Maintaining Factors in Social Anxiety DisorderWritten by Dr. Kat Harris, PhD, LCPSocial Anxiety Disorders is defined as persistent, intense fear or anxiety about specific social situations for fear of being judged negatively, embarrassed or humiliated. Individuals with Social Anxiety Disorder will either avoid anxiety-producing social situations completely or endure them with intense fear or anxiety, often using safety behaviors as a way to cope with their distress.
Individuals with Social Anxiety Disorder are thought to experience anxiety in response to social situations because they assume that they will be evaluated negatively and catastrophize about the implications of negative evaluation. More specifically, individuals with Social Anxiety Disorder assume that they will be evaluated negatively because they think that their abilities will fall short of others’ expectations, that there are high expectations for social performance, have unconditional negative beliefs about the self, and assume that acting in certain ways will result in negative consequences (Clark & Wells, 1995). There are a number of maintaining factors in Social Anxiety Disorder that are targeted in treatment as a way to stop the cycle of anxiety and to help ensure individuals with social anxiety are able to overcome their fears. Negative Thoughts/Beliefs Individuals with social anxiety engage in thinking patterns that tend to reflect “cognitive distortions” or thinking errors that put them at risk for anxiety. For example, an individual with social anxiety may predict that others will think that they are incompetent or stupid, or that others will be able to tell that they are very anxious, and that these negative evaluations from other’s will result in disasterour consequences (e.g., “everyone will laugh at me and I will be shamed and have to leave”). These are typically referred to as catastrophic likelihood and cost estimates, and treatment specifically works to target these thoughts/beliefs and alter them to reflect healthy predictions. This can be done either directly via cognitive restructuring, or indirectly via the use of exposures or behavioral experiments. Avoidance/Safety Behaviors Passive Avoidance (complete avoidance of a situation, people, or places) and safety behaviors (behaviors done to help the person feel more safe) can actually create and perpetuate thinking errors because they can: exaggerate physical symptoms of anxiety (e.gripping a podium tightly will increase shaking), prevent an individual from learning that they overestimate the likelihood and severity of their feared social consequences, maintain self-focus of attention and self-monitoring (see below) and potentially increase the likelihood that others will notice symptoms of anxiety. Therefore, treatment aims at helping individuals with Social Anxiety Disorder approach their fears without the use of safety behaviors. Common safety behaviors in social anxiety are always needing to bring a “safe” person to social events, avoiding eye contact, not asserting oneself, prefacing interactions with excuses such as “I’m not really myself today so excuse me if I seem off,” being a “wallflower,” exiting conversations as quickly as possible, only engaging in social situations with the use of benzodiazepine medications such as Xanax, perfectionistic preparations (e.g., practicing what one will say over and over again), etc. Internal Self-Focused Attention and Observable Self Individuals with social anxiety engage in detailed monitoring of themselves which then enhances the individual’s awareness of anxiety symptoms and hinders their ability to gather disconfirming information from their environment (Clark & Wells, 1995). In addition, the individual is then thought to use this internal information to construct an impression of the self (perceived observable self) which they assume is also the impression that observers will construct (when in fact, a socially anxious individual's perceived observed self often significantly differs from what others perceive). For example, a socially anxious individual may assume that others can tell they are terrified and shaking and sweating when others may not notice, or not notice to the same degree. Anticipatory and Post-Event Processing Anticipatory Anxiety refers to the tendency for a socially anxious individual to hyperfocus on an upcoming feared social event and worry intensely about it. For many individuals with social anxiety, their anticipatory anxiety is described as being either equally as anxiety provoking or even more anxiety provoking as the event itself. Some individuals describe this experience as a sense of dread or doom. Post-Event Processing is a kind of repetitive thinking pattern that is negative following a social event. For example, an individual that just finished a social interaction may focus on one or two specific incidents that occurred during the social interaction where they felt they failed or embarrassed themselves or didn’t live up to their expectations or the perceived expectations of the other individual(s). They may think to themselves “why did I say that, I’m so stupid, now they think I’m selfish.” The individual will then ruminate about this perceived failure/embarrassment/confirmation of their fears over and over again. In fact, I work with many socially anxious individuals that can recall in great detail a long list of past social events/interactions that they still feel ashamed of and ruminate and think about many years and decades after it took place. For many socially anxious individuals, thinking about these past events can feel very shameful and painful. In treatment, individuals with social anxiety are taught several tools to inhibit the use of Anticipatory Anxiety and Post-Event Processing. Some examples include using present-focused attention, de-catastrophizing, self-compassion exercises, worry/possibility exposures, and fact-based evidence processing. References Clark, D. M., & Wells, A. (1995). A cognitive model of SP. In R. G. Heimberg, M. R. Liebowitz, D. A. Hope, & F. R. Schneier (Eds.), SP: Diagnosis, assessment, and treatment (pp. 69-93). New York, NY: Guilford Press. Stop Solving the Unsolvable: When Worry Goes OverboardWritten by Hillary Gorin, PhD, LCPChronic, persistent worry, exhibited in individuals with generalized anxiety disorder tends to fall into two categories (American Psychiatric Association, 2013): Worries about solvable problems and worries about unsolvable problems. Often my patients with Generalized Anxiety Disorder (GAD) are incredibly good at managing solvable problems. If you are reading this and you have been diagnosed with GAD, I bet you have been called an effective problem solver by people who know you well. Worrying about unsolvable problems similarly is often an attempt to solve a problem that has not yet occurred. In this sense, it should be emphasized that healthy worry serves as an important cognitive function. Healthy worry helps us prepare for the future, plan for navigating challenges, and keep our lives in order. If you know someone who doesn’t worry often, you may know the problems that sometimes result from never engaging in the cognitive process of worrying. They may not be the best at planning, timeliness, or remaining organized and vigilant of what tasks need to be managed. However, chronic and excessive worry often fuels catastrophic thoughts and endless “what ifs'' that cycle through your brain (Zinbarg, Craske, & Barlow, 2006). It can be very difficult to stop and/ or to control these “what ifs.'' Therefore many worriers lose a tremendous amount of time and energy thinking about future catastrophes that could happen and struggle to remain in the present moment (Zinbarg, Craske, & Barlow, 2006).
So what can you do to stop trying to solve the unsolvable problems and catastrophes of the future (sometimes called hypothetical worry)? First, I recommend that my patients determine which worries reflect solvable problems and which worries reflect unsolvable problems (Zinbarg, Craske, & Barlow, 2006). Not only can it be helpful to sort out solvable vs. unsolvable worries, but also it can be helpful to start asking yourself “do I need to solve this problem today?” We are bombarded with endless problems in our lives that need solving. Chores will always need to be completed, new work will keep piling up at your job, and family gatherings will continue needing planning. But does the task need to be managed today? Most problems can actually be solved tomorrow; however, some must be managed today. Start with those. Zinbarg, Craske, and Barlow (2006) recommend doing as follows to manage solvable problems that warrant immediate attention: 1). Identify the problem; 2). Consider all solutions; 3). Rank solutions from the best solution to the worst; 4). Create a plan to carry out the best solution; 5). Do it! Implement the solution and try again if it doesn’t work. Essentially, fix what you can in the most effective and efficient way possible. After recognizing which problems need solving today, the unsolvable problems may still seem well… unsolvable. I argue that is simply not the case. Unsolvable problems can be managed in two ways. The first is by “sitting with” the “what-if” long enough to see that the “what if” has not happened yet and likely won’t. Most of our catastrophic fears actually do not come true or are unlikely to come true. With the assistance of a mental health professional who specializes in anxiety disorder treatment, you can learn a variety of tools for sitting with catastrophic thoughts. The goal is to desensitize yourself to such thoughts because the reality is, they are simply thoughts. If you repeatedly expose yourself to scary “what if” thoughts, eventually you will no longer be afraid of them and/or learn to tolerate them without having to do anything about them (e.g., unhealthy worry). In treatment, we will help you do so in a systematic way. In addition, we will help you learn how to become a scientist. We will encourage you to ask questions such as, what evidence do you have that this is truly going to happen? Oftentimes, it seems to be difficult for my patients to believe such evidence until after they have “sat with” their anxiety for a period of time. In other words, rational thinking can be difficult until the emotion brain has been exhausted. Another strategy we will assist with is called decatastrophizing (Zinbarg, Craske, & Barlow, 2006). Catastrophizing can be defined as considering potential future events as awful and intolerable (Zinbarg et al., 2006). If you are a chronic worrier, you may often say “I could never deal with that” when certain “what-ifs” pop into your head. For instance, if you have recently had the thought “what if I make a mistake at work and then appear incompetent and then I lose my job and then I am without income and then I am homeless,” you may then state, “well, I could never deal with that, that would be too terrible.” You may try to leave it there, push the thought out of your brain, and try to avoid the thought for the rest of the day. But oftentimes, that doesn’t work because that terrible “what if” keeps intruding into your thought processes. For this reason, you will learn to decatastrophize in treatment. If that “what if” persists, it is important to actually take a look at it and consider several things. First, would you survive it? If you would, how would you cope with it? How long would it last? How bad would it be? Essentially, you will realize that you will live through even the most catastrophic events and somehow cope with them. Of course, it would be difficult. It would not be easy to make a critical error at work and to get fired and to go on unemployment. But would you get through it? Yes. You could go on unemployment and start looking for new jobs and find a new job and start working at your new job. It would be a hassle. It would be hard. But you would get through it. Negative, sometimes devastating, events will happen in all of our lives but we will survive and deal with them because unpleasant emotions and circumstances do not last forever (Zinbarg, Craske, & Barlow, 2006). In sum, managing worry entails becoming an effective problem solver. Solve the problems you can. Sit with or de-catastrophize the problems you can’t. Solve the unsolvable problems by recognizing you will be able to handle/ cope with even catastrophic problems, even if we can’t solve the unsolvable. References: American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596 Zinbarg, R. E., Craske, M. G., & Barlow, D. H. (2006). Mastery of Your Anxiety and Worry: Therapist Guide (2nd ed.). Oxford University Press. Organization Strategies for Adult ADHDWritten by Hillary Gorin, PhD, LCP(from Mastering Your Adult ADHD: Cognitive-Behavioral Treatment Program by Steven Safren, Susan Sprich, Carol Perlman, and Michael Otto, 2017)
Individuals with attention deficit/ hyperactivity disorder (ADHD) struggle with focus, attention, and/ or hyperactivity and impulsivity (American Psychiatric Association, 2013). ADHD can therefore often lead to difficulties organizing tasks, focusing on tasks, and completing tasks (American Psychiatric Association, 2013). Because of these difficulties, someone with ADHD may be more prone to procrastinate and wait until the very last minute due to feeling overwhelmed and unable to complete a task (Safren et al., 2017). They also may generally struggle with keeping life organized and taking care of responsibilities. In part, this is due to the prefrontal cortex abnormalities associated with ADHD, or abnormalities in the part of the brain involved in rational thinking, planning, organizing, and impulse control (Vaidya, 2012). Safren and colleagues (2017) have created a Cognitive-Behavioral Treatment Program for Adults with ADHD. In this program, they suggest some strategies for overcoming difficulties with organization. They first provide suggestions for prioritizing tasks by creating daily task lists: What is it you are hoping to accomplish today? Individuals with ADHD may be prone to complete the easy and less important tasks first. However, this may then halt progress towards important, more challenging goals. Therefore, Safren and colleagues (2017) suggest that, after a daily task list is created, the level of importance of tasks on the list should be considered. Specifically, they suggest labeling tasks as A, B, or C tasks. The A tasks should be the most important tasks that must be completed today or tomorrow. The B tasks are less important and the C tasks are of lowest importance (Safren et al., 2017). After the most important A tasks have been determined, they recommend mapping out when you will have time to complete the A tasks and adding A tasks into a daily schedule/ planner. They further emphasize that it is important to create daily goals that are realistic (Safen et al., 2017). If the plan for the day or completion of a task feels too overwhelming, the plan or task may need to be reconsidered. They suggest breaking overwhelming tasks into more manageable steps if a task feels too large. In other words, write out steps of a complex task/ break the complex task into smaller steps. These smaller steps can then be placed into the schedule/ plan for the day. Although these strategies may seem simple, they can be critical for organizing and prioritizing task completion which in turn can improve productivity, reduce frustration, and reduce self criticism for “not accomplishing enough today.” Many other strategies can be helpful in cognitive behavioral therapy for ADHD for organizing tasks, reducing procrastination, improving focus, etc.. Reach out today to work with a trained mental health professional for additional support in applying these and additional strategies! References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596 Safren, S. A., Sprich, S. E., Perlman, C. A., & Otto, M. W. (2019). Mastering your adult ADHD: A cognitive-behavioral treatment program: Therapist Guide (2nd ed.). Oxford University Press. Vaidya, C. J. (2012). Neurodevelopmental abnormalities in ADHD. Current Topics in Behavioral Neuroscience, 9(1), 49-66. https://doi:10.1007/7854_2011_138 “So What” ing Social AnxietyWritten by Dr. Hillary Gorin, PhD, LCPSocial anxiety disorder can be defined as anxiety in social situations due to fear of evaluation (American Psychiatric Association, 2013). Essentially, this leaves an individual with social anxiety with two options: 1) Avoid social interactions all together; 2) Do so with anxiety and then engage in hours of what is referred to as post-event reprocessing. Post-event reprocessing entails revisiting social interactions and events mentally after they have taken place and critically evaluating your performance (Leigh & Clark, 2018). Ruminative thoughts about social errors may consume hours or even days after a social encounter for someone struggling with social anxiety disorder (Leigh & Clark, 2018). In addition, because social approval is never certain, uncertainty can fuel further rumination (Leigh & Clark, 2018). For instance, you may start to ask “did I really say that or did it come out incorrectly?” which further fuels uncertainty and an endless spiral of anxiety. Furthermore, because social anxiety tends to create internal focus (what should I say next, are they looking at me?, etc.), it can be very difficult to objectively evaluate social performance and therefore the cycle of post-event rumination can persist for extended periods of time, without factual data that one performed well (Leigh & Clark, 2018). It makes a lot of sense that many of my socially anxious patients come to me exhausted and disinterested in engaging socially with the world, as this process can be incredibly exhausting both during social encounters and after they are over.
In Cognitive-Behavioral Therapy for social anxiety disorder, we will help you learn many strategies for combating social anxiety, including how to challenge your thoughts before, during, and after social events and how to “sit with” the anxiety during and after interactions. When “sitting with” anxiety, you learn that anxiety does not last forever and that what you are afraid of may not be as frightening or catastrophic as it feels. Here, I will describe a “sit with it” tool I have entitled “so what” ing your social anxiety. Applying this tool involves starting to accept social mistakes. Many of my patients will ask the following types of questions after a stressful social encounter:
The “so what” approach involves saying to yourself, “so what if I sounded incompetent in that one conversation? What happens then? Hmm. I guess nothing.” We evaluate others based on data patterns. One slightly ignorant comment or error typically does not completely change our perspective on someone. If it does, the other person should likely engage in some cognitive therapy so that they can stop thinking so extremely and inaccurately about the world and other people. One data point does not create a line. Similarly, one error does not completely alter our social image. We can say, “so what, I made a mistake,” and move on. Alternatively, we can ruminate for days about the one part of a conversation we could have engaged in better and change absolutely nothing about the past or the way it may impact our social image. Typically, “so what” ing honest mistakes is more helpful and less exhausting. If “so what” leads to more catastrophic thinking, we can keep “so what” ing until we get to a resolution. For instance, “so what if I sounded incompetent in that conversation with my boss?” may lead to “what if I get fired?” We can “so what” the next thought too. “If I get fired, I will collect unemployment until I can find a new job. Would that be miserable? Of course. Would I survive it? Yes.” This technique is sometimes referred to as decatastrophizing (Zinbarg et al., 2006). If we can start to “so what” social fears, it becomes possible to recognize that we all make social mistakes and most of them are not at all catastrophic. Generally, we are all doing our best to make a good impressions but no one will do so perfectly. Social errors are a part of our social existence. “So what” the social errors so that you can start to “sit with” your reality: You are a human being, an imperfect social creature like the rest of us. References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596 Hope, D. A., Heimberg, R. G., & Turk, C. L. (2019). Managing Social Anxiety: A Cognitive-Behavioral Therapy Approach: Therapist Guide (3rd ed.). Oxford University Press. Leigh, E., & Clark, D. M. (2018). Understanding social anxiety disorder in adolescents and improving treatment outcomes: Applying the cognitive model of Clark and Wells (1995). Clinical Child and Family Psychology Review, 21(1), 388-414. https://doi.org/10.1007/s10567-018-0258-5 Zinbarg, R. E., Craske, M. G., & Barlow, D. H. (2006). Mastery of Your Anxiety and Worry: Therapist Guide (2nd ed.). Oxford University Press. Exposure and Response Prevention for OCDWritten by Kat Harris, PhD, LCP and Vanessa Osmer, MA, LCPC, NCCApproximately 1 in 100 adults (and about half that number of children) are thought to have Obsessive-Compulsive Disorder (OCD). OCD can cause a great deal of suffering and impairment. Usually, OCD presents obsessional content in themes, and there is significant diversity in the content areas. Some of the more common content areas or themes of OCD include, but are not limited to, obsessions related to contamination, harm, perfectionism/just-right, religion and morality (often called scrupulosity), identity, relationships, and so on.
Obsessions are defined as persistent unwanted thoughts, images, impulses, or intrusive doubts that cause significant distress. People with OCD tend to interpret these obsessions as being dangerous, shameful, or meaning something sinister or concerning, and therefore want to avoid them and try to push them away. These obsessions can cause many emotions, such as anxiety, fear, doubt, guilt, disgust, uncertainty, and frustration. Obsessions are repetitive, and attempts to suppress the thoughts often only worsen them. For example, what is the first thing you think of if I tell you not to think of a polar bear? That is right. No matter how much you attempt to avoid the thought of a polar bear, it continues to show up in your thoughts. It is not a big deal when we are talking about a polar bear that is relatively meaningless, but what about when the thought is disturbing or upsetting? Compulsions are strong urges to engage in a behavior and/or mental act to reduce the obsessions and/or to keep the obsessions' feared outcome(s) from happening. Although compulsions are technically purposeful behaviors or mental acts, many individuals with OCD describe compulsions as feeling automatic, especially those that occur mentally. When people engage in compulsions, they become reinforced by a short-term sense of relief. However, compulsions tend to strengthen the danger signal of the obsessions long-term. Exposure and Response Prevention (ERP) is a form of Cognitive Behavioral Therapy. While ERP is usually associated with treatment for OCD specifically, the foundations of the treatment itself can apply to several other disorders, including other anxiety disorders and eating disorders. ERP is considered a gold-standard treatment for OCD. It involves asking clients to either trigger or allow obsessions to exist (this part is called exposure). During the exposure, clients are directed to resist pushing the obsessions away and are discouraged from engaging in compulsions or other forms of avoidance (this part is called response prevention). I am sure this sounds hard and scary, and for someone with OCD, it really can be. For this reason, therapists and clients work collaboratively in a safe environment to develop a gradual, systematic approach. Working together helps to increase the chance that clients are successful and have the best chance at learning safety. Learning safety is a critical component of treatment. OCD convinces client's that their thoughts, images, impulses, or doubts are dangerous, and if compulsions are not utilized, something dangerous or bad will happen. Ideally, ERP will teach clients that they can handle distress and uncertainty. As a result, many clients build self-efficacy and learn to trust their ability to face complex thoughts and internal experiences. Additionally, clients get the opportunity to learn that compulsions are not helpful or necessary (and, in fact, perpetuate the cycle of anxiety). I often tell clients that compulsions get all the credit for safety, but they rarely measure up when put to the test. Clients will likely learn that what they are afraid of is unlikely to occur and that thoughts/images/impulses are not necessarily meaningful and essential. Once safety is learned, and clients consistently manage their intrusive thoughts without pushing them away or seeking safety through compulsions, clients enter into the relapse prevention phase of treatment. Relapse prevention is a critically important part of therapy. Relapse prevention aims at reviewing the skills developed, processing the evidence obtained, identifying how the client can generalize the skills moving forward, and developing plans to address any symptoms of lapses or relapses in the future. In some instances, clients may request to return to therapy for booster sessions to ensure they stay on track and do not fall into old OCD habits. For more information, blogs, and resources on OCD and ERP, please visit OakHeart's Obsessive-Compulsive Disorder specialty page: https://www.oakheartcenter.com/obsessive-compulsive-disorder-ocd.html What is Cognitive-Behavioral Therapy for Insomnia (CBT-I)? Frequently Asked Questions for Skeptical PatientsWritten by: Dr. Hillary Gorin, PhD, LCPWhat is Cognitive-Behavioral Therapy for Insomnia (CBT-I)?
CBT-I addresses behaviors and thinking patterns that interfere with sleep (Manber et al., 2014). In treatment, you can expect a thorough examination of your sleep patterns and habits followed by a structured and brief treatment (typically 6-8 sessions) that assists in creating new patterns. Does it really work? According to many studies, CBT-I is as effective as medication in the short term and more effective than medication in the long term (as cited in Muench et al., 2022). Why? Because we may become tolerant of medications but behavioral and cognitive changes can be maintained over time. What does good sleep even look like? ‘Good’ or ‘healthy sleepers’ take on average 30 minutes to fall asleep (as cited in Manber et al., 2014). They also wake up two times or less in the night and are awake for 30 minutes or less once awake. If your sleep difficulties extend beyond this range, you may benefit from treatment. What does CBT-I entail? You can expect the first few weeks to entail data collection (as cited in Manber et al., 2014). We will ask you many questions about your sleep habits and routine. In CBT-I, we generally will collect 2 weeks of sleep data, in what is often called a sleep diary, to identify averages. We will then calculate what is called your sleep efficiency. Sleep efficiency is defined as follows: Total Sleep Time/ Time in bed x 100. This number should be more than 85% for a healthy sleeper. What is the goal of treatment? In short, the goal is to sleep in your bed and to stop wasting time tossing and turning! How will we help you do that? We will recommend, if indicated, what is called sleep restriction or a structured way to restrict time in bed. This may not make sense at first. Why would we recommend you sleep less to sleep more? Because this will help you reset and create new sleep rhythms and habits. Essentially, we will calculate, on average, how long you are actually sleeping in your bed. We will encourage you to only be in your bed for that amount of time for a short period of time (days or weeks, at most) by setting a consistent rise time and changing your bedtime over the duration of treatment (as cited in Manber et al., 2014). Once sleep efficiency improves, we will assist with expanding more time in bed slowly so that your body can adjust to sleeping more when you are supposed to when in bed. For example, if on average you are only sleeping 5/ 8 hours in bed, we will encourage a bed time and rise time that only allows for 5 hours in bed. Once you start sleeping during the majority of that time in bed, we will assist with slowly expanding time in bed. We will do so by recommending an earlier and earlier bed time while maintaining the same wake time and ensuring you are still sleeping the majority of that time in bed. Can I do anything before I get started to help improve sleep? Yes! Follow some general sleep guidelines as follows (as cited in Manber et al., 2014):
How will my sleep anxiety be addressed in treatment? Many people have anxiety-provoking thoughts about sleep. For instance, some people think, if they wake up, they won’t be able to go back to sleep, or they may think they will not fall asleep and oversleep and miss work and and and! Unfortunately, sometimes these anxiety-provoking thoughts end up creating a self-fulfilling prophecy… if you wake up and have the thought “it’s 2am, now I’m never going to get enough sleep and my day will be horrible,” that thought will trigger anxiety which will then make falling back asleep even more difficult. We will help you challenge your thoughts about sleep by helping you become a scientist. We will encourage you to ask yourself “is this really accurate?” We can also assist by helping you learn how to tolerate anxiety and uncertainty, in general. Most of our thoughts are not really accurate. Also, I bet you have gone to work exhausted many days and somehow got through it. That is the goal: To learn that you will get through the next day even if sleep deprivation occurs! References: Manber, R., Friedman, L., Siebern, A.T., Carney, C., Edinger, J., Epstein, D., Haynes, P., Pigeon, W., & Karlin, B. E., (2014). Cognitive behavioral therapy for insomnia in veterans: Therapist manual. Washington, DC: U.S. Department of Veterans Affairs. Emetophobia: The Vomit PhobiaWritten by: Dr. Kat Harris, PhD, LCPAn intense, disproportionate fear of vomiting might not sound all that debilitating for those who don’t suffer from emetophobia or for those without a loved one with emetophobia. However, having an intense fear of vomit can wreak havoc on one’s life and interfere in one’s ability to engage in activities that they might otherwise love to do, such as travel, eat at restaurants, try new foods, attend school, watch certain movies or tv shows, have children or care for sick children, spend time around children, visit a loved one in a hospital, etc.
Essentially any activity that might create a situation perceived as being conducive to nausea or vomiting might be completely avoided or only engaged in with significant safety behaviors or compulsions such as bringing medications, water, safety people, excessive checking, washing, reassurance seeking, etc. Emetophobia is sometimes considered a Specific Phobia and is sometimes considered to be a form of Obsessive-Compulsive Disorder. Either way, the recommended treatment is Exposure and Response Prevention (ERP). ERP is a type of Cognitive-Behavioral Therapy (CBT). This treatment includes having individuals confront the things that cause them anxiety and distress and then having the client "response prevent," or in other words stop engaging in, or significantly modify, the avoidance/safety behaviors/compulsions that are normally used in response to external (e.g., certain foods, public transportation) or internal (e.g., feeling dizzy, the thought “I might puke”) triggers. This is done in a safe, gradual, systematic way to ensure that individuals are as successful as they can be. There are typically three exposure types: in-vivo, imaginal, and interoceptive. An in-vivo exposure is an exposure where a client is asked to directly face their feared situation or physical trigger in real life. In the case of emetophobia, this may encompass traveling via various modalities (e.g., flying, taking a bus, train, driving, etc.), eating foods outside of what the client may usually deem “safe” (e.g., foods with certain textures that are normally avoided, eating foods that have not been excessively checked for their expiration), listening to the sound of someone else vomiting in a movie or tv show, looking at or holding a substance that resembles the texture or smell of vomit, mimicking the motion or experinece of vomiting, reading a book about vomit (yes those exist), etc. An imaginal exposure refers to an exposure where a script or informal image is used to confront a feared situation and/or image specific to the client’s fear. These might be used as a build-up to in-vivos, or may be used when exposure to the in-vivo might not be feasible. For example, the client might be asked to imagine sitting with the possibility of vomiting, imagine eating at a certain restaurant and incorporate their senses such as what they would hear, smell, and taste, etc. An interoceptive exposure involves asking a client to face their “interoceptive symptoms” that are associated with their fear of vomiting. Interoceptive specifically means physical/somatic symptoms/symptoms associated with the internal state of the body. For someone with emetophobia, this might include intentionally inducing symptoms such as dizziness, nausea, hot flashes, etc. Usually, a mental health provider will clear their client’s for light to moderate activity with their client’s physician and ensure that interoceptive exposures are indicated. The goal of all of these exposures and treatment is not necessarily to induce vomiting. The goal is to encourage the client to approach the situations, people, places, things, physical symptoms, and thoughts that they might normally avoid because of their fear, and teach them that they are safe and can handle the distress associated with facing their fears, and that they can do so without the use of avoidance, safety behaviors and/or compulsions. And IF they do vomit, they can handle that too. This all, with the goal of getting the individual back to their life, doing things that they love to do and value, with the power and freedom that comes with not being bossed around by anxiety. Insomnia: Causes and Recommendations for TreatmentWritten by: Dr. Pamela Heilman, PsyD, LCPWhat is sleep?
The sleep cycle is comprised of 4 stages and all play a role in getting quality rest. One of the 4 stages is referred to as REM (rapid eye-movement) and the other 3 stages are part of the NREM (non-REM). Stage 1, also referred to as N1 is a very light sleep and typically lasts about 1-5 minutes. It is easy to wake a person up during this stage. Stage 2 (N2) is a deeper, more restorative sleep and lasts for approximately 10-60 minutes. During this stage, body temperature drops, muscles relax, and breathing and heart rate slow down. Stage 3 (also known as N3, Slow wave or Delta Sleep) is the deepest stage of sleep that helps consolidate memories and typically lasts for 20-40 minutes. Muscle tone, pulse, and breathing rate continue to decrease during this stage. Experts suggest that this stage is crucial for recovery and growth. Finally, REM is the 4th stage of sleep and lasts for 10-60 minutes. Much of dreaming happens during REM sleep. Research suggests that REM sleep is essential for functions such as learning and creativity (Suni, 2022). In a normal sleep period, a person will experience 4-6 sleep cycles. Most of deep sleep occurs during the first half of the sleep cycle. Evidence suggests that not only is it important to obtain a certain amount of sleep per night (approximately 7-8 hours), but proper cycling through the 4 stages is essential as well. Individuals who do not get enough deep sleep or REM sleep may experience more impairment in functioning that impacts thinking, emotions, and physical health (Suni, 2022). Processes that Affect Wakefulness and Sleepiness The sleep drive and circadian rhythm/body clock are biological processes that promote wakefulness and sleep. Sleep drive refers to a person’s likelihood of falling asleep at a given time. A person’s body accumulates sleep drive every hour that they are up and moving. It takes approximately 16-18 hours of alertness/activity to build up enough sleep drive to go to sleep (Danforth, 2017). The circadian rhythm/body clock refers to internal processes which schedule bodily functions and activities. Our circadian rhythm responds to outside cues to keep our body in sync. When the sun goes down, it signals our body clock. Anything we do on a regular schedule helps to keep our body clock in sync. Regular bed times, wake times, light exposure and even meal times help to set our internal clock (Danforth, 2017). What Causes Insomnia? The arousal system allows us to respond to dangerous threats and can override the processes controlling sleep. Individuals who have experienced trauma may experience physiological hyperarousal which interferes with ability to fall asleep. An overactive mind (cognitive hyperarousal) is often associated with depression and anxiety disorders and can disrupt sleep processes. Some individuals who experience insomnia become conditioned over time to develop anxiety about being able to sleep (Danforth, 2017). When people experience difficulty getting quality sleep, they will often use “compensatory behaviors” such as going to bed early, drinking alcohol, worrying about sleep, sleeping in, and napping. These behaviors can actually worsen sleep over time because they disrupt proper cycling through the 4 stages of sleep. Factors that negatively impact your sleep drive such as excessive time in bed, inactivity, napping, and sleeping in can all lead to insomnia. Variable bed times/wake times and jet lag can disrupt your circadian rhythm and impair sleep quality (Danforth, 2017). Treatment for Insomnia There are important considerations when determining appropriate treatment for insomnia. A sleep specialist will assess your symptoms, other co-occurring conditions, and possible causes for your insomnia. Typically, you will be asked to log at least 1 week (ideally 2 weeks) of sleep activity to help assess what treatment is right for you. If you report symptoms associated with Obstructive Sleep Apnea (a medical condition which blocks your airway during sleep), you will be encouraged to participate in a sleep study and to work with a medical doctor to determine the appropriate course of treatment. The following is a list of treatments utilized in CBT for insomnia (CBT-I). Stimulus Control Therapy Individuals with insomnia often spend too much time in bed lying awake. Over time the brain begins to associate the bed with wakefulness. This type of therapy involves strategies to re-establish the connection between bed and sleep and helps to reset the circadian rhythm. Examples might include having the individual wait until they are tired before going to bed, having a regular wake time, and getting out of bed if they have been awake past a certain period of time. Sleep Restriction Therapy This type of therapy is meant to help individuals who are experiencing problems with sleep drive and overall sleep quality. The individual’s sleep diary is used to help calculate a “time in bed prescription.” The goal is to shorten time spent in bed until sleep quality improves. Cognitive Therapy These are strategies that help target thoughts and beliefs about sleep. An individual will be taught healthy ways to manage worry and rumination around bed time. Relaxation Strategies Relaxation therapy is most appropriate for individuals with sleep onset difficulties. Examples include progressive muscle relaxation and diaphragmatic breathing (Danforth, 2017). Sleep Hygiene Sleep hygiene refers to lifestyle habits that may impact sleep quality. Healthy sleep hygiene may include some of the following:
Therapy for insomnia is not a one-size-fits-all approach. The above-mentioned therapies may be contraindicated for some individuals. It is important to get a thorough assessment with your therapist and possibly, primary care physician in order to determine what treatment may be most beneficial. References: Danforth, M. (2017). Treating Insomnia: Evidence-based strategies to help your clients sleep. PESI. Suni, E. (2022, August 10). Stages of Sleep. Sleepfoundation.org Eating Disorder Recovery: 3 Tips to Navigate the Summer MonthsWritten by: Laura Lahay, MAI absolutely love the summer months. I love the great amounts of sunshine, the blooming of plants and trees, getting to do fun activities like swimming, boating, fishing, roller-blading, etc., and having extra time to spend with friends and family. A favorite memory I have of the summer months as a child was getting to swim pretty much every day (sometimes multiple times a day) in our backyard pool. I anticipate and look forward to these months as they approach, but I know for others, especially those who are recovering from eating disorders, the summer months can create discomfort, bring up immense insecurities, and feel overwhelming to navigate.
It is common for a majority of people to become more aware of their bodies during the summer months. With summer clothing covering less of the body, having a less structured schedule with more time to think about one’s body, more social events or obligations to compare one’s self to others, and more time to be on social media platforms, it can be hard not to give more attention to one’s body and physical appearance during the summer. It is particularly difficult for those who are in the recovery process from an eating disorder, as each of the above factors and more can be triggering and difficult to avoid. It is brave to engage in the recovery process at any time of the year, but especially during the summer months, as they can be the most challenging to navigate. So if you are currently on a recovery journey from an eating disorder, know that you are brave and seen during this time. I wanted to share three tips that might help give support to anyone who is choosing recovery during the summer months or knows of someone who is struggling and could benefit from this information. Tip #1: Identify Trigger Places, Events, and Habits and Talk About How to Navigate Them Triggers are sensory reminders that can cause certain symptoms to resurface. Triggers can be anything from the smell of a certain kind of perfume to a loud, abrupt voice to seeing pictures on billboards of people in bathing suits. I would encourage someone who is recovering from an eating disorder during the summer months to be mindful of their specific triggers during this season. These triggers might look similar or different to other people who are in recovery, and that is ok. The key is to determine what one’s specific triggers are and then talk about how to navigate them throughout the summer months. If a person’s trigger is seeing lots of pictures of people in bathing suits, a way to navigate that trigger could be to limit their social media time during the summer months. If a person’s trigger is excessive amounts of free time during the summer, a way to navigate that trigger could be to make a daily schedule for themselves to follow to create a routine. These ways of coping do not have to become the norm for a person; they can be used as a helpful tool temporarily to further protect one’s mental and emotional health during the summer as the person is continuing to recover. Tip #2: Focus on Doing Activities That Have Nothing to Do With Changing The Body The summer months are a time when a majority of people talk about “getting into shape.” This can mean spending more time at the gym, doing excessive outdoor exercise, or attempting to eat a healthier diet. These goals are by no means a bad thing for certain people. For those who are in recovery from an eating disorder though, they can be triggers and make the person feel pressure to engage in further unhealthy patterns or behaviors for them in the midst of recovery. In order to continue to protect one’s mental health, I encourage my clients who are in recovery from an eating disorder during the summer to intentionally find activities they can do that have nothing to do with changing their body. This can be things like gardening, reading a favorite book, going mini-golfing with friends, backyard stargazing, creating DIY projects, visiting the local library, volunteering, doing puzzles, or having a water balloon fight with friends. There are so many fun activities one can do to create memories this summer that have nothing to do with changing the body. I would encourage a person in recovery from an eating disorder to make a list of these activities and begin checking them off. Tip #3: Create a Summer Affirmations List Self-talk is the dialogue a person has with themselves about themselves. The way a person talks to themselves affects one's self-esteem and self-perception. If a person is consistently engaging in negative self-talk, this can create a negative self-image and affect one’s mood and functioning. It is common for those who are in recovery from eating disorders to be working on challenging and reframing their negative self-talk to create further acceptance of themselves. Fostering healthy self-talk during the summer months can be difficult for lots of people, but can be especially difficult for those in recovery from an eating disorder. A helpful way that I encourage my clients to engage in healthy self-talk is to create a “Summer Affirmations List.” This is a list of affirming statements about themselves and their body image that they can look at when needing to challenge some of their negative self-talk. Some affirmations clients will write include: “I am more than my body”; “I love and accept my body just as it is today”; “I take care of my body and my body takes care of me”; “It is ok to love myself now as I continue to grow and change.” I encourage my clients to place this affirmation list in a place where they will easily see it such as their bathroom mirror or their bedroom wall, or I encourage them to make it their screen saver on their phone during the summer. It is important to find ways to remind oneself of healthy self-talk during the summer months when in recovery. The summer months can be challenging, especially in recovery from an eating disorder, but they are possible to navigate. For those who are in recovery during these summer months, know that you are doing hard work that does not go unnoticed. Keep prioritizing your healing journey and remember to have some fun in the sun. To make an appointment with Laura, please visit: Contact Behavioral Activation for Depression: What, Why, and HowWritten by Kat Harris, PhD, LCPWhat
Behavioral activation is an important component of Cognitive Behavioral Therapy (CBT). Cognitive Behavioral Therapy includes many components and is based on the principle that thoughts/beliefs (Cognitions), emotions, physical symptoms, and behaviors are all intricately related. Helping someone feel better using CBT would typically involve changing unhelpful thoughts/beliefs (Cognitions), emotions, and behaviors via a variety of tools such as cognitive restructuring, emotion regulation and distress tolerance skills, mindfulness, behavioral activation, coping skill development, interpersonal effectiveness skill refinement, trauma processing, etc. CBT is considered a Evidence-Based Practice (EBP)/an Empirically Supported Treatment and is the gold-standard treatment approach across many client concerns. Why Specifically, changing behaviors is one of the core goals in CBT, as it is thought that behavioral change allows for healthy corrective experiences that can alter unhealthy beliefs about the self, world (including others), and one’s future. Avoidance and withdrawal, some of the key features of depression and other disorders, inhibits an individual's opportunity and ability to obtain corrective experiences and positive reinforcement from their environment. Therefore, behavioral activation treatment involves encouraging “activation” and participation in “anti-depressant” activities…interaction with one’s environment in a way that offers opportunities for positive reinforcement and increases in self-efficacy (a person’s belief in their ability to exert control over their lives and their world). How
To learn more about depression, see our Depression Specialty Page. |
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