Therapy That Works A blog about psychotherapy and treatments that work. 2013-12-03T06:37:14Z Marla W. Deibler, PsyD <![CDATA[How to be Happy…]]> 2013-12-03T06:37:14Z 2013-12-03T06:18:59Z happy

When most people are asked to identify their goals in life, what they really want in life, most people say they want to be happy. A “happy” life is then defined by a feeling of contentment and satisfaction with oneself, one’s family and relationships with others, one’s job, one’s home, etc., yet there is always room to strive toward unmet goals or facets of one’s life to be improved. In some respects, we all continually strive to be happy in one way or another for the duration of our lives.

“To feel good” or “to be happy” is a common therapy goal identified by our patients when they initially meet with us, but what does it really mean to be happy and how does one achieve this sense of satisfaction?

With the hustle and bustle of the holidays and the frenzy of holiday shopping, the old adage, “Money can’t buy Happiness” comes to mind. A Harvard professor set out to disprove this notion, but he did not, sort of.  He learned something very interesting…how to buy happiness.  Check it out:

As Dr. Norton mentions at the conclusion of his talk, is a really unique charity opportunity.  In the spirit of holiday giving to those who are in need, my practice donated to a fundraising effort to purchase social skills training items for special education children in a nearby inner city school. This is a really great website that allows donors to choose projects they wish to fund from a wide variety of projects in schools nationwide. We feel happier already.

Happy Holidays!


…Marla W. Deibler, Psy.D.



Marla W. Deibler, PsyD <![CDATA[Is Abnormal the New Normal?]]> 2013-05-17T23:00:39Z 2013-05-15T19:35:25Z mental-health-2013Oh, the outrage! Well, not really. It’s more like mass confusion.  Several new diagnoses will appear in the Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition (DSM-V). But, has the firestorm of criticism grounded the manual before it even takes off?

Even Dr. Allen Frances, psychiatry professor emeritus at Duke University, who chaired the DSM-IV task force, called the day on which the DSM-V was approved “a sad day for psychiatry.” Of greatest concern to many, is the new manual’s potential to over-pathologize human behavior, calling into question the validity of new diagnoses.

Disruptive Mood Dysregulation Disorder, for example, is intended to describe children between 6 – 18 years of age who show some signs of potential childhood-onset bipolar disorder. This new disorder’s hallmark criteria are “temper outbursts that are grossly out of proportion in intensity or duration to the situation.” Yes, that’s right. It sounds like temper tantrums. Good intentions likely steered DSM-V to create this classification in the hopes of deterring clinicians from prematurely diagnosing bipolar disorder, a serious mental illness with associated stigma, as well as medications that carry with them a host of potentially significant adverse effects.

Excoriation (Skin Picking) Disorder has been added to the list of new diagnoses, which is characterized by repetitive skin picking that results in lesions, accompanied by recurrent unsuccessful attempts to cease the behavior. Critics have asserted that everyone picks their skin as a normal part of grooming behavior and turning such a behavior into a psychiatric illness will result in the inappropriate psychiatric diagnosis of many normal individuals with normal behaviors.  But, as others have noted, skin picking is more than “just popping a few pimples and having a few scars.” Yes, everyone picks at his or her skin at some point; however, skin picking as a disorder, is intended to far exceed “normal” grooming behavior. Think of grooming behavior as occurring on a continuum, with normal, washing and exfoliating on one end of the continuum, extending to picking, scraping, or gouging that results in scarring or disfigurement on the other end.  So, perhaps the poor DSM-V may be getting a bum rap for being misunderstood? Maybe. Maybe not.

So, what does this mean for the average person?  It’s unclear. What this could mean is that children with temper tantrums (that would be most kids, right?) could potentially be thought of and evaluated and/or treated for a psychiatric illness. Tantrums may become more than tantrums, but rather potential symptoms of mental illness. That’s a pretty frightening prospect, as in most cases these children are not likely to go on to struggle with bipolar disorder.  Or, it could mean that seemingly normal grooming behavior, such as skin picking, may become associated with mental illness, bringing legions of those struggling with acne to therapists’ offices.

We may be on the verge of a societal shift in what is viewed as normal behavior being over-pathologized.  Or, perhaps these are mere over-reactions and these problems will only be seen as problems when manifested in their extremes.  Only time will tell.

Is DSM-V truly the “be all and end all” tool for diagnosing mental health? Actually, no. Healthcare isn’t quite that simple. Some clinicians argue that there is little point in lashing out against the DSM-V, as may will have little relevance. Healthcare providers are tied to a different, essential manual for billing and coding purposes, the International Classification of Diseases, Ninth Edition (ICD-9). It is actually this manual that diagnoses call home. Without it, insurance companies will not process claims for payment. The ICD-9 codes are largely consistent with those of DSM-IV, but with the release of DSM-V, there is likely to be confusion and billing issues. Incidentally, ICD-10 will not be released until 2014. So, some frustrated clinicians contemplate whether they will pay any attention to the DSM-V’s release, and, instead, continue to use the DSM-IV/ICD-9 coding system. This does raise an excellent point, but perhaps this is merely disgruntled resistance to change.

This recent revolt has perhaps culminated in the bold, yet, not unexpected, statement by Thomas Insel, MD, Director of the National Institute of Mental Health (NIMH). Dr. Insel’s “Director’s Blog” entry on April 29, 2013, expressed his displeasure with DSM’s symptom-based categorical approach as a whole.  He noted that the longstanding goal of the DSM as a diagnostic tool is to provide clinicians with a common language for psychopathology, and, it continues to meet that goal. However, in an era of significant advancements in neuroscience, the DSM’s approach to diagnosis has become outdated, relying on clusters of observable symptoms, rather than measurable science.

Although Dr. Insel’s statement came as a surprise to some, the NIMH has been working to develop a set of criteria for the development of a new system for classifying mental illness for more than a year.  It just so happens that this may be a convenient time to gain support and momentum for NIMH’s newly launched Research Design Criteria (RDoC) project, which has been in development for 1.5 years. Its goal will be “to transform diagnosis by incorporating genetics, imaging, cognitive science, and other levels of information to lay the foundation for a new classification system.”

Ask clinicians when DSM-V is expected to be released or how long it was “in the works,” and they are likely to joke about the more than a decade painstaking wait for this lackluster manual.  However, it’s difficult to even fathom the probable wait that the mental health field has to endure for the fruit of the RDoC’s labor to come to fruition. I hope I am alive to see it. And, I hope it’s worth the wait.  For now, I’m still hovering over the button to order my new DSM-V.


Dr. Deibler

I’m blogging for mental health. Mental health month blog day.


Further reading:

Marla W. Deibler, PsyD <![CDATA[Normal Behavior or Mental Illness?]]> 2013-04-29T06:51:36Z 2013-04-29T06:51:36Z skin pickSeveral new diagnoses will appear in the soon to-be-released Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition (DSM-V).  In fact, quite a bit of controversy surrounds the inclusion of several of these new “disorders” in what is considered to be the mental health world’s diagnostic “bible,” as many question their validity and appropriateness for inclusion.

Among the new DSM-V disorders is Excoriation (Skin Picking) Disorder, classified within the Obsessive Compulsive and Related Disorders.  It is understandable that the initial public reaction to this release of information has been skeptical (at best). News outlets have begun to question the validity of the diagnosis. Readers have begun to leave comments such as, “Great, now we’re all mentally ill.”

Yes, everyone picks at his or her skin at some point; however, Excoriation Disorder far exceeds “normal” grooming behavior. Think of grooming behavior as occurring on a continuum, with normal, washing and exfoliating on one end of the continuum, extending to picking, scraping, or gouging that results in scarring or disfigurement on the other end.

 A Case Example

Daphne is an attractive, intelligent twenty-six year old woman who works long hours as a surgical assistant, a job she very much enjoys.  She lives alone in a one-bedroom apartment. She is not currently in a relationship. Although Daphne considers herself “on the market”, she reports that she is reluctant to date, as she is self-conscious and embarrassed of her body. She explains this as she rolls up the pant legs of her work scrubs to reveal her legs, which are covered in scars. She then removes her sweater to reveal her arms, which are similarly marked.

Daphne explains that she spends two hours each morning applying make-up to her face to cover discoloration and blemishes from picking her facial skin. She tells me that she finds it easier to cover her legs and arms with clothing. Daphne has made many attempts to stop picking, but feels like she “can’t help it.” She describes her typical picking urge as an attempt to make a given spot look less red, less scabbed, less, bumpy, or to speed the healing process. She knows that picking at the spot rarely results in this improvement, and moreover, results in further damage; however, she proceeds. She stated that she wants to stop; yet she spends approximately 45 to 90 minutes per day engaged in skin picking. She describes herself as frustrated and somewhat isolated as a result of her picking.


DSM-V Diagnostic Criteria for Excoriation (Skin Picking) Disorder will include:

  1. Recurrent skin picking that results in skin lesions
  2. Repeated attempts to stop the behavior
  3. The symptoms cause clinically significant distress or impairment
  4. The symptoms are not caused by a substance or medical, or dermatological condition
  5. The symptoms are not better explained by another psychiatric disorder

The Straight Facts

  • Excessive skin picking occurs in up to 5.4% of U.S. adults.
  • Those who engage in skin picking tend to pick from multiple body sites, for extended periods of time, targeting both healthy and previously damaged skin.
  • Commonly reported antecedents (experiences prior to skin picking) include: an urge or physical tension prior to picking, unpleasant emotions, cognitions, or sensations, and a displeasing aspect of his or her appearance.
  • Commonly reported consequences (experiences following picking behavior) include: urge reduction, sense of relief, or pleasure, psychosocial difficulties or embarrassment, avoidance, reduced productivity, and emotional sequelae such as anxiety or depression, scars, lesions, disfigurement.
  • There is emerging evidence that skin picking is both environmentally and biologically influenced.
  • The study of skin picking (and other body focused repetitive behaviors – BFRBs) is still in its infancy. There remains a great deal to learn.


Evidence-Based Treatment

Habit Reversal Training (HRT), a form of Cognitive Behavioral Therapy (CBT), is the most studied, evidence-based treatment at this time for skin picking and other BFRBs.  Some HRT plans include additional components, but all HRT plans consist of:

1) Awareness training – to monitor and increase the awareness of the behavior

2) Competing Response Training – substituting a competing response for picking behavior that is incompatible with picking

3) Social Support – gaining support from loved one and the community


Comprehensive Behavioral Treatment (ComB) was developed by Dr. Charles Mansueto and colleagues from a growth of HRT as a cognitive behavioral means of more comprehensively and individually tailoring treatment plans.  Although there is no formal outcome data at present, ComB is considered among the standard of care. It is currently undergoing clinical trial. The ComB treatment involves:

1)   Assessment – Awareness training through and self-monitoring of behavior

2)    Identify Target Modalities – Behavior “triggers” are identified which may include Sensory, Cognitive (thoughts), Affective (feelings), Motor, and Place/Environmental factors.

3)   Choose Target-Specific Intervention Strategies – Based upon behavior analysis information (information regarding behavior “triggers” and consequences), interventions are chosen. Interventions vary widely and are cognitive behavioral in nature.

4)   Evaluation – Assess effectiveness of strategies and implement additional strategies, as needed


Acceptance and Commitment Therapy (ACT) and Dialectical Behavior Therapy (DBT) strategies, as adjunctive strategies, have been demonstrated to be helpful in reducing problematic grooming behavior in studies of a related disorder, trichotillomania.


Medication – Only four controlled skin picking medication studies have been published to date. Two studies examined the use of fluoxetine (Prozac).  Both studies, although involved very small sample sizes, found that fluoxetine was more helpful than placebo in improving skin picking.  The remaining two studies produced non-significant findings.  Serotonin Reuptake inhibitors (SRIs) and Selective Serotonin Reuptake Inhibitors (SSRIs) are considered to be the most useful prescription at this time. N-Acetyl Cysteine (NAC), an amino acid demonstrated to be moderately effective in a study of adults with trichotillomania, is currently being studied in adults with skin picking.


There is such a thing as a seemingly normal behavior gone awry, to the point at which it is no longer normal.  Excoriation (Skin Picking) Disorder can be a devastating problem. It is my hope that with time and education, we will be able to acknowledge the significance of this problem and provide the help that is so desperately needed.


Dr. Deibler 

Photo available at

Marla W. Deibler, PsyD <![CDATA[Redefining Success: Today, It’s Personal.]]> 2013-04-11T03:01:28Z 2013-04-08T06:24:46Z success

Today, it’s personal.  This isn’t about evidence-based therapy or psychological disorders – not this time. This will, however, come full circle to quality “Therapy That Works” though, so hang in there. Trust me on this one.

If you read the news, you have likely read about Sheryl Sandberg, Facebook’s Chief Operating Officer, and her recently published book, “Lean In,” a declaration that women need to become more assertive in the workplace and assume more leadership roles.  She notes that for the past 30 years, despite earning more college degrees than men, women account for only 4% of CEOs in Fortune 500 companies. This number should definitely give us pause and I have a great deal of respect for Sheryl Sandberg and what she has accomplished, but I do believe her declaration only applies to those who are willing to “lean in” to that environment.

Sheryl Sandberg stated that too many smart, talented women become intimidated by work environments and their potential for leadership due to their aspirations of marriage, children, and family life. They therefore, instead of leaning in and achieving great things, lean back, essentially sacrificing career for personal goals.

I am not willing to lean in.

Leaning Back Toward Success

I admit it. I was always an overachiever. I graduated high school at 16, as the valedictorian of my class. I gained quite a bit of experience throughout college and graduate school and following my doctoral internship, in my mind, I was clearly ivy-league bound. I don’t think I was being arrogant. I think I was leaning in. I was being ambitious. I had an offer for a post-doctoral fellowship at one ivy-league University department, but was holding out for an interview with another. This interview was with a very impressive, internationally known female psychologist and her colleagues.  I was young, newly married, and had a great deal of very specific experience in her area of expertise. The interview was going well, until…

She noticed my wedding ring and asked if I planned to have children. (I know, she was not technically legally permitted to ask such a question, but she did.) I said, “yes,” to which she responded, “If you want to be successful in this career, you will need to hire a nanny to raise your children like I did. Are you prepared to do that?”  After I picked my gaping jaw up off the floor, I told her, “No, no, I’m not. I think I can have it all. I can have a family and a meaningful career. ” (Don’t be too impressed. I think I said this out of naiveté, rather than confidence). She may as well have asked me to leave then. Our interests clearly did not “match.”

And, thank goodness, too. I leaned back, way back.  I didn’t take the other ivy-league position either, which required weekend work.  Truth is, I wanted to start a family, and I hold no shame for having decided that, nor should any other woman (or man, for that matter).  I was not willing to lean in, not to 7-day workweeks, not to the politics of grant writing and University politics, not when I also wanted a family life. I leaned back.


My Realization

This experience helped clarify my goals for me, at least for a few years, until I would be faced with an impressive job opportunity in Washington, DC that I would ultimately turn down, again, deciding to lean back.

You see, for me it’s about balance.  The DC job would have been impressive, but seeing my children less than one hour per day would have been unacceptable to me.

Ultimately, it’s not about assertiveness, leaning in, OR leaning back; it’s about finding your skill set and what you enjoy, standing up and confidently contributing to the world on your own terms. And so I did. This time, I was going to do it my way. Truthfully, I really always had, but that’s a post for another blog on another day.


Ten Years Later

Now, I have no delusions of leading a Fortune 500 company, but I do own and serve as the Executive Director of two outpatient behavioral health facilities as well as provide services as a licensed clinical psychologist.  I won’t bore you with details, but I am fortunate to have wonderful opportunities and experiences in my career for which I am continually thankful.  What’s important is that my career has been on my terms and I run my business in this manner too.


Why it Works

Here’s the thing; everyone wants to be happy. Right? Very few of us want to work an 80-hour workweek (even if we love what we do). Why does our culture believe it’s necessary to “lean in” to this environment in order to achieve success or become a “leader”?

I believe so few women “lean in“ to leadership positions, not because they don’t have the intelligence or talent, or because they are intimidated by the environment or distracted by their dreams of having children; they simply don’t want to. And, there’s nothing wrong with that.

I believe we can shape our own successful environments.  In my facilities, I aim to hire highly skilled clinicians who are a good fit for our needs. However, we are a flexible, family-friendly, facility which encourages each employee to achieve their own work-life balance.  I extend that same vision of success and work-life balance to them.

Employees set their own hours to a large extent and they are supported in their professional growth. I never ask my employees to take on more than they feel they are able to easily handle.

Just because we are not working 24 hours/day, does not mean we are not dedicated to our jobs.  In fact, I believe that when we are not overworked, we are more willing to be available. And, with the technology of today, we can be available. We use these to our advantage to connect with one another when needed, despite our differing schedules and locations.  In fact, I am available to my employees 24 hours/day by phone or text.

Work should be about quality, not quantity. Being overworked, in workload or in on site work hours, leads to burnout. When an employee begins to feel burned out, fatigued, and perhaps, down or unhappy about the job, it is reflected in all areas of their life. Their relationships at home may become strained and their work may become negatively impacted.  We need to rethink our work hours. If we did, I believe we would see a more balanced and satisfied workplace, and, perhaps more females in leadership roles.

Ah see, I told you, I’d get to it.

When, an employee is treated well, that is, they are valued, well-compensated, respected, and not overworked, this will likely be reflected in how they feel about their work and colleagues, the quality of their work, how their patients feel about them, and their overall well-being. It’s a win-win for everyone.


Redefining Success

I am still the same achievement-striving woman I ever was.  I am just now that woman with a husband, house, three children, business to run, clinical work, media contributions, etc. I honestly do put in 80 hours a week, but not all in the office.

I have redefined, for myself, what it means to be successful. Whereas my definition used to greatly limit me, positioning me to “lean in” to an environment that discouraged my personal goals, my new definition and flexibility has lead me to both personal satisfaction and more professional successes than I would likely have achieved by “leaning in” years ago. I didn’t lean in and assert myself to obtain a leadership role; I stood up and created my own. That IS success.


Dr. Deibler

Marla W. Deibler, PsyD <![CDATA[A Quiz to Help You Uncover Your Level of Anxiety]]> 2013-03-19T12:46:43Z 2013-03-19T03:42:45Z man adEveryone experiences anxiety. Anxiety is our body’s reaction to what we perceive as threatening. Anxiety can be a healthy and adaptive response to stress. But, anxiety occurs on a continuum, ranging from normal, healthy concern, on one end, to worry, anxiety, and panic toward the other end. Normal caution and concern can help to motivate you, to estimate risks, and to get things done. Worry, anxiety, and panic are more akin to apprehension or fear. They can dominate your thoughts and make things harder for you. They don’t help you solve problems. They create more problems.

Where do you fall on the anxiety scale? Test your level of anxiety and discover ways to manage your daily stress.


Directions: Over the last 2 weeks, how often have you been bothered by the following problems? Read each of the “7” items. For each item, assign a score of:

“0” if you have not experienced this symptom at all,

“1” if you have experienced this symptom for several days,

“2” if you have experienced this symptom for more than half the days, or

“3” if you have experienced this symptoms nearly every day.


1.    Feeling nervous, anxious or on edge

2.    Not being able to stop or control worrying

3.    Worrying too much about different things

4.    Trouble relaxing

5.    Being so restless that it is hard to sit still

6.    Becoming easily annoyed or irritable

7.    Feeling afraid as if something awful might happen


Scoring: Once you have answered each item, add all answers for a total score.

Understanding your score:  Total score:

0 – 4 = Minimal/non-significant

5 – 9 = Mild

10 – 14 = Moderate

15 or more = Severe


Total Score of 0 – 4

Scores between 0 and 4 fall in the minimal/non-significant range. These individuals are likely to experience some anxiety from time to time, but do not find anxiety to be problematic in their daily lives.

Total Score of 5 – 9

Scores between 5 and 9 fall within the mild range. These individuals may worry and/or experience mild physical symptoms of anxiety. Intrusive thoughts may be begin to become bothersome or distracting, causing stress.

Strategies to Take Action

  1. Change your thoughts – Be aware of your unhelpful thoughts and modify unrealistic thinking. We all have moments wherein we unintentionally increase or maintain our own worry by thinking unhelpful thoughts. These thoughts are often unrealistic, inaccurate, or, to some extent, unreasonable. Identify those thoughts. Think about them and how the affect your feelings and behavior. If they are not helpful, change them to more helpful, adaptive thoughts. For example, beware of “what if” thinking, thoughts that are all-or-nothing in nature, or catastrophizing.
  2. Practice Self-Care– Attend to your own feelings and healthy lifestyle practices: good nutrition, sleep, and exercise are important to well-being, resilience, and healthy stress management.
  3. Stay Connected – Social support is vital to managing stress. Maintain connections to family and friends. Talking with others can do a world of good.
  4. Take a break – Whether it be a simple change of pace or scenery, enjoying a hobby, or switching “to-do” tasks, breaking from concerted effort can be refreshing.
  5. Take action – Engage in an activity you enjoy; take a walk; listen to music; read a book. Or, engage in problem-solving (In what ways might you address the stressors that are causing these feelings?)

Total Score of 9 – 14

* A score of 10 or above warrants further assessment and may be indicative of an anxiety disorder.

Scores between 9 and 14 fall within the moderate range. These individuals may experience increased worry or preoccupation in addition to greater emotional and behavioral responses. Chronic levels of moderate anxiety may also result in symptoms of chronic stress such as headaches, stomach upset, and tense muscles in the neck, back, and shoulders.

Strategies to Take Action

  1. Take a deep breath – Deep diaphragmatic breathing triggers our relaxation response (switching from our fight-or-flight response of the sympathetic nervous system, to the relaxed, balanced response of our parasympathetic nervous system). Try slowly inhaling to a count of 4, filling your belly first and then your chest, gently holding your breath to a count of 4, and slowly exhaling to a count of 4 and repeat several times.
  2. Practice mindfulness and acceptance – It is “normal” to experience some degree of anxiety when stressors are unfamiliar, unpredictable, and/or imminent. Anxiety, in itself, feels bad, but is not inherently harmful and does pass. Think of it like a wave of the ocean; allow it to come in, experience it, and ride it out.
  3. Challenge your thoughts – Ask yourself about your anxiety. “Is this worry realistic?”  “Is this really likely to happen?” “If the worst possible outcome happens, what would be so bad about that?”  “Could I handle that?”  “What might I do?” “If something bad happens, what might that mean about me?” “Is this really true or does it just seem that way?” “What might I do to prepare for whatever may happen?”
  4. Practice positive coping statements. –  For example, “Anxiety is just a feeling, like any other feeling”. “This feels bad, but if I can use some strategies to control it.” Positive thoughts about your ability to manage stress can be helpful in maintaining motivation and persistence in making healthy stress management strategies.


Total Score of 15 or more

Scores of 15 or more fall within the severe range. When severe levels of anxiety persist, most or all areas of one’s life may be impacted.  It can become difficult to work, relationships with others can become strained, the ability to do everyday tasks becomes difficult, and caring for oneself, one’s home, and one’s family can be a challenge. Some individuals may experience panic attacks, which are short periods of overwhelming, very intense anxiety wherein they feel a sense of impending doom that something horrible is going to happen from which they need to find safety.

 Strategies to Take Action

  1. Slow your breathing – Practice relaxation. Diaphragmatic breathing or other relaxation inducing practice (e.g., guided imagery exercises, tai chi, yoga) can reduce stress by helping to encourage the relaxation response.
  2. Develop skills to control your physical experience of anxiety/panic
  3. Progressive muscle relaxation, for example, is a kind of guided relaxation exercise that leads you to tense and release different muscle groups of your body, teaching you to notice and learn the difference between tension and relaxation so that you may have greater awareness and control over these bodily experiences.
  4. Biofeedback training, for example, involves heightening awareness of and gaining greater control of your physiological processes through feedback from the ongoing processes themselves.  Some of this feedback may include instruments that measure and provide feedback regarding heart rate variability (HRV), brainwaves (EEG), skin temperature/conductance, and/or muscle tension. There are some great smartphone apps available at low cost to assist in building these skills.
  5. Face your fears – Avoidance of that which causes anxiety can unintentionally maintain the anxiety. Challenge yourself to face your fears and learn that the feared situation is not nearly as frightening or dangerous as it seems. Aim for mastery experiences, experiences after which you can say, “I did it!”
  6. Seek professional help – Sometimes anxiety can be difficult to manage without professional help.  A clinical psychologist who provides cognitive behavioral therapy can assist individuals in learning to face their fears and better manage their anxious thoughts and feelings.

Originally written by Dr. Deibler for

Lead photo available at

Marla W. Deibler, PsyD <![CDATA[The Key to Why YOU Get Anxious]]> 2013-03-11T02:17:22Z 2013-03-11T02:17:22Z stressed man adWe know that when we get anxious, the fight-or-flight response is triggered and our bodies experience many physiological changes and symptoms that we find stressful and unpleasant. But, do you know what causes us to get anxious? It may not be what you think.

No, it’s not that upcoming presentation at work or that plane flight next week.  It’s not something external.

I’m a psychologist, so I’m going to try to help you discover the answer. Here’s an example.  You and a friend are out on a morning walk and a neighborhood dog barks loudly.  You love dogs and this makes you smile as you comment, “He’s up bright and early.” Your friend, on the other hand, is startled. Her heart begins to race and she finds herself a bit breathless, as she comments, “Oh my! Where is it? I don’t like dogs.”  Same situation.  Very different reactions.  Okay, now do you have an idea of what causes anxiety?

Anxiety is caused by a cognitive process; it is the meaning we make of something.

The process goes like this:

The Cycle of Anxiety

  1. We are faced with an event or stressor (such as the dog barking).
  2. We respond to it, as with do with anything in our environment (as this is our self-protective nature) by thinking about it (consciously or unconsciously) and judging its potential for harm to us.
  3. If we do not consider it to be a possible threat, we continue to go about our day. All is well.
  4. If we consider it to be a possible threat, we respond to that judgment in four ways:
    1. Physiologically – with our body’s fight-or-flight response and all of its effects on the body.
    2. Emotionally – such as anxiety, fear, overwhelm, helplessness
    3. Behaviorally – such as running, crying, aggression, screaming
    4. Cognitively – more cognition – such as worry, rumination, attempts to problem-solve, attempts to cope, positive and/or negative self-talk

When we make a judgment of potential harm, we respond. By responding in maladaptive ways (cognitively, behaviorally, emotionally) that do not match the reality of the danger of the situation or in ways that are not helpful to solving the problem, we may unintentionally perpetuate the cycle of perceiving danger, physiological activation, and it’s physical, emotional, behavioral, and cognitive effects. And so the cycle of anxiety continues.

Our Bodies are not our Brains

Yes, the mind and body are interconnected and it is important to treat them as such to achieve and maintain whole wellness (and to learn to master problems with anxiety).  However, in some ways we are very simple machines.

Let’s take the fight-or-flight response as an example.  If we interpret a situation as potentially harmful, our bodies respond. What’s important here is that the body will respond whether there is a real threat, like a car nearly rear-ending us at a traffic light, or when we incorrectly perceive danger, such as when our friend hears the dog barking. It doesn’t need to be potential physical danger either; it could be potential harm to our feelings or our well-being.  For example, we may respond this way if we are asked to speak in public and we fear embarrassment in this situation.

If the meaning we make of the situation is one of potential harm, our bodies will respond, whether the threat is real or one that just seems that way because it is intimidating or threatening to our “selves”.

Yes, it is the meaning we make of our perceptions. This being said, how we interpret stressors may be influenced by genetics, which can prime us for overactive or underactive stress responses.  Life experiences, such as exposure to extremely stressful or traumatic events or learning patterns of overactive stress reactions through observations early in life, may also contribute to an increased vulnerability to stress reactions.

So, What Needs to Change?

Okay, I’ve lead you there. Let’s hear your thoughts on this.

I’ll discuss evidence-based therapy for anxiety in an upcoming post.

Dr. Deibler


Lead photo available at 123rf

Marla W. Deibler, PsyD <![CDATA[Stress & Anxiety: In Plain English]]> 2013-03-04T04:33:15Z 2013-03-04T04:27:12Z stress womanAnxiety…the word alone can make you feel uneasy. It can come out of nowhere or be easily anticipated. Why is it that anxiety affects so many of us and how can we harness it to be helpful, rather than stressful?  Let’s look at anxiety and in plain English, answer some of the most common questions asked.

1. What is the difference between stress and anxiety?

Stress is a state of mental and bodily tension you experience when faced with a demand. We feel stress when we have a long to do list and very little time to accomplish it. Anxiety is the fear we may experience when we think about what may happen if we don’t complete our to do list. — Stress and Anxiety both involve tension. Both involve some of the same physiological responses such as the release of adrenalin, but anxiety involves fear. Stress does not.

2. How can anxiety be helpful to you?

Everyone experiences anxiety. It is our body’s reaction to what we perceive as threatening. Anxiety can be a healthy, normal, and adaptive response to stress. It can be motivating and helpful to us. A little anxiety can help us move faster in the morning so that we get to work on time. It can help us to be careful when we drive or when walk to our cars alone in the dark. Too much anxiety can be a problem.  It can overwhelm us with worry, fear, or even panic. If we become aware of our body’s reactions and ensure that our thoughts and reactions match the realistic nature of the situation, we can use it to be more organized, more effective, safer, and in control.

3. What happens in the body when you’re anxious?

When we are faced with a stressor, our brain assesses the situation. If it interprets the stressor as threatening, it activates our sympathetic nervous system. For instance, if we are taking a walk through our neighborhood and a dog unexpectedly barks loudly, our hypothalamus, a small area at the base of our brain, sets off an alarm in our body. This alarm prompts our adrenal glands, located just above our kidneys, to release a set of hormones such as adrenaline (also known as epinephrine), noradrenaline (also known as norepinephrine), and cortisol. These hormones cause effects throughout our body, including our brains. This is called the fight-or-flight response. It essentially prepares our minds and bodies to fight or flee this danger.

When what is perceived as dangerous passes, our body returns to its normal functioning. Our fight-or-flight response will continue to do its job to protect us, even if it is not a real threat to our safety, but is perceived to be. For example, our bodies will react this way whether we are crossing the street and a car unexpectedly charges down the road in front of us, or, we are asked to speak in a public forum, if we interpret the situation as threatening. It doesn’t know the difference between a real threat and one that is not really a threat to us, but is intimidating. It will respond the same way.  If we do not need the body’s activation, the body’s responses can be quite distressing, and, in severe anxiety or panic, can in itself be misinterpreted as dangerous.

4. How might I experience anxiety?

  RAPID HEART BEAT, PALPITATIONS – caused by surges of adrenaline, feeling of your heart beating heavily and rapidly in your chest, feeling as though your heart skips a beat, can lead to feeling dizzy or lightheaded

 FAST, SHALLOW BREATHING – this is rapid, unsatisfying breathing that can be experienced as shortness of breath, heaviness of the chest, or not being able to take a good, deep breath

DRY MOUTH – As body fluids are diverted to other parts of the body, the mouth can become dry

SHAKING OR SHIVERING – as a result of our muscles contracting, creating friction between our muscles and other body tissue

STOMACH PROBLEMS – such as stomach upset, nausea, constipation, or diarrhea, indigestion, heartburn – caused by elevated cortisol levels, as the body focuses on energizing and preparing our muscles, rather than helping our organs such as with digestion (it constricts the blood vessels to these areas of the body)

TINGLING IN THE HANDS AND FEET – can be caused by lack of oxygen to these areas and a pooling of blood carbon dioxide during periods of intense anxiety due to persistent shallow breathing

PROBLEMS WITH ATTENTION, CONCENTRATION, AND MEMORY – we become so focused on the perceived threat and our response to it that we may be forgetful and have difficulties with memory

5. What are some of the effects of chronic stress and anxiety?

DECREASED IMMUNE FUNCTIONING – leaving us more susceptible to illness such as colds, viruses, and infections

INCREASED RISK OF PHYSICAL HEALTH PROBLEMS – such as heart disease, hypertension, obesity, stomach problems such as ulcers and acid reflux

INCREASED RISK OF MENTAL HEALTH PROBLEMS – such as anxiety disorders, depression, suicidal thoughts

HEADACHES OR MIGRAINES – due to chronic muscle tension in the neck, back, face, and shoulders

PAIN AND NUMBNESS – caused by chronic muscular tension and constricted blood vessels. Common areas of pain include the face, jaw, neck, and shoulders

Have you experienced anxiety? Tell us about it?

Dr. Deibler

Marla W. Deibler, PsyD <![CDATA[4 Great Apps to Release Tension]]> 2013-02-18T03:30:14Z 2013-02-18T03:30:14Z relaxThere’s no greater skill to easing anxiety and physical tension, than learning to relax.  It sounds silly, perhaps, to think of relaxing as a skill, but think about how many times you’ve said or heard someone else say, “relax,” “calm down,” “settle down,” or “chill out.”  And, if you’re on the receiving end of that comment, it’s not as easy as it seems.

Yes, relaxation is a skill.  There are many paths to learning relaxation skills. I, personally, like progressive muscle relaxation (PMR).  An empirically supported approach to learning the difference between the experience of tension and the experience of relaxation, PMR is a guided practice of tensing and relaxing various muscle groups while engaging in diaphragmatic breathing.  Other approaches to gaining a self-soothing skill set include, guided imagery, diaphragmatic paced breathing, yoga, meditation, tai chi, and others.

Let’s discuss an often under-recognized, yet very useful, evidence-based approached to learning relaxation…biofeedback.  Biofeedback training involves heightening awareness of and gaining greater control of one’s own physiological processes through feedback from the ongoing processes.  Some of this feedback may include instruments that measure and provide feedback regarding heart rate variability (HRV), brainwaves (EEG), blood pressure, skin temperature/conductance, and/or muscle tension.

There is strong evidence for the use of biofeedback in health psychology, including efficacy in the treatment of:

  • Constipation
  • Irritable bowel syndrome
  • Migraines / tension headaches
  • Neuromuscular rehabilitation after traumatic brain injury or stroke
  • Temporomandibular Joint (TMJ) dysfunction
  • Urinary / Fecal incontinence
  • Phantom limb pain
  • Circulatory difficulties

Modest research has demonstrated the utility of biofeedback in the treatment of:

  • Anxiety
  • Sleep difficulties
  • Hypertension
  • Stress management

There are a number of other clinical problems that have been discussed in the biofeedback literature, but there is not yet evidence to support its utility with these presenting problems.

Biofeedback is a unique approach to learning to gain control over one’s physiological responses. I sometimes prefer it in providing treatment, as it gives a specific focus to relaxation practice and provides immediate feedback on one’s progress. For those who are intimidated at the idea of structured relaxation or for those who have difficulty controlling distraction by thoughts and other cognitive processes, biofeedback gives a focused goal to work toward.  And, when it works, it’s quite astonishing.  An experienced biofeedback practitioner, for example, can warm their hands in a matter of seconds by simply focusing on that task. Likewise, slowing heart rate, loosening muscle tension, and lowering overall arousal is easily accomplished by focusing on one’s bodily sensations.

Biofeedback equipment can be quite costly, but with our changes mobile technology, biofeedback tools have become much more affordable and accessible.  Although they do not replace biofeedback training with an experienced therapist with this skill set, these home-use devices/apps are great ways of achieving the relaxation response:

  1. Belly Bio – – a great app for the iPhone that brilliantly uses the device’s accelerometer to monitor proper diaphragmatic breathing.  Inexpensive and very useful.
  2. Mindfield eSense Skin Reponse ( and Mindfield eSense Temperature (app available at: , two unique apps that work with your iPhone or Android to provide skin conductance or temperature feedback with guided practice. To use the apps, the monitoring instrument, which connects to the phone must be purchased. The instruments are available at:  Mindfield Biosystems website:  A bit pricey, but much less expensive than many of its professional use counterparts.
  3. My Calm Beat – – A very nicely designed, inexpensive app for the iPhone or Android that personalizes and monitors paced breathing practice. Add-on modules, each at a low cost, are available, which include various paced breathing exercises and games.
  4. Breath Pacer – – A simple, inexpensive, paced breathing app available for iPhone or Android devices.


Have you had experiences with biofeedback?  Feel free to share.


Dr. Deibler


Lead photo available at 123rf 

Marla W. Deibler, PsyD <![CDATA[6 Inspiring Mental Health TED Talks (Video)]]> 2013-02-11T05:02:16Z 2013-02-11T03:55:13Z It was a brilliant idea, inviting the best scholarly minds around the world to record brief, succinct videos on very specific topics of their special interest.  And, so, the TED talks were born. Ranging across a very wide array of topics from science and religion to art and communication, TED talks share the best of what the best have to offer.  Here are 6 of the best mental health TED talks to inspire you to think outside of the box, question your understanding of the world around you, and explore:

1.  How Meditation can Reshape our Brains –  Sara Lazar, Ph.D., Research Associate, Massachusetts General Hospital, Harvard Medical School

Dr. Lazar shares her experiences and her research on the positive effects of meditation on the brain.

2.  What Hallucination Reveals About our Minds –  Oliver Sacks, M.D., Professor of Neurology, New York University School of Medicine

Dr. Sacks discusses the relationship between vision and hallucination.

3.  The World Needs all Kinds of Minds –  Temple Grandin, Ph.D., Renown Autism Activist, Professor of Animal Science, Colorado State University

Dr. Gradin shares her experiences with autism and how those with autism see and understand the world.

4.  The New Era of Positive Psychology –  Martin Seligman, Ph.D., Professor, University of Pennsylvania

Dr. Seligman, the father of positive psychology, shares his views on moving beyond the disease model, toward happier lives.

5.  The Surprising Science of Happiness – Dan Gilbert. Ph.D., Harvard Medical School

Dr. Gilbert shares his theories on our natural inclination toward happiness.

6.  A Tale of Mental Illness – From the Inside – Elyn Saks, J.D., Ph.D., Professor, University of Southern California

Dr. Saks, a scholar and advocate for those suffering with severe mental illness, shares her own personal experiences with schizophrenia.



Dr. Deibler

Marla W. Deibler, PsyD <![CDATA[The Neglected Side of Hoarding]]> 2013-02-04T04:57:35Z 2013-02-04T04:57:35Z Compulsive hoarding has attracted a great deal of media attention. These media portrayals, whether they are television, newspaper, or other illustrations of the problem, tend to be somewhat unidimensional.  Yes, these individuals’ homes are frequently difficult to navigate, and, yes, these individuals appear to be excessively attached to items that many of us view as of very little or no value. However, these snapshots into the lives of these individuals sometimes lack the depth of difficulty these individuals have in their lives.

Let’s look at a few of the challenges that are often under-conveyed, but that are very real, very significant challenges to individuals, their family members, and to us, as psychologists who treat them.

  • Interpersonal Difficulties. Hoarding behavior frequently leads to social isolation in individuals who reside alone. They tend to keep to themselves and do not have guests in their homes. This can lead to problems with depression, loneliness, and further difficulties. Adult children often have strained relationships with a parent who hoards, as the stress of the situation causes significant conflicts.
For those who do not live alone, this behavior is frequently a significant strain on a marriage and on relationships between the individual and his/her children. Feelings of anger, resentment, sadness, embarrassment, and frustration are commonly reported by such family members.

  • Co-Occurring Psychopathology. These individuals frequently have co-occurring psychopathology which poses an added challenge to their treatment and to improving their living conditions. For example, 60% of these individuals meet criteria for major depressive disorder.  Other conditions that commonly co-occur include social phobia (30%), generalized anxiety disorder (25%), and obsessive compulsive disorder (15%-17%). These problems also need to be identified and treated.
  • Perfectionism and other Erroneous Beliefs. Compulsive hoarders frequently have thoughts, beliefs, and values that are maladaptive and contribute to the maintenance of the problem. For example, an individual may believe that they must clean and organize their kitchen perfectly. They then get overwhelmed by this expectation and do not approach the task at all because they believe they will not do it perfectly.
By avoiding the task, they avoid experiencing those unpleasant, anxious, overwhelmed feelings, but the clutter continues (negative reinforcement). These engrained patterns of thinking need to be identified, challenged, and replaced with more adaptive thoughts, a major goal in therapy.
  • Insight and Desire to Change. Many individuals are considered to have poor insight and are resistant to change; however, this is often misunderstood. These individuals typically know there is a problem and they experience a great deal of anxiety about failed efforts or desires to change, but their anxiety can be so significant that it is paralyzing.

Many of these individuals have made efforts to change their environment. They do not have guests in their come, as they know that their home would not be met with approval, yet their tendency toward over-valuing of their belongings, fear of losing their belongings, as well as many other associated worries leads them to emotionally shut down and reject assistance, leaving them prisoners in their own homes.

Contrary to some beliefs, individuals who hoard are not simply “lazy.” Their difficulties are complex. It is only with compassion, understanding, and dedication that we may help these individuals improve their homes and their lives.


Dr Deibler

This entry was originally written by Dr. Deibler as a guest entry for the blog of professional organizer and talented “tech-ee,” Deb Lee, MA: &

Lead photo available at 123RF