How Nervous System Imbalances Cause Emotional Dysregulation

I'd like to welcome everybody to today's presentation on understanding and addressing dysregulation, a pieces functional behavioral health approach. I'm your host, Dr. Donnisee Snipes. Just think for a minute, what percentage of the people that you work with experience intense emotional responses that are often out of proportion, especially in their assessment, to the situation. Now, in the moment, they may think it's proportional, but in retrospect, they may look back and say, "Uh, yeah, I probably overreacted." What commonalities do people who disregulate share? You know, thinking about are they do they have a diagnosis of PTSD, of depression, substance use, what's going on that is common to all of these people? In this presentation, we'll define emotional dysregulation, identify disorders and conditions in which emotional dysregulation is a core feature, and it extends past DSM5 TR diagnosis. I'll give you that hint there, too. And then we'll explore the underpinnings of emotional dysregulation and tools to help people start managing their emotional reactions a little bit more effectively. What is emotional disregulation or emotional regulation? the perception, prediction, expression, identification, and control of emotion in response to negative, neutral, and positive stimuli. All right. Well, let's just break that down a little bit. The perception of and and which leads to the response to negative, neutral, or positive stimuli. We've talked so many times about our experiential vault. What is benign or what is neutral or positive for some people may be negative for other people. And I've shared the example of roller coasters. I hate roller coasters. They terrify me. But my cousin can't get enough of them. He thinks they're the greatest thing in the world. We have different reactions, gut reactions when we see roller coasters. Prediction is another one. I'm perceiving what's going on now. I'm predicting. Is this safe? Is this a threat? Or is this a nothing burger? And again, that goes back to that experiential vault. If I have had negative experiences similar to this before, then I'm going to predict it's going to be negative. If I have positive experiences in relation to this before, guess what? I'm probably going to expect it to be positive. Using the example of dogs, some people had bad experiences with dogs from a very early age or they were taught that dogs were dangerous. So they see dogs and they go, "H, not so good." I see a dog, even one that may be drooling like Kujo. And I'm bending down on my knee going, "Come here, puppy." Um, [gasps] not the smartest thing, no doubt, but different reactions. I'm predicting that that dog is thirsty or maybe licked a toad, which is why it's salivating versus, you know, it's rabid and about to bite me. The expression, do you express the emotion proportionally? If you're upset, do you express irritation and anger and rage differently, or do they all look the same? You get upset and you go from zero to 250. and control of emotion in response to those stimuli. Can you downregulate easily? Can you feel that rage bubbling up but recognize not appropriate right now or this situation doesn't call for it and downregulate it. Those are all really advanced skills. Those are all skills that we have to learn over time. And we cannot effectively learn skills when we're in fight or flight. A lot of things that we were exposed to when we were younger, and that could even be last week that were traumatic or really stressful, today we may perceive it as a threat. We may predict it's going to be problematic. We may express distress and we may have dis control difficulty controlling that distress. Why? Because all that's happening in our emotional mind. Our wise mind offline. We are in our sympathetic reactive state. Almost all forms of human psychopathology, I hate that word, but whatever, are associated with disregulated emotions stemming from the failure to apply appropriate cognitive, attentive, and behavioral regulatory strategies. That sounds really critical and I don't like the way they said it in the article. However, again, let's break it down. Almost all diagnosis when we talk about psychopathology, we're talking about DSM5TR are associated with disregulated emotions stemming from the failure to apply appropriate cognitive and attentive strategies. Well, if we are in fight or flight, cognitive and attentive, they're not there. We are um in emotion-based thinking. We have to be able to downregulate before we can get into cognitive and attentive before we can use um contextual cognitive behavioral therapy and evaluate the facts in this context at this time. Therefore, the behavioral regulation that kind of follows. If we're not thinking, we're just reacting, and what we're attending to is the threat, not everything else that says, "Hey, you're safe." Then our behavior is going to follow in line. We're going to fight or flee. It makes sense. It makes total sense. And a lot of times again people are being triggered by prior experiences and expectations based on those prior experiences which trigger the stress response take the wise mind offline and then you know we're in f fight or flee. What would cause this? Let me do just stop there and ask you to reflect. What would cause people to what experiences might people have that would cause them to expect the worst to feel unsafe in certain situations even in neutral situations. Remember people who are experiencing distress, who are have anxiety, who have depression, who have PTSD, often perceive not only negative but also neutral stimuli as threatening. People want to survive and our prior experiences can cause problems. people who didn't develop secure attachment or people who currently have insecure attachment. Maybe it developed later in life because of really bad relationships, whatever. People with insecure attachment often have difficulty downregulating, evaluating, exploring what's going on because they were never taught those skills. And we need to look backwards to identify whether the people we're working with even have the skills necessary to identify the emotion, downregulate, explore the options, and act appropriately or to help them move toward their rich and meaningful life. Remember that pneummonic idea, identify, downregulate, because we can't evaluate squat until we're in our wise mind. So identify, downregulate, explore, and act. Most people when I ask them what is emotional dysregulation a core feature or a core symptom of, what do they say? Borderline personality. Yeah, it is. That's true. And almost all psychopathology, including psychotic spectrum disorders, when people are and and when we identify some of these disorders, it's important to recognize that we're talking about conditions that the person is experiencing that are not wellont controlled. when they are wellont controlled, um the person will may have a lot less emotional dysregulation if they have the skills and tools to deal with threat and perception of threat. Anyway, psychotic spectrum disorders, major depression, bipolar disorder, borderline personality, autism spectrum disorders, ADHD. A lot of people uh with ADHD have what they call impaired sympathetic modulation during stress exposure, which means when they get triggered, they go from zero to 250. They disregulate. People with anxiety, especially, and this is true for all disorders, but for some reason, the research highlighted, people with anxiety, especially those who are not sleeping well, if they're if they've got insomnia or if their sleep uh architecture is all flubbed up, uh those people tend to have a lot more emotional dysregulation. Why? When we're sleepdeprived, our brain is not able to rebalance and reregulate through the night. Our brain is not able to clear out the toxins. Our brain starts experiencing neuroinflammation. Therefore, the body starts recognizing that or perceiving that as a threat, as a stressor, which ramps up the stress response in response to that sleep deprivation. Maybe not anything else, but if you're sleepdeprived, you may be starting out with your stress bucket half full. Addiction and relapse. If you've worked with people with addictions, whether it's tobacco or illicit drugs, alcohol, pornography, um many of them have been using the addictive behavior to as a coping skill. They don't have the skills to downregulate, to identify their emotions. A lot of them have very low um emotional awareness. What makes me angry? What makes me sad? They don't even know how they're feeling from moment to moment. They're just on autopilot all the time. And especially when they are not able to access their substance or behavior of choice, they may feel like they're a fish out of water. They're flopping on the flopping on the floor and there's no hope. They don't feel like they're in control. a core step for a lot of people in early recovery. And this is something that can start even right after detox. And I know I've talked before about how because of post-accute withdrawal and all the physiological changes and healing that have to go on. People can't focus very well in early recovery. first I say at least the first 90 days but let's go with the first 30 which is when most people are in residential but during that time we can encourage them to become more mindful more aware of how they're feeling check in with them we can prompt them and that's what we need to do that's what a good parent does when they are raising a child to help the child learn to identify early warning signs of distress to help the child evaluate what's going on or downregulate first and then evaluate what's going on and determine a course of action. A lot of our clients never had that. And in addiction recovery, in those first 30 days, tell me how you're feeling. What's going on with you right now? What needs to happen next can be huge in helping them get up, show up, and stay somewhat present. People with obsessivempulsive disorder, PTSD, also have a lot of emotional dysregulation. Binge eating disorder. A lot of people with binge eating disorder um binge eat in response to distress. They're eating their feelings, so to speak. And often this is because they go into fight or flight and they don't have that stop, downregulate, think break in there to decide what is it that I really want to do. Some people that I work with with binge eating disorder um and definitely people with addiction, I say, "Let's not keep your pre preferred binge foods in the house. If all you've got is in the refrigerator is celery and, you know, meat and and whatever else, none of the really processed, really sugary foods. No crackers or ice cream or bread." Um, and I know some people are going, I can't imagine not having those in the house. But for some people, when they're first starting to learn that stop and down regulate step, if they go into the kitchen and their preferred binge food, their preferred numbing strategy is not there, then they've got to figure out something else to do. It's like, "Oh, okay. Well, I'm not really hungry enough to eat turkey, so what should I do? And that can even allow the body time to downregulate some. Obviously, the same thing with addiction. Don't keep alcohol in the house. Don't keep cigarettes in the house if those are your addictions. And that way when you're feeling a when you're having a craving, when you get triggered, there's a time space between when you have that urge and when you could even possibly access it. Obviously, in suicidality and non-suicidal self-injury, we also see emotional dysregulation. It's important to recognize and I have a video on non-suicidal self-injury if you haven't watched it, especially if you're a new clinician. A lot of people who engage in NSSI behaviors have no intention of trying to commit suicide. They're trying to make the pain stop. And that is their numbing response that helps them focus on a pain that they can control as opposed to a pain in their mind that they can't turn off. It turns attention because that pain can be significant. It turns attention from what's going on in here to what's going on in that injury. Not saying it's healthy, not saying it's helpful, don't get me wrong, but it is a strategy that they've developed to try to survive overwhelming emotions. Now, it is worth mentioning disruptive mood dysregulation disorder. And I believe this was added to the DSM in DSM 5. Um, could have been DSM 5 TR, but I think it was five. Anyhow, DMD is for children that are aged 10 and under. Severe temper outbursts, verbal or behavioral, three or more times per week for at least 12 months prior to age 10. Obviously, we want to rule out things like autism and we want to make sure that when we're grading the severe temper outburst, we're using things that are um developmentally appropriate. A two-year-old screaming at the top of their lungs when they don't get their own way is not pleasant. But does that rise to the level of pathological? In my mind, no. Um, especially if it's at home with mom and dad, whatever. If it's across multiple situations, they don't get their way at school, they do it. They don't get what their way with their friends, they do it. Okay. Well, then we might look at it's causing problems in multiple areas of their life. The child who is under age 10 is chronically irritable or angry most of the day, nearly every day. Oh my gosh, this is heartbreaking. And if you see this in children, you know, that's what we call a clue. Most children that don't have something going on are not chronically irritable or angry most of the day, every day. Again, let's rule out things like uh diabetes. Is their blood sugar going down, making them really, really irritable? Let's rule out things that may be going on under the hood. But a lot of times, you know, it's due to stress in one or more pieces of life. They have trouble functioning due to irritability in more than one place. So again, it's not just at home with mom and dad or not just with mom and dad. It is with teachers, it's with friends, etc. I know there are children out there. Thank God my children never [laughter] [gasps] never pulled this one on me. But uh there are children out there who have learned that if they throw a large enough tantrum, they get their way and they'll be in the middle of the grocery store and they'll want Cocoa Puffs and they'll throw themselves on the floor demanding Cocoa Puffs. Um is that a severe temper outburst? Yes. Are they with mom and dad? Yes. And if mom and dad or caregivers have given in before, that's reinforced that temper tantrum behavior. With some children, getting a um behavioral analyst involved can be very helpful to identify things that we as caregivers may be doing to reinforce that unfortunate behavior. And uh it is not co-occurring with obs oppositional defiant disorder, intermittent explosive disorder or bipolar disorder again in children. However, it can coexist with most other diagnoses which I thought was really really interesting. Uh if a person has autism, for example, and they're under the age of 10 and they're having these symptoms, they may be eligible for a diagnosis, an additional diagnosis of DMD. Interesting. Premenstrual dysphoric disorder. And for those of you who haven't been part of my classes before, in the PDFs, the hyperlinks will take you to the PubMed articles that go into great detail about this issue. Um, so yes, PMDD, there is scientific evidence that shows that people with PMDD during certain times of the month because their hormones are woo way out of whack or way out of balance, they may experience emotional dysregulation. There is a hormonal component to it which you know makes some of the mood swings that we see in teenagers make a lot more sense because when our stress response kicks off the uh hypothalamic pituitary gonatal axis and the hypothalamic pituitary thyroid axis also kick off when our hormones are not in balance as our body wants them to Our body registers that as a stressor, kicks off the stress response, disregulates things even more. Approximately 26%, now this is heartbreaking, 26% of preschool age children evidence emotional dysregulation disproportionate to their age. Again, all children have some level of impulse control and distress tolerance deficits. We don't want to pathize something that is a normal developmental sort of learning curve. Young children don't have downregulation skills. They have poor communication skills. They tend to be a lot more impulsive. Those areas that for impulse control in their brain haven't developed yet or not developed much yet. Therefore, most young children may have emotional dysregulation, especially if they're stressed, if they're tired, if they're hungry. We see it even more. Transient, as I my word, not in not in the literature. What I call transient emotional dysregulation is also prevalent in children and adolescence due to immature cognitive processing, lack of response strategies and hormone changes. We already kind of talked about that. But what I mean by transient is they experience distress and they may disregulate once or a few times. However, when they're provided the strategies to manage it, when somebody meets them and acknowledges, responds to their distress, helps them identify the feeling, downregulate, explore options, and choose choose how to act, then that dysregulation tends to start to go away. children. Most caregivers you may there are probably some just fabulous caregivers out there that start with emotion dis uh regulation strategies from birth. That wasn't me. You know, I I'll admit that. But when my son started to disregulate, you know, when I saw dysregulation in him, I noticed it. I addressed it. I started providing skills which means in order to start learning the skills for a lot of children they have to disregulate at least once or twice and then the caregiver can say all right you're seeming and the word in our our household was overstimulated and Sean started recognizing hey I feel overstimulated I need to take a break and he would go somewhere he has always had um some neuroatypicality and ADHD. He would have to go where it was quiet. And oh, he loved watching his fish tank. Watching those two goldfish swim back and forth was very soothing for him. Helped him downregulate and he would come out when he was ready. We have aging related sympathetic dominance. This is due to multiple things. Yes, we have hormone changes in aging. Post-menopausal females um andropausal postandopausal males um often have more irritability, more sympathetic dominance than those who are younger who have more of their primary gonatal hormones. But that's not the only thing. It's not just a hormonal thing. As we age, our body starts to kind of wear out and those aches and pains and changes in our body that happen as a natural part of aging, our brain registers as a stressor. It's our brain's going, "Hey, you're not 20 years old and you can't escape from the hungry lion as easily, so I'm going to be a little bit more hypervigilant for you. Thank you very much." Older adults also tend to have a narrowing of their field of view. Therefore, they are more easily startled and they are often more on edge. There's an underlying um tendency in humans to feel more on edge when we can't see what's coming up around us. One of the techniques that's really helpful for uh people, any people, is to use mirrors. And it doesn't have to be, you know, a glistening mirror. It can be something that is just reflective enough that you can see somebody coming up behind you. Um but helping people divi uh create environments in which they feel safe, in which they're not worried about somebody coming up behind them without them knowing. As people age, their hearing declines. So not only can they not see, they cannot hear as well. um a lot of that contributes to age related um stress. Additionally, cognitively older people's cognition slows. It's not dementia, it's aging. And when they can't think as quickly, when they can't keep up with conversations, uh when it's hard for them to process all this input, when they've got six grandkids running around like little Chihuahua, it can be really stressful for them, which can increase their stress response and lead to more irritability and potential dysregulation. Not every older adult disregulates. Most don't. However, we don't want to pathize, if you will, something that may be a natural consequence of aging. What we need to do is help them develop more balance between their sympathetic nervous system and their parasympathetic nervous system or their relaxation response. One of the easiest ways to start with that is to figure out what's causing unnecessary stress. Is there do you have difficulty with lots of chaos in your environment? Okay, let's help you create environments where you feel safe, where you can relax. What other things are adding to your stress? Let's help you identify some of those so you don't feel like you've got to be hypervigilant and scanning all the time. Heat is another thing that can cause irritability and sometimes even emotional dysregulation. And it's not something OSHA talks about a lot, but when people are hot, it's a stressor. The body's going, I can't cool off fast enough. My son, when he was little, uh, could not, well, my daughter either, I don't know why, but neither one of them could regulate their temperatures. And when they would get hot, they would just lose it. Um, and you know, we'd start stripping off socks and clothes and whatever else um to help them cool off. But heat can be a trigger for emotional dysregulation. When you talk to law enforcement and fire rescue, they will tell you when it's hot outside, you're going to have more violence. It is what it is. And I wish it wasn't so, but that violence is often the behavioral demonstration of emotional dysregulation. Likewise, people who are in chronic pain, guess what? When you're hot or in chronic pain, you ain't going to sleep very well most of the time. So, you're already sleepdeprived. That's one, you know, mark towards dysregulation. But being in pain chronically is also very stressful. And we've talked about that in other videos. We've talked about how it impacts um social relationships, how it impacts self-esteem. When you're in chronic pain, it's a stressor. So, it's harder to think clearly. And as your pain goes up, your cognitive abilities also go down. Um, which is again really stressful. It's hard to live the life that you want when you don't feel like you can think clearly and you can't do the things that you want to do. And all of that grief and anger and stuff can bubble over, especially if the person with chronic pain is not getting adequate quality sleep. Encourage them to work with their physician on sleep strategies. Encourage them to potentially try to get a referral for physical therapy to identify ergonomic adjustments in their sleep environment. kind of going with sleep and aging related sympathetic dominance. I didn't mention it earlier, but for people who are going through menopause, those hot flashes, which come any time of the day, but they seem to be really prevalent at night, those disrupt your sleep, and that's another stressor. Underpinnings of emotional dysregulation. For many people, the emotional conditions of early childhood are important in optimizing or interfering with how the child's emotionality impacts their emotional regulation. Our ability to regulate our emotions is learned through secure attachment with our caregivers. Caregivers that are consistent, attentive, responsive, encouraging, and safe. When children don't have that, they don't learn the skills to identify their emotions. How terrifying is it for young children who are all of a sudden overwhelmed with terror or rage and there's nobody there to help them? It I mean, we've as adults sometimes feel overwhelmed with really powerful feelings and it can feel like we might lose control for a second. Um, children, they feel even more powerless because they can't go, "Okay. Let me breathe for a second. I can handle this." Children are at that point need a caregiver to say, "I'm here. I can help keep you safe. Let's downregulate." And maybe they hold hands and they breathe together or they blow bubbles together. Or sometimes kids like to make noise. So you can give them the those party favors that you blow on and it blows out the little paper spiralally thing or give them a harmonica. It's really noisy but kids like harmonas. Um either way that helps them downregulate. uh recognizing a lot of people who experienced ACEs or adverse childhood experiences often did not develop secure attachment. Therefore, they often did not develop the skills they need to effectively regulate their emotions. Plus, there are a lot of things that they experienced that got programmed into their experiential vault that says other people aren't trustworthy and I'm not safe. We need to help people not only learn the skills to regulate emotions, but learn what they need to do for themselves to feel safe and empowered in their own skin. The capacity to regulate one's emotions shifts over time from dependent co-regulation. the child relies on the caregiver to, you know, help them co-regulate to more independent regulation. Think about infants when they start crying, when they get scared, especially and they're upset. If you hold on to them and you're upset, they're not going to downregulate because they're mirroring you. But if you hold them, you're not invalidating what they're feeling. You're holding them and they recognize, you know, this is an infant. You can't rationalize with them, but they recognize that you are breathing more slowly and innately they start syncing their breathing with yours. Their heart rate slows down. They start downregulating. That's what we're call talking about with co-regulation. In the beginnings in toddlerhood and early elementary school, there's still a lot of co-regulation that goes on. When the child gets upset, the adult identifies you're it seems like you're feeling angry right now. Why don't we [snorts] go on a walk outside and then we can talk about this? Or why don't we do this to help the child apply those down regulation skills so they can get into their wise mind and effectively deal with them what's going on. Long-term effects of unresolved trauma and ACEs cause not only psychological distress but persistent disregulation of the body's stress response and its associated neuroendocrine systems. We have talked about this multiple times. When people are exposed to stress, the stress response kicks off. It helps them fight or flee. When the stress is over, they downregulate. Everything gets healed and we're great. However, when the stress is chronic, that means those receptors are constantly getting bathed in glutamate and cortisol and, you know, all these stress hormones. And the stress response actually becomes the amygdala um and and the stress response actually become more sensitive. They will trigger the stress response a lot more easily in someone who does not feel safe and does not feel empowered. Well, that makes sense. Like thinking about that stress bucket when it gets full of water, it starts to overflow and that's our disregulation. How full is your stress bucket if you are feeling chronically unsafe and powerless wherever you go. You know, for me, that would probably mean my bucket was about 3/4 full already. Um, which means that it doesn't take much of a stressor for me to feel completely unsafe, powerless, and and disregulate. Hardships, including low socioeconomic status, low parental education, caregiver, physical or mental illness, have all been associated with difficulty with emotional regulation through the lifespan. Why? Same reason we've been talking about because those things often prevent the caregiver from being able to effectively develop secure attachment with the child. Now, unfortunately, when you talk to a lot of these parents, guess what? They have dysregulation themselves. They have a history of trauma themselves. They never learn the skills to manage the emotionality themselves. How can they teach it to a child, let alone, you know, they're having a hard enough time dealing with life on life's terms? They're trying to meet the child's needs. I really believe that all parents do or the majority of them. However, sometimes they're just not un they're just not able because they just they don't have the skills, they don't have the tools, or they don't have the bandwidth. Emotional dysregulation is linked to difficulties with peer relations, stress management, and increased risk-taking behaviors. What are risk-taking behaviors? They're impulsive behaviors. They're behaviors that produce an adrenaline rush. They are behaviors that may be involved in the fightor-flight um response. If you watch some of these cop shows, you'll see people, you know, fleeing from the cops and you're like, you had a warrant for driving on a suspended license. Why the heck did you just get on a high-speed chase and incur six new charges? doesn't make a lot of sense. But they were disregulated. They weren't thinking clearly. They were in the oh crap frame of mind and they weren't processing what was going on as well. So we do want to recognize that emotional dysregulation doesn't have to be screaming and crying. It can be extreme impulsive behaviors, behavioral dysregulation represented of of the attempt to fight or flee to escape from that threat. The neuroscience chronic stress causes a persistently elevated sympathetic nervous system. That's your stress response. This leads to hypervigilance. When you're persistently stressed, you're going to be scanning for those threats and you're going to notice more of the negative and neutral, which you'll perceive as negative things in the environment. You're not noticing the bunny rabbits or the rainbows. You're noticing the snakes and the spiders and whatever else. Um your people will tend to have more anxious states because when you're scanning and all you're seeing or all you're noticing are the threats, the world starts to seem like a very dangerous scary place which would make anybody anxious. This suppresses top-down regulation, which is what we've been talking about as that wise mind, prefrontal cortex, that goes offline because all of our energy is devoted over here to fight or flee when we're feeling like there's a threat. When it's persistent, we start seeing systemic and neuroinflammation. The body, the the gut changes, the lower part of the gut starts leaking toxins. Those get up into the brain. We've got neuroinflammation. There's all kinds of inflammation that starts happening when the stress response is activated for too long. When there's chronic stress, that inflammation is registered as what? A stressor. This further increases your stress response or your sympathetic nervous system sensitivity and increases the imbalance between your stress response and how easily it's triggered and the relaxation response which is your parasympathetic nervous system. A lot of us talk about the parasympathetic nervous system very basically in terms of the vagus nerve. The vagus nerve is our main parasympathetic um sensory organ if you will. A lot of people with sympathetic dominance or an imbalance between those symptoms or systems need to learn how to downregulate because once they're triggered, they don't know how to slow their breathing. They don't know how to slow their heart rate. They just feel like they're stuck in this tornado spiral whirlwind thing. Their body doesn't automatically register, hey, there's really not that much of a threat right now. Therefore, we need to help them develop the skills. Cognitive deficits, particularly those related to executive function such as inhibition, working memory and cognitive flexibility and problem solving also play a crucial role in this process. As I mentioned earlier, in order to regulate emotions, you have to be able to recognize emotions. You have to be able to think clearly enough. working memory and cognitive flexibility to recognize you need to downregulate and then explore what's going on and solve the problem with flexibility. And we talked about psychological flexibility last week. It's almost impossible to be cognitively anything when you are completely stressed out, when you're feeling like you're in a crisis. uh the cognitive deficits. Some people may not have the skills. That can cause a cognitive deficit. Uh once they learn the skills, they still need to learn how to downregulate or they're not going to be able to use the skills. So, they're still they're going to have the skills, but they're still going to have the deficits because they have this stuff in their toolbox that they can't even use. Downregulation, huge huge tool. Emotion related impulsivity also plays a pivotal role in emotional dysregulation. For some people when they experience an intense emotion, they want it to go away. If you don't like bees or wasps, my best friend is terrified of wasps. If one lands on her arm, she's like, "Get it away. Get it away. Get it away." She just she'll start running. She's not allergic to them. She just is terrified of them. That's [snorts] her emotion related impulsivity related to wasps. Um, for some people when they experience an emotion, it is so painful that or it feels so overwhelming or they're so afraid that it's going to overtake them that they just want to make it go away right now. Make it stop right now. exposure with respon response prevention can be helpful in this situation if done under you know clinical supervision. This is not something that we want people to try on their own but when they feel distress helping them not engage that behavior. I used to pick um especially at my neck skin when I'd get stressed. My husband would always know when I was stressed or I'd bite my fingernails. And those were two things that I did when I started feeling stressed. And they were impulsive behaviors. I wanted to do it or they were almost automatic sometimes. Uh and bringing those to my awareness helped me become more cognizant of those things so I could choose better responses. interventions. Basic basic basic step for everybody. I don't care what your diagnosis is. Help people create safety and a sense of empowerment. As long as we feel unsafe and or powerless. Notice I said and or uh the tendency to be more impulsive, react more intensely is going to be a lot higher. What can you do at your home, at your office, in your car to feel safe and empowered? What can you do in your relationship with each significant other so that you feel safe and empowered? And some of this goes back to creating secure attachment, developing those consistent, attentive, uh, responsive, uh, uh, encouraging and safe relationships with yourself and with others. Help people evaluate their dysregulation triggers. Not everything is going to disregulate everybody. what things or what environments tend to be more likely to cause that person to disregulate u help them improve veagal tone. That's what we were talking about earlier. The vagus nerve is the part of the body that says okay the threat's passed. We can start secretreting GABA and relaxing and it's okay. It slows the heart rate. It slows the breathing. It stops the sweating. Um, we've talked a lot about different techniques for slowing your breathing. And that is one of the easiest non-invasive strategies to do it. Chew bubble gum, blow bubbles. Uh, blow bubbles with bubble stuff. Use a harmonica. Use a party favor. Uh, blow up a balloon. Or just do square breathing. Those are a lot of them. However, transcutaneous or uricular vagus nerve stimulation, which means stimulation of the vagus nerve through the skin of the ear, it's not invasive. It's, you know, touching, but it's not invasive. Addresses both poor veagal tone and has been shown to reduce chronic inflammation in a lot of neurossychiatric applications. Uh some people will use a TENS unit that has an ear clip that they clip onto their tragus here for transcutaneous uricular vagus nerve stimulation. There's also a device that I have um that you can put right here just kind of right under your ear and it stimulates that vagus nerve. This is not a magic bullet. This is not something that's going to make you downregulate right away. What it does is assist you in activating that vagus nerve. The person still needs to engage in slowed breathing or distraction. You know, having them even just notice the the tingling means that they're not thinking about whatever's stressing them out. Having them notice their breathing, having them engage in grounding exercises, whatever it is that they can do during that period can be helpful. The instrument itself again is not going to just magically do it, but it does strengthen that association between down reggulation and research. There's a lot of research out there that has shown it's really effective. There was one really cool study I didn't put in here, but they did uh TAVNs on infants who were born opioid addicted and they were able to get those infants off of the methadone um three weeks faster. you know, generally one week they were able to get the infant off of the the detox medications um as opposed to infants that did not have that. And their cow's scores um were really very good. So, they weren't just doing it and going, "Hey, you know, we can do this a lot faster." But they were able to wean the children a lot faster. and their blood pressure and their other um physiological responses were not um intensified with the more rapid detox when they had that TA VNS. It was interesting. Mindfulness meditation is helpful to enhance attentional control, reduce mind wandering, and reduce emotional dysregulation. When you're aware of how you feel in the moment, then you can notice early warning signs of anxiety, anger, sadness, what have you, and you can start to address them before your stress response starts spiraling. You can also enhance your attentional control with mindfulness, open awareness, noticing everything, not just the stressors, or focusing on one thing like the flame of a candle um can help people learn to control their attention a little bit more and reduce mind wandering. Cognitive restructuring obviously helpful for emotional dysregulation because when we get into that really stressed state, we tend to think in all or nothing terms. We tend to magnify the negative and minimize the positive. We tend to engage in a lot of those cognitive distortions when we're in our emotional mind. helping people restructure those cognitions. Even if they have to do it after the event, have them think about what was I thinking, what was I telling myself during this situation and how could I restructure that statement to myself for the next time. Functional coping, emotional dysregulation and emotion focused coping positively predicted PTSD. Emotion focused coping is doing something to kind of numb that emotion. Not solving the problem, not addressing the situation, but just making it go away. When people did that and they didn't address the underlying trigger, they continued to feel unsafe and powerless a lot. So many uh went on to develop PTSD symptoms. Strategies for functional coping, pretty simple. There's two responses. You can change the situation, do something to address it, or change your response to the situation, including sometimes just letting it go, going, you know what? This is not worth my energy. That is so much easier to say than to do. We want to make sure when we introduce this concept to people that we explore it with them. Tell me something that you disregulated over. In what ways could you change the situation so you felt safer and more empowered? in what ways could you change your response to this situation? And have them apply that a few times instead of just saying, "Well, here are your two options. Good luck." Mindfulness, present moment awareness, and non-judgmental radical acceptance. Learning that phrase, all right, this sucks, but it is what it is. Distress tolerance, downregulation, and wise mind engagement are also important. Chain analysis. Now, I love this one, but then again, I minored in behavior [clears throat] analysis. So um backward chaining after the dysregulation looking back the pre previous hours maybe the previous day what things led up to the point that I felt dysregulated you know was there were there any vulnerabilities like lack of sleep or pain or was I hungry that may have contributed to my dysregulation. Forward chaining is planning how to prevent those things in the future. What can I do the next time this happens? What are the next steps I want to take forward? Behavioral activation. There's some research supporting it can be helpful. And this is engaging in things that actually help the person feel happy, content, things that they enjoy. It doesn't make the emotional dysregulation go away. And you don't want to say, "Oh, well, when you're upset, why don't you go on a hike because you'll love that?" That's invalidating. But they found that if people engage in regular regularly in activities that help them feel okay, then they start to feel safer and more empowered, and they're less likely to disregulate because they're actually giving their body a break from some of those stress hormones. Interpersonal skills training on boundaries, all five types, physical, interpersonal, affective, cognitive, and environmental boundaries is important. How to communicate assertively. Some people disregulate because they're not getting their needs met or they feel that people are going to take advantage of them or whatever because they can't communicate what their needs are or they are afraid to communicate in a way that sets boundaries and maintains them. And you may have to deal with things that they learned about whether it was okay to set boundaries or not. You know, that's a whole therapeutic issue. But we need to people to learn the tools of assertive communication as well as develop the ability to do it without guilt. Help them develop secure attachment with themsel, being consistently mindful of how they feel, attentive, spending time with themselves, getting to know themselves, responsive to their needs, encouraging to their wants, and safe, accepting of themselves as people, as lovable even when they make mistakes. You know, unconditional positive regard. Health related skills training is also helpful. Good sleep, good quality sleep can help a lot with irritability and dysregulation. Nutrition and hydration give the body the building blocks it needs to make those neurotransmitters and hormones that are necessary and help keep everything in that, as they call it, homeostatic balance and pain management. Not everybody has chronic pain, but most of us when we're in a lot of pain can be really cranky. Um, helping people develop skills, especially um, non-farmacological tools to manage pain, ice, heat, TENS units, um, guided imagery, distraction. There are a lot of things that people can do to help them manage pain. Controlled exposure and response prevention. I mentioned before and this is only under the supervision of a therapist, but helping people expose themsel to something that triggers their anxiety and then preventing them from engaging in that impulsive response, helping them stop, downregulate, and then determine the appropriate course of action. Schema therapy targets adverse childhood experiences and core beliefs through helping the person reparent themselves. Empathetically confront their beliefs. Is this accurate? Schema therapy aims to do exactly what it sounds like. change some of that stuff that has been programmed in our experiential vault to be more accurate based on the facts in context at that time as well as at this time. Children don't think and don't understand the world the same way the adults do. So sometimes what a child believed as an adult, you look backwards and say, you know, that wasn't really accurate. And experiential techniques such as chair dialogues and imagery rescripting can also help address those threatbased schemas and help the person feel safer and more empowered in this context at this time. And finally, mentalizationbased therapy helps patients view problems from multiple perspectives to improve self-regulation and interpersonal functioning. What was what was in the mind of your coworker when they did that? You know, were they actually trying to spite you or were they just, you know, not thinking? So, mentalizationbased therapy is a lot of perspective taking. Emotional dysregulation is a symptom in many people exposed to chronic stress in any of the pieces of their life as a result of hormone, neurotransmitter, and neurological alterations. Stress in any of those pieces is additive across domains. So if you have a little stress in all of them, that's still maybe a lot of stress. Addressing emotional dysregulation means normalizing and depathizing the response. This is not a weakness. You're not crazy. This is a evidence that your nervous system is out of balance. Assisting the person in eliminating unnecessary stress and mitigating unavoidable stress so that stress response can turn down a little bit. Enhancing stress response skills and assisting them in creating a sense of safety and empowerment to work toward their rich and meaningful life. Are there any questions? addiction intervention CEUs. [gasps] Let me see um specifically on addiction. No, but a lot of these tools apply to addiction and mental health. If there's a particular topic you're looking for that you need in live, um, feel free to share. I have over 600 hours of addiction related courses on on demand CEUs at all CEUs. So, if you need them on demand, there's a bunch of them there. Um, but if you need them live, email support and let us know what topic you're interested in because I'm going to have to add some more classes pretty soon. I'm glad you all enjoyed this. I'm glad it was helpful for you. Thank you very much, Courtney. Um, please remember if you took this for CEUs in your classroom. There's also a worksheet. I try to include a worksheet or a handout in every on uh in every live class that will eventually translate into the on demand classes. Um, so you have something that you can actually take away and maybe even use with your clients. To get your CEUs for uh lensure, log into all ceus.com and click on the class and then you can take the CEUs. If you're not a member yet, you have to sign up for the unlimited CEU package and then you can access the webinars and take the quiz. I thought it was fascinating how much research was out there that supported emotional dysregulation as a core feature of so many different things. When you look in the DSM5 TR, emotional dysregulation is not a diagnostic symptom of a lot of things, but the research says, "Yeah, maybe it should be.