Best Practices for the Treatment of Anxiety
Instructor: Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC
Executive Director, AllCEUs
~ Explore common causes for anxiety symptoms
~ Identify common triggers for anxiety
~ Identify current best practices for anxiety management including
~ Counseling Interventions
~ Medications
~ Physical Interventions
~ Supportive Treatments

Why I Care/How It Impacts Recovery
~ Anxiety can be debilitating
~ Low-grade chronic stress/anxiety erodes energy and ability to concentrate
~ Anxiety is a major trigger for:
~ Addiction relapse
~ Increased physical pain
~ Sleep problems
Triggers for Anxiety
~ Abandonment & Rejection
~ Low self-esteem
~ Irrational thoughts and cognitive distortions
~ Unhealthy social supports/relationships
~ Ineffective interpersonal skills  relationship turmoil and/or social anxiety
~ The unknown & Loss of control
~ Negative self talk and cognitive distortions
~ Negative others
~ Physical complaints
~ Sense of powerlessness

Triggers for Anxiety
~ Death & Loss
~ People and pets
~ Jobs and promotions
~ Safety and security
~ Dreams and hopes
~ Sickness, spiders and other phobias
~ Failure
~ Perfectionism
~ Negative self-talk

General Treatment Recommendations
~ Anxiety, depression and substance disorders as well as a range of physical disorders are often comorbid. This provides researchers key opportunities to explore pathways to mental disorders and provides clinicians key opportunities to intervene accordingly.
~ Anxiety disorders should be treated with psychological therapy, pharmacotherapy, or a combination of both.
~ Cognitive behavioral therapy can be regarded as the psychotherapy with the highest level of evidence.
~ Current conceptualization of the etiology of anxiety disorders includes an interaction of psychosocial factors such as childhood adversity or stressful events, and a genetic vulnerability.
General Treatment Recommendations
~ Current conceptualization of the etiology of anxiety disorders indicates clinicians need to explore the interaction of:
~ Psychosocial factors such as:
~ Childhood adversity or stressful events
~ Trauma related brain changes
~ Coping skills (learned or not learned)
~ Trauma issues still needing to be dealt with (domestic violence, parental absence, bullying…)
~ Current stressors
~ Current availability of social support
General Treatment Recommendations
~ Current conceptualization of the etiology of anxiety disorders includes an interaction of:
~ Genetic vulnerability
~ Medications
~ Susceptibility to effects and development of dependence
~ Which medications will be effective
~ Vulnerabilities – Which conditions are more challenging for each person
~ First-line drugs are the SSRIs and SNRIs
~ Effexor was effective according to the Hamilton Rating Scale for Anxiety
~ Zoloft, Paxil, Luvox, Lexapro, Celexa have all been found effective.
~ At least 4 different genetic variations can be correlated with development of generalized anxiety disorder. Different medications are more or less effective depending upon the genetic makeup of the person.
~ There is a higher mortality rate among benzodiazepines users compared with nonusers.
~ There is an increased risk for dependence with use for more than 6 months.
~ An increased risk of dementia was also identified in long-term (>6 months) benzodiazepine users.
~ Benzodiazepines do not treat depression, and may be associated with a higher suicide risk in comorbid anxiety and depressive disorders.
~ Other treatment options include tricyclic antidepressants, seroquel, buspirone. WebMD Health News Reviewed by Louise Chang, MD on May 06, 2008
~ After remission, medication should be continued for ~12 months.
Symptoms of Generalized Anxiety
~ Physical signs and symptoms may include:
~ Fatigue
~ Irritability
~ Muscle tension or muscle aches
~ Trembling, feeling twitchy
~ Being easily startled
~ Trouble sleeping
~ Nausea, diarrhea or irritable bowel syndrome
~ Headaches
~ Mitigate the symptoms and prevent misidentification of causation

~ Floatation-REST (Reduced Environmental Stimulation Therapy) reduces sensory input to the nervous system through the act of floating supine in a pool of water saturated with Epsom salt.
~ The float experience is calibrated so that sensory signals from visual, auditory, olfactory, gustatory, thermal, tactile, vestibular, gravitational and proprioceptive channels are minimized, as is most movement and speech.
~ 50 participants with anxiety reported significant reductions in stress, muscle tension, pain, depression and negative affect, accompanied by a significant improvement in mood characterized by increases in relaxation, happiness and well-being.
~ Tai Chi produced significant reductions in anxiety (approximately 25%) in patients with anxiety and fibromyalgia who practiced twice a week for a year.
~ Acupuncture at HT7 can attenuate anxiety-like behavior induced by withdrawal from chronic morphine treatment through the mediation of GABAA receptor system.
~ Pain
~ Anxiety about things getting worse, rejection, inability to handle pain
~ Guided imagery
~ Other-focus mindfulness
~ Physical therapy
~ Ergonomics
~ Hormones
~ Imbalances of estrogen or testosterone can contribute to anxiety
~ Rapid heart rate, sweating, palpitations are not uncommon in women in perimenopause or menopause

Biological Interventions
~ Supportive Care
~ Create a sleep routine
~ Helps the brain and body rebalance
~ Can help repair adrenal insufficiency
~ Improves energy level
~ Nutrition
~ Minimize caffeine and other stimulants
~ Try to prevent spikes (and drops) in blood sugar which can trigger the stress response
~ Drink enough water
Biological Interventions
~ Supportive Care cont…
~ Sunlight
~ Vitamin D deficiency has been implicated in some mood issues
~ Sunlight prompts the skin to tell the brain to produce neurotransmitters
~ Sunlight sets circadian rhythms which impact the release of serotonin, melatonin and GABA
~ Exercise
~ Studies have shown that exercise can have a relaxing effect. Start slowly.
Biological Interventions
~ Supportive Care cont…
~ Aromatherapy
~ Also…Clary Sage

Psychological Interventions
~ Your body thinks there is a threat. Figure out why
~ Anxiety=Threat Threat=Basic Fears
~ Failure
~ Rejection/Isolation
~ Loss of Control
~ The Unknown
~ Death/Loss (Person, Self Concept, Dreams)
~ Distress Tolerance: It isn’t always about controlling your anxiety
~ Distract don’t react
~ Use distancing techniques– “I am having the thought that…”
Cognitive Interventions
~ Functional analysis makes it possible to specify where, when, with what frequency, with what intensity, and under what circumstances the anxious response is triggered.
~ From there, psychoeducation about cognitive distortions and techniques to mitigate those circumstances can be provided.
~ Positive writing. Each day for 30 days, the experimental group engaged in 20 minutes of writing about positive emotions they felt. Long-term expressive writing of positive emotions appears to help reduce test anxiety by using insight and positive emotion words.
~ Mindfulness
~ In a meta-analysis, six articles about mindfulness-based stress reduction, four about mindfulness-based cognitive therapy, and three about fear of negative appraisal and emotional regulation were reviewed.
~ Mindfulness is an effective strategy for the treatment of mood and anxiety disorders and is effective in therapy protocols with different structures including virtual modalities.
~ Mindfulness & Acceptance activities
~ Observation | Acceptance | Labeling and Letting Go
~ Identify trigger thoughts

Cognitive Interventions
~ Address Unhelpful Thoughts
~ It is a dire necessity for adults to be loved by significant others for almost everything they do…
~ Concentrate on their own self-respect, on winning approval for practical purposes, and on loving rather than on being loved.
~ People feel they aren’t able to stand it if things are not the way they want them to be or are not in their control
~ Focus on the parts that are in their control and other things in life which are going well and to which they are committed
~ Misery is invariably externally caused and is forced on us by outside people and events…
~ Reactions are largely caused by the view that people take of unfortunate conditions.
Cognitive cont…
~ If something is or may be dangerous or fearsome people should be terribly upset and endlessly obsess about it (hurricane, surgery, child driving)
~ Figure out how to face it and render it harmless, and, when that is not possible, accept the inevitable.
~ It is easier to avoid than to face life difficulties and responsibilities
~ Running from fear is usually much harder in the long run.
~ People believe they should be thoroughly competent, and achieving in all possible respects or they will be isolated, rejected and failures
~ Accept themselves as imperfect with human limitations and flaws.
Cognitive cont…
~ Because something once strongly affected peoples’ lives, they should indefinitely fear it (getting lost, strangers, hurricanes)
~ Learn from past experiences but don’t be overly-attached to or prejudiced by them.
~ People must have complete control over things
~ The past and the future are largely uncontrollable. People can control their actions in the present to stay on the preferred path, and develop general skills to deal with adversity should it arise.
~ People have virtually no control over their emotions and cannot help feeling disturbed about things…
~ People have real control over our destructive emotions – if we choose to work at changing the unhelpful and inaccurate thoughts that often create them
Cognitive cont…
~ Cognitive Distortions
~ Personalization
~ What are 3 alternate explanations
~ Magnification (and minimization)
~ Focus on the facts
~ Don’t confuse high and low probability events
~ All or Nothing
~ Find the exceptions
~ Selective abstraction/filtering
~ Look for the good, the bad and the ugly (Complete the picture)
~ Remember that hindsight is 20/20.
Cognitive cont…
~ Jumping to conclusions
~ Get all the data
~ Mind reading
~ Ask. Talk. Communicate.
~ Emotional reasoning
~ Are you afraid because you feel anxious or are you afraid because there is a factual reason to be concerned?

Psychological Interventions
~ Relaxation Skills
~ What is relaxation…
~ Diaphragmatic breathing
~ Combat breathing
~ Meditation
~ Cued Progressive Muscular Relaxation
~ Self-Esteem (Fear of failure and rejection esp.)
~ Real vs. Ideal Self
~ Compassionate self talk
~ Spotlighting strengths & acceptance of imperfections

Psychological Interventions
~ Cognitive Restructuring
~ Reframe challenges in terms of current strengths (not past weaknesses)
~ Create an attitude of gratitude and optimism
~ Acceptance and Commitment Therapy (FEAR)
~ Fusion with your thoughts (Unhook)
~ Evaluations of your experience (Empower)
~ Avoidance of your experiences (Gradual exposure, Find Exceptions)
~ Reason given for your behavior (Challenging Questions)

Social Interventions
~ Improve your relationship with yourself
~ Identify your needs and wants (Mindfulness)
~ Be your own best friend
~ Internal vs. external validation
~ Develop healthy, supportive relationships
~ Learn about boundaries
~ Develop assertiveness skills (Ask for help and say no to requests)
~ Describe the ideal healthy, supportive relationship
~ Separate the ideals from the reals
~ Identify who that is, or where that could be found
~ Play the “What Does It Mean When…” game
~ Anxiety is a natural emotion that serves a survival function
~ Excessive anxiety can develop from
~ Lack of sleep
~ Nutritional problems
~ Neurochemical imbalances
~ Failure to develop adequate copings skills
~ Cognitive distortions
~ Low self-esteem/a need for external validation
~ Recovery involves
~ Improving health behaviors
~ Identifying and building on current coping strategies
~ Addressing cognitive distortions
~ Developing a healthy, supportive relationship with self and others