Anxiety and the fight flight response, a quick guide

Anxiety – it can be tricky.

Below is a quick and basic guide to addressing long term anxiety.

For a deeper dive on Anxiety [Link]

The graphic below says "How do I teach my body that my fight or flight response is supposed to be for life or death situations, not answering an email", 11:56 AM 8 December 2022 from @ _chismosa_

It starts with some CBT (Cognitive Behavioural Therapy), where we look at a combination of the thoughts and behaviours around the triggering things, in this case emails.

If there are only a few triggering things, then you may have had an adverse event that has led to a heightened response to things that seem similar to that bad event. We can do some de-escalation and mood regulation exercises around those triggers to take the power out of them so that you can overcome that fight / flight response.

If there are a few more triggers than can be explained by a simple adverse event or two, then we need to look at some of your boundaries around people. This is often around when it is fair that someone is angry versus when it isn’t, and what your share of responsibility is towards that person who may or may not be justly angry. These core values may need some tweaking if they are set to “self sabotage” mode. That combined with some of the de-escalation and mood regulation, reinforced with boundary ascertion, possibly getting away from toxic environments, and some timely mantras to remind you that you have rights as much as they do often does the trick.

If this fight or flight response feeling is pervasive, then either we are dealing with a trauma response (PTSD style) or a neurotransmitter imbalance.

PTSD style first.

If you know the traumatic event(s) that created this anxiety, and your anxiety doesn’t pre-date the traumatic event, then we can do some trauma therapy around this. Trauma therapy has a few parts:

– ensuring the neurotransmitters are okay; which might mean some medication, exercise and dietary adjustments to correct

– mood education; so you can understand what your feelings actually are and are actually trying to tell you – and importantly when they are wrong

– mood regulation skills; to get your mood back under control so that your mood informs you and you choose your actions, rather than your actions are chosen by your mood

– understanding toxic behaviours and how they can manipulate you

– and finally, if and when you have a good handle on all of the above, stepping through what you know of the traumatic memories, mapping out timelines, separating facts from story, decompressing events and working out what the event(s) mean to your older you now vs your younger self

* sometimes even then the event(s) are too stressful to process directly, so we can use a distraction method to decrease the feeling of intensity such as eye movements, textured items, building lego objects, drawing and so on

If you can’t remember the trauma, then it isn’t trauma.

If the anxiety predates trauma, or isn’t explained by trauma, then we are looking primarily at neurotransmitter problems. That often starts with SSRI medication. If SSRI’s don’t give an adequate relief, likely switching to SNRI or a Beta Blocker medication depending on certain traits/symptoms. If that doesn’t work, then a more comprehensive assessment needs to occur to figure out what is going on, which exceeds what this quick guide can do.

Importantly, while SSRI is often a good place to start, it isn’t the end of the medical line; just often the end of what the GP is likely to trial. At that point you really want a therapist who is informed about medication and probably a psychiatrist. This will help work out the actual likely diagnosis for mental health and the likely medication that will help that medical problem.

Biological problems require biological responses. You can’t will power your way through diabetes, heart conditions or neurotransmitter irregularities.

The Five Phases of Trauma Therapy

Trauma is a term that is often very misunderstood in Mental Health. While PTSD (Post Traumatic Stress Disorder) is a serious condition, far too many people misdiagnose PTSD when in reality the situation was merely uncomfortable, regretful, confusing or better attributed to another condition. Trauma is often uttered as an explanation for odd cognition or behaviours, without either an investigation of whether a traumatic experience truly is the source of these thoughts or behaviours, or any attempt being made to do something about the cognition or behaviours.

Phase 0: Understanding Trauma

Phase 1 – Balance Neurotransmitters

Phase 2 – Stabilise Environment

Phase 3 – Stabilise Self

Phase 4 – Mood Management

Phase 5 – Trauma Therapy

Basic drawing of a brain and a person in a chair looking at it with a question mark above their head indicating questioning.

Phase 0: Understanding Trauma

While I did say that there are 5 phases to Trauma Therapy, this is on the assumption that Trauma Therapy is actually warranted.

Trauma is a medical term that refers to the damage left after an incident has occurred. A doctor might describe that their patient has “a rupture caused by blunt force trauma”, where “blunt force” is the nature of the “trauma”, and the “rupture” is the damage to the body from that blunt force. Body trauma can have a range of consequences, from short term to long term. Most trauma will heal in a short amount of time, often tracelessly. Sometimes there are some signs of healed damage that linger such as a scar, and importantly, this does not cause any serious long term consequences. Sometimes the consequences of the traumatic incident affect a person for the remainder of their life, some in minor ways and some profound.

We are not just physical beings.

A traumatic incident that affects our bodies can also affect our minds, both the hardware of the brain and the wetware of the thoughts and behaviours we exhibit. This can be brief, such as a minor burn to your hand on some cooking equipment prompting you to be cautious of how hot the kitchen ware is; moderate such as a romantic break up prompting you to greive, or long term.

PTSD is an initialism for Post Traumatic Stress Disorder, and while the concept was a rebranding of prior names names that describe the psychological damage to soldiers who survived war, it is also applied to any person who is having a range of specific ongoing consequences to an incident that they define as strongly traumatic after 4 weeks from the incident.

Even if your experience isn’t technically PTSD, some experiences can be very unsettling. We can experience lesser traumatic events, which can be a single incident or a series of linked or semi-linked events, that still affect us. Talking to a therapist can be helpful to understand what has occurred, what was fair, what is within the range of “normal” (even if it is unusual), and how to adjust to that and similar situations. Ideally you will exit the therapy with a greater understanding of the incident, some positive changes you can make from something that was likely out of your control, and a plan for if such a thing were to happen again.

It is important to note that the above is important if the behaviours and stress are only due to the incident identified as traumatising. I would estimate that upon proper investigation, around 80-90% of the people that come to see me for their Trauma discover that their behaviours and distress (most often anxiety) pre-date the incident/event identified.

When you are holding a hammer, all problems look like nails.

Too often people and therapists decide that this series of behaviours must be a trauma based response. When I expose that the behaviours existed prior to that event, they go looking for another trauma to heal, even going as far as “repressed memories” and “early childhood trauma”. We have excellent evidence where people suffering from clinically diagnosed and in-the-process of being treated for PTSD have had an accident that has caused an amnesia (loss of memory) that includes the traumatic events. These people have stopped experiencing the PTSD symptoms and no further treatment was needed. What we have learned from this is, if you can’t remember the incident, you aren’t traumatised by it.

This does not give you leave to go out and try to get amnesia!

In the cases where the problems that have brought a client to therapy predate the hypothetical incident, and no actual triggering traumatic event appears to be a starting point to the symptoms, we need to consider that we are dealing with a mental health or neurodivergent situation and shift gears to deal with that instead.

It is time to Put the Hammer Down.

Where the situation is either ambiguous or clearly trauma related, we need to look at Trauma Therapy. The gold standard for Trauma Therapy is a modified Cognitive Behaviour Therapy – Trauma CBT (sometimes tCBT, or TF-CBT [Trauma Focused CBT]). This should be in conjunction with other therapies for a holistic treatment plan. Specifically, a medical expert who can prescribe relevant medications, the therapist performing the Trauma Therapy on the backbone of CBT, other therapies to help target specific mal-adapted behaviours and or neurodivergent traits that are uncovered, potentially a relationship counsellor, domestic violence counsellor, home support and so on depending on what may be de-stabilising the client. In my case, I do all of the bits listed after the medication and I’m not shy about making recommendations for which medications types I think are most likely to help.

There are 5 important phases to Trauma Therapy

Phase 1 – Balance Neurotransmitters 

Many of my clients come to me either self medicating, on the wrong medication or no medication. While not all people require medication, many do – either short term or long term. Often much of their current struggle is an exacerbation of lifelong undiagnosed conditions. It is hard to think clearly and behave as you want when your brain is misfiring, and hard to know what to do if yoru brain is misinforming you, and or pushing you towards certain behaviours.

This needs to be stable enough for phase 4 and 5  to be possible.

Phase 2 – Stabilise Environment

While Maslow meant for all of his hierarchy of needs to be met, the baseline housing, nutrition, physical health and social safety are fundamental to good mental health.

This needs to be stable enough for phases 4 and 5  to be possible.

Phase 3 – Stabilise Self

The most common trauma that I see is relationship violence [Extensive list: Link]. This leaves the client with a destabilised sense of self, feeling over responsible for everyone and everything, and poor to no personal boundary definition or defence. People who have had non-relationship trauma (for example, a motor car accident) can lose these as they try to survive their understandable reaction to a traumatic event.

As the medication side is being explored, the therapist begins to rebuild the person’s core principles and helps build a scaffold for the person’s identity and boundaries to be tied to. This needs to be self-referential rather than tied to an external person, as if that person is no longer available, the scaffolding will fall, leaving the client even more lost. 

While progress will seem slow in the absence of medication (if needed) or environment stabilisation (if needed), once these previous two phases have progressed enough, the client will begin to enact the new core ideas and behaviours.

Phase 4 – Mood Management

This begins with some education on identifying what it feels like to have each of the major mood categories, and how to correctly assess the levels of those moods. This will then progress through to understanding the biological and social purpose of moods and how to tell if your emotional reaction matches the environmental cue. Checking on this is learning to note when your mood exceeds a mild level, giving you time to make decisions rather than just reacting.

A choice that is important to be able to make is to calm your mood back down. You can’t make a choice if you don’t know you have a choice to make, nor the skill to implement it. This leads to upskilling on how to manage your mood – but remember, this can only work temporarily to get you through a short term interaction. Long term mood dysregulation often points back to phase one.

[We have covered mood management before Link]

Phase 5 – Trauma Therapy

While it may seem like a great deal of pre-work to get to the actual therapy for the trauma, without a properly (or as best as we can manage) working brain to comprehend and make wise choices, without a stable environment to go to after therapy, without a sense of who you are and growing to be; and without the skills to recognise your mood and stabilise that – it is very dangerous to explore an event that was so traumatic that it damaged all of these things.

It is not uncommon that my clients don’t actually need this final step. What they thought was trauma related mental ill health was actually their brain using a traumatic memory to drive the mood to produce neurotransmitters to try to balance their brain, frequently on a background of unstable home life. When these are stabilised, it becomes apparent this was the actual problem.

If it is still relevant to continue with trauma therapy, a range of techniques are employed, depending on the nature of the trauma, the nature of the effect of the trauma and most importantly the individual client. The most common elements are:

  • Unpacking the trauma, noting falsely conflated events, facts vs assumption
  • Unpacking the narrative, seeking the best objective reality understanding
  • Desensitisation to specific triggers
  • Regaining Power and Choice
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