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NIMH Expert Dr. Krystal Lewis Discusses Managing Stress & Anxiety

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KRYSTAL LEWIS: Hello, and happy new year. Thank you for joining us today. My name is Dr. Krystal Lewis. I'm a licensed clinical psychologist at the National Institute of Mental Health or NIMH, which is part of NIH, the National Institutes of Health. At NIH, I provide clinical services to youth who are participating in the pediatric anxiety study, and my research interests focus on identifying mechanisms of treatment such as self-efficacy and other factors which impact the effectiveness of cognitive behavioral therapy or CBT, which I'll talk a little bit more about later on.

KRYSTAL LEWIS: So with the new year upon us, it's a good time to check in on ourselves. 2020 was challenging for many reasons. The continued uncertainty surrounding the COVID-19 pandemic and the social unrest is still also very stressful for many of us. We know that everyone experiences stress from time to time, and it's normal to experience a wide range of emotions when you're feeling stressed, such as anxiety or fear, anger, and even grief, especially during challenging times such as these. However, there are long-term stress impacts, so the more you experience stress for long periods of time, this can significantly impact our overall health. People who are diagnosed with anxiety disorders also may be experiencing a heightened level of anxiety. For those individuals, the anxiety tends to persist and does not go away. It's often very distressing and interferes with daily functioning and can get worse over time if not treated.

KRYSTAL LEWIS: So during the next half an hour together, I'm going to share some information about stress and anxiety. I'll suggest some coping techniques for maintaining your mental health during this pandemic and discuss when it might be appropriate to get professional health. I'll wrap up at the end with a brief guided meditation, and if there's some time, I'll take a few of your questions from the comments. It is important to note that I cannot provide specific medical advice or referrals. Please consult with a qualified healthcare provider for diagnosis, treatment, and any answers to your personal questions. If you need help finding a provider, please visit www.nimh.nih.gov/findhelp. If you or someone you know is in crisis, please call the National Suicide Prevention Lifeline at 1-800-273-TALK, 8255. 1-800-273-8255. You can also ask for help in the comments section of this feed, and someone from NIMH will assist. All of the websites and phone numbers that I mentioned will be posted in the comments section below so that you can easily access them.

KRYSTAL LEWIS: So to get started, let's talk a little bit about stress and anxiety. It's first important to distinguish between stress and anxiety. Stress is the physical or mental response to an external cause such as having a lot of homework to do, having an illness, or experiencing difficulty paying your bills. A stressor might be a one-time or a short-term occurrence, or it can happen repeatedly over a long time. Stress can have a positive or a negative effect on your behavior. For example, if you are stressed about meeting a deadline, it might actually cause you to get the work done so that you can meet that deadline. But the stress might also cause you to lose sleep or have difficulty sleeping because you're stressed out about meeting that deadline. Different effects. Likewise, stress can be a result of positive or negative experiences. So starting a new job, that's a positive stressor. It can be. But losing a job or getting fired, that's a negative stressor.

KRYSTAL LEWIS: Now, anxiety, anxiety is your body's reaction to the stress and can occur even if there's no current threat. So its origin is internal. Usually, anxiety involves a persistent feeling of apprehension or dread that seemingly may not go away. You might experience uncomfortable physical feelings that interfere with how you live your life. But both stress and anxiety can affect your mind and your body. You may experience such symptoms like excessive worry, feeling uneasy or having trouble relaxing, having tension in your body, or that might be headaches or muscle pain. Even physically it can affect you, and you might experience high blood pressure, or you might have difficulty sleeping. If stress or anxiety doesn’t go away and begins to interfere with your life, it could affect your health. You could experience problems with sleeping or with your immune, digestive, cardiovascular, and even your reproductive systems. You might also be at higher risk for developing a mental illness such as an anxiety disorder or depression.

KRYSTAL LEWIS: So with that said, we're going to talk about some ways you might be able to cope with this stress or anxiety. It is necessary to have coping mechanisms in place. You want to avoid potentially harmful behaviors such as drinking alcohol, excessive news watching, overeating, isolating yourself, which can lead to poor hygiene. Keeping a routine is a key piece to maintaining some sense of normalcy. Eating properly, staying hydrated, exercising and moving around, and getting enough sleep are all very important. The first step to restoring a sense of calm is what I call disrupting anxiety. Once you're aware of the anxiety, you can do certain things to disrupt the worrying and the anxious feelings that you experience. This means you can challenge anxious or irrational thoughts by reframing your worries and using previous example going back to that deadline for work. So you have a deadline, and you're stressed about it. Instead of saying to yourself, "I should have already done this. They'll think I'm incompetent. I can't do anything right," catch yourself. And once you catch yourself experiencing those unhelpful thoughts, you can say, "I'm doing the best that I can. No one is perfect. Sometimes things might be late right now, and that's okay." It can also be helpful to reach out to loved ones to vent or problem solve. And sometimes, it might be necessarily to employ calming or relaxation techniques, which I'll discuss a little bit later.

KRYSTAL LEWIS: Oftentimes, we, as parents, friends, or colleagues, may want to tell people with anxiety or those who seem stressed to just calm down. Things will be okay. However, we know that this is not an effective approach. We want to be the person who is able to provide a listening ear and perhaps impart more helpful suggestions after you learn a few things here today because, as noted, this is a tough time for us all right now. When thinking of parents, parents can help children deal with stress and anxiety by using some of the techniques I just mentioned and helping kids to focus what is in our control. As an example, worries about COVID-19 are common. However, what we can do is remind kids that there are certain things we can do in the situation such as wearing our mask, washing our hands, and engaging in social distancing. If there's a family member who, unfortunately, has COVID, or a neighbor, we can write get well cards, or we can make food or drop food off for them. Having discussions with your children about the social unrest that's occurred, when appropriate, explain to them how you're keeping them safe and discuss things that the family can do. Oftentimes, when you feel stressed and anxious it's because we don't believe we can handle things. However, this is a reminder that we are stronger than we believe, and we can get through this. So we can engage in great practices to help manage feelings of stress and being overwhelmed.

KRYSTAL LEWIS: Earlier last year, this acronym, GREAT, was developed as an easy reminder to engage in these helpful practices to manage stress and anxiety. G, G stands for grateful. Be grateful. Find small things each day to be grateful about. This might be when you wake up in the morning or in the evening before bed, thinking of, what are the small things throughout the day that you can express gratitude for, such as the bed that you're about to fall asleep in or a nice meal that you've had earlier that day. R stands for relaxation. Practice relaxation. Do things that help you to calm down and relax. That might be different for each of you, but find ways to integrate that throughout your day. E stands for exercise. Engage in exercise, some type of activity. We know that physical health and mental health are tied together. We know that activity is important, so you try to implement that in your day. A stands for acknowledge. Acknowledge your feelings. Be aware of the many feelings, and accept them as they occur. Right now, things are very frustrating. You may be feeling angry at some of the things that we're seeing on the news. We might feel anxious about our health and our family's health. Whatever feelings that you are experiencing, know that it's okay. Accept them, acknowledge them, and then make sure that you use one of these practices to help manage them. And lastly, T. T is for track your thinking. Track your thoughts and change them. Ensure that you are engaging in helpful thinking. We all have thoughts that, oftentimes, aren't the most helpful. So if you pay attention to your thinking patterns, you can then engage in more helpful thinking.

KRYSTAL LEWIS: So to build on that acronym of GREAT, I'm going to talk a little bit more about other strategies that may help promote resilience during these tough times right now. So change your expectations of daily productivity and accept that this is your norm right now. This is our norm. We have to acknowledge that we have different demands being at home than before maybe when we were in the office. We have to limit comparisons to friends or peers or colleagues who seemingly are living productive lives and have it all together. Remember that everyone may have different circumstances, and what people tell you and what you might see on social media often isn't a comprehensive picture of what's going on. So the comparisons aren't very helpful. As noted earlier, focus on what is in your control. We don't know when we'll be able to safely return to work or when our kids are going to go back to school. Therefore, we need to attend to what we do have control over. Create schedules and deadlines, and remember that your expectations should be adjusted for this current time, and you may not be able to do everything that you would like to do and plan to do, but that's okay. Acknowledge and validate your thoughts and feelings. Pay attention to your own physical and mental fatigue. There is no right or wrong way to feel right now, so work on accepting your feelings as they come. Practice self-compassion. You're going to have some good days, and there may be some days that aren't so bad, but that's okay.

KRYSTAL LEWIS: What can be helpful is engaging in mini breaks throughout the day, which can help with you managing general stress and potentially even increasing your productivity by taking a break. Watch a funny show. Watch a funny clip on YouTube. You can engage in social media briefly. Call a loved one. Just take a minute to detach from the pressures of work and your expectations throughout the day. Give yourself a break, and that can help improve your overall mental health. Use relaxation strategies to help reduce your anxiety throughout the day. These include deep breathing, taking a few minutes, sitting, and taking some deep breaths in through your nose, out through your mouth. Visualizing pleasant places, places that you've been in the past, places that you see yourself going in the future. Close your eyes and picture yourself in that location. Body scanning includes just paying attention to how you're feeling, different areas of your body. Are you stressed? Do you need to relax in those areas? Do you need to stretch? You can meditate. You can light candles. You can do anything that you find brings you a sense of calm, but make sure that you do those things. And maintaining a regular schedule or routine during the work week, as I noted. This can help with managing your time more efficiently. The schedule can take many forms, and it might be a shared schedule with a partner, or it might be your schedule with your child or elder care. Be flexible and forgiving. Have a schedule, but if you don't stick to it, something gets in the way, that's okay. We're going to try again tomorrow.

KRYSTAL LEWIS: And lastly, ask for help. We might feel that we're expected to solve all of our own problems and figure things out, but we know that these are uncharted waters for all of us right now. And if we ask for support, whether that be extra time on a project for work or seeking support from a friend or a colleague, verbalize to your partner when you need a break, or even reaching out for professional help from a therapist, these are all ways that we can help ourselves. So how do we recognize when we need more help? If you notice that you are struggling to cope, and the symptoms of stress and anxiety just won't go away, it may be time to talk to a professional. Maybe you've tried some of these strategies, and it just seemingly is not helping. You can reach out to a professional and engage in psychotherapy, also called talk therapy, or medication if need be. These are the two main treatments for anxiety, and many people benefit from a combination of the two.

KRYSTAL LEWIS: So let's talk a little bit about the anxiety disorders. Anxiety disorders are the most common form of mental health in adults. There are several types of anxiety disorders, which include generalized anxiety, panic, social anxiety, and various phobia-related disorders, just to name a few. Generalized anxiety disorder display excessive anxiety or worry for most days for at least six months about a number of things. This can be personal health, work situations, social interactions, essentially everyday work/life circumstances create some worry. The worries cause significant problems in different areas of your life, such as interactions with other people, school, work. And you may often feel some physical symptoms of just being restless, difficulty relaxing, having sleep difficulties, and a few others.

KRYSTAL LEWIS: People with panic disorder have recurrent or unexpected panic attacks. Panic attacks are sudden periods of intense fear that seem to come quickly out of the blue and reach their peak within minutes. These attacks can occur unexpectedly or can be brought on by a trigger such as a feared situation or a feared object. During a panic attack, people may experience a racing heart. They might be sweating. They might have a feeling of impending doom, something bad's going to happen, feel like they're out of control. People with panic often worry about when this next attack will happen, and they actively try to prevent their future attacks by avoiding places, people, things, behaviors that they associate with panic attacks. And the worry about the panic attacks and the effort spent trying to avoid these attacks causes significant problems in different areas of your life.

KRYSTAL LEWIS: And we'll do social anxiety. People with social anxiety disorder have a general intense fear or anxiety in social situations or situations requiring a performance. So they worry that their actions or behaviors associated with the anxiety will be negatively evaluated by others, leading them to feel embarrassed. And this worry often causes people with social anxiety to avoid social situations. So there might be physical symptoms that they experience such as chest pain or feeling hot, shakiness, headaches, a racing heart, muscle tension. The social situations almost always provoke fear or anxiety, and the situations are avoided or at least endured with intense anxiety when they're in those situations. So the fear is persistent, lasts for six months or longer, and causes significant distress. There are other anxiety disorders, and you can visit our website for more information.

KRYSTAL LEWIS: Researchers are finding that both genetic and environmental factors tend to contribute to the risk of developing an anxiety disorder. And although the risk factors for each type of anxiety disorder might vary, some general risk factors for all types of anxiety disorders include what's called behavioral inhibition or a temperamental trait of being shy that is often noticeable in early childhood, exposure to stressful and negative life events that occur in childhood or in adulthood, a history of anxiety or other mental illnesses in biological relatives in the family, and some physical health conditions like thyroid condition, heart arrhythmias. Caffeine consumption or other substances can produce and aggravate anxiety symptoms. A physical health examination is helpful in evaluating the possibility of anxiety disorder. So it's really important that you seek help from a provider to receive an accurate diagnosis and appropriate treatment if you experience any of these symptoms.

KRYSTAL LEWIS: So let's talk a little bit about treatment. Despite anxiety being very common, the good news is that anxiety is quite treatable. Anxiety disorders are generally treated with psychotherapy or medication or both. There are several ways to treat anxiety, and people should work with their doctor to choose, well, what treatment is best for you. Psychotherapy or talk therapy can help people with anxiety disorders. And to be effective, psychotherapy must be directed at the person's specific anxieties or tailored to their needs. So this therapy can be adjusted to meet the needs of each individual. Cognitive behavioral therapy is an example of one of the psychotherapies that can help people with anxiety disorders. CBT has plenty of scientific support which demonstrates its effectiveness for people with anxiety. CBT teaches people different ways of thinking, feeling, and reacting. And when we're in these situations, we teach people how to manage the anxious thoughts that they may be experiencing. Generally, people with anxiety fear that bad things will happen, and they won't be able to handle them. So CBT can also help people learn skills and strategies which increases general efficacy.

KRYSTAL LEWIS: Cognitive therapy and exposure are two CBT methods that are often used together, and they treat the different anxiety disorders. Cognitive therapy focuses on identifying challenging and neutralizing unhelpful or disordered thoughts that underline anxiety disorders. Exposure therapy focuses on confronting fears underlying the anxiety and helping people engage in the different activities that they've been avoiding. So therapists who are trained in exposure therapy can help people to safely face their fears through graduated or step-by-step practice. And during CBT, you might also learn different ways to manage the extreme anxiety you have through learning relaxation and coping tools that you can use outside of the session when you're feeling very anxious.

KRYSTAL LEWIS: So sometimes when therapy's not as effective or symptoms get in the way of engaging in therapy, medication is a great option. Medication does not cure anxiety disorders, but it can relieve symptoms. So medication for anxiety is prescribed by doctors such as psychiatrists or primary care providers. Some states also allow psychologists who have received specialized training to prescribe. The most common class of medications to combat anxiety disorders are anti-anxiety drugs such as benzodiazepines, antidepressants, and beta blockers. So anti-anxiety medications can help reduce symptoms of anxiety, panic, or extreme fear, and the most common anti-anxiety medication are called benzodiazepines. Although benzodiazepines are sometimes used as a first-line treatment for generalized anxiety, other anxiety, they have benefits and drawbacks. Some benefits of benzos are that they-- of benzodiazepines are that they're effective at relieving anxiety and take effect, basically, more quickly than antidepressant medications. Some drawbacks are the benzodiazepines, people can build up a tolerance to them, and if they're taken over a long period of time, then you might need a higher and higher dosage to get the same effect, and people might even become dependent on them. So to avoid these problems, doctors sometimes prescribe benzodiazepines for short periods of time. They're helpful for adults, older adults, maybe people who have substances abuse problems and people who become dependent on medication easily. If people suddenly stop taking these medications, they may have withdrawal symptoms, so we advise that you work closely with your doctor when you decide it's time to stop the medication.

KRYSTAL LEWIS: So again, for long-term use, the first line of treatment we say to use is antidepressant medication. So benzodiazepines can be considered as a second-line treatment, but for long-term use, we suggest antidepressants. And these are helpful for treating anxiety. They might improve ways that your brain uses certain chemicals that control your mood or control stress. You might need to try several different ones before finding one that improves your symptoms and has manageable side effects. Knowing a family member who's taken an antidepressant can be helpful in knowing if a medication may work for you as well. So do know that antidepressants can take some time to work, so it's important to give the medication a chance before reaching a conclusion about if it's effective. If you begin to take antidepressants, don't stop them without the help of a doctor. Again, any medication that you're on, consult with your doctor, and you guys can come up with a plan for how you can slowly and safely decrease your dosage. It is best to engage in CBT while on medication for the greatest benefit when treating your anxiety disorder, so it's important that you find a provider with whom you feel comfortable so you can work together to find the best treatment for you, whether that be CBT, medication, both. But talk with a qualified professional.

KRYSTAL LEWIS: Okay. So thus far, I've given you a lot of information, and now is a good time to sit back and do a guided meditation with me. Meditation is a useful tool for calming stress and anxiety and helping you to relax, refocus, and bring you to the here and now. We'll do a brief meditation to connect to the present moment. So take a few seconds to find a comfortable position. If you're sitting, keep your back straight but relaxed, and keep your feet planted to the ground. You can close your eyes to really get into it, or, if you'd like, rest your eyes on one particular spot on the wall or in front of you. Take a deep breath in, hold, and release. Take one more deep breath in through your nose. Focus on the sensation of the air passing through your nose and into your body. Feel the slight movement in your chest as you breath and exhale, gently letting the air out. Focus on the calmness of the space around you. Relax your muscles as you continue to breath. Notice any tension and relax those areas of your body.

KRYSTAL LEWIS: As you continue to breath, slowly in and out, notice how your body feels in that chair or on the couch, what you're feeling as your body is resting in that space. Notice the pressure on the different parts of your body. There's no particular way to be. Just notice how you are in this moment. If you notice physical discomfort or distressing thoughts, simply allow them to be. Let them come and go. Be open to any sensations, feelings, or thoughts that you may be experiencing and know that they're going to come, and then they're going to pass. Continue to breath and focus on any physical sensations. Do you feel the air around you? Do you feel it on your skin? Is the air still? Imagine yourself as light as the air. Relax. Can you hear the air coming from your vent or through the window? What else do you hear? Pay attention to the sounds around you. Do you hear other voices in your home or just my voice? Let the sounds come and go as they please.

KRYSTAL LEWIS: Now, let's shift your attention and awareness to your emotions. How would you describe what you're feeling right now? Are you happy? Sad? Irritated? Bored? Are you not sure what you're experiencing? Be aware of your emotional experience and allow it to be. Whatever emotion you're experiencing is fine. It's okay. Refocus on your breathing. Hold and release. Focus on air moving in and out of your body and the quiet that surrounds you. Let any sounds, thoughts, and feelings come and go as they occur. Notice and acknowledge them and let them leave. Bring yourself back to your physical space. Open your eyes and take a few more deep breaths, in and out. Now, pat yourself on the back for taking time to engage in this meditation. Take note of how you're feeling before you jump right back into your day. Remember that you can use this exercise or any similar exercises like this whenever you feel you need to take a break. And you see it only takes a few minutes to do. You can integrate breaks throughout your day and do a relaxation tool-- or use a relaxation tool to help yourself calm down and refocus yourself to the present moment.

KRYSTAL LEWIS: Okay. So at this time, be mindful. We've reached the end of our discussion today on managing stress and anxiety. Thank you for joining us today. Get the latest shareable resources on coping with COVID-19 from NIMH at www.nimh.nih.gov/covid19. Thank you so much for joining us today, and please, everyone, stay well.