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At The Center for Stress and Anxiety Management, our psychologists have years of experience. Unlike many other providers, our clinicians truly specialize in the diagnosis and treatment of anxiety and related problems. Our mission is to apply only the most effective short-term psychological treatments supported by extensive scientific research. We are located in Rancho Bernardo, Carlsbad, and Mission Valley.

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Read our award-winning blogs for useful information and tips about anxiety, stress, and related disorders.

 

Filtering by Tag: exposure therapy

Misophonia: A “Rarely Known” Conditioned Aversive Reflex Disorder

Jill Stoddard

by Annabelle Parr

Most of us can probably agree that it’s very unpleasant to hear nails scraping a chalkboard. Other sounds that tend to make us cringe include a woman’s scream, a disc grinder (think construction site), and a baby crying. This is because we are genetically wired to respond to a baby’s cry, so any other sound similar in frequency tends to be upsetting (Dozier, 2015).

There are sounds that are almost universally annoying, and then there are those sounds that get to each of us individually. But for some of us, a specific sound can be more than simply annoying or unpleasant; it can be intolerable. Do you find yourself experiencing a particularly extreme or adverse reaction to a sound or stimulus that seems strange or out of proportion? If so, you may be encountering a misophonic reaction.

What is misophonia?

Misophonia is a condition characterized by an extreme, immediate, involuntary emotional response accompanied by a reflexive physiological reaction to a specific, commonly occurring sound or visual stimulus (Dozier, 2015).

Tom Dozier, director of the Misophonia Institute, describes misophonia as a Conditioned Aversive Reflex Disorder. Though misophonia is most commonly identified by the emotional response – typically anger, rage, disgust and even hatred - there is almost always a physiological response that occurs as well. Tom’s research suggests that it is actually the physical response that lies at the heart of misophonia. When a person hears (or sees) their trigger, the autonomic nervous system elicits a reflexive physical reaction. It could be contracting of a particular muscle group or it could be an internal reaction, varying from nausea to a numbing sensation to constriction of the esophagus. Because the intense emotional reaction follows so quickly, the physical response often goes unnoticed. But it appears that the emotional reaction is directly related to the physical reaction. In individuals with misophonia, the connection between the autonomic nervous system and the limbic system (emotional center) becomes hypersensitized (Bernstein, Angell, & Dehle, 2013), such that the trigger stimulus elicits the physical reflex which then elicits the extreme emotions and fight or flight response.

What misophonia is NOT.

Misophonia is not a sensitivity to the volume of the sound; it is not a fear of a sound; it is not becoming upset by a continuous, loud, intrusive, irritating sound; and it is not a logical response to the meaning behind a sound (for example, responding to a baby’s cry is a natural response to address the infant’s distress). It IS the emotional and physiological response to a single occurrence of the trigger, regardless of how loud or noticeable the trigger is.

What are some common triggers?

There is an enormous range regarding potential trigger stimuli. However, some common examples include the eating or chewing sound, breathing sounds, coughing, swallowing, pen clicking, whistling, typing, and a dog barking. A trigger can be any repeating sound or sight. Triggers tend to be most strongly associated with one particular person, but they do have the ability to generalize. For example, the original trigger might be the sound of a sibling chewing. This will likely remain the strongest trigger, but it could also generalize to the sound of any person chewing.

How common is misophonia?

Not very many people know about misophonia, doctors and therapists included. Many people with misophonia struggle with feelings of guilt for their reaction, as they are aware that it is both out of proportion and irrational. They may also feel isolated in their experience. But if you struggle with a misophonic reaction, you are far from alone. It is not a rare disorder, but rather a “rarely known” disorder. Based on several studies and surveys, it is estimated that misophonia affects about 15% of the population (Dozier, 2015), compared with Major Depressive Disorder which, according to the Anxiety and Depression Association of America (2016), affects about 6.7% of the population above the age of 18 in a given year.

How does misophonia affect people?

Misophonia can range from manageable to debilitating. If a person’s trigger is fairly uncommon, it may hardly affect him or her at all. However, if a trigger is very common and the reaction is severe, it can lead to avoidance of situations and serious strains on relationships.

Can I get help for misophonia?

If you think that you may be struggling with misophonia, you don’t have to continue to try to handle it alone, particularly if it is something that has begun to impair your day-to-day functioning or affect your relationships. Misophonia can continue to increase in severity if it is left unaddressed, so it is important to know that help is available.  However, because there is not a widespread awareness of misophonia, it can often be misdiagnosed as anything from oppositional defiant disorder to ADHD to anxiety or OCD. So if you are struggling with what sounds like misophonia, it is important to find a professional who understands what you are experiencing and knows how to help.

For more information about misophonia, how it is treated, and related resources, please visit http://misophoniainstitute.org. If you think you or someone you love may be struggling with misophonia, CSAM’s Dr. Michelle Lopez offers specialized treatment at our Rancho Bernardo office. If you would like more information…

CSAM IS HERE TO HELP

Please contact us at (858) 354-4077 or at csamsandiego@gmail.com if you or someone you love might benefit from treatment for misophonia. We also offer acceptance and commitment therapy (ACT), cognitive behavioral therapy (CBT), or biofeedback for anxiety, depression, stress, or PTSD, and would be happy to provide more information about our therapy services.

References:

Anxiety and Depression Association of America. (2016). Facts & statistics. Retrieved from: https://www.adaa.org/about-adaa/press-room/facts-statistics

Bernstein, R. E., Angell, K. L., & Dehle, C. M. (2013). A brief course of cognitive behavioural therapy for the treatment of misophonia: A case example. The Cognitive Behaviour Therapist, 6(10), 1-13. doi:10.1017/S1754470X13000172

Dozier, T. H. (2015). Understanding and overcoming misophonia: A conditioned aversive reflex disorder. Livermore, CA: Misophonia Treatment Institute.

Anxiety in the Courtroom

Jill Stoddard

Witness Preparation Services

by Annabelle Parr

Have you ever felt especially nervous before a big presentation? Do you find your heart racing and palms sweating when you have to speak in front of a large group of people? You’re not alone. On average, people rate their fear of public speaking higher than their fear of death. Potentially one of the highest pressure, highest stakes public speaking situations is on the witness stand in a courtroom or during a deposition. Even the most experienced witnesses can feel anxiety, which left unaddressed can hinder their testimony. Anxiety is the number one communication obstacle in legal proceedings (Pitera, 2013).

Source URL: http://www.utahcriminallaw.net/what-happens-if-a-witness-lies-in-court/

Source URL: http://www.utahcriminallaw.net/what-happens-if-a-witness-lies-in-court/

Witnesses typically have very specific fears related to testifying. Some common witness fears include, but are not limited to, a fear of letting people down, losing their job, making a mistake, looking incompetent, being embarrassed, judged or blamed, or having to reveal private, personal information. Witnesses also tend to take on more responsibility for the outcome of the case than is necessary or realistic (Pitera, 2013).

Though the source of a witness’s anxiety may be completely unrelated to their credibility or honesty, jurors tend to judge witnesses more on the basis of behavior than testimonial content (Afremow, 2011). Therefore, a testimony could be flawless and completely true, but if it is delivered poorly the concrete verbal content may not matter.

Typical anxious behaviors that jurors tend to interpret as signs of unreliability include non-verbal cues such as poor eye contact, fidgeting, appearing tense, and inconsistency of demeanor or tone (Afremow, 2011). Helping witnesses to become conscious of these subtle reactions as well as the sources of their anxiety before testifying can help them to manage the visible cues thus increasing their perceived credibility.

Meeting with a licensed psychologist who specializes in anxiety management is a great way to help prepare witnesses and allow them to address their anxiety before taking the stand. Using cutting edge, evidence-based, cognitive-behavioral techniques, the therapist can help witnesses modify their anxiety, bringing it into an optimal range for peak performance.

Source URL: http://www.everydayhealth.com/smoking-cessation/living/coping-with-the-urge-behaviorally-and-mentally.aspx

Source URL: http://www.everydayhealth.com/smoking-cessation/living/coping-with-the-urge-behaviorally-and-mentally.aspx

Therapeutic techniques that can help prepare witnesses include:

  • cognitive reappraisal, which involves changing catastrophic cognitions that fuel anxiety and lead to poor performance
  • grounding, mindfulness, and relaxation
  • reduction of safety seeking, avoidance, or anxiety driven behaviors such as lack of eye contact, speaking too softly, fidgeting, talking too much or too little, or looking to the attorney for reassurance
  • video-taped feedback, which can help reduce anxiety by showing the witness that they don’t look as anxious as they feel, as well as helping them to notice and address visible safety behaviors

A therapeutic setting offers a safe space to practice testifying and receive non-judgmental, constructive feedback and tools that the witness can apply in court and during depositions. If you or your client are preparing to stand as a witness, know that feeling anxiety is normal, but that it doesn’t have to determine the tone of the testimony.

CSAM IS HERE TO HELP

If you or someone you know might benefit from witness preparation services for anxiety or stress, or if you would like more information about our therapy services, please contact us at (858) 354-4077 or at csamsandiego@gmail.com.

References:

Afremow, J. (2011). Witness this: Behavioral science in the courtroom. Psychology Today. Retrieved from https://www.psychologytoday.com/blog/trust-the-talent/201110/witness

Pitera, M. J. (2013). Witness tip: Anxiety is the #1 barrier affecting communication. Litigation Insights. Retrieved from http://www.litigationinsights.com/witness-preparation-2/witness-tip-anxiety-is-the-1-barrier-affecting-communication/

The Importance of Boundaries

Jill Stoddard

by Annabelle Parr

Do you ever feel like you can’t say no?  Do you believe that you are responsible for the emotions of others?  Do you take others’ opinions and needs into account before your own?  Do you find yourself unsure of what you want or need (Eddins, 2015)?  If so, you are certainly not alone.  However, your feelings, thoughts, and needs matter.  By setting some boundaries in your life, you can begin to treat your needs as important.

Boundaries and Anxiety

Image source: https://blogs.goarch.org/blog/-/blogs/boundaries-healthy-limits-or-barriers-to-relationships-

Image source: https://blogs.goarch.org/blog/-/blogs/boundaries-healthy-limits-or-barriers-to-relationships-

For people who struggle with anxiety, learning how to create healthy boundaries can be a helpful tool.  Though sometimes people cope with anxiety by creating unnecessary boundaries or avoiding situations that serve as triggers, other times anxiety is experienced as a result of unclear lines between self and other.  When you don’t protect your sense of self, it is easy to feel overwhelmed and take on responsibility for everything and everyone (Eddins, 2015).  This can lead to feelings of guilt and anxiety.  It is not hard for a vicious cycle to ensue, where a lack of boundaries leads to anxiety, and where anxiety leads to a feeling that you cannot set clear and effective limits.

What Are Boundaries

So what exactly are boundaries?  Boundaries help us to define who we are.  They orient us in our relationships, and signify to us and to others where “I end and you begin” (Eddins, 2015).  Boundaries can apply to any area of our lives, and can range from material boundaries to physical, mental, or emotional boundaries to sexual or spiritual boundaries (Lancer, 2015).  Boundaries are very personal, and there is not a right or wrong answer regarding to how to set ones that work for you.  They are based on your beliefs, values, opinions, and needs (“12 Signs,” 2015).

Boundaries as an Act of Love

A common misconception for people who struggle in this area is that setting boundaries is selfish.  However, self-care is not selfish.  Have you ever flown on an airplane, and heard the stewardess tell the passengers in case of an emergency to put their own oxygen mask on before helping others with theirs?  This “oxygen-mask” rule is a profound metaphor for the idea that we cannot take care of others if we have neglected to take care of ourselves first. 

Image source:  http://www.thedynamicturnaround.com/healthyboundaries.htm

Image source:  http://www.thedynamicturnaround.com/healthyboundaries.htm

Setting boundaries for ourselves and giving ourselves permission to articulate our needs is an act of self-love (Strgar, 2010).  And in the wise words of Brené Brown, “we can only love others as much as we love ourselves” (2010).  Furthermore, when we set clear limits in our lives, we are better able to be compassionate towards others.  Brown (2010) states that “the heart of compassion is really acceptance,” and when we lack boundaries, we are not accepting our own needs and we may have a difficult time accepting others if we feel they are taking advantage of us. 

So contrary to this idea that boundaries are selfish, they actually help us love ourselves and others better.

How Therapy Can Help

You are the only one who has the ability to set boundaries in your life.  However, therapy can be helpful in navigating this challenging task.  Therapy offers a place where you can explore your values, your feelings, and your relationships.  Your therapist can help support you in the process of determining where you need to establish stronger boundaries or areas in which you might benefit from more flexibility.

Therapy can also be a good place to experience a relationship with very clear boundaries.  Dr. Irvin D. Yalom (2002) describes “therapy as a dress rehearsal for life,” meaning that it is a safe place to encounter challenging aspects of life and relationships before you face them outside of the therapy room.  An important goal of therapy is to take what you have learned and apply it to the rest of your life, but it can be helpful to practice new skills in a safe space first.

Don’t Forget to Be Kind To Yourself

One final thing to note is that boundaries are learned (Lancer, 2015).  If you are not used to setting clear limits in your life, know that it is a skill that takes practice.  The best way to start learning this skill is to cultivate self-awareness and practice asserting yourself (Lancer, 2015).  Remember, it is important to give yourself grace and to seek support throughout this process.  If you feel like you could benefit from some professional support in developing boundaries in your life…

CSAM IS HERE TO HELP

If you or someone you love might benefit from acceptance and commitment therapy (ACT), cognitive behavioral therapy (CBT), or biofeedback for anxiety, depression, stress, or PTSD, or if you would like more information about our therapy services, please contact us at (858) 354-4077 or at csamsandiego@gmail.com.

References:

12 Signs you lack healthy boundaries (and why you need them). (2015).  Harley Therapy Counselling Blog. Retrieved from http://www.harleytherapy.co.uk/counselling/healthy-boundaries.htm

Brown, B. (2010). The gifts of imperfection: Let go of who you think you’re supposed to be and embrace who you are.  Center City, MN: Hazelden Publishing.

Eddins, R. (2015). Keeping Good Boundaries & Getting Your Needs Met. Psych Central. Retrieved from http://psychcentral.com/lib/keeping-good-boundaries-getting-your-needs-met/

Lancer, D. (2015). What are personal boundaries? How do I get some?. Psych Central. Retrieved from http://psychcentral.com/lib/what-are-personal-boundaries-how-do-i-get-some/

Stgar, W. (2010). The importance of boundaries. The Huffington Post. Retrieved from http://www.huffingtonpost.com/wendy-strgar/working-boundaries_b_717339.html

Yalom, I. D. (2002).  The gift of therapy: An open letter to a new generation of therapists and their patients. New York, NY: HarperCollins Publishers.

How To Listen When Someone You Love Is Struggling

Jill Stoddard

by Annabelle Parr

Life presents us each with challenges.  While it is often uncomfortable and painful to grapple with adversity, to experience this struggle and to feel pain is to be human.  At some point, we will all find ourselves in this place, as will those we love.  So how can we help each other?  How can we listen when someone we love is struggling, whether it is with a mental health condition or with a painful experience in his/her life?

 LET GO OF THE IMPULSE TO TRY TO FIX

Source URL: https://scott-williams.ca/2013/03/

Source URL: https://scott-williams.ca/2013/03/

It is painful to watch someone we care for struggle or hurt.  And it’s natural to want to take away her pain or try to fix the problem at hand.  However, despite our best intentions, trying to “fix” does not actually help.  It tends to make the person struggling feel as though she cannot share her pain, sadness, or anger.  Trying to “fix” sends this message: “I can’t handle seeing you in pain, so I have to make everything better.”  It also implies that it is not okay to feel sad or angry or anxious, and that these feelings should be avoided at all costs.

AVOID ADVICE

Just like our impulse to fix the pain, we also often believe that the best way to help is to offer advice.  But advice is usually not helpful for several reasons.

  1. If we offer good advice, our loved one will think that anytime he is struggling, he needs our instruction. 
  2. If we offer bad advice or our advice doesn’t work as we hoped, our loved one can place the blame on us instead of owning responsibility.
  3. Advice takes away the gift of helping our loved one to realize that she knows herself best, and ultimately she is capable of navigating difficult situations herself.  (Though, of course, she will always have our love and support).

LIMIT SHARING YOUR OWN SIMILAR EXPERIENCES

Source URL:  http://www.lifehack.org/articles/communication/the-biggest-communication-problem-not-listen-understand.html

Source URL:  http://www.lifehack.org/articles/communication/the-biggest-communication-problem-not-listen-understand.html

If you have had a similar experience or believe that you have felt the same way, you can share this with your loved one.  But don’t make it all about you.  Keep your story brief, and make sure the purpose of the story is to let him know that he is not alone.  Also, be sure to include that you understand that your experience, while maybe parallel in some ways, is yours, and you are not claiming to have experienced the exact same situation or feelings.  This allows him to feel comfort in not being alone, but also gives him space to communicate how his experience may be different.

If we shouldn’t try to fix the pain or offer advice, and we should limit how much we share of our own experience, what can we do to help?

REFLECT OR PARAPHRASE BACK TO YOUR LOVED ONE WHAT YOU HEAR HIM/HER EXPRESSING

This shows that we are listening, and gives us the opportunity to clarify that which we don’t understand fully.  While it may sound too simple to just reflect what our loved one is saying, it actually makes the person feel heard and understood.  It also offers her the opportunity to hear what she is expressing, and to clarify how she feels or what she wants.

USE NONVERBAL SIGNALS TO SHOW YOU ARE ENGAGED

Nodding and using eye contact and engaged body language shows that we are interested and open to what our loved one is sharing.  It gives him the space to express himself, and makes him feel heard.

SHOW EMPATHY

Empathy is: “I see that you are struggling and hurting right now, and I am so sorry.  I can’t fix it for you or take it away, but I will sit here with you and listen to your story.  As much as this hurts, it is okay to feel this way.”

Check out Brene Brown’s brilliant short on empathy.

Sometimes, all our loved ones need when they are in pain is to be heard; to be given a space with someone they trust to express how they are feeling.  Sometimes, however, they may need some extra support or professional help.

CSAM IS HERE TO HELP

If you or someone you love might benefit from acceptance and commitment therapy (ACT), cognitive behavioral therapy (CBT), or biofeedback for anxiety, depression, stress, or PTSD, or if you would like more information about our therapy services, please contact us at (858) 354-4077 or at csamsandiego@gmail.com.

REFERENCES:
Brown, B.  (2013, Dec 10).  Brené Brown on empathy. Retrieved from https://www.youtube.com/watch?v=1Evwgu369Jw

 

How Anxiety Affects Couples

Jill Stoddard

by Jan E. Estrellado, Ph.D.

Most of CSAM’s blogs focus on the experience of having a mental health condition, such as anxiety, depression, or PTSD.  This blog is a little different because it focuses on the impact of a mental health condition, anxiety, on couples.  What is it like to care for, live with, and support someone with anxiety?  What kind of strain might this cause in a relationship and what can couples do to sustain each other and their relationship?

Loving Someone with Anxiety

Partners or spouses of individuals with anxiety might experience feelings of helplessness.  When anxious loved ones feel intense fear (i.e., scared of having a panic attack or becoming severely preoccupied with worried thoughts) or avoid certain situations (i.e., not wanting to drive on the freeway or refusing to leave the home), partners may not feel there is much they can do to help reassure or calm them down.  When a partner does attempt to help ease his or her loved one’s suffering, those attempts (i.e., reassuring, problem-solving) may be rejected by the anxious individual.  This can be extremely hurtful and can lead to other intense feelings described below.  In addition, partners may try to help by offering to drive for the anxious partner, agreeing to skip a social event, or allowing the anxious partner to engage in compulsions so that he or she gets relief.  While these efforts are meant to be helpful, the avoidance partners are enabling actually contributes to and maintains the anxiety-related problems.   

The emotions that partners of anxious individuals can experience range and vary greatly.  They may feel anger and frustration that the anxiety inhibits their lives, and because their partner’s anxiety is outside of their control.  It is difficult to accept that a loved one may continue to feel anxious, regardless of the actions of the partner.  If a partner’s anger remains unresolved over a long period of time, this can turn into resentment, minimization, or blame.  Partners may feel overlooked or overshadowed by their loved one’s anxiety, perhaps feeling like their needs can’t be met when calming their partner down feels the most urgent.

Being the Anxious Partner in the Relationship

The partner who experiences extreme worry can easily feel guilt, shame, and embarrassment at their lack of ability to manage anxious feelings.  They may also feel misunderstood and alone.  These negative feelings, if not addressed or acknowledged effectively, might actually contribute to further anxiety.  If an anxious person feels his or her partner is getting frustrated, that person might shut down, withdraw from the relationship, or engage in unhelpful coping behaviors, such as smoking cigarettes or shopping excessively. When worry and stress take up a lot of space in a relationship, the anxious individual often feels responsible for his or her partner’s feelings of frustration, hurt, or helplessness.  These feelings of guilt or embarrassment compound the individual’s pre-existing feelings of worry, increasing the suffering of that person. 

It may be difficult for the anxious partner to know what he or she needs.  Perhaps he or she is too ashamed to ask for support when so much help has already been requested of the partner.  When a person experiences intense fear in the moment, it can be challenging to know what is helpful and perhaps even more challenging to communicate those needs effectively.  Intense fear, by nature, prevents a person from thinking logically or rationally and it can be tough to know how to reign one’s self in during those moments.

Sustaining the Relationship

What can a partner of an anxious individual do to help make the relationship work?  One crucial element is for the partner to make sure that he or she is able to maintain his or her own health and wellness.  A partner can feel guilty for taking care of himself or herself, especially knowing that his or her loved one may be suffering.  However, if both partners are suffering, especially over a long period of time, the relationship is no longer sustainable.  A partner might need to seek this support outside of the relationship.  Examples of support outside the relationship include trusted friends, family members, health providers, faith leaders, co-workers, and therapists.

In addition, a person may want to communicate his or her needs to the anxious partner, even if it is difficult.  If only one person’s needs are being met or paid attention to consistently, the relationship feels one-sided—another predictor of an unsustainable situation.  Asking for one’s needs to be met can also include discussing feelings and reactions to the partner’s anxiety.   While communicating feelings in an authentic, yet caring way, can be challenging, both partners might experience some relief and a greater connection, and the likelihood of resentment decreases.

An anxious individual may not want to wait until he or she experiences intense fear to know what help the partner can provide.  Rather, identify wants and needs during more calm or grounded moments.  When an anxious person knows what works, it is easier to engage his or her partner in a collaborative manner.  Having a “game plan” can ease some of the intensity of fear in the moment. 

Finally, as we say in Acceptance and Commitment Therapy, anxiety can have a place in the relationship, but it shouldn’t be “driving the bus.”  When anxiety appears to be controlling the direction of the relationship despite the couple’s best efforts, it’s time for one or both individuals in the relationship to seek outside support.

CSAM is here to help

If you or someone you love might benefit from acceptance and commitment therapy (ACT), cognitive behavioral therapy (CBT), or biofeedback for anxiety, depression, stress, or PTSD, or if you would like more information about our therapy services, please contact us at (858) 354-4077 or at csamsandiego@gmail.com.