 This episode was prerecorded as part of a live continuing education webinar. On-demand CEUs are still available for this presentation through all CEUs. Register at allceus.com slash counselor toolbox. 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, is going to be very similar to what we talked about with anxiety. But some of it may be a little bit different. Well, 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 over generalization. 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 in counter 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, 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-flea. So thinking about how something that happens, 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. 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 and 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 superventricular tachycardia, which basically meant that when I was sitting down, especially blood, according to my my OB blood would kind of pull down in my in my feet and not get up to my brain in my in 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. But I mean, 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 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 going to race. And I just kind of work with that if I have to take something with a 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 going to 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 going to lose control of my body. And this is going to 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 palms, they hypothesized might actually be a evolutionary response because it's harder to hold something that's 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 mind's response to panic. Oh, crap, something bad's going to 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 going to pass out, I'm going to die, I'm going to 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 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'd pull off. Once I understood what was going on when I was pregnant with Haley, 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 I knew 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 it 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 stomach ache. Now, sometimes, you know, 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 that 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 cognitives. 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 20 or 30 people or more, you know, three days before, or maybe even long before that, you might start dreading it and kind of getting your worry 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't 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 reduce 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 agoraphobic. 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 may say, you know, I wasn't. But it's important to know. Then 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, you know, whatever it was, because we're going to 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 that 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, 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 to fight with their spouse or, 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 made 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 do 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 printed out and stapled and correlated 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 11th 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 base 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? Are they at 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 panicky 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's 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 attack started, in order to rule out anything that could be like hyperthyroid 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 keep a lot 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 the 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 sometimes. 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 depressing 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 an feelings of anxiety, when the alcohol is getting out of their system about two hours in 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 biopsychosocially at what might be triggering the panic. Some people may have a lot of repressed stress and anxiety. If we look at PTSD, and that's 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 hypocortisolism, 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 going to get stressed about some of the mundane stuff because there's no point. We're not winning this battle. So I'm going to serve 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 starts 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 hypocortisolism, you can have that zero to 200 reaction, especially with with stressors. Danielle suggests asking people to track and log times they feel anxious or have panic attacks, and make noted 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 where we're solely focused on my heart was racing, what was causing that, instead of, you know, what else was going on? Life through 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 going to create a self fulfilling prophecy. So encouraging people to review their anxiety logs, identify their triggers to 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 going to get there. 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? And 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 neurochemicals. 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 helps them get into their cognitive mind? It's only a false alarm by mindfully attending to panic, we can help people feel the sensations and ride the wave without getting tied up in them and go, I need to control this. It's going to come and it's going to go. It's going to 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 10 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 10 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 sensation. So they're like, focus on breathing. Alright, I got this. Use positive self talk and then distract. 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 that goes, Are we there yet? 17 times and dad's like, Oh, 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 flea 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 10 to 15 minute period. When the body's on high alert, because it's getting stress 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 in your brain's 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 going to 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. Exercise 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 20 or 30 minutes. So it's not a cure for a panic attack. But it can help reduce underlying anxiety and 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 going to 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, guarana, alright, 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 indigestion 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, 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 cold hands, 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 for four and breathe out for four 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, feel your belly contract, you know, 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 going to die or whatever, encouraging them to just let it go and be in the moment. Relaxation techniques and bio feedback 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 their calming hormones, and those excitatory nor 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, hyper tension and hyper thyroid, 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 and 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? You know, when you're thinking about yourself, your friends, your clients, people may say, feel like I'm going to 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 are 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 of 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 going to 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, seven 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, does it mean it's scary? Does it 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 going to 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 is no, you know, 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 going to 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 going to 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 embarrassed myself, I'm never going to be able to show myself my face here again, because everybody is going to remember forever what I did. No, most people are probably going to forget in 30 minutes, but a few 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 than, 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 catastrophically, 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. And when I say the big city, I mean Nashville, I'm not even talking 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 going to get lost. I'm going to get into a car accident. Because there's lots of one way roads and stuff that I'm going to get pulled over. Well, I drive like a granny. So it's unlikely I'm going to get pulled over. I have Google on my phone. So it's unlikely I'm going to get lost. And as long as I'm careful, I'm not going to turn the wrong way down 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 going to 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 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? 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 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 be terse with me because I was bothering them, you know, I would feel bad and feel rejection and 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 panicked 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? 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? 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, 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 in that where they got those messages from start talking to that internal critic and getting it 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 in time management, you can feel time stressed when you're over committed, or if you've procrastinated. It's important to remember that sometimes procrastinations 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 11th 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 the 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 happen if I don't go to the gym. So separate into those categories. Prioritize and delegate the must do's, you know, paying your bills, whatever it is that has to be done or they're 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. Fierce 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 going to die. They can't live without 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 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 them met. If you put them out there, then it's easier to get them 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, if we go through this this group and usually it takes me two 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 and 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 low blood sugar is generally benign. 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. Do your clients need a little help staying on track between sessions? Are you looking for a great aftercare resource? Look no further than docsnipes.com. 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 docsnipes.com.