Writing a New Story

Anxiety tells us “stories” about our experiences. For example, if you experience panic attacks, the story you may hear is that these feelings are bad and dangerous, that you can’t handle them, and that they must stop in order for you to be safe. Anxiety’s talent for storytelling becomes so powerful that we believe the story and become engrossed in it time and time again!!

The truth is that you can rewrite the story. It’s not as simple as convincing yourself using a new story. Instead, it will take some steps:

  • Step 1: You must be aware of Anxiety’s story – this means being mindful and objective in your observation of the story (“Ah, there’s Anxiety’s story again!”) and even “getting used” to the story through this lens to help it have less power and believability in time.
  • Step 2: Develop your new story with emphases on the following:
    • The costs of listening to and abiding by anxiety’s story
    • Your personal goals in taking this on – what you want to do and what you want to learn about yourself and the triggers
    • What you value about responding differently to this trigger and rewriting your story
    • Affirming your decision to practice a new response in order to learn and overcome the “false alarm” fear story over time
  • Step 3: Put it into action! Be aware of Anxiety’s story and apply your own story and action plan to handle these moments differently. In time, Anxiety’s story will become less noisy and less believable, and your story will be strengthened! Remember that the story is not entirely erased from your memory – it will still be there!! It’s how we respond and relate to it that helps it to have less power and significance over time.

“Fear, to a great extent, is born of a story we tell ourselves, and so I chose to tell myself a different story” – Cheryl Strayed

 

 

Finding Joy Through Perceived Mistakes

The experience of making mistakes is a part of life. How we relate to these “mistakes” or perceived failures is what matters most.

 

When my nearly 7 year old daughter had the chance to get her ears pierced at the same time as her older sister, we decided to let her go for it. There was so much excitement in it for her, and the adrenaline of being a “big” girl in this way superseded any fear of the pain in the moment. It was only later that the pain and fear emerged – when the time came to change the earrings. It was then that she felt the sting of the first earring coming out, and she quickly retreated and screamed. This erupted into tears and saying repeatedly, “I made a mistake! I wish I never pierced my ears!!” With lots of ice to numb the earlobes (and admittedly the reward of an ice cream cone if she did it!), we eventually worked up to getting the new earrings in, and little by little day by day we worked on changing them out and helping her ears to heal. In the end, she was able to stick with it and reach the point of enjoying her earrings. She learned that she could handle the discomfort, that it was temporary, and that she was enjoying her earrings. If she had avoided this process and viewed this as a mistake she regretted, she would have missed out on a lot of helpful learning and fun with her new earrings.

 

Whether we fear the possibility of making a mistake or have trouble handling real or perceived mistakes, we tend to overestimate how bad our “mistakes” are and underestimate our ability to handle them. We must remember that anxiety tricks us in two major ways – it leads us to overestimate how bad situations are and underestimate our ability to cope. In reality, it is through allowing mistakes, taking some risks, and being open to the feelings of discomfort and vulnerability that greater joy and freedom can enter our lives.

 

I find the following stories to be inspirational when it comes to how we think about “mistakes,” failure, and taking risks – hope you will enjoy them, too!

Thomas Edison’s 2,998 Mistakes

Spanx CEO on Failure

 

 

Supporting Your Loved One with a BFRB

Handout from the Pulling Together Conference in May 2016

Amy Jacobsen, Ph.D. & Becky O’Halloran, LMFT

A common reaction when discovering that a loved one is pulling their hair or severely picking their skin may be a combination of fear, distress, frustration and hopelessness. Many parents describe feeling angry – at their child for not stopping the behavior and at themselves for not being able to fix it. There also may be shame – about how the loved one looks and how others are judging them. Here are 10 helpful strategies to support your loved ones (and yourselves!):

  1. Educate yourself about the condition and what evidence-based treatment entails
  1. Stop being the Hair/Skin Police!
    1. It is rarely helpful to tell individuals to stop pulling or to insist on daily updates – this can actually cause more stress – on both you and your loved one – and give unhelpful attention to the behavior that could exacerbate it
  1. Be loving, supportive, and without pressure or judgment
  1. Remember that these are not life-threatening conditions
    1. At times, medical intervention is still important, such as with skin infections or indications of hair ingestion
  1. Consider who is more motivated: you or your loved one? – Be aware that your loved one may not be at the same point of readiness as you, and don’t make it more your problem than theirs! Hand it over to your loved one, be there to support them accordingly, and love unconditionally.
  1. Remind yourself that you did not cause this condition in your loved one
  1. Join the TLC Foundation for BFRBs (bfrb.org)
  1. Consider joining a group email or forum, such as the ParentTrichSupport@yahoo.com, a group email set up by TLC Foundation
  1. Consider setting up an incentive plan with emphasis on rewarding use of new strategies in place of pulling/picking, rather than the absence of pulling/picking
  1. Be patient with slips that will occur and take a problem-solving approach

 

Resources

The Hair Pulling “Habit” and You: How to Solve the Trichotillomania Puzzle,” Revised Edition by Sherrie Mansfield Vavrichek & Ruth Goldfinger Golomb

“A Parent Guide to Hair Pulling Disorder: Effective parenting strategies for children with Trichotillomania” (Formerly “Stay Out of My Hair”) by Suzanne Mouton-Odum & Ruth Goldfinger Golomb

The TLC Foundation for BFRBs, www.bfrb.org – an outstanding resource for articles, education, and treatment information

 

Treatment and Resources for Body-Focused Repetitive Behaviors

A Follow Up: Pulling Together Conference

 

Last month, I had the pleasure of serving as one of the speakers at the first Pulling Together Conference. This conference, which was sponsored by the Kansas City Center for Anxiety Treatment’s Community Education series, promoted education and resources for Body Focused Repetitive Behaviors (BFRBs). It was fantastic to see so many people – individuals affected by BFRBs, loved ones, and clinicians – coming together to learn, share and support the journey toward recovery and greater management of these conditions.

 

BFRBs include compulsive hair pulling (Trichotillomania), skin picking (Dermotillomania), and nail biting, among other repetitive behaviors (e.g., lip biting). These conditions cause significant distress and impairment in the person’s life and are linked to anxiety, depression, and shame.

 

Here is an outline of the major discussion points for a presentation I provided on treatment options, followed by resources to learn more:

 

Treatment Approaches for BFRBs

While there are still many unanswered questions, clinical research to date most highly recommends the following approaches:

  1. Cognitive Behavioral Therapy – First line approach
  2. Pharmacotherapy – Mixed results
  • There are still few randomized controlled trials evaluating these treatment, and even fewer studies involving children and adolescents.
  • The focus of treatment is on strengthening the person’s active management of symptoms.

Cognitive Behavioral Therapy (CBT) includes:

  • Self-Monitoring (to increase awareness and understanding of factors that contribute to the unwanted behavior)
  • Habit Reversal Training (core interventions)
    • Awareness Training
    • Stimulus Control (e.g., barriers and use of fidgets as “speed bumps” to prevent unwanted behavior)
    • Competing Response Training (learning to replace the unwanted behavior with an incompatible response, such as making tight fists with hands)
  • Relaxation Training
  • Cognitive Techniques (challenging unhelpful thinking patterns that contribute to the BFRB)
  • Enhanced with Acceptance and Commitment Therapy (ACT)/Dialectical Behavioral Therapy (DBT) techniques (to promote self-regulation, tolerance of distress/urges of BFRB, and management of slips)
  • Relapse Prevention/Lapse Management to promote maintenance of gains and adaptive management of slips

 

Pharmacotherapy:

  • No FDA approved medications for BFRBs
  • A few medications have been found to reduce symptoms in some individuals
    • Often seem to work by lessening feelings or sensations that trigger the BFRB, rather than directly targeting the BFRB itself
    • Also believed to help address comorbid conditions that can interfere with treatment
  • SSRIs (selective serotonin reuptake inhibitors)
    • Mixed results for trichotillomania and skin picking
  • Several other medications are currently being studied and/or have initial promising results, such as:
    • Mood stabilizers
    • Glutamate modulators
    • NAC (N-acetylcysteine; amino acid supplement)
    • Inositol (B-vitamin)

How do we define “Successful Response”?

  • Reduction in episodes of BFRB
  • Reduction in distress and interference
  • Increased knowledge and management of urges and “slips”
  • Franklin and Tolin (2010) also note:
    • Even if the pulling/picking does not decrease, individuals can still benefit from an initial trial of CBT by gaining an understanding of the condition, not feeling so alone or blaming self for being “weak,” and enhancing their awareness of strategies that can be implemented when they decide to proceed.

Treatment Resources:

For a wealth of information, visit the TLC Foundation for Body-Focused Repetitive Behaviors: www.bfrb.org

CBT Resources

Mansueto, C., Goldfinger Golomb, R., McCombs Thomas, A., & Townsley Stemberger, R. (1999). A Comprehensive Model for Behavioral Treatment of Trichotillomania. Cognitive and Behavioral Practice, 6, 23-43. Available Online: http://www.bfrb.org/storage/documents/ComB_Article.pdf

The Hair Pulling Habit and You: How to Solve the Trichotillomania Puzzle by Ruth Goldfinger Golomb & Sherrie Mansfield Vavrichek

A companion workbook for Trichotillomania: An ACT-Enhanced Behavior Therapy Approach by Douglas Woods and Michael Twohig

Pharmacotherapy

Grant, J. (2016). “Medications for Body-Focused Repetitive Behaviors.” Retrieved from http://www.bfrb.org/component/content/article/3/186.

 

 

Entering the world of “Inside Out”

 

I recently watched the movie “Inside Out” for the second time with my daughter. As someone who studied emotional development during my graduate school years, I was delighted and impressed by how well the writers conveyed the complex and evolving nature of children’s emotional awareness. As young children, we largely experience emotions as discrete entities – if we are happy, we are only aware of our happiness. As we move into middle childhood, however, we become aware of the finer nuances of emotional awareness, such as our ability to have more than one emotion at the same time. This article by Susanne Denham, Ph.D. provides a helpful overview of childhood emotional development.

 

As the “Sadness” character touched the girl’s memory spheres, these memories which had been purely “Joy”ful changed to a combination of joy and sadness. Isn’t this true for a lot of our experiences? For example, we can think back on experiences with happiness and at the same time feel sad about missing the people or activities that were so important at that moment in time.

 

We then see the girl’s “personality islands” start to fall apart and “Joy” is not there to fix it. This leads us, the audience, to worry about how she is going to recover and how disastrous this could be for her emotional well-being. In the end, though, we realize that these struggles were an essential step toward building new “islands” for the next stage of her development. A great illustration of how challenges encourage our growth…and an important reminder that each emotion has value, and it’s okay and important to feel all of them.

 

I also enjoy the concept of externalizing our emotions in this way. This movie offers a helpful -and humorous – way to observe how each of our emotions has a purpose and, for the most part (!), wants to help us out. There is space for all of our emotions at the control panel, and we can learn to observe them with compassion and understanding.

 

A great movie for kids and adults alike!

Insideout

 

 

What does “overcoming” anxiety really mean?

Naturally, when individuals seek treatment for anxiety, their primary response when I ask about their goals is, “To stop…worrying/panicking/obsessing/etc.” This is understandable because their symptoms have caused such turmoil in their lives!

As a CBT clinician, I often use the classic metaphor of anxiety as an alarm. An alarm serves the purpose of alerting us – letting us know when to wake up, when to call the police, and when to quickly escape a house or building to seek safety. Similarly, our natural anxiety alarm puts us in a state of action and can help us be aware of potential threats and dangers. Unfortunately, just as my smoke detector sometimes goes off when it doesn’t need to (i.e., a burning pizza), our internal anxiety alarm can also send false alarms. The tricky part is that it feels like a true alarm, so we react as we would to a true threat, and the unfortunate effects of this over time are increased anxiety and limited functioning.

So, is anxiety helpful or unhelpful? It’s both! It can make us work hard and help us know when danger is present – and it also can trick us into perceiving danger where there is none.

A major goal of CBT involves helping the individual to filter true vs. false alarms and learn new ways of responding to false alarms that will provide corrective information, foster tolerance, and reduce disruptive false alarm experiences.

A key ingredient in this process is not actually getting the fears and anxiety to go away – rather, it is enhancing our ability to tolerate anxiety and uncertainty when it is present. By learning how to tolerate distress, we learn to have the “wiggle room” to filter information better and take actions that are consistent with our values and goals. A natural and pleasant side effect of increased tolerance of anxiety is lower anxiety – as we become stronger in our ability to handle it, our sensitivity to it comes down, and our experience of triggers can increasingly change and improve. There’s a great quote in Forsyth and Eifert‘s workbook, The Mindfulness and Acceptance Workbook for Anxiety, that says, “Remember that the goal is not to feel better but to get better at feeling.” This paradox gets easier to appreciate as we take steps to face and overcome fears!

A few additional principles to keep in mind:

  • The process of building tolerance can be similar to gaining muscle strength through weight training. Find your starting point and practice that “weight” of anxiety until your strength and stamina improve – move on to the next “weight” from there!
  • Externalize anxiety to see it for what it is. For some, it is helpful to view it as an opponent that is tricking them. For others, it is more helpful to see it as a fearful “side kick” that is just working too hard to find threats and dangers in the world. Seeing it as a separate entity or only a part of your experience offers perspective when it tries to pull you in.

Further readings:

Forsyth, J., & Eifert, G. (2008). The Mindfulness and Acceptance Workbook for Anxiety: A Guide to Breaking Free from Anxiety, Phobias, and Worry Using Acceptance and Commitment Therapy. New Harbinger: Oakland, CA.

AnxietyBC, “How to Tolerate Uncertainty” http://www.anxietybc.com/sites/default/files/ToleratingUncertainty.pdf

 

Psychogenic Non-Epileptic Seizures (PNES)

Despite estimates that 1 out of 5 patients sent to epilepsy centers for difficult seizures have PNES, it often takes years (about 7 years!) to receive an accurate diagnosis. The challenge is that PNES attacks look like epileptic seizures to an outside observer, yet they are not actually caused by abnormal electrical discharges in the brain. In contrast, they are emotion- and stress-related attacks.

A thorough evaluation is critical to identifying an accurate diagnosis. Working with a team of professionals that has an understanding of PNES is invaluable. For further information on the evaluation process and differentiating PNES attacks from epileptic attacks, http://www.nonepilepticseizures.com/epilepsy-psychogenic-NES-events-clinical-diagnosis.php.

The psychological processes underlying PNES attacks vary across patients, although the most commonly diagnosed psychological conditions include conversion disorder, anxiety disorders, in particular posttraumatic stress disorder (PTSD), mood disorders, dissociative disorder, and somatization disorder.

Fortunately, there is a growing initiative to enhance the understanding and treatment of PNES. Within the Northeast Regional Epilepsy Group, director Lorna Myers, Ph.D. and the PNES Diagnostic and Treatment Program are at the forefront of this initiative. There is a wealth of information on PNES offererd by Dr. Myers and her colleagues at http://www.nonepilepticseizures.com. This includes a helpful list of PNES referral sites by state, http://nonepilepticseizures.com/epilepsy-psychogenic-NES-information-referral-sites.php.

See the following additional resources to learn more:

Psychogenic Non-Epileptic Seizures: A Guide by Lorna Myers, Ph.D.

View from the Floor: Psychogenic Non-Epileptic Seizures: A Patient’s Perspective by Kate Berger

Psychogenic Non-Epileptic Seizure Community, http://nonepileptic.org

More than PNES: My life with Psychogenic Non-Epileptic Seizures, a blog by Nadine Boesten, https://morethanpnes.wordpress.com

Relaxation Apps

Technology has its ups and downs. While so much of what we encounter can increase our stress and anxiety, it’s refreshing when technology brings opportunities for relaxation. The world of apps has led to the development of numerous programs that assist with relaxation and mindfulness skills on the go. Check out the following apps that offer a variety of exercises to encourage self-calming and anxiety management.

Calm – Meditate, Sleep, Relax by Calm.com

Cleveland Clinic Stress Free Now by Cleveland Clinic Wellness Enterprise

Walking Meditations by Meditation Oasis

Breathe2Relax by The National Center for Telehealth and Technology

Stop, Breathe & Think by Tools for Peace

Relax Melodies by iLBSoft

 

Note: I am not involved in the development or marketing of these apps. I welcome feedback on additional apps that have been helpful to you.

 

Anxiety Disorders in Older Adults

Anxiety disorders were previously believed to be less prevalent among older adults. Newer findings, however, suggest that anxiety is just as common across age groups.

One factor that may have contributed to this misconception is the tendency for older individuals to report their physical symptoms. There also is significant overlap among symptoms of medical conditions and anxiety disorders, making it especially challenging for both providers and individuals to recognize and separate out anxiety symptoms. For example, symptoms of lightheadedness, muscle pain, concentration problems and increased heart rate can be symptoms of anxiety, medical conditions, as well as side effects of prescription medications.

The clinical picture becomes even further complicated when the individual experiences anxiety secondary to or in response to a general medical condition or declining cognitive and physical functioning.

Whether this is a new experience or a longstanding one, it’s important to be aware of the signs of anxiety and to seek assistance.

The following questions have been suggested to help identify signs of anxiety:

  • Are there triggers for the feelings of anxiety?
  • Are excessive concerns present most days?
  • Is it difficult to put things out of your mind?
  • When physical symptoms begin, what are you doing or thinking about?
  • Are there fears about physical symptoms or falling that interfere with your activities and quality of life?

References and Helpful Resources to Learn More:

Older Adults | Anxiety and Depression Association of America (ADAA)
http://www.adaa.org/living-with-anxiety/older-adults

Cassidy, K., & Rector, N. (2008). The Silent Geriatric Giant: Anxiety Disorders in Late Life. Geriatrics and Aging, 11, 150-156.

Rabins, P. V., & Lauber L. (2006). Getting Old Without Getting Anxious. Avery Publishers.

Welcome

“Do one thing everyday that scares you” ~ Eleanor Roosevelt

Welcome!

It is an exciting time of change and new experiences as I transition into independent practice! Roosevelt’s quote inspires me to embrace these new experiences and grow through them.

Through this blog, I aim to post information on common questions or topics that arise in my work with patients and to share new insights and resources on anxiety disorders and beyond.

I look forward to the opportunities ahead. I will begin seeing patients at my new location after April 20, 2015. I am currently scheduling new patients to start services after this date.

For further inspiration, I recommend the following NPR news story that describes one man’s quest to overcome the fear of rejection:

http://www.npr.org/blogs/health/2015/01/16/377239011/by-making-a-game-out-of-rejection-a-man-conquers-fear?utm_source=npr_newsletter&utm_medium=email&utm_content=20150401&utm_campaign=npr_email_a_friend&utm_term=storyshare