School Anxiety: Back to school can be a challenging time for both children and parents. After a summer of fun and freedom, the approach of school often brings butterflies and anxious anticipation. This nervousness can range from mild jitters to school refusal. Most kids (and parents) experience some anxiety with the return of school. After all, there is a host of new things to worry about: What will my teacher be like? How much homework will I have? Who will be in my class? Where will I sit at lunchtime? These natural concerns typically go away within the first week or so of school. For some kids, however, anxiety reaches a level that makes it difficult to cope with all these changes and uncertainty. When this occurs, children often refuse to attend school. This behavior is known as school refusal. As the name suggests, school refusal is an anxiety problem that occurs when a child will not regularly attend or stay in school. School refusal is often accompanied by physical complaints ("I have a headache" or "I have a stomach ache") or tantrums, separation anxiety, or avoidance. CBT is an effective form of treatment for school refusal. If you're seeking help for a child who is refusing school, please contact us at (704)631-3980.
Driving Anxiety: Do you suffer from anxiety while driving? Driving anxiety is one of the most common reasons people seek our help. What is driving anxiety? As the name suggests, it’s the experience of intense fear or anxiety while driving. Another name for this problem is driving phobia, because anxiety often reaches phobic levels for individuals with this type of fear. There are many reasons why a person might develop driving phobia. For example, if you suffer from panic attacks, you might fear that you’ll panic while driving and lose control of the car, crashing and harming yourself or someone else. If you’ve had a traumatic experience behind the wheel, you might feel anxious and panicked at the thought of driving. Driving anxiety often occurs on highways, in heavy traffic, or in others spots where you might feel stuck or trapped. Cognitive Behavioral Therapy is effective in the treatment of driving anxiety.
Orthorexia: Are you so focused on “clean eating” that you are avoiding groups of foods altogether? Do you find that thoughts about eating healthy are taking up a lot of your mental space? Do you feel guilty when you eat foods considered “unhealthy”, such as chocolate, bread, full-fat dairy, or non-organic produce? Does preparing food take you more than three hours per day and require extensive reading about healthy recipes? We all try to lead a healthy life, including maintaining proper eating patterns. However, when the intention to eat healthy becomes a burdening concern, we call it Orthorexia Nervosa. Orthorexia is a term coined by a physician, Steve Bratman, in 1997 from Greek terms meaning “right eating”. It refers to an initial goal of seeking health by maintaining a nutritious diet. However, this positive wish becomes overridden by inflexible eating patterns, elimination of food groups deemed unhealthy (such as fat, or gluten), obsessively thinking about researching and preparing foods, and guilt when deviating from these staunch eating guidelines. At an extreme, orthorexia becomes a source of social isolation, self-criticism, and depression, as the person spends hours of their time planning their diet and recovering from “slip-ups”. It may also lead to physical illness, as eating rules may eliminate important food groups, robbing the person of needed nutrients. Orthorexia shares similarities with eating disorders such as anorexia in its need to exert control, perfectionism, and guilt about food. It also shares similarities with OCD in terms of intrusive thoughts about food, rituals about preparing meals, and fear of foods contaminated with unhealthy substances (like pesticides or sugars). Similarly to eating disorders and OCD, orthorexia responds well to an integrative treatment combining cognitive restructuring, behavioral modification, exposure and response prevention, and relaxation techniques. For more information, please visit the national eating disorders website and check out this article about Orthorexia.
Retraining the Amygdala: The amygdala is a small, almond-shaped part of our brain that controls our fight-or-flight response. When we're faced with danger, the amygdala sounds the alarm and our bodies leap into action--our pulse quickens, our blood pressure rises, our breathing gets faster. This response is essential to our survival and our amygdala is always scanning the world looking for threats. It never turns off, even when we sleep. Which is why we can leap up from a sound sleep if we hear a loud noise. The amygdala's main job is to protect us. However, in many anxiety disorders, our amygdala has become too active. It's sounding the alarm when there really isn't a threat. For example, if you suffer from panic attacks, you might get on a perfectly safe elevator to go up a few floors. Your amygdala, however, misreads this safe situation as one where you're trapped and can't escape and pushes the panic button, leading to a false alarm. Your amygdala simply thought you were in danger and tried to protect you. When these false alarms occur, it can be a sign that the amygdala needs a bit of retraining. The good news is that Cognitive-Behavioral Therapy (CBT) can do just that. By using the techniques of CBT, you can retrain your amygdala to be less reactive, to be less sensitive in safe situations.
Mental Rituals in OCD: When we hear the term "compulsions", we tend to think in terms of OCD behaviors such as hand-washing or repeated checking. While these behaviors are common, there is another form of compulsion that is common in OCD: mental rituals. Like any compulsion, a mental ritual helps reduce the anxiety that comes with an obsessive thought. However, unlike hand-washing or checking, mental rituals are rituals that take place solely in your mind. Mental rituals can take many forms, including replacing a "bad" thought with a good thought, prayer, or repeating a phrase in your mind to undo the unwanted thought. For example, if you have an unwanted, intrusive thought of harm coming to someone you love, you may feel compelled to perform a mental ritual (such as saying "I don't mean that" to yourself) to reduce the anxiety connected with that thought. Since they are private rituals, other people often aren't even aware that they exist, leaving you to feel alone with your OCD. Fortunately, mental rituals are very common in OCD. Many people feel initially discouraged by mental rituals, thinking they can't be helped in therapy. However, just because a symptom is less publicized, doesn't mean it's less common or more difficult to address. Conquering mental rituals is a common and essential part of effective treatment for OCD.
OCD and Tics: Obsessive-Compulsive Disorder consists of two main symptoms: unwanted, intrusive thoughts that cause distress (obsessions) and behaviors designed to reduce the distress associated with those thoughts (compulsions). Common forms of OCD include contamination, checking, and “bad thoughts” OCD. Tics, on the other hand, are sudden and recurrent motor movements or vocalizations. These movements or vocalizations can be preceded by urges and often feel difficult to resist. However, those with tics can often suppress them at times. For example, a child may not exhibit tic behaviors at school, but engages in tics as soon as he gets home. Examples of tics include coughing, throat clearing, eye blinking, grunting, sniffing and barking. In children, particularly boys, these two problems often occur together. When this occurs, there are often other features as well, including earlier age of onset, and other complains such as attention difficulties, oppositional behavior, and learning difficulties.
Children who are experiencing both OCD and Tics often benefit from Exposure and Response Prevention Therapy (ERP) along with Comprehensive Behavioral Intervention for Tics (CBIT). These two therapies, in combination, have been shown to effectively address the symptoms that the child with both OCD and tics experiences.
Mindfulness: While mindfulness is one of the newer tools used in Cognitive-Behavioral Therapy, the origins of this ancient practice actually date back thousands of years. The term mindfulness refers to focused attention on the present moment. When we feel anxious, we are in the future, worrying about things that might happen. By cultivating mindfulness, we bring our attention back into the present, focusing instead on what is happening in the moment. In this way, we live more fully and relieve anxiety brought on by fears in the future.
Give mindfulness practice a try and see if helps tame your anxiety. Here's a simple exercise to get you started: Sit comfortably and close your eyes. Now bring your attention to your breathing and let it settle there, focusing on the sensation of your breath as your diaphragm rises and falls. As you focus on your breathing, you'll notice the tendency to get lost in your thoughts. When that occurs, simply notice your thoughts and gently return your focus back to your breath. By practicing this regularly, you'll improve your ability to live in the moment and let go of unwanted, upsetting thoughts about the future. To learn more about mindfulness, read this helpful article from Psychology Today.
How to Set Effective Goals: Setting goals is something we learn at a young age. Unfortunately, we often learn to set vague, ineffective goals, not knowing that there are five simple steps to setting a good goal. Effective goal setting is also key in overcoming worry and general anxiety. The research on goal setting is fascinating, and it highlights these keys to making sure you meet your goals:
Be Specific: When setting a goal, the more specific, the better. Compare "lose weight" to "lose five pounds by March 1st by eliminating sugary drinks from my diet" and it's easy to see which is the more effective goal. Consider your recent goals. Are there ways to make them more specific?
- Reach for the Stars: This one is exciting and counterintuitive. It turns out that setting a more difficult goal is actually better. The more difficult goal we set for ourselves, the harder we work to achieve it. So next time you set a goal, think big and go for it!
- Get Feedback: Just like we use a GPS to track our progress toward our destination (and tell us when we are off track by persistently repeating "recacluating"), we need feedback on our progress toward our goals. When you set a goal for yourself, ask yourself "how can I track my progress?" If you can't easily track it, consider revising your goal so you can get feedback along the way.
- Check Your Commitment: Committment means your willingness to work consistently over time to achieve a goal. In order to achieve success, it's vitally important to choose goals that you feel strongly committed to accomplish. These goals should be important to you and reflect your own personal values.
- Make it Achievable: As you review your goals, make sure they are achievable. As you now know, a difficult goal is a good goal, but it's also crucial that the goals you lay out for yourself are ultimately things that you can achieve.
Now that you know the keys to setting good goals, you can use them to overcome the tendency to worry and procrastinate. By becoming a more effective goal-setter, you'll become more productive and reduce your anxiety as a result.
Tips to Conquer Worry: We all worry--also known as thinking about bad things happening in the future--from time to time. It's a uniquely human ability that's wonderfully helpful at times. Left unchecked, however, worry can run rampant, making us feel tense and anxious, dispruting our sleep, and harming our relationships. Here are some tips for taking control of our mind's radar alert system:
- Understand productive worry: Keep in mind that worry can be a good thing. The key is knowing when your worry is productive--and when it's not. Productive worry has three main characteristics: the problem is realistic, it's likely to occur, and it's solvable. Unproductive worry, on the other hand, often focuses more on unrealistic scenarios that are unlikely to occur and that you can't do much about anyway. The next time you catch yourself worrying, ask yourself if you are focused on a realistic problem, if the problem is likely to occur, and if it's solvable. If not, your worry is most likely unproductive.
- Practice relaxation: Consistent relaxation practice is a great way to counter the physical arousal that comes with worry. Relaxation allows our body and mind to quiet down for a bit, unwind and let go of anxiety and worry. Formal relaxation techniques include progressive muscle relaxation, deep breathing, and meditation. These can be effective in reducing worry. You might also have activities or hobbies that you find relaxing that work equally as well. The activity isn't as important as the end result--that you find time to get into a calm, relaxed, worry-free state on a consistent basis.
- Accept uncertainty: Worry is often an effort to reduce or eliminate uncertainty. It's as if our brains are trying to "fill in the blanks" for us. Our worry remains, unfortunately, because the future is uncertain and we can't truly fill in the missing pieces until we actually live those moments. The next time you're caught in the web of unproductive worry, identify the situation about which you feel uncertain. Then practice accepting uncertainty instead of allowing worry to cause havoc. You can remind yourself that you can't predict the future, that you'll just have to wait and find out, and that there's no way to know for sure at this moment.
Exposure Therapy: Cognitive Behavioral Therapy (CBT) is one of the most effective forms of treatment for anxiety and OCD-related problems. One of the main strategies used in CBT for anxiety is a technique called "Exposure Therapy". Exposure therapy simply means gradually confronting the situations that cause you to feel fear. The idea of exposure therapy often brings about feelings of fear and dread in patients suffering from anxiety--after all, if you have an anxiety problem you're probably trying to avoid the things that frighten you, not face them head on. However, the science behind exposure therapy is strong--if you gradually face the situations that trigger your fears, these fears will decrease over time and often go away entirely. How does this happen? Exposure therapy is based on the principle of extinction: that is, if we stay in contact with the object of our fears long enough, the fear response that we feel will extinguish and we will no longer react in the same anxious, fearful way. This idea is also intuitive--we tend to realize at some level that if we are to overcome a fear, we need to face it to fully conquer it. For sufferers of anxiety and OCD, exposure therapy can be powerful medicine to ease those symptoms and help you get back to being you again.
What is Generalized Anxiety Disorder? Do you suffer from excessive worry? Do you find you worry too much? Do you tend to focus on the things that might go wrong in the future? We all worry from time to time. However, for some, the tendency to worry can feel out of control and become all consuming. When this happens, we call this Generalized Anxiety Disorder or GAD for short. GAD is the clinical term for those who's worry is causing significant interference in their life. The core feature of GAD is the tendency to worry excessively about everyday things such as work, relationships, health, finances, or school.
This excessive worry is often accompanied by a host of unwanted physical symptoms that include:
- Muscle Tension and aches
- Upset Stomach
- Difficulty concentrating
GAD is a common type of anxiety disorder. Some even consider it the "core" anxiety disorder, since the tendency to think about bad things happening in the future is at the root of all anxiety. If you suffer from GAD, the good news is you can learn to take control of your worry. Cognitive Behavioral Therapy offers specific strategies for learning to defeat worry and regain your life. In addition, our book, 10 Simple Solutions to Worry, highlights key steps you can take to conquer worry once and for all.
Understanding Cognitive Behavioral Therapy: Cognitive Behavioral Therapy, or CBT, is a form of therapy that It is frequently used for a wide range of psychological problems. CBT is especially effective for anxiety and OCD. CBT differs from many other forms of therapy in that it is based on scientific principles and a research-based understanding of how people learn. Using this understanding, effective CBT-based treatment techniques were developed that form the core of therapy. These methods are based on skills that are learned over the course of therapy to cope with, reduce or even eliminate the sources of anxiety and OCD.
As the name suggests, CBT addresses two main areas:
- Cognitions: The cognitive model is based on the idea that how you think greatly influences how you feel and how you behave. For example, if you are experiencing anxiety about a particular situation, you might notice that you have fearful and catastrophic thoughts which then leads to the urge to avoid that situation. . In therapy, these you'll learn how to identify and modify these negative thoughts as well as address any core beliefs that might lie at the heart of your anxiety. Using proven techniques, you'll learn how to replace the thoughts and beliefs that are causing or contributing to feelings of anxiety or symptoms of OCD.
- Behaviors: In addition to our thoughts, our behaviors also play an important role in anxiety and OCD-related disorders. These behaviors can be involved in both the onset and maintenence of these difficulties. The behavioral part of CBT targets the behaviors involved in the development and maintenance of these problems. Examples of behavioral change techniques include exposure, response prevention, social skills training, activity scheduling and relaxation training.
CBT is one of the most extensively researched forms of treatment for anxiety and OCD-related disorders. This research has consistently proven that CBT is a highly effective form of treatment for these problems, making it the current gold-standard of care. Using the methods of CBT, you'll learn how to modify catastrophic thinking and change problematic behaviors to overcome anxiety and OCD-related disorders.
How to Conquer Insomnia and Get a Good Night's Sleep: If you're suffering from anxiety or stress, it's almost certain to disrupt your sleep. Tossing and turning, taking forever to fall asleep, waking up too early--these are all hallmarks of anxiety. Poor sleep can also contribute to feeling anxious as well as your body relies on adrenaline--which is what makes us feel anxious--to give you the energy you need for the day ahead. This can result in a vicious cycle--being anxious disrupts your lsleep patterns, and disrupted sleep patterns make you feel more anxious. One way to address difficulty with sleep is to oonsider sleep hygiene. The term sleep hygiene refers to the ingredients that go into getting a good night sleep. Addressing these issues often results in better quality sleep, which in turn leads to feeling calmer and more focused.
Here are 10 keys to better sleep:
- Use your bed only for sleeping. Avoid watching TV, reading or using your computer in bed.
- Go to bed at the same time each night. Keep in mind that we typically need about 16 hours from the time we wake up until we are ready to sleep again Your wake up time helps determine your bed time.
- Wake up at the same time each day.
- Eliminate naps. While naps can be helpful, if your nightime sleep is disrupted, it's best to avoid naps until you are sleeping well at night again.
- Reduce or eliminate caffiene (especially 4-6 hours before bed)
- Cover the clock in your bedroom.
- Eliminate fluids 2 hours before bed.
- Make sure your room is cool, dark and quiet.
- Get plenty of sunlight during the day.
- Get some exercise each day (but not too close to bedtime)
Following these steps can greatly improve your sleep hygiene and the quality of your sleep. You'll feel more rested and energized and less anxious as a result.
An Update on PANDAS: PANDAS--short for Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections--has recently undergone a name change. It's now known as PANS for Pediatric Acute Neuropsychiatric Syndrome. This change reflects the discovery that other illnesses such as mono or Lyme disease in addition to strep can cause the acute onset of symptoms found in PANS.
PANS usually appears in children and teenagers and is associated with an acute-onset of symptoms of OCD. These symptoms literally seem to appear "overnight" in many cases and are often severe. In addition, other changes may be apparent as well, such as:
- Sensory and eating issues
- Handwriting that deteriorates
- Difficulty separating and panic attacks
- Inattentiveness and difficulty concentrating
In addition, those with PANS may also exhibit:
- Oppositional Behaviors
- Difficulty with fine motor skills
- Deterioration in school performance
PANS can be frightening for parents and children who suffer from this syndrome because the onset is so rapid. The exact day the syndrome started is often very clear in everyone's mind. Researchers continue to study and develop new treatment methods for this disorder. The current gold standard for treatment for PANS symptoms typically involves Cognitive-Behavioral Therapy as well as consultation with a physician trained in treating PANS to consider other forms of therapy such as antibiotics.
A Closer Look at "Bad Thoughts" OCD. Obsessive-Compulsive Disorder, or OCD, is one of the most common forms of anxiety that people experience. Experts estimate at any one time that millions of people in the United States suffer from OCD. In my practice in Charlotte, OCD is the most common problem I treat. If you watch TV or movies, OCD symptoms are often presented as a fear of germs--or what we call contamination OCD--with the actor furiously washing and scrubbing after coming into contact with anything dirty. Jack Nicholson in As Good As It Gets comes to mind. However, while contamination OCD is a common form of OCD, there are many other ways that obsessive-compulsive disorder can show itself. One type that I see frequently in my practice is what is called "pure O" or "Bad Thoughts" OCD. In this form of OCD, instead of fearing germs or disease, it's thoughts themselves that are the source of fear. The person with this form of OCD fears having specific types of thoughts. These "bad" thoughts usually--but not always--revolve around three themes: violence, sex, and religion. With violent thoughts, those with this form of OCD are fearful of having thoughts of harm coming to themselves or someone they love. For example, a person with these intrusive thoughts might pick up a knive to slice an apple and think "I could just stab myself right now" or have the thought "What if I swerved into oncoming traffic?" while driving down the highway. These thoughts usually cause intense fear. They come as a shock. And because these thoughts feel so frightening and outrageous (feeling intense panic, the person with OCD will often think "What kind of person would have those thoughts? What if I acted on them?") they often result in avoidance and compulsions to lessen the fear associated with these thoughts. For example, if you have a "bad" thought, you might say a prayer immediately afterward to lessen the anxiety associated with that thought. Or you might simply try to avoid thinking those obsessive thoughts altogether. These two phenomenon--intrusive, bad thoughts and compulsive rituals (including avoidance) are what make up "bad thoughts" OCD. If you suffer from this type of OCD, it can be a very frightening experience. You may feel alone and isolated and like you are losing control over your mind. The good news is, this form of OCD is very common--one of the most common types I see at the Anxiety and OCD Treatment Center. It's also a very treatable form of OCD and those with this type often get better quickly. If you do experience this form of OCD and you'd like to discuss treatment, contact me to learn more about how you can overcome these obsessive thoughts and get back to being you.
What is Anxiety? Anxiety is a word that comes up frequently in conversation--so frequently in fact that the meaning of anxiety itself seems to have been lost a bit--and is of course often a topic in my Charlotte practice. In this blog entry, I'll offer a definition of anxiety and compare it with two similar words: fear and stress. Let's start with anxiety first. I define anxiety as the emotional state that results from thinking that something bad is going to happen in the future. In this definition, the future can be very soon or a long time off. For example, in the case of panic attacks, we believe that something catastrophic is about to happen very soon. We think "I'm dying", "I'm about to have a heart attack" or "I'm going crazy". The result is an intense rush of anxiety. In other anxiety disorders, the future is a bit further off. In contamination OCD, for instance, the belief may be something more like "if I touch that doorknob, I'll get AIDS and die." This consequence is much more distant time-wise than panic attack fears. In both cases, though, the common thread is anxiety--that believe that something bad is going to happen in the future.
Fear is different than anxiety in that when we feel fear we believe something bad is happening right now. For example, if a rattlesnake slithered out from under your couch, you'd probably feel fear. A sort of "uh-oh" reaction that urges us to act now to protect ourselves. This difference is a bit subtle and anxiety and fear have a lot in common. The main similarity is that the physical sensations are almost identical. Whether we feel fear or anxiety, we are likely to experience:
- Racing heart beat
- Trembling or shaking
- Shortness of breath
- Difficulty swallowing
- Chest pain
- Muscle tension
Now let's take a look at our last defintion: stress. Stress is the emotional state of having demands placed upon you. The greater and more intense the demands, the greater the stress you will feel. With stress, there is not necessarily an element of a negative consequence, which explains why even positive events can be stressful. Taking a vacation, for example, can be stressful because you have to plan your trip, pack, get to your plane on time, travel away from home and all your creature comforts, manage your work from a distance, and cope with all that you missed while you were gone. So stress can occur as a result of both positive and negative events. Stress simply means something in the world is demanding that you take action. Like anxiety and fear, stress will bring similar physical symptoms and sensations.
So those are our three definitions: anxiety, fear, and stress. Each one overlaps with the other, but carries important differences as well. If you notice yourself experiencing some of the physical symptoms listed above, it can be useful to determine which of the three emotional states you are experiencing at the moment. Identifying what you are feeling can be an important element to making positive changes.