4 Healthy Ways To Deal With Anxiety

tea1Everyone gets anxiety. It’s when you worry about something in the future, which let’s face it, can be tomorrow. A meeting, an interview, an exam, a commute, the weather…so much to worry about, right?  Wrong.

STOP those thoughts from spiraling because you’ve no control of tomorrow.

carlsbadmineralwater12

You have THIS moment. Make it a HEALTHY ONE. Repeat that. STAY in the NOW.

Number ONE: Exercise daily. Don’t make excuses like rich people have a personal trainer.

When I was a kid I was influenced by one man I saw on TV. He had nothing, except ONE chair beside him. I was in the first grade when I first saw him.

His name was Jack La Lanne.  He spoke about the benefits of daily exercise. I listened. Kids brains are like sponges. Mine absorbed his message. His message is still true.

It is proven your brain benefits at the 45-minute mark. So, if you’re feeling anxious it may be a signal from your body or brain that you need to move.

Look at all the benefits you get simply from walking.  Best part? Do it anywhere.

walk.jpg

And stay hydrated. Drink water, even when you’re not thirsty. Look at all the benefits of staying hydrated in the photo below.

drink_water

When people tell me they get headaches, the first thing I ask is how much water they drink. Most say none.

Well, that’s why you have a headache. Most tell me they drink coffee, which DE-HYRDRATES. Your brain needs water.

Your doctor in a rush to get his or her next patient will be too quick to give you pills for headaches or migraines before even asking you this simple question.

If you are prone to headaches –you need to check how much water you should be drinking (use search in my blog to find that) daily and do that. Your headaches will probably magically disappear. You’re welcome.

The times you need to visit a Physician is when you’re doing everything right and you’re still experiencing some sort of pain.

But if you’re not doing the basics of self-care, then you need to make a LIFESTYLE change first to find out if that’s what’s causing your pain. We were created to be healthy and feel good, but we need to take care of ourselves. Here’s that photo magnified.

drink_water

Speaking of sweat, if you can get to a SAUNA after you exercise, even better. If not, no worries. Can’t get to a sauna?  Take a long hot shower or hot bubble bath with Epsom salt afterwards. They now make Epson salt with bubbles.

Try Dr. Teal’s. It contains Magnesium, which can only be absorbed through the skin. CVS sells it. It costs about six dollars. Smells nice too. Like lavender. It’s usually near the soap section. A lot of people lack Magnesium.

Remember, the second you start to feel anxious get up, DRINK WATER, STRETCH, BREATHE and MOVE.  Drink water, even when you’re not thirsty. Go for a walk.

photography of a man drinking water
Photo by Thomas Chauke on Pexels.com

WALK. WALK BRISKLY and TAKE DEEP BREATHES (BREATHE IN…AND HOLD FOR 4 SEC. AND breathe out slowly) until the feeling passes. It will.  You can do this anywhere, even in a tiny room. Stand up. STRETCH AND HOLD. Then, walk. Every cell in your brain and body benefits when you do this. Don’t focus on what you were worried about. Instead, repeat the words “You can do it…” while breathing. Yes, you CAN walk off anxiety.

walking8

Number TWO:  Take a good look in your refrigerator and pantry. Toss out the garbage. You don’t need me to tell you what’s garbage. Sugar, soda, junk food, processed foods, white bread, alcohol, cookies, cake, donuts, potato chips.

NOW replace those things with healthy go-to items like alkaline water, almonds, walnuts, blueberries, strawberries, greek yogurt without sugar in lieu of ice-cream or cottage cheese, veggie sticks instead of regular chips, cook veggies in olive oil and garlic, green tea.

Veggie sticks are so yummy I regret blogging about them because like everything else I blog about –it’s suddenly SOLD OUT on store shelves the next day.

I’ve blogged about emotional eating in the past and which foods to reach for when you feel a certain emotion because having different emotions are part of being a human being. Don’t let anyone numb them with pills.

The healthiest thing you can do is try all the good stuff first, because the good stuff works.

The good stuff is what they mean when they say the proof is in the pudding.

 

Proven healthy lifestyles are proven time and time again from centenarians and those of us who are healthy.

If someone gets through their 40’s and 50’s feeling great with natural energy and no prescription medications they are doing something right.

Unfortunately, there are males and females in their 20’s and 30’s who still think how they look, even if it’s through plastic surgery, or extreme dieting, makes them healthy. Health magazines (which I no longer buy) fuel this misinformation by placing these cropped top people on their covers. That’s insecurity, folks.

The good news is what it means to really be healthy is rising above all that noise.

As I predicted decades ago, the world has shifted conscientiousness regarding health. Take a look at this circle. There’s no bikini in it. There are no six or twelve pack abs for men.

HEALTH comes from inside and it doesn’t need external approval.

There is no longer any denying how interconnected the following are:

 

health2.png

Every generation goes through the same feelings as the one before them, so it’s time to start educating ourselves on how to LIVE HEALTHY and PREVENT ILLNESS while living in a crazy world.  Even if we live in a healthy bubble and try to shield ourselves from all the craziness –there is no escaping it. Even family members, friends, partner, colleagues, boss, kids, parents, strangers driving near you on the road  can infiltrate your peace. You can’t control that.

cherries

The healthiest advice anyone can give you is DON’T REACT. The calm one is the healthy one.  Did someone less qualified get a position you earned, because they’re related to or know someone? Don’t react. Don’t despair.  Didn’t close a deal when something less deserving did? Same thing. It may make you angry. You’ll want to grab a bag of chips or drown your sorrows in ice cream.

527553_4350958337325_794915800_n
pistachio

Keep your pantry or refrigerator stocked with healthy stuff you can grab instead. A bag of cherries, a large bowl of blueberries or those veggie sticks I told you about earlier.  You can snack on a ginormous bowl of these thing and not be left feeling even worse afterwards, as you will with regular chips and junk food.

watermelondiced

blueberries

Number THREE: Turn off TV. Get out in nature instead or read a good book. I’ve been reading a book a day since I was a kid. I thought everyone did until my younger brother laughed and said I was crazy and people are lucky if they read one a year.

pile of five books
Photo by Pixabay on Pexels.com

Fine.  Then, make it one positive book a year.

blur book girl hands
Photo by Leah Kelley on Pexels.com

 

Keep that ONE book on your nightstand and reread it when you need inspiration. For non-readers I recommend you start with, “The 7 Laws of Spiritual Success” by Deepak Chopra. I used to give them out as gifts. Little gem of a book. Then, get “The Four Agreements.” These are 2 books you can re-read during stressful times.

bookcover

My book, “Healthy Within” is one every celebrity who writes a Tell All Memoir should read. The reason is I never mention my ex’s name, or what actually happened. No details. Why? That part is not important. That part is no one’s business. What’s important is how to get through anything that at the time feels like a personal or professional tsunami.

That is the HEAL part in HEALthy. Other than that, it’s tabloid toxicity.

When you’re blaming someone else or pointing out all of your ex’s flaws, people reading it are actually cringing.  No one wants someone in they’re in an intimate relationship with to write a kiss and tell, so to speak.  There are two people in a relationship or marriage. Two.

frozen1

Advice to Demi.  Let.It.Go

I don’t know who advised her to write this in the first place. It feels like something that should have never been made public. When someone is in the public eye and they reveal they were someone entirely different than we believed them to be –it feels like WE were lied to and betrayed. So, I felt more let down from who I thought Demi Moore was than anything having to do with Ashton. Even when the other person betrays you it’s enough to know it was a betrayal –we don’t need details, thank you.  I would have passed on this book. I’m an avid reader and have zero desire to buy it.

light nature sky sunset
Photo by Pixabay on Pexels.com

Back to self-care. Fuel your body and brain daily with nutritious foods. What does healthy food look like? Here are a few visuals.

sliced tomato and avocado on white plate
Photo by Artem Bulbfish on Pexels.com

FRUIT.jpg

a7fourth27proteinandcarbs

PINEAPPLE.jpg

And do not forget how important SLEEP is…

sleep12

NUMBER FOUR: REST. NAP. SLEEP. Allow your brain and body to shut down and reset itself just like you do when your computer has lost it’s charge or starts acting up.  Shut it down. Anyone who brags about only getting or needing little sleep isn’t healthy. Every cell in your brain and body is created to regenerate and health itself, but you need to sleep and shut it down in order for it to do what it does naturally. It’s called Beauty Sleep for a reason.

BANANAS.jpg

I’ve blogged about foods that help you sleep. If you’re a late-nigh snacker keep bananas, cottage cheese, blueberries and a bag of cherries in your pantry, along with decaf organic tea. Turn off all electronics 2 hours before a set time. Keep the room you sleep in a little chilly. Wear eye shades. Take that hot bath with lavender and you will crash naturally.

sleep2

If you are on any type of anti-anxiety or depression medication it needs to be under the supervision of a physician, who should ONLY prescribe TEMPORARY low-dose if you are in crisis mode, say after the death of a loved one or other tragedy. It needs to be in combination with Cognitive Behavioral Therapy, fancy word for Talk Therapy, to taper you off prescribed medication.

person holding white medication tablet
Photo by rawpixel.com on Pexels.com

It’s not dealing with what is causing your anxiety or depression. What’s causing it is change and stress from it. That change can come from work, finances, seasons, relationships, age, moving, parenthood –anything in life.

That’s why it’s natural and you need to LEARN healthy coping mechanisms for LIFE. Having a trusted confidante in life to go through ups and downs also helps keep your brain and body in top form.

Healthy relationships are a wonderful buffer against daily stressors in life. It’s having someone in your life to talk to, bounce ideas off of and be there during good times and bad. Healthy relationships proven to be a positive  constant in a sea of change. Positive because healthy relationships release all the feel good chemicals and hormones in your body and brain. Love releases oxytocin. When you have LOVE and commitment everything is less stressful.

So what do you do when you don’t have a trusted hand to hold during it all?

man and woman looking at earch other
Photo by Jasmine Wallace Carter on Pexels.com

Revert to the Four Tips solo, because HEALTHY attracts HEALTHY. Be your best you in mind, body and spirit.  Work on healing any past hurts. Put them in the past. Forgive. Move on. YOU need to BE that which you want to attract. Think about that. You want a healthy, intelligent, kind, independent, fun, supportive, honest, loving, faithful, committed, loyal, trustworthy partner?

BE that.

Photo by Rosie Ann on Pexels.com

walking

When your friends and the people you surround yourself with are healthy –you’ll learn healthy coping mechanisms, even through observing their habits. HealthDay

HealthyHalloween

walnuts in a bowl
Photo by Mircea Iancu on Pexels.com

Post note: I love tea and have blogged about the benefits of tea and my favorites in the past. USA Today and Washington Post now says tea bags contain plastic and that it is toxic. I cut right to the bottom to find out which brands contain plastic bags because not all of them do. Here are brands to avoid.

Mostly, it’s those cute triangle bags. Apparently, it looks like they are made out of paper, but it’s plastic that holds them together. They are cute. Recently, a restaurant served me on that looked was so cute. I commented asking how it was held together Now we know.

Avoid brands in RED

“So which tea bags contain plastic?

Brands that use plastic sealants include Tetley, Twinings’ ‘heat-sealed’ and ‘string and tag’ ranges, Yorkshire Tea and some Aldi tea bags.

Co-Op and PG Tips have all switched to 100% compostable bags.

Abel & Cole and Teapigs using plant-based SoilOn and Clipper makes a plastic-free teabag made from bananas, while some Tetley and Twinings ranges are biodegradable.

But if you want to be absolutely sure your tea is plastic free, loose leaves are the best way to go.”       [Source: USA Today, September 2019]

It’s not all tea and it’s not all brands, so get past their hype to the facts. Then, get back to:

Remember, when you have a bad day, week, month or year –don’t call it a bad life. Think of it as a bad season, like leaves falling off a branch in Fall. What do you need for leaves to grow back?  Oxygen, water, nourishment, sunshine. Nourish yourself every day and your leaves will return one day at a time. You got this!

Stay healthy!

blog contact: maria.dorfner@yahoo.com

 

Most Chronic Pain Caused By Inactivity

Relationship Between Chronic Pain and Inactivity: The Disuse Syndrome

If you suffer from chronic pain of almost any type, you are at risk for developing a physical “disuse” syndrome.

Back Muscles

Muscles will get smaller and weaker if you don’t use them, which can add to back pain.

See Exercise and Back Pain

What is disuse syndrome?

Basically, it describes the effects on the body and mind when a person is sedentary.

Disuse syndrome was first characterized around 1984 and, since that time, has received much attention in relation to back pain problems, other chronic pain disorders, and other illnesses. It has been generalized beyond chronic pain problems and some feel it is related to “the base of much human ill-being.”

See Depression and Chronic Back Pain

The disuse syndrome is caused by physical inactivity and is fostered by our sedentary society.

Back Muscles

Muscle wasting and chronic pain can be mitigated by exercise.

See How Exercise Helps the Back

Effects of disuse syndrome

This disuse of our bodies leads to a deterioration of many body functions. This is basically an extension of the old adage “Use it or lose it.”

There are several physical consequences from disuse. These occur in many body systems, most notably those of the muscles and skeleton, cardiovascular, blood components, the gastrointestinal system, the endocrine systems, and the nervous system. For instance, consider the following:

  • In the musculoskeletal system, disuse of muscles can rapidly lead to atrophy and muscle wasting. If you have ever had an arm or a leg in a cast, you will be familiar with the fact that the diameter of the affected limb may be noticeably smaller after being immobilized for some time.
  • Cardiovascular effects also occur due to disuse including a decrease in oxygen uptake, a rise in systolic blood pressure, and an overall blood plasma volume decrease of 10 to 15 percent with extended bed rest.
  • Physical inactivity also leads to nervous system changes, including slower mental processing, problems with memory and concentration, depression, and anxiety.

A key factor in chronic pain

Many other detrimental physiological changes also occur. Disuse has been summarized as follows:

“Inactivity plays a pervasive role in our lack of wellness. Disuse is physically, mentally, and spiritually debilitating.”

Many experts believe that the disuse syndrome is a key variable in the perpetuation of many chronic pain problems.

The disuse syndrome can result in a myriad of significant medical problems and increase the likelihood of a chronic pain syndrome developing or becoming worse.

Unfortunately, common attitudes and treatments in the medical community often lead to more passive treatment without paying attention to physical activity and exercise (of any type).

The disuse syndrome can also lead to a variety of emotional changes that are associated with an increased perception of pain.

See Diagnosis of Depression and Chronic Back Pain: Depression Questionnaire

So, what to do? Get more mobile. 

So, if you are suffering from disuse syndrome, you may be wondering what you can do about it. It can be overwhelming for some people in chronic pain to consider how to get moving. See Chronic Pain Coping Techniques – Pain Management

About Dr. Deardorff:

https://www.spine-health.com/author/william-deardorff-phd

“Research has demonstrated that disrupted sleep will, in turn, exacerbate chronic back pain.3 A lack of restorative sleep also hampers the body’s immune response and can affect cognitive function. Thus, a vicious cycle develops in which the back pain disrupts one’s sleep, and difficulty sleeping makes the pain worse, which in turn makes sleeping more difficult, etc.”

Learn more:

This post was Originally Published: 08/26/2015
_____________________________________________________

MORE ON TREATING PAIN FROM

THE CLEVELAND CLINIC

ccf22

Low Back Pain Killing You? Try 8 Remedies (Before Taking Pills)

Our spine expert reviews new treatment guidelines

physical therapist working with patient

You may have heard that doctors are getting away from prescribing opioids for chronic low back pain. New guidelines from the American College of Physicians (ACP) advise doctors to start with options that don’t involve any type of medication.

 

This breaks from the World Health Organization tiered medication scale favored in the past. The scale previously focused on drugs that included opioids.

“We interpret the new guidelines as saying, ‘Try a number of non-pharmacological options before starting the use of long-term medication for low back pain.’ That’s a positive step,” says spine specialist E. Kano Mayer, MD.

While the ACP reviewed lots of studies to formulate its guidelines, he notes that it failed to look at how long each intervention was effective or at outcomes other than pain reduction.

“Cleveland Clinic spine specialists favor the active, rather than the passive, therapies recommended,” says Dr. Mayer. “We prefer that you do things actively to control pain and improve function, rather than waiting for things to be done to you.”

What to try first for your back pain

Cleveland Clinic spine experts support the following ACP recommendations, he says:

  1. Physical therapy
    “Cleveland Clinic very much advocates active physical therapy,” says Dr. Mayer. An exercise prescription can help to ease back stiffness and strengthen muscles that support the spine.
  2. Acupuncture
    This ancient Chinese technique involves inserting hair-thin needles at key points to ease pain. “Acupuncture is better at relieving the radiating leg pain that can accompany low back pain. We often recommend acupuncture because relieving pain allows you to exercise and be active,” says Dr. Mayer.
  3. Exercise
    Individual, group or supervised exercise can make you sore at first. “But it can help improve your core strength, spine flexibility, endurance and balance,” he notes.
  4. Yoga and tai chi
    Practicing these meditative forms of exercise from ancient India and China “has shown good benefit for those with low back pain, improving their function, endurance and symptoms,” says Dr. Mayer.
  5. Cognitive behavioral therapy (CBT)
    “Research shows this popular form of talk therapy improves coping, lessens social isolation and decreases the social impact of pain on your life,” he says. Combining psychological therapy with physical therapy and social work support is also beneficial.
  6. Biofeedback
    Placing electrodes at certain points allows you to control and release tension in your back muscles. “This improves function, positional tolerance and muscle pain,” says Dr. Mayer.
  7. Stress management and mindfulness
    Relieving stress and focusing on the present help to take your mind off pain.
  8. Progressive relaxation
    Gradually releasing tension in each part of the body can be helpful in easing pain, especially before bed.

Remedies less likely to help

Cleveland Clinic spine specialists generally do not support the use of passive treatments for low back pain.

“Chronic use of low-level laser therapy, ultrasound, transcutaneous electrical nerve stimulation (TENS) and spinal manipulation may only help in the short term,” Dr. Mayer points out. “We don’t want you to waste your money on treatments unlikely to provide more than a day of benefit.”

When you may need medicine

If non-drug interventions don’t help, the ACP recommends first trying non-steroidal anti-inflammatory drugs (NSAIDS) such as ibuprofen, naproxen, indomethacin or meloxicam. While NSAIDs provide some pain relief, they may put you at risk for GI bleeding or kidney damage.

As second-line drugs, the ACP recommends duloxetine (an antidepressant) or tramadol (a novel opioid, but still subject to abuse).

Due to their serious side effects and addictive nature, opioid medications (morphine, oxymorphone, hydromorphone, tapentadol) should be used only as a last resort when patients fail all other therapies, the ACP advises. The rule of thumb: Use the lowest possible dose of opioid for the least amount of time.

If you’ve been suffering with long-term low back pain, it’s worth exploring these non-drug treatment options before resorting to pills. You’re likely to find your quality of life improving.

Related Articles

senior woman with back pain

13 Ways to Fix Your Age-Related Back Pain

Man at computer suffering neck pain

What’s Causing That Pain in Your Neck (and What Can You Do About It)?

My Back Went Out 3 Weeks Ago. What Should I Do?

My Back Went Out 3 Weeks Ago — What Should I Do?

nerves in the shoulder and spine illustration

Need Pain Relief? Consider Radiofrequency Ablation

Physical Therapy

When (and How) Physical Therapy Can Provide Relief for Your Low Back Pain

Radiating leg pain

Radiating Pain in Your Leg? Best to See Your Doctor

Related Stories:

How Doctors Are Treating C-section Pain — Without Opioids

A Q&A examining the reasons behind this change and what it means for new mom + their babies

As the opioid epidemic rages on, some doctors are facing the problem head-on by looking in the mirror — reducing the amount of opioids and opioid prescriptions given out after surgeries, including cesarean sections.

Anesthesiologist Eric Chiang, MD, is on the frontlines, helping spearhead a change in pain meds prescribed after C-section at Cleveland Clinic. He explains the reasons behind this trend — and what it means for both mom and baby.

Q: Why are doctors reducing opioid prescriptions to treat pain after a C-section?

A: In the U.S., for the last two decades and continuing to today, we’ve focused on opioids as the main pain medicine. And not just for after C-sections — for after any surgery.

But this single-minded approach has led to excessive prescribing, which fuels the opioid crisis: Overprescribing means people are frequently left with extra pills. The meds are often diverted and sold on the street. A lot of people are exposed to these narcotics, which eventually lead them to heroin and other drugs.

Overprescribing has become a habit for doctors. There was pressure to prescribe them. There was pressure from the government on treating pain. And there’s been a demand for these medications from patients. Culturally, American patients think opioids are a stronger pain medicine. It all snowballed.

Although opioid use is on the rise around the world, the U.S. remains an extreme outlier. In other countries, Tylenol® and Motrin® are the first-line drugs. You hear statistics about how the U.S. has 5% of the world’s population and uses 80% of the world’s opioids. It’s totally true.

Q: What opioids have doctors traditionally prescribed during C-section recovery?

A: One of the main pain meds we used to give after C-section is Percocet®. It was very common to prescribe Percocet after any kind of surgery. Percocet is a combination drug. It’s an opioid (oxycodone) plus 325 milligrams of Tylenol. Vicodin® is similar — it’s an opioid (hydrocodone) plus Tylenol.

One problem is that if you prescribe Percocet to your patients, it becomes their go-to pain medicine. If they have 2 out of 10 pain, they’re going to take Percocet. If they have 10 out of 10 pain, they’re going to take Percocet.

We have had tremendous success by separating these drugs instead of giving a combination pill. This approach provides options: The patient can maximize non-narcotic medications (4,000 mg acetaminophen plus Motrin) and only take opioids if she really needs it — if she has “breakthrough” pain.

What happens if you prescribe a combination pill? Patients will have to make complex calculations and keep track of dosages. “How much Tylenol is in that Percocet? How much is in this pill that I’m going to take now? How much am I getting over 24 hours? I can’t go over 4,000 milligrams.” In our experience, patients end up taking Percocet for all pain, increasing their exposure to opioids unnecessarily.

Q: What pain meds do the doctors in your program prescribe after C-sections? What have been the results?

A: One of the objectives of our project at Cleveland Clinic was to try to address over-prescription. We made Tylenol and Motrin our primary pain meds after C-section. There are very few side effects, and they’re not opioids.

We have patients take Tylenol and Motrin around-the-clock, alternating them every three hours. Patients can use oxycodone in addition to the Tylenol and Motrin if they really need it. We let the patients decide.

When we did this, patients decided they didn’t want or need opioids:

  • Opioid use on our postpartum floors went down by 70% almost overnight.
  • Now, almost half of our C-section patients never get any intravenous (IV) or oral narcotics.

Previously, even if a patient did not use opioids during their hospital stay, we gave them an opioid prescription when we discharged them. We are trying to change this practice — patients who don’t need opioids in the hospital are no longer sent home with a prescription for them.

For patients who do need opioids in the hospital, we now sending them home with five oxycodone pills. For comparison, in 2016, C-section patients were going home with around 32 pills. We also give people prescriptions for three days of Tylenol and Motrin, emphasizing that these are their primary pain medicines for C-section recovery.

Q: How does reducing opioid prescription after C-section help both mother and baby?

A: Women need effective pain relief after childbirth because they need to take care of an infant. They need to learn how to breastfeed. Poorly controlled pain is also associated with postpartum depression.

Our patients are doing much better and are better able to care for their babies. They have fewer problems with issues associated with opioids. Patients are:

  • More awake.
  • Less nauseous.
  • Walking around more.
  • Recovering faster.
  • Passing their bowel movements sooner.

Patients have more control as well. They’re not left feeling like their only option is a narcotic pain med after C-section. They can decide what they want to take and if they’re going to take an opioid.

It’s also better if the baby is not exposed to opioids through breast milk. While all of the oral medicines we use are generally considered safe for breastfeeding, we prefer for the baby to get Motrin or Tylenol than oxycodone. Opioids can be a risk because they can cause respiratory depression — a decrease in the drive to breathe, both with the mother and the baby.

For more information please visit:

How Doctors Are Treating C-section Pain — Without Opioids

 

blog contact: maria.dorfner@yahoo.com

Treatment of Insomnia in Anxiety Disorders

by Gregory M. Asnis, MD, Elishka Caneva, MD, and Margaret A. Henderson, MD
Insomnia is highly prevalent in psychiatric disorders, and it has significant implications.

This review focuses on insomnia in the context of anxiety disorders. The prevalence of comorbid insomnia in anxiety disorders is addressed and the clinical implications associated with insomnia are discussed as well as when and how to treat this important comorbidity.

Just how specifically insomnia relates to and possibly affects anxiety disorders is highlighted by the fact that insomnia is one of the defining criteria in a number of the DSM-IV-TR anxiety disorders.

For example, difficulty in falling or staying asleep is a criterion for PTSD, acute stress disorder, and generalized anxiety disorder (GAD).

The relationship of insomnia to anxiety disorders is also influenced by comorbid major depression. The severity of insomnia is increased when an anxiety disorder is comorbid with a major depressive disorder (MDD).1 This is highly relevant because 58% of MDD patients have a lifetime anxiety disorder.2

The presence of insomnia has a deleterious effect on daytime functioning and negative effects on quality of life, including social and work relationships.3

Insomnia (1997 film)
Image via Wikipedia

Also, there is clear evidence that the presence of insomnia in anxiety disorders is associated with increased morbidity.

For example, in patients with PTSD, insomnia is associated with an increased likelihood of suicidal behavior, depression, and substance abuse as well as nonresponsiveness to treatment.4-6

In addition, insomnia as an early symptom in traumatized patients increases the risk of the development of PTSD 1 year later.7

Early assessment

It is important to carefully assess for insomnia early in the evaluation of patients with anxiety disorders and to aggressively treat this complicating comorbidity.

Insomnia is an underrecognized and undertreated problem. Patients rarely report their symptoms of insomnia spontaneously to their doctor. Adding to the problem of detecting insomnia is the finding that doctors rarely inquire about insomnia in their patients.3,8,9

 Thus, a carefully taken history is an important first step in the assessment of insomnia.

Self-rating sleep questionnaires and direct clinical interviews are used to obtain a history of potential sleep disorders (eg, insomnia). A number of well-validated sleep questionnaires have been widely used.

The most widely used and validated questionnaire is the 19-question Pittsburg Sleep Quality Index. The questions cover sleep quality, sleep problems, sleep medications, and so on, within the past month.10

Another widely used questionnaire is the Leeds Sleep Evaluation Questionnaire (LSEQ). The LSEQ consists of 10 self-rating questions that cover sleep and aberrant sleep behaviors.11

Besides self-rating questionnaires that depend on memory of sleep disturbances, a sleep log or diary can confirm questionable sleep disturbances prospectively.

The use of a sleep log allows for an analysis of day-to-day sleep patterns, such as the time that the patient went to bed, sleep latency, and nighttime awakenings.8,9 The log is filled out by the patient shortly after awakening in the morning (see Morin9(p38) for an example of a sleep log). If at all possible, monitoring for up to 2 weeks is highly recommended because it allows for sleep abnormalities that might show marked day-to-day variability and would more likely be detected by extensive monitoring.12,13

What is already known about insomnia
in patients with anxiety disorder?
No Me Mireis!

■ Anxiety disorders frequently coexist with insomnia. The latter is believed to be part and parcel of various anxiety disorders and is one of the defining criteria of a number of them.

What new information does this article provide?

■ Our article clarifies new approaches to considering insomnia in anxiety disorders. The presence of insomnia should be considered a comorbid illness and treated on its own. Pharmacotherapy, cognitive-behavioral therapy, and a combination of both are discussed.

Insomnia is an added pathology that brings increased morbidity to patients with anxiety disorders. Our review suggests that successful treatment of insomnia actually increases the responsiveness of anxiety disorders to many antianxiety treatments.

What are the implications for psychiatric practice?

■ When evaluating patients with anxiety disorders, psychiatrists should carefully evaluate for the presence of insomnia. Patients infrequently bring up this symptom on their own. If insomnia is present, aggressive treatment early in the course of therapy is highly suggested.

If the presence of insomnia is suspected, interviewing a spouse, a significant other, or a caregiver is helpful. Some patients who believe they have insomnia symptoms appear to have “sleep state misperception,” where their partners clearly state that their sleep is normal.14

These “others” can also report problems that are likely not obvious to the patient:

• Apnea spells or excessive snoring as seen in obstructive apnea

• Excessive body movements as seen in periodic leg movement disorder and restless legs syndrome

• Various sleep-related behaviors (sometimes violent and aggressive) as seen in rapid eye movement behavior disorder (RBD)

• Sleepwalking

Referral to a sleep specialist and sleep polysomnography has been recommended if pharmacological or nonpharmacological options are not working. Referral is also warranted for patients with insomnia in whom a specific sleep disorder, such as obstructive sleep apnea, periodic limb movements, narcolepsy, or RBD, is suspected.12,15

Even when a visit to a sleep laboratory is suggested, the cost of an overnight visit is often prohibitive—more than $1000 per night; usually 2 nights are required with the first being an adaptation night for the patient. Insurance frequently does not cover these costs.16

If it is found that the patient has sleep apnea, a sleep movement disorder, RBD, or a number of other sleep disorders, specific nonhypnotic treatments may be required (eg, continuous positive airway pressure for sleep apnea is the treatment of choice).

Before beginning treatment of anxiety disorder–associated insomnia symptoms, rule out any concurrent medical illness, medication treatment, or substance use that might be inducing or worsening insomnia. Many medical illnesses, such as cardiovascular disorders (eg, congestive heart failure), pulmonary disorders (eg, emphysema), endocrinopathies (eg, thyroid disorders), GI disorders (eg, acid reflux), and neurological disorders (eg, pain syndromes), are associated with insomnia.12

Carefully assess the use of medications for medical and psychiatric disorders that may be implicated in insomnia as well as caffeine(Drug information on caffeine) or alcohol(Drug information on alcohol) use. Even small amounts of the latter have been associated with increased nighttime awakenings.

Insomnia
Image by EasyPickle via Flickr

Before providing any significant intervention for insomnia, a careful evaluation regarding behaviors that might contribute to insomnia should be made.

Daytime naps, late nighttime snacks or meals, watching television in bed, nighttime exercise, or excessive light or loudness in the bedroom should be identified and modified. Eliminating these behaviors can lead to significant sleep improvements. A 13-item self-rating questionnaire by Mastin and colleagues17 can help elicit sleep hygiene information.

Pharmacological options

The treatment of insomnia in patients with anxiety disorders is, for the most part, the same as the treatment of insomnia per se: pharmacological, nonpharmacological, or a combination of the two.

The primary treatment of insomnia is pharmacological because of the rapid onset of action (eg, hypnotics are usually effective within days to 1 week of use). The most common nonpharmacotherapy, cognitive-behavioral therapy for insomnia (CBT-I) takes considerably longer.3,8,12 Currently, the FDA has 11 approved drugs for the treatment of insomnia:

• Nonbenzodiazepines: eszopiclone, zolpidem(Drug information on zolpidem), zolpidem ER, and zaleplon(Drug information on zaleplon)

• Benzodiazepines: estazolam, flurazepam(Drug information on flurazepam), quazepam, temazepam, and triazolam

• A tricylic antidepressant: low-dose sinequan

• A melatonin(Drug information on melatonin) agonist: ramelteon

In recent years, nonbenzodiazepines have become the most recommended of the approved hypnotics. (There has been less and less reliance on benzodiazepines.) Not only are nonbenzodiazepines effective in treating insomnia (equivalent to the benzodiazepines), but there is a notion that they are safer than benzodiazepines.3,12

Both nonbenzodiazepines and benzodiazepines are associated with adverse effects that include fatigue, dizziness, ataxia, and the development of dependence and tolerance with long-term use. Although head-to-head studies comparing these classes of hypnotics have been minimal, a recent meta-analysis supports the finding of reduced adverse effects for the nonbenzodiazepines.18 The nonbenzodiazepines typically have a shorter half-life and are more selective at the γ-aminobutyric acid receptor, factors that are partially responsible for less residual daytime sedation and other adverse effects.

In the treatment of anxiety disorders with comorbid insomnia, the latter should be treated concurrently with, but independently of, the anxiety disorder per se. The idea that one should wait to see whether the insomnia resolves with only the treatment of the anxiety disorder is no longer valid. Clinical experience has shown that without targeted insomnia treatment, insomnia frequently persists.3,19

When adding a hypnotic to an antidepressant in the treatment of anxiety, the risk to benefit ratio must be considered. Pollack and colleagues20 looked at a large group of patients with GAD comorbid with insomnia (N = 595). The patients received either 10 mg of escitalopram(Drug information on escitalopram) coadministered with 3 mg of eszopiclone or the escitalopram with placebo. Those in the active hypnotic treatment group had a significant response in their insomnia by the first week. The combination of medications was well tolerated with no significant increase in adverse effects.

Most surprisingly, the anxiety scores for those patients who received the hypnotic significantly improved starting at week 4 even after removing insomnia symptoms from the anxiety assessment. The time to onset of the anxiolytic response was also reduced. In addition, the combination treatment led to a slightly better symptom response and remission rate for the anxiety disorder.

Similar results were reported in a 12-week open-label study (N = 27) undertaken by Gross and colleagues.21 The researchers evaluated ramelteon (8 mg/d), a melatonin agonist, in patients who had GAD comorbid with insomnia and whose condition was partially responsive to an SSRI or a serotonin norepinephrine(Drug information on norepinephrine) reuptake inhibitor. The hypnotic was well tolerated, effective for insomnia, and appeared to facilitate the treatment of GAD.

A double-blind placebo-controlled study by Fava and colleagues22 evaluated the efficacy and safety of zolpidem(Drug information on zolpidem) extended-release (12.5 mg/d) versus placebo in patients with comorbid GAD and insomnia who were being treated with escitalopram (10 mg/d). Sleep measures improved significantly by the end of week 1, and there was no added burden of adverse effects. Zolpidem did not show a beneficial anxiolytic effect.

Approximately 50% of patients with insomnia continue to have insomnia 3 years after initial diagnosis, and many patients require months to years of treatment. Nonbenzodiazepines for primary insomnia were found to have continued efficacy and to be well tolerated with no evidence of abuse or withdrawal symptoms on discontinuation of use after 12 months.23,24 Ramelteon was also found to be efficacious with no significant issues of abuse or tolerance in a 24-week open-label study.25 The literature for longer use of hypnotics is scarce.

Anxiety disorders are frequently comorbid with alcohol(Drug information on alcohol) or substance use disorders.4,26 Consider ramelteon or low-dose sinequan to avoid potential issues of abuse and addiction. Nonbenzodiazepines are preferred over benzodiazepines; there is evidence that the former have decreased potential for abuse and a better adverse-effect profile.

In some patients with insomnia, benzodiazepines are clearly necessary. The other hypnotics may not be as effective for some patients, and the anxiolytic properties of benzodiazepines may be helpful.

When hypnotics are used (particularly, benzodiazepines and nonbenzodiazepines), their use should be reassessed—every 3 to 4 weeks.3,12 Many patients with insomnia do not experience sleep disturbances nightly. Therefore, the use of hypnotics on an as-needed basis or a few times a week helps cut down on the amount and exposure to medication.27

Trazodone and mirtazapine(Drug information on mirtazapine) are also widely used for insomnia, as are atypical antipsychotics and herbal preparations. Unfortunately, these agents have not been rigorously studied for insomnia and thus their effectiveness and safety remain unclear.3

Nonpharmacological interventions

CBT-I is an important, widely accepted, multimodal treatment for insomnia and the best-studied of the nonpharmacological approaches for this disorder.

It is a manualized treatment that focuses on various components of CBT (ie, cognitive restructuring and the use of psychological interventions, such as the practice of good sleep hygiene, stimulus control, sleep restriction, and relaxation therapy).

These methods address negative and distorted cognitions and behaviors that initiate and perpetuate insomnia.9,28 Treatment duration is relatively short. It is administered for 5 hours divided over 4 to 6 weeks and can subsequently be used as a maintenance treatment in monthly sessions. There are approximately 12 well-designed CBT-I trials that have clearly demonstrated that it is a highly effective intervention for insomnia for 1 year or longer.29,30

Studies that compared CBT-I with pharmacotherapy found equivalent efficacy.31 This has led the NIH Consensus and State of the Science Statement to conclude that CBT-I is “as effective as prescription medications are for short-term treatment of chronic insomnia. Moreover, there are indications that the beneficial effects of CBT, in contrast to those produced by medications, may last well beyond the termination of active treatment.”3 In contrast to hypnotics, learned CBT-I skills may persist even when active treatment ends.9 Furthermore, some patients may prefer CBT-I over hypnotic drugs because of their possible adverse effects or because of concerns about drug interactions or taking a drug during pregnancy.9

In general, CBT-I is underutilized—only about 1% of patients with chronic insomnia receive this therapy.32 To increase the availability of CBT, it can be administered via self-help strategies (eg, educational books and materials) and in group formats. In addition, the use of the Internet to provide CBT has been shown to be effective. Nonetheless, patients frequently prefer face-to-face contact.33

Besides CBT-I, a number of other nonpharmacological therapies, such as bright light, physical exercise, acupuncture, tai chi, and yoga, have been used to treat insomnia. Unfortunately, the results have been inconsistent.32,34

Combination therapy

  • Is a combination of pharmacotherapy and nonpharmacotherapy more effective than either alone in the treatment of anxiety disorders with insomnia? Combination therapy has not been addressed in studies of this particular patient population. Furthermore, the question has been minimally addressed even in the treatment of insomnia per se.
    Study findings suggest only modest differences in outcomes with a combination of therapies. Similar results were seen in a study that compared CBT with CBT pluszolpidem(Drug information on zolpidem). The 6-week acute study demonstrated a 60% response rate and a 40% remission rate; the group with the combination treatment did have a significant increase in sleep time of 15 minutes, but the researchers question the clinical significance of this isolated finding.29

Summary

Anxiety disorders with comorbid insomnia are highly prevalent with potential negative consequences. Therefore, assess for insomnia with self-rating scales and careful clinical interviews. When appropriate, refer patients for polysomnography.

Insomnia should be treated aggressively with pharmacotherapy, nonpharmacotherapy (particularly CBT-I), or a combination. Some of the hypnotic treatments actually appear to facilitate successful therapy for the anxiety disorder.

Benzodiazepines and nonbenzodiazepines have a number of adverse effects and can lead to abuse and dependence. Patients with an anxiety disorder may be particularly vulnerable, especially those with a history of alcohol(Drug information on alcohol) and drug abuse. Treatment with benzodiazepine and nonbenzodiazepine hypnotics needs to be reassessed monthly. Alternatively, ramelteon, low-dose sinequan, and CBT-I should be considered because they have minimal adverse effects and no risk of abuse.

Successful treatment of insomnia is an important goal in patients with anxiety disorders. Both pharmacological and nonpharmacological interventions have response rates of approximately 60%.

ABOUT THE AUTHORS:  Dr Asnis is Professor in the department of psychiatry and behavioral sciences at the Albert Einstein College of Medicine and Director of the Anxiety and Depression Clinic of Montefiore Medical Center, Bronx, NY; Dr Caneva is a Psychiatry Fellow at the Anxiety and Depression Clinic of Montefiore Medical Center; Dr Henderson is Research Coordina-tor at the Anxiety and Depression Clinic of Montefiore Medical Center. Dr Asnis is Consultant for Bristol-Myers Squibb and has received grants in the past year from Forest Pharmaceuticals, Lilly, Otsuka, and Pfizer. Drs Caneva and Henderson report no conflicts of interest concerning the subject matter of this article.

Face Fears and Panic Attacks by Maria Dorfner

More than 3 million Americans have panic attacks.  According to womenshealth.gov it affects women twice as often as men.  The reasons are unknown.  I’m thinking maybe more women report it.  Even more people have fears you can’t even imagine.  Things like Anthrophobia, fear of flowers or Allodoxaphobia, fear of opinions or Acousticophia, fear of noise.  Someone has actually been tracking all phobias and fears since 1980.  The A to Z list of phobias will boggle your mind. http://phobialist.com/  Someone probably has a fear of fears. Or lists. Or lists of fears!

Fast forward to 2012 and you have fear of the economy, fear of losing your job,  fear of not finding another job, fear of losing your house, fear of not getting funding, fear of the shananigans going on in politics, fear of losing your health, fear of other people in your life or in the world being afraid.

It appears everyone is afraid of something.

Whenever you’re with a large group of friends and the topic of fear comes up, you’ll probably hear a wide range of fears tossed into the conversation.  One person may say, “Oh…I’m terrified of heights!” while another adds, “I can’t even look at any type of bug without hyperventilating.”  It can be fun exchanging fears.  But, it’s not fun when you’re caught in the grip of it.

After Sept. 11, I suddenly developed a fear of driving over bridges. The fear struck suddenly while ON the bridge.  Something I had done  hundreds of times before in New York suddenly seemed terrifying.  The terror would manifest itself into physical effects.

Fear is only as deep as the mind allows.
~Japanese Proverb

I thought, What the heck is happening? Heart racing.  Dizzy.  Trembling.  Sweating.  Quadruple CHECK! All I could see was my white 380SL smashing into water on my right OR concrete on my left.  Fear flooded my mind and convertible.  

Then, the fear of my fear –made me panic MORE.  

The bridge morphed into a larger than life monster.  I drove at 20 miles per hr in the center of the lane. Fortunately, drivers behind me knew something was wrong & kept a F-A-R distance behind me.   It felt like an eternity getting across it.

If you are distressed by anything external, the pain is not due to the thing itself, but to your estimate of it; and this you have the power to revoke at any moment.  ~Marcus Aurelius

When I finally got to the other side of the bridge, I had to pull over as I couldn’t breathe and was trembling. I nearly fell over believing I was having  a stroke or heart attack.

Turns out, it was to be my first (and last) full blown panic attack.  I recall calling my family to tell them what happened and saying, “NEVER again!! I’m donating my car to charity.”  I swore never to get inside a vehicle again, let alone go over a monster bridge. I never wanted to experience that fear, breathlessness and tension again.

Then, I remembered something Elenor Roosevelt said.

You gain strength, courage, and confidence by every experience in which you really stop to look fear in the face. You must do the thing which you think you cannot do.

~Eleanor Roosevelt

Eleanor Roosevelt with Fala
Image via Wikipedia

NEVER ONLY MEANS “NOT AT THE MOMENT”

It took a few attempts after I said, “Never!” and “I can’t!” to anyone who suggested I drive over a bridge again.   But mind over matter won as my mobility became limited.

Drive to New York City?  Bridge.  Staten Italy?  Bridge.  Pennsylvania?  Bridge.  If I had not faced this fear back then, I would be extremely limited in my mobility.

The enemy is fear. We think it is hate; but, it is fear.
                                    ~Gandhi

All fears have something in common. They limit you in some way.  The person afraid of heights may avoid travelling to otherwise beautiful locations because of their fear, while the person afraid of bugs won’t enjoy a company picnic.  Most people will dig their heels in and insist there is absolutely NO WAY they can overcome their fear.  Some fears have been there since childhood.

Others develop later in life.

Some fear public speaking.

 Then, there are those that seem to develop out of nowhere. The latter are usually triggered by an emotional event, which you now associate to the fear.  A lot of people who were in New York City when September 11th happened suddenly developed fears of all sorts of things — tall buildings, elevators, stairs, enclosed places, trains — it can usually be traced back to their experience.  Post Traumatic Stress Disorder is closely linked to fears because the mind keeps reliving the traumatic incident through nightmares or flashbacks.

If you say, “I will never (insert fear) again” –it’s simply not true.  You CAN and WILL overcome any fear.

FACE YOUR FEAR

Here’s How to Face Your Fears and Overcome Them

The key is to expose yourself gradually to whatever it is you fear.  Gradual.   That means if you are afraid of heights, don’t  go to the observation deck of the Empire State Building. Start with looking out the window of the 5th floor.  Then, the 10th floor. Bring a friend with you.  Each week, commit to raising the bar.  Breathe when you get there and realize you are safe. Smile. Laugh.  Eventually, you will go the top and feel on top of the world.  This feeling of confidence  will carry over into other areas of your life.

  1. F = Find a friend to share your fear with and have them cheer you on
  2. E = Expose yourself slowly to what you fear (Baby steps)
  3. A = Act with confidence
  4. R = Relax & breathe

Inaction breeds doubt and fear. Action breeds confidence and courage. If you want to conquer fear, do not sit home and think about it. Go out and get busy.  ~Dale Carnegie

MORE ON RECOGNIZING PANIC ATTACKS

The American Psychiatric Association’s official Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV) defines a panic attack as a discrete period of intense fear or discomfort, in which 4 (or more) of the following symptoms develop abruptly and reach a peak within 10 minutes:

  • Palpitations, pounding heart, or fast heart rate
  • Sweating
  • Trembling and shaking
  • Sensations of shortness of breath or smothering
  • Feelings of choking
  • Chest pain or discomfort
  • Nausea or abdominal distress
  • Feeling dizzy, unsteady, lightheaded, or faint
  • Derealization (feelings of unreality) or depersonalization (being detached from oneself)
  • Fear of losing control or going crazy
  • Fear of dying
  • Paresthesias (numbness or tingling sensations)
  • Chills or hot flashes

Some of these symptoms will most likely be present in a panic attack. The attacks can be so disabling that the person is unable to express to others what is happening to them. A doctor might also note various signs of panic: The person may appear terrified or shaky or be hyperventilating (deep, rapid breathing causing dizziness).

———————————————————————————————————————————————–

If you still need some motivation, here are some more terrific inspirational quotes to help you think about your fears differently.  Print them.  Read them daily.  Repeat them to yourself.  Change the way you think.  Your actions will follow. The first time I drove back over a bridge I remember repeating, “Fear is false evidence that appears real…false evidence that appears real” in my mind while being aware of breathing calmly.  Feed your mind courageous thoughts.

That fight or flight feeling is temporary.  It’s not based on anything real. So, don’t feed into it.  You can overcome it.

When a resolute young fellow steps up to the great bully, the world, and takes him boldly by the beard, he is often surprised to find it comes off in his hand, and that it was only tied on to scare away the timid adventurers.
Ralph Waldo Emerson

I must not fear.  Fear is the mind-killer.
Fear is the little-death that brings total obliteration.
I will face my fear.
I will permit it to pass over me and through me.
And when it has gone past I will turn the inner eye to see its path.
Where the fear has gone there will be nothing.
Only I will remain.
Frank Herbert

I am not afraid of tomorrow, for I have seen yesterday and I love today.
William Allen White

Who sees all beings in his own self, and his own self in all beings, loses all fear.
Isa Upanishad, Hindu Scripture

Where no hope is left, is left no fear.
Milton

Avoiding danger is no safer in the long run than outright exposure. The fearful are caught as often as the bold.
Helen Keller

You can discover what your enemy fears most by observing the means he uses to frighten you.
Eric Hoffer

In skating over thin ice our safety is in our speed.

Ralph Waldo Emerson

The oldest and strongest emotion of mankind is fear, and the oldest and strongest kind of fear is fear of the unknown.
H. P. Lovecraft

%d bloggers like this: