what does that mean about you? Why are you embarrassed about these panic attacks? And then help them find statements to dispute it. Don't over commit. And don't procrastinate. Easier said than done. If people over commit, again, we need to look at why they do it, what they're getting out of it, and how they could meet that need. Otherwise, remember your decisional balance exercises. What happens if you say no? Oh my gosh. Yeah, some people can't even fathom telling someone no. Other people can't fathom telling someone yes. Help them understand why they're saying yes to everything. And maybe they just feel like, Oh, sure, I can squeeze that in or I can squeeze that in because they don't stop to really look at it. Some personality types, people who are more impulsive, people who are more free about things may tend to always feel like there's plenty of time to get stuff done. So helping them chart it out, teaching people to always say no, I'll get back to you as soon as I consult my calendar. Since we have smartphones now, a lot of times you can say, let me check my calendar and pull it out and check right then and there. That way you don't actually have to say no, if that's something that is too overwhelming for your client at that point. Have people make a list of all the things they have to do? And when clients come into my office and they talk about being overwhelmed and stressed, I'm like, what do you have to do? And they just start with this laundry list of stuff. And I'm like, wow, I'm exhausted just listening to it. But in reality, I'm hearing there are a lot of things there they don't have to do. Things you have to do are things that if they're not done, there are going to be significant consequences. Pay the light bill. Feed your children. Now, do you have to make a seven course meal? No. You know, sometimes you may get a frozen dinner or fast food or something that is not what you would consider your ideal meal for your kids. But it feeds them, you know, it nourishes their little bodies. So have people separate this list into three categories. I like using index cards just because I can sort them and it's easier. Some people use Excel spreadsheets. Other people use whiteboards, whatever works for your clients. The pile that's must do are those things that if they're not done, there's going to be consequences. Go to work. Feed the kids. Pay the light bill. All those things are have to do. Need to do soon. Laundry. You know, most of the time you don't wait until everybody's out of underwear before you do laundry. So you probably have a couple days grace period here. That goes in the need to do soon. You know, maybe by the end of the week or, you know, over the weekend. But it's not something that has to be done today. And then the third pile is those things you would like to do. You would like to, you know, go out to the lake. You would like to take your kids to the park. You would like to do these other things. But if they don't get done this week or next week, the world is not going to come crashing down. And then encourage people to prioritize and delegate the must do's. You know, okay, there are these things that have to be done. So which one am I going to do first? And are there any that I can have someone else do? You know, maybe laundry, maybe you did wait until everybody was out of underwear. So maybe laundry somebody else can help with. So we go we've gone over a lot. Thinking back over the past week, and clients that you've seen that have had anxiety, that have had panic. How do they handle it? And ask them in the short term, how effective was that for you? And in the long term, how effective was it? And how are you going to handle it in the future? You know, if in the short term, you just avoid going to that place. Okay, that might have prevented you from having a panic attack today. But in the long term, that means you can't ever go back there again. What does that mean? What can they do differently? What haven't they tried? What if they tried this worked? And how can we build on that? And if you would have had any of these tools and have clients identify what tools they think would work for them? If you would have had any of these tools, which ones may have made a difference for you? And how can you start integrating them into your routine? Have them develop a step by step treatment plan, goal plan, whatever you call it for them. So they can start doing what they need to do to address their anxiety. Don't identify too many goals at once. What are the first two things that you need to do? All right, between now and next time we meet next week, how are you going to start making that happen every day or start using that to your advantage? Panic is caused by the fight or flight reaction. Many things that are mostly benign may cause symptoms of the stress reaction and people just cognitively interpret them as the world is crashing down, which can cause a full blown panic attack. For some people, body scans and breath awareness can help them calm themselves down. The rain method and distraction, not naming it, just letting it be, may work better for others. Eliminating vulnerabilities can also eliminate low grade chronic stress, which can increase the likelihood of a panic attack. So they're not constantly just high strong and ready to ready to pop. Are there any questions?