Therapists Discuss COVID-19 Anxiety

Therapists Discuss Covid-19 Anxiety & Stress Management

Note: This is part of an interview that Jennifer Yeh and Blake Thompson gave for local reporter Julie Muhlstein.

Q1) Do you believe the stay-home and social distancing measures may have an unintended consequence of also raising people's anxiety (OCD, panic or agoraphobia) once they do begin to go out and resume more normal activities? 

BT: Yes. Especially when it comes to Agoraphobia. For many clients, managing agoraphobia means engaging in the ongoing work of challenging themselves to be out in public.  Without exposure, it's not uncommon for them to have a relapse (i.e., for their sensitivity to these triggers to increase again).

JY: Yes.  Anxiety is associated with the overestimation of danger, and the underestimation of our ability to cope with a potential threat.  The stay-home and social distancing measures send messages that there is increased risk ‘out there, among other people’.  This is both truly unfortunate for humans as social beings, and also an unavoidable reality of fighting a global pandemic.  It follows that re-emerging from quarantining can heighten anxiety - it involves facing the uncertainty of the world, with its visual reminders that we are still very much in the middle of a pandemic (i.e, masked community members, copious hand sanitizer bottles and gloves, plexiglass partitions, and 6 feet spacing markers on the sidewalk).

Q2) Are there some tips you could share for people who may be feeling especially anxious about going into public places, or even back to work? 

BT: Make decisions about what types of risks you're willing to take before you leave home. It can be inordinately stressful to have to make decisions about risk on the fly. Being clear with yourself about what you are and are not comfortable with ahead of time (and communicating those boundaries to friends and family members) has the power to make your life much less stressful when you venture out into the world. This is more difficult when it comes to work, as many workers don't have the ability to make decisions about which risks they take at work, but to the extent that you are able this can also be a useful strategy for work.

JY:  Blake, I really like your response here, especially communicating boundaries so important.  This can be tough to do, but helpful.

I’d say, first, imagine yourself ahead of time going into public places – see if you can picture these scenarios as vividly as possible.  Consider what possible problematic situations could arise, and how you would handle those effectively. This is what we’d call the “DBT Cope Ahead” strategy.

Second, if possible, give yourself time to break down your re-entry process into steps.  

- Start with situations that are more contained (like a walk in your neighborhood).  As you get your bearings with being out and about, build up from there to different destinations and/or activities where you could be around more people (like getting take-out from a favorite restaurant, or visiting a park).

- Set an intention to leave the home at least once a day, and continue to increase the frequency and length of these outings.

Third, Get social support in this process (even if your companion is masked-up and 6 feet away). Navigating pandemic life alongside someone you trust can help with recalibrating to the ‘new normal’.

Fourth, Give yourself and others as much compassion as possible in this potentially awkward and uncomfortable process.  If you find compassion and judgement of yourself and/or others wearing thin, see if you can speak with a supportive person.

Q3) Could you comment on the notion that while anxieties may typically be based on fears that are unfounded, with COVID-19 the fear is based on reality, the possibility of contracting the disease?

BT: Most theories that we operate from in clinical psychology focus on intra-psychic issues. Covid is definitely an extra-psychic issue. So a lot folks in clinical psychology are thinking about this less in terms of 'curing an irrational fear' and more in terms of 'stress management'. Keep in mind, we don't want people to be fearless, that wouldn't be helpful in this situation (this could result in potential harm to you or others you interact with). But stress is dangerous as well, if only on a different time-scale. Stress causes cancer, it causes cardiovascular disease, it causes insomnia, it leads to substance abuse problems, it can lead to marital problems... it can lead to suicide. We need to take stress management very seriously. Luckily, you don't have to believe that you're 100% safe in order to manage your stress. Even hostage negotiators and fighter pilots can learn to manage their stress, it just takes the proper training - you have to learn the right tools.

JY: First off, great points about the problems with stress and stress-management, but I don’t think this conceptualization of anxieties outside of COVID-19 being based on unfounded fears is particularly useful.  Many of the things that people have anxiety about aren’t always that irrational – rather the level of preoccupation with the fear has become so much more functionally impairing and misery-making than is useful or productive.  I find it more helpful to consider COVID-19 anxiety similarly to other anxieties – the goal is ultimately to boost the signal-to-noise of actual dangers to perceived dangers.  With things we fear (including contracting COVID-19), less preoccupation with the background noise of improbable risks mentally frees us up to attend effectively to the higher probability risk factors – while also leaving space for moments of joy, connection, and calm.

Q4) Is there something especially troubling about a risk that is invisible -- we can't know who might be spreading the disease, so we begin to fear everyone we encounter? 

BT) For many people, yes. Invisibility means more uncertainty and uncertainty is a huge component of anxiety for so many people.

JY: I agree! The invisibility is problematic because it goes hand-in-hand with great uncertainty and this coronavirus pandemic is particularly insidious in that it has presented us with the perfect storm of uncertainty.  For example, the COVID-19 virus has an idiosyncratic process of infection - it has a long incubation period and there is the potential for pre-symptomatic people to unknowingly shed the virus. 

BT: Exactly! These obscurities combine with the novelty of having yet to fully understand the nature of what we are contending with and how to effectively get a handle on it, especially in ways that balance unintended economic and social harms. 

JY: We can add to that things like long waiting periods to be tested and to find out those results. These factors add layer upon layer of uncertainty - and all that uncertainty can pile on to an already stressful situation.

Q5) Anything else you'd like to share?

BT: This is all related also to why so many people, on the other side of the spectrum, act like there's nothing to worry about. They overcompensate for their fears by pretending there's nothing to be afraid of. They pretend so hard, they often fool themselves. If you find that you're afraid of getting sick and dying, or of a loved one getting sick and dying, in the middle of a pandemic, that's not irrational of you and it isn't a weakness - what it means is that you're not in denial. Acknowledging dangers and taking appropriate steps to protect yourself and others - this is a rational and emotionally mature response. Acknowledging that you're stressed and afraid and taking steps to work through these feelings so they don't grind you down - this is a rational and emotionally mature response. Pretending there's nothing to be afraid of and pretending that you aren't afraid - these are emotionally immature responses to a global pandemic.

Shame and Anti-Racism Work

Seattle Therapist Discusses Shame and Anti-Racism Work

A guest post by Tina Alvarado, LMFT

ABSTRACT

We, as White people, need to work on building up our shame resilience as a way to continue to engage in dismantling White Supremacy. The lives of Black, Indigenous, and People of Color (BIPOC) depend on it. It is normal and okay to have hard feelings come up as you confront the White Supremacy you have internalized. Follow the steps explained below to increase your tolerance of these uncomfortable feelings so that you can remain steadfast in your anti-racism work.

INTRODUCTION

As a White Latina and a psychotherapist, I see one of my roles in anti-racism work as supporting other White and White-passing people in exploring their racial identity, privilege, and the role they play in systems of oppression. 

I have noticed a lot of the same themes come up in therapy sessions over the past two weeks as my White clients are responding to a new-found urgency to explore their Whiteness. The purpose of this post is to gather them in one place and share them here in the hopes that it will help other White and White-passing people in their process. 

Below, you will find seven steps that White people can take to help them prevent shame from getting in the way of their anti-racism work. Let this be a starting-off point for conversation and action. I, myself, am excited to engage with others around it as I continue to do my own work.

Dear White People

I want to address something that often gets in the way of our work when it comes to confronting and addressing the ways that we have internalized, participated in, and contributed to White Supremacy: SHAME. Specifically, to use a term coined by Dr. Brene Brown, low shame resilience. 

It is common to experience shame when we are confronting something we have done that contradicts our values or calls attention to a blind spot that we have had. Having a low shame resilience means having a hard time moving through experiences of shame. You are likely get stuck or immobilized by it. Sometimes we approach shame like it's the boogey monster: don’t talk about it, don't think about it, avoid it at all costs and maybe it'll go away. Sometimes we get stuck in a shame spiral and can't seem to find our way out.

Shame does not have to be so scary

In fact, it is partly this response to shame that makes it feel so bad. The action urge associated with shame is hiding, it causes us to isolate and move away. Shame, just like any other emotional state, exists for a reason. It has been evolutionarily effective. We are communal people and as such want to avoid anything that disconnects us from our community. Historically, to be disconnected from our people meant that we would not survive (think about the animal that gets separated from the pack and is vulnerable to prey). 

Present-day, that is not our reality. For the most part, especially if you are white/cis/able-bodied/straight, to be separated from your group is not a threat to survival. The emotional toll of being separated from relationship and connection does have a detrimental effect on our mental and emotional well-being, but that is a topic for another time. The need to be connected is still biologically hard-wired into us. We still feel shame. 

The function of shame is to tell us when we have done something that violates our own values or our community's values. However, shame becomes a problem when it starts to control us. We can easily get fixated on how to avoid it. This fixation can send us into a shame spiral or keep us stuck. 

Shame is also a problem when we get repeated "false positives.” This is when we feel shameful about something that we do not actually need to feel shameful about. False positives can happen with respect to our sexuality, our sexual orientation, the moments in which we confront racism, and so on. When this happens, we need to ask ourselves what forces are conspiring to generate the false positive. In the previous examples it would be: a sex-negative culture, a hetero-normative culture, a culture of White Supremacy. When we are able to successfully reflect on and identify the sources of these false positives, the shame no longer has to be personal. We can overcome, in certain respects, this experience of ourselves as bad or wrong. We can come to see that our shame is just another emotional state that indicates to us that there is something for us to learn.

When we say that there is no room to center white peoples' feelings in anti-racism work, we do not mean "don't have feelings." Of course, you are going to have feelings. You are coming up against blind spots and re-orienting to all the things that White Supremacy has hidden or distorted in order to maintain power (e.g., most of the history coursework in this country centers White people and White experiences almost exclusively). What we mean is that your feelings should not be taking center stage. Your White experience(s) should not be distracting from the experiences of People of Color. This is about how you impact People of Color, not about how they impact you. 

However, you do need to process your feelings. If you get stuck in your feelings or are unable to let yourself become emotionally transformed by this work, you will be ineffective in creating real change for People of Color. Keep in mind that while we White people are experiencing emotional discomfort when we choose (note: this is privilege) to engage in anti-racism work — BIPOC are losing their lives when we do not.

What do you do if you are struggling with hard feelings as you learn about your role in White Supremacy? You increase your shame resilience.

How to increase shame resilience in anti-racism work:

1. Acknowledge that a hard feeling is coming up.

2. Get curious about this hard feeling. Do you have a name for it? Sometimes it helps to give it a label. Other times naming it is more trouble than it's worth, but you can still describe it.

3. Notice what it feels like in your body when you have this hard feeling or what urges come up for you. For example, do you have the urge to hide or to justify and defend yourself? Noticing this is important because it will help you recognize this hard feeling more quickly in the future. It will also help you practice mindfully responding to your feelings so that you can choose what is the most effective course of action.

4. Ask yourself: what is there for me to learn about this hard feeling? What is it that I already know? How can I connect these things?

5. What is the most effective next step that aligns with my goal of dismantling racist systems and the value I recognize in supporting and centering BIPOC lives and experiences?

6. Do that thing.

7. Be kind to yourself and take a deep breath (we will talk more about kindness below).

At any point in these steps, talk to other White people who are doing anti-racism work and continue doing your research about BIPOC lived experiences. After all, one of the ways shame functions is it keeps us silent and shame THRIVES in silence. This silence really serves White Supremacy because it means the system does not have to change.

Example

Reading an article about the importance of contributing funds to anti-racism advocacy work led by Black folks brought a tightness in my stomach. What is there for me to learn about that response? It feels closely tied to the messages about "protecting your hard earned money" or "pull yourself up" or the capitalist idea that there isn't enough to go around. That's uncomfortable to admit. But I know that those messages are actually untrue and rooted in the systems I am trying to dismantle … so I can say “look, there is my internalized White Supremacy showing up again.” 

My urge is to hoard my money. Yet I am aware that this urge is not aligned with the value I recognize in supporting BIPOC lives and in dismantling the systems that falsely say that their lives are less important than mine. How can I, for the sake of living in accordance with my values, act in opposition to this urge? Considering this question in earnest could lead to a flash of insight and to moral clarity. For example: I realize that what I must do is choose to donate to this organization that works for racial justice and is led by a Black Queer person. I will also pay attention to when I have this feeling again so that I can look for more opportunities to un-learn and re-learn.

A note on being kind to yourself

It is important to be kind to yourself. It is a myth that the only way to motivate ourselves is to bully ourselves or be mean to ourselves. This myth is, as you might have guessed, rooted in a number of different interlocking systems of oppression (another topic for another time). 

It is important to be aware that kindness is different from politeness or nice-ness. Politeness or nice-ness values intention over impact and says: "it's ok, I know you were trying and that is enough." True kindness, on the other hand, is not afraid to name a hard truth and call us up into our own potential to do better. It takes ownership over the impact and seeks growth. True kindness says: "I know you were trying and you missed the mark. That's ok because we are all human and we all make mistakes. It makes sense that you're feeling something hard right now. Let's look at what you need to do to repair (if possible), what there is for you to learn, and what you can do differently next time.”

SUMMARY

If you truly want to work for sustainable change to shift the system so that Black folks and POC are no longer bearing the brunt (READ: DYING), you MUST be willing to build the shame resilience necessary to work through your hard feelings and keep them from immobilizing you. The steps enumerated above are just ONE way of doing it. This will take time. It is not a quick fix, but it is necessary for the marathon of work it will take to dismantle the systems that value White lives over BIPOC lives.

Do not let your shame get in the way of learning and doing better.

ABOUT THE AUTHOR

Tina Alvarado, LMFT is an individual and relationship therapist who provides telehealth services to clients in Seattle and throughout Washington state. As a Mexican-American clinician rooted in systems theory, she specializes in identifying and exploring the practical, relational, and psychological impacts of the systems at play in our lives. With expertise in food/body issues, healing attachment wounds, and increasing emotional intimacy she helps millennial clients develop more satisfying connections with themselves and others.

ADDENDUM

As mentioned above, Brene Brown coined the term “shame resilience” and she has authored a number of excellent books that are relevant to developing shame resilience. Here is a list of the books that Brown has written that touch on shame/shame-resilience (as well as a TED Talk):

- I Thought It Was Just Me: Women Reclaiming Power and Courage in a Culture of Shame (2007)

- Connections: A 12-Session Psychoeducational Shame-Resilience Curriculum (2009)

- The Gifts of Imperfection (2010)

- Men, Women and Worthiness: The Experience of Shame and Power of Being Enough (2012)

- The Power of Vulnerability: Teachings of Authenticity, Connections and Courage (2013)

- Braving the Wilderness: The Quest for True Belonging and the Courage to Stand Alone (2017)

- "Listening to Shame" TED Talk (March 2012)

You can order these titles from any number of black-owned bookstores.

Please Donate:  https://therapyforblackgirls.com/ 

Learn + Support: https://blacklivesmatter.com/  https://www.rachelcargle.com/ 

Therapy for COVID-19 Fear & Isolation

New Online Therapy Group: Coping with Fear and Isolation During COVID-19

During the COVID19 lockdowns, many people found that it was helpful to remind themselves that this was only temporary, that in a matter of weeks or months they would be able to see friends and family again. Sadly, this is not true for everyone. For example, those with chronic illness face far more uncertainty because they are at higher risk of death or serious complications should they contract COVID19. This in turn, puts them at much higher risk of anxiety and depression.

This is why we’ve designed a therapy group specifically for those at higher risk of death or serious complications due to COVID-19, to provide a supportive environment for them to connect with others and to learn evidence based psychological tools to help them cope with the isolation, anxiety, and depression that they are struggling with (you can email sonya@seattleanxiety.com to learn more about this group).

We've also launched a low-fee therapy program aimed at helping those who've lost their jobs due to COVID19 and others who wouldn't normally be able to afford the costs of therapy (you can email kate@seattleanxiety.com to learn more about this program).

Understanding the Impact

In any given year, nearly 18% of people in the United States experience an anxiety disorder.(1)  Taking a physical toll, anxiety and mental health issues often manifest and present themselves as physical ailments, such as headaches, stomachaches and/or cognitive problems (such as difficulty concentrating) and can impact all facets of life.(2)   Those with chronic illness face far greater stressors because they are at higher risk of morbidity or serious complications, should they contract COVID-19.  Coupled with increased isolation while avoiding potential exposure to the Coronavirus, those with chronic illness are at much higher risk of anxiety and depression during this time.  

Common signs of distress include:

• Feelings of numbness, disbelief, anxiety or fear

• Changes in appetite, energy, and activity levels

• Difficulty concentrating

• Difficulty sleeping or nightmares and upsetting thoughts and images

• Physical reactions, such as headaches, body pains, stomach problems, and skin rashes

• Worsening of chronic health problems

• Anger or short-temper

• Increased use of alcohol, tobacco, or other drugs(3)

• Guilt

• Sadness and grief

• Helplessness

• Surrealness

• Increased worry and empathy for others(4)

During the ongoing COVID-19 pandemic, participants in Seattle Anxiety Specialists’ recent community survey reported a significant increase in stress, anxiety and worry.  Primary points of concern comprised the health and safety of themselves, followed by that of their family and friends.  Financial concerns were also prominently noted, with 35% reporting their employment situation had been negatively impacted by the pandemic. Overall, 45% reported their quality of life has been significantly impacted during this time.(5)

While anxiety disorders are highly treatable, on average, only one-third of those suffering from anxiety receive treatment.(6)  Of the SAS study participants who indicated their quality of life has been negatively impacted during the pandemic, only 20% reported seeking therapy, with those in high-risk groups less-likely attending therapy.(7)

In the UK, psychiatrists are warning of a potential “tsunami of mental illness” from problems during the pandemic lockdown due to isolation and fears of getting sick and of hospitals.  Professor Wendy Burn, President of the Royal College of Psychiatrists, noted that they are already seeing the devastating impact of the pandemic on mental health, with more people in crisis.  A recent survey of 1,300 mental-health doctors from across the UK found that 43% have seen a rise in urgent cases, with 45% reporting routine appointments have decreased.  With anxiety levels rising and the fear of getting sick hindering patients’ likelihood of seeking therapeutic assistance, many are dealing with increased suffering to the point that they seek help only when they are in absolute crisis and their suffering has reached a point of being unbearable.(8)  By attending therapy sessions while anxiety levels are more manageable, patients can more-easily alleviate their symptoms before peaking at absolute crisis levels.  

Telehealth sessions offer people in isolation the opportunity to connect with others and feel like they’re not alone in their struggles with anxiety, forming supportive bridges with others.  Telepsychology has existed for over 20 years and has been utilized via phone, webcam, email and text messaging platforms.  Smartphones have increased availability of assistance, with people now able to engage in telehealth sessions anywhere they have a phone or Wi-Fi signal.  Lindsay Henderson, PsyD, assistant director of psychological services at a Boston-based telehealth company, has found that online platforms “normalize mental health care, especially among generations who are so accustomed to interacting with people using technology.”  Henderson noted that teletherapy eliminates so many barriers and is a “huge draw for consumers, many of whom are seeking therapy for the first time in their lives.”  Research studies have found videoconferencing telehealth sessions to be equivalent in efficacy as in-person care.  Further, teletherapy can be used as a more-comfortable stepping stone for patients who are new, and perhaps hesitant or nervous, to therapy or counseling.(9)  

Our new group

Seattle Anxiety Specialists’ therapist, Sonya Jendoubi, is well-versed in leading anxiety-based group-therapy sessions.  She will be hosting a new group-therapy option at SAS, starting in June: Coping with Fear and Isolation During COVID-19.  This group offers a supportive environment for individuals, particularly those who are immunocompromised and at higher risk of morbidity or serious complications due to COVID-19, to learn evidence-based psychological tools to help them cope with the isolation, anxiety and depression with which they are struggling.  Sonya intends the group will, “Learn skills of acceptance, resiliency and managing uncertainty during high levels of isolation.  My hope is that participants will learn from and with one another.”

Meeting weekly on Monday mornings, Sonya’s “Coping with Fear and Isolation During COVID-19” group-therapy will be online, welcoming patients with rolling admission.  Since SAS research has found that traditional therapy may be too financially restrictive during the COVID-19 pandemic, group-therapy is particularly beneficial during this time, as sessions cost half of a one-on-one session with most insurance companies offering substantial out-of-network reimbursements – lowering your out-of-pocket expenses, exponentially.  Further, while traditional one-on-one sessions last 60 minutes at SAS (or 45-50 minutes at many other therapy offices), our group therapy sessions will run for 90 minutes each week, ensuring everyone in the group benefits from and gains the most possible during these therapeutic workshops. 

If you are 18 or older and would like to attend Sonya’s group sessions, please register here.  

References

1. “Understand the Facts” Anxiety and Depression Association of America (2020) https://adaa.org/understanding-anxiety

2. “Coronavirus Disease 2019 (COVID-19): Stress & Coping” Centers for Disease Control and Prevention (2020)  https://www.cdc.gov/coronavirus/2019-ncov/daily-life-coping/managing-stress-anxiety.html#risk 

3. “Emergency Preparedness and Response: Taking Care of Your Emotional Health” Centers for Disease Control and Prevention (2020)  https://emergency.cdc.gov/coping/selfcare.asp 

4. “Impact of Covid-19 on Stress in the Seattle Community” Seattle Anxiety Specialists (2020) https://seattleanxiety.com/blog

5. Ibid.

6. “Understand the Facts”

7. “Impact of Covid-19 on Stress in the Seattle Community”

8. “Psychiatrists Fear ‘Tsunami’ of Mental Illness After Lockdown” BBC (2020) https://www.bbc.com/news/health-52676981

9. “A Growing Wave of Online Therapy” American Psychological Association (2017) https://www.apa.org/monitor/2017/02/online-therapy

Free App for Covid19 Anxiety Management

We are excited to introduce you to COVID Coach, a free app designed to provide evidence based anti-anxiety tools and enhance emotional support during the coronavirus pandemic. This app is not a replacement for therapy or psychiatric treatment for anxiety, but it is still a great tool for those struggling with increased anxiety during this time.

Developed by the licensed clinical psychologists at the National Center for PTSD at the VA, it joins other free, widely-used mental health apps like PTSD Coach and Mindfulness Coach. Although this is an app developed by the Department of Veterans Affairs, it is intended for use by everyone in the community (not just veterans and not just people suffering from PTSD) and is available for both iOS and Android phones.

Like other apps developed by the psychologists at the National Center for PTSD, it is designed to be totally private and secure. This means that no email account or password is required. It also means that user data are not collected.

COVID Coach offers access to stress management tools such as audio-guided mindfulness and deep breathing, as well as exercises designed to address anxiety, trauma reactions, and relationship conflict. It also has quick links to resources for finding crisis care and mental health support, and service agencies for families and those seeking basic fundamentals.

The VA let us know that Covid Coach will be updated regularly and that they encourage your feedback on ways it can be improved upon.

We hope that you’ll help us spread the word about COVID Coach!

The Six Types of Anxiety

Patients often want to know what the best kind of therapy is for anxiety. This is a great question, but in practice it’s often really difficult to give an answer without first knowing more about the person seeking therapy. We find that the right approach to therapy often depends on what type of anxiety the patient is presenting with. The aim of this post is to break down the six most common types of anxiety and explain the types of treatment we would typically recommend for a patient if that were the type of anxiety they were primarily struggling with.

Keep in mind that this list is not exhaustive, there are certainly other ways of drawing these distinctions, and any one person will usually experience more than one type of anxiety. There are also lots of reasons why someone might be better served by an alternative approach to therapy. However, we believe that there is much to be gained from clarifying anxieties along these lines and we hope clinicians and patients alike will find this a useful way to aid in assessment and treatment.

#1 - Fear

You are trying to get to sleep and you hear a noise downstairs (a “bump” in the night). Suddenly you feel unsafe. “Did I lock the door?” … “Is there someone in my house?” … It is normal to feel fear in a situation like this. However, many people feel fear more than they would like to and in situations that do not warrant it. 

Irrational fear can impact an individual’s life in significant ways. You may avoid medical care if you experience fear of needles or have other medical phobias (lack of proper preventative care and early diagnoses drastically reduce the lifespans of millions of Americans). Or maybe you wash your hands too many times because you experience fears of germs and of infection (this can cause your hands to dry out, crack, and bleed - leading to eczema and, ironically, to a substantially increased risk of infection). 

There are countless things we can find ourselves irrationally afraid of, but whatever the irrational fear there is typically a very real cost to not dealing with it. These fears not only lead to complications in our lives, they also become worse over time if we simply try to avoid what we fear. Failure to deal with our fears can also lead to increased feelings of shame (see section #3 below).

Fear is a primal emotional experience directed toward someone or something. It is a feeling that is often triggered by sensory experiences. A sight, sound, or even a smell might throw us into a state of fear if we perceive in that sensation some form of imminent threat or danger. 

Biologically, fear is characterized by spikes in autonomic activation. This means that it tends to come on very quickly. We can become “gripped with fear” when something triggers our perception of threat. These spikes in autonomic activation make it difficult for us to think clearly and we can easily begin seeing things solely through the lens of our fear. 

When in a state of fear, the things we are afraid of will typically seem inherently threatening. No explanation is needed. The threat feels obvious and immediate. Because the nature of the threat is viewed as inherent (e.g., "it's just fundamental to flying through the air in a giant tube of metal that you're in grave danger...") reasoning is rarely effective in reducing the fear response (if we’re able to mobilize it at all). This helps explain why psychotherapies such as psychodynamic therapy and cognitive therapy (therapies without behavioral protocols) often fail to produce results in clinical studies of phobias and OCD.

Much of what we think of as “anxiety disorders” fall within the fear sub-type. Those who carry diagnoses of specific phobia, agoraphobia, panic disorder, PTSD, and OCD usually struggle with fear as a central component of their anxiety. In the face of fear, we feel compelled to respond - often these compulsive responses are automatic - and the dominant form of compulsion is usually avoidant in nature.

There may be other ways to address any given fear, but one approach to therapy has distinguished itself as especially helpful for those clients who struggle with fear. This is therapy that leverages behavioral psychology (included as a part of cognitive-behavioral therapy and it’s derivatives such as ACT, PE, ERP, and CPT). We’ve found that through utilizing the toolkit of contemporary behavioral psychology, focusing on gradual and systematic exposure to feared stimuli, the client’s fear response can be diminished greatly in a relatively short period of time - even extinguished entirely in many cases. 

The idea of exposure therapy often frightens clients, but keep in mind that contemporary exposure therapies are all about very gradually desensitizing you to the object of fear. Whatever you’re afraid of, you won’t have to face your fears all at once. We start with what’s actually doable - we push you out of your comfort zone little by little until your fear response starts to dissipate. 

Keep in mind that there is a difference between rational fear and irrational fear. Rational fears are those fears that accord with our intellectual judgments about what’s really dangerous. They are important because they tend to keep us safe. Irrational fears are fears that we wish we didn’t have, because they keep us from living our lives to the fullest. Behavioral therapy (exposure) only works on irrational fears. This is because it allows our emotional experience to catch up to what we already know intellectually - that despite how dangerous the situation feels (and how real that danger feels), the probability of danger is not nearly as high as it seems. So you don’t have to worry about therapy making you too fearless.

#2 - Worry

"Worry" is far more cerebral than fear. It’s often ruminative, analytical, and apprehensive. Unlike fear, which tends to get triggered by sensations, worry tends to get triggered by ideas. Also unlike fear, which tends to be present focused (focused on what is imminent), worry is usually future oriented (focused on hypotheticals). 

It isn't unusual for someone to view their own worry as productive (at least on some level) ... as a form of proactive risk assessment and planning for negative eventualities. When you view your worry in this way, it can give you a sense of control. 

Because most things that most people worry about turn out fine, they usually end up feeling relieved once they discover that their worry was false. However, people rarely let themselves believe that (on top of being false) their worry was also unwarranted in the first place. Instead, they end up believing that their worrying helped them narrowly avoid a bad outcome (even when it had no such effect). It’s because they let themselves believe this that they feel relief - and because this relief feels so good it conditions them (through reinforcement) to worry as much or more in the future. This might sound bizarre, but unconscious conditioning is a powerful force that governs much of our lives.

Worry doesn't usually produce emotions that are as intense or acute as a primal fear response. Instead, worry tends to feed into (and be fed by) less acute levels of stress that last longer periods of time. This sustained level of autonomic activation can lead to insomnia, erectile dysfunction, high blood pressure, quasi-panic-states, increase risk of cardiovascular disease and cancer, as well as a number of other health issues (including dementia and suicide).

Everyone worries, and people who struggle with anxiety and anxiety disorders tend to worry more than most. However, those who carry a diagnosis of Generalized Anxiety Disorder usually struggle with worry as a central component of their anxiety. In fact, they may spend more time worrying than doing anything else.

Worry based presentations of anxiety often respond really well to courses of therapy that emphasize new ways of engaging with our thoughts. This could look like cognitive therapy (part of CBT), which tries to directly intervene and change the thinking patterns implicated in our worry. It might also look like acceptance and commitment therapy (a derivative of CBT), a type of therapy that helps us to find more emotional distance from our thinking and choose a meaningful alternative to rumination.

Other effective approaches to treating worry focus on the role that heightened physiological activation plays in the process. That is, increased worrying not only causes us to feel more stressed, feeling more stressed also causes us to worry more. Because this causal relationship goes both ways, we are able to utilize techniques such as progressive muscle relaxation and differential relaxation to effectively interrupt the worry cycle. 

Again, it’s important to distinguish between rational worry and irrational worry. A little bit of worry is normal and can be helpful (we need to at least periodically consider ways in which things might not go according to plan). There comes a point, however, at which the costs of worrying start to outweigh the benefits. For chronic worry, there is a high price to be paid, both in terms of the toll that so much stress can exact in terms of missed opportunities and its very real health consequences.

#3 - Shame

"Shame" is a feeling associated with a negative experience of oneself. Most people have some level of shame in their lives (nobody thinks they’re perfect). When shame is healthy and context appropriate, it’s usually just called “humility”. However, shame can show up in an irrational (neurotic) form (similar to irrational forms of fear and worry).  

Although mild shame might manifest simply as low self-confidence (a suspicion that you’re not good enough), more severe experiences of shame often present as a sense of worthlessness (a suspicion that you’re not good at all). Those who struggle with shame often are concerned with specific ways in which they might not be good enough. Intelligence and attractiveness are two of the most common things that individuals experience shame about, and this can lead to a preoccupation with these traits in others (comparing ourselves to others).

Because shame is such a distressing and pervasive experience (we are always with ourselves), it is often forced out of awareness by defense mechanisms. Here, a defense mechanism is anything we habitually use to keep ourselves from having to deal with our feelings of shame head on. Denial, intellectualization, and reaction formations are all common examples of these defensive responses to shame.

When our fight-or-flight reaction is triggered, we are likely to become reactive in a way that is distinctive to how we've habitually opted to defend ourselves against these feelings. When these defensive reactions break down, and our negative understanding of self breaks into conscious awareness, a very different (more “vulnerable”, to borrow a term popularized by Brené Brown) aspect of our personality is likely to emerge.

This is the type of anxiety that Alain de Botton is gesturing at when he says that “the largest part of what we call 'personality' is determined by how we've opted to defend ourselves against anxiety and sadness.”

Imposter syndrome, on one end, and many of what we call "personality disorders" on another, can all be viewed through this lens. Psychologists often call these characterological (think “personality quark”) presentations of anxiety. It's the focus on the value we bring to the table and the chronic and global nature of the coping response that are clues to shame lurking underneath (again, we are always with ourselves and concerned more with our status in the world than with just about anything else (we all deeply want to be “good”)). 

Workaholism, unrelenting standards (e.g., “perfectionism”), chronic avoidance, pervasive relational dependence (“codependency”), grandiosity (“narcissism”), entitlement, subjugation, and so on are often defense mechanisms (coping responses) that are anchored in a sense of shame (of not being good enough). What makes these responses to life problematic is that they are based on a distorted self-image. If we saw ourselves as we really are, we would be more calm, more confident, and more able to direct our lives toward things we really care about rather than feeling compelled to carry on in this way - always compensating for ourselves.

It may not be the right approach for every client, but shame based presentations of anxiety often respond really well to courses of therapy that emphasize new ways of engaging with significant events and relationships in our lives (especially those from our childhood). Psychodynamic Therapy and Schema Therapy are two approaches that have a proven track record of addressing these issues through helping us re-engage with these events and relationships, as well as with our past. 

#4 - Angst

"Angst" isn’t just for teenagers. As the feeling of distress associated with existential disorientation, this particular type of anxiety is often connected with questions like “who am I?” and “who am I supposed to be?”… "should I believe in God?", “how can I really know what’s right and what’s wrong?”, and “how can my life be of any real significance?” We tend to think of these as the questions of adolescence, but this is only because it is in adolescence that we start to develop the abstract reasoning needed to formulate them. Adults also face these questions, and often feel no more prepared to answer them than they did when they were thirteen.

Because these questions are so hard to answer, or even pose in ways that lend themselves to an answer, they tend to get buried. Unlike shame, they tend not to get buried by “personality” defense mechanisms (such as workaholism, perfectionism, avoidance, procrastination, and so on) but instead by ideological ones (such as materialism, nihilism, nationalism, romanticism, and so on) that provide superficially functional but ultimately unsatisfying answers. 

These questions and concerns can sometimes become unburied when we are snapped out of our autopilot mode of existence and confronted with the arbitrariness of our lives. We might find angst in the wake of losing faith in the religion we were brought up in, after a near death experience, after receiving a terminal diagnosis, in the wake of divorce, after receiving the promotion we've been working toward for years... and so on. But more often, angst presents as a pervasive, yet subtle, sense of not quite being at home in or understanding the world in which we live (what an academic philosopher might refer to as a feeling of “ontological alienation”).

In writing about the importance of tackling angst head on, Wilfred Sellars writes: “The ideal aim . . . is to become reflectively at home in the full complexity of the multi-dimensional conceptual system in terms of which we suffer, think, and act. I say ‘reflectively’, because there is a sense in which, by the sheer fact of leading an unexamined, but conventionally satisfying life, we are at home in this complexity. It is not until we have eaten the apple with which the serpent philosopher tempts us that we begin to stumble on the familiar and feel that haunting sense of alienation which is treasured by each new generation as its unique possession. This alienation, this gap between oneself and one’s world, can only be resolved by eating the apple to the core; for after the first bite, there is no return to innocence. There are many anodynes, but only one cure.” 

It may not be the right approach for every client, but angst based presentations of anxiety often respond really well to courses of therapy that emphasize philosophical exploration. Existentialism is a school of thought within philosophy that explicitly tackles these questions, but a broad knowledge of philosophy and history can be especially helpful when working with such clients - as topics such as ethics (and meta-ethics) as well as epistemology and the history of ideas can all play into helping these clients orient themselves... indeed, pulling from literature, from critical theory, from religious studies, and from other parts of the humanities can be tremendously useful and transformative in therapy with such clients.

Treating angst well is very much an under-appreciated challenge in our field (in Clinical Psychology) - and these clients sometimes struggle to find therapists that are a good fit. Keep in mind that for religious individuals, often pastoral counseling or another form of guidance based in their faith tradition can be helpful. For non-religious individuals, finding a therapist that has extensive training in existential psychotherapy can often be helpful.

#5 - Stress

"Stress" is a biological and psychological response to challenges in one's environment. What's distinctive about stress is that it isn't, strictly speaking, irrational. That is, it isn't the result of unconscious mental machinations or distorted thinking patterns, nor is it about existential disorientation - it's about confronting a set of concrete challenges. 

Someone who isn’t struggling with irrational fears, doesn't chronically worry (even if they have to think a lot to deal effectively with the challenges they're facing), is generally a confident person (doesn’t struggle with shame), and knows what their values are and what their life is all about (doesn’t struggle with angst) - this person can still walk in the door of our clinic with lots of anxiety - though we might say that this is “just stress" if it seemed like a mostly normal reaction relative to the challenges they're facing (e.g., if they're the director of a non-profit trying to save the wetlands and Scott Pruitt just got nominated to head the EPA and vowed to slash their budget... they have legitimate things to be worried about... but it's not "worry" in the pathological sense that's happening here... they aren't inventing a catastrophe... they're actually facing one).

It may not be the right approach for every client, but stress based presentations of anxiety often respond really well to courses of therapy that emphasize wellness coaching and humanistic therapy (non-directive person-centered supportive counseling). 

Note that while coping skills training can be anti-therapeutic for fear based anxieties (serving as a means of avoidance and negative reinforcement that make the fear worse over time) ... coping skills are actually a perfect fit for clients who are primarily struggling with stress. Mindfulness training and learning breathing exercises are just a couple of the many helpful approaches to coping better that someone might explore with their therapist as they work to reduce their stress level.

Also, while supportive counseling is often derided as an ineffective approach to treating anxiety disorders, it’s arguably the most helpful approach for ameliorating stress. Because the client doesn't have a thought or mood disorder, the therapist is probably doing their job best here when they don’t act as if the client had one. Instead, they can help the client by providing a warm and empathic ear, help them unpack and organize the complex tangle that their life has become, get things off their chest, clarify the issues that they’re facing, so they feel more equipped to tackle these challenges and don’t have to feel like they’re carrying this burden alone. 

#6 -Tension

"Tension" is a relational phenomenon that can develop between couples as well as family members or co-workers. It's often specific to one person or a small group of people and is sometimes detectable even by those who aren't participating in it - the dysfunction infects the atmosphere - you can feel it (sometimes right when you walk into a room). This is the type of anxiety people often describe as “like walking on eggshells.”

Tension might be as simple as one miscommunication or as complex as layers of resentment built up over time. Because of the way we participate in it, it's difficult for us to have objectivity and to be able to work on it productively with the person with whom we are in tension. This is where couple's therapy or family therapy becomes an ideal solution. Here, a skilled guide in relationships can provide a more objective take, point out things that either party was perhaps not noticing, and help the parties to begin the work of seeing each other again and healing the wounds that have been created up to that point.

These tensions aren’t always able to be healed, but if both parties are willing to be vulnerable and want things to get better - then there’s a good chance that things will improve with the right help. But keep in mind that the sooner you work to resolve these tensions, the better. The average couple waits six years after becoming unhappy before they choose to pursue couples counseling. The more time goes on the more these relational tensions deepen, resentments build upon resentments and insecurities upon insecurities, making them more difficult to resolve.

40 years ago, couple’s counseling was about 50% effective at resolving these tensions and saving relationships. In the last 40 years, advances in Psychology have allowed us to bring that number up to around 75%. Modern approaches such as EFT and the Gottman Method have hundreds of rigorous studies backing up their effectiveness.

Thanks for tuning in Seattle!

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An observation on shame by Friedrich Nietzsche.

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A Psychiatrist Explains Anxiety Medications

Anxiety Medications

One thing that’s not clear to most patients is that there is a huge number of different medications that can be used to treat anxiety. Obviously, the point of this post is breadth rather than depth, and there is so much more to say about any one of the categories mentioned here - but we hope that this will provide a helpful overview for patients and will help them feel more prepared when walking into a prescriber’s office.

The topics we are going to touch on in this post are:  1) which classes are useful for which types of anxiety disorders, 2) general pros and cons of each class, and 3) basic mechanisms of action of each group. 

Keep in mind that while medicines can be helpful for many, it is important to always stress the need for a holistic treatment plan including (but not limited to) psychotherapy, exercise, nutrition, mindfulness training, work life balance, social support, and so on.  In our experience, those relying on medications only may be more likely to experience tolerance to medications over time. The decision of which medicine should be tried should always be made after a complete in person evaluation, which this blog is not meant to supplant.

Selective serotonin reuptake inhibitors

These include fluoxetine (aka Prozac), paroxetine (aka Paxil), sertraline (aka Zoloft), fluvoxamine (aka Luvox), citalopram (aka Celexa), and escitalopram (aka Lexapro).  They tend to be the first line choice for multiple anxiety disorders and depression.  They are technically classified as antidepressants (which is a poor and oversimplified classification, but we don’t yet have a new and better system).

Sertraline is FDA approved for multiple conditions including:  Major Depression, OCD, PTSD, Social Anxiety, Panic Disorder, and Premenstrual Dysphoric Disorder.  While not all SSRIs have this many FDA approved indications, we often use the other ones for the same conditions.  Pharmacy companies do not always bother pursuing FDA approvals due to cost reasons and the realization that the meds will be used off-label.  It is completely legal and ethical to use medications for off-label purposes, but ideally the patient and provider should have a discussion about this first.  

While SSRIs can have an immediate effect, the full effect can take anywhere from 3-8 weeks (even longer sometimes) depending on the person.  They are generic and cheap. I tend to prefer generic meds b/c they have been around longer with a proven track record, and the risks are known too (as opposed to medicines that get taken off the market relatively soon because a new side effect is discovered).  This is my style, and there is certainly nothing wrong with those who do prescriber newer meds (which I also do on occasion).  

While they are overall fairly well tolerated and arguably with less side effects than older classes of antidepressants, some people may be more sensitive to side effects of this class (e.g. sexual side effects like decreased libido or difficulty with orgasm) and may do better with older classes like tricyclic antidepressants or MAOIs (these classes are discussed below).

In this class, the risk of discontinuation syndrome (aka SSRI withdrawal) will be greatest with paroxetine.  Most people do not have significant symptoms of this syndrome when they wean off slowly, but a small subset of people are quite sensitive to such and struggle to wean off.  This syndrome will be much greater with medicines with short half lives including paroxetine and the SNRIs discussed below, but can also occur with other SSRIs mentioned above (but less so with the others).  Again, typically this is a mild or absent syndrome, but some are more sensitive than others to it.

The mechanism of action of any anxiety medication can never be truly understood as it’s virtually impossible to prove cause and effect in research of these types of meds (as compared to antibiotics, for example, in which the mechanism of action is quite clear).  That being said: one mechanism of action of SSRIs may be boosting serotonin levels in the brain.  Research also shows these meds may also enhance glial cell function (these are brain cells that support, nourish, insulate and protect the brain neurons), and increase BDNF levels (brain derived neurotrophic factor).  Many people presume the serotonin boost is the main mechanism, but this is not necessarily true.  The other mechanisms I mentioned tend to peak in effect at 1-2 months, and this actually correlates more with the timing of the peak therapeutic effect in some people.  

These may be a good choice for those experiencing both anxiety and depression.  However, sometimes higher doses can be overstimulating and contribute to anxiety.  This may be less likely with citalopram and escitalopram.  Sometimes even low doses can trigger anxiety in certain people.  I know it sounds paradoxical that the medicine being used to help anxiety can trigger it instead.  This at least partially reflects many issues including the fact that while we have come a long way in psychiatry with psychotropic medicines, we still have a long way to go.  The prescribing of anxiety meds is not an exact science at all.  

While people can theoretically abuse any medication (esp something sedating or stimulating, even things like over the counter Benadryl), SSRIs (and all the other antidepresant classes mentioned below) are generally not thought of as addictive.

Some research shows when treating OCD, you need higher doses, and it takes much longer to get peak effect.  However, some clinicians question the validity of such research.

Paroxetine is not ideal for elderly patients.  It may also have the most potential weight gain within this class of medications.

Serotonin–norepinephrine reuptake inhibitors

These include venlafaxine (aka Effexor), duloxetine (aka Cymbalta), desvenlafaxine (aka Pristiq), levomilnacipran (Fetzima), and milnacipran (Savella).  These are very similar to SSRIs; in fact, some SSRIs are more closely related to SNRIs than others.  Venlafaxine actually acts as a SSRI at low doses and turns into an SNRI at higher doses.  Most of the comments I made above about SSRIs also apply to SNRIs.  

One difference is they also boost more noradrenaline in the brain, and not just serotonin (but some SSRIs also boost noradrenaline).

In theory, any antidepressant could also treat pain.  However, duloxetine does have an FDA approval to treat certain kinds of pain.  It’s possible SNRIs have more ability to treat pain than SSRIs because of the boost in noradrenaline.

Milnacipran (Savella) is actually only FDA approved for fibromyalgia, and not any specific anxiety or depressive condition (but still might help latter).

Benzodiazepines 

These include (but are not limited to) alprazolam (aka Xanax), lorazepam (aka Ativan), clonazepam (aka Klonopin), and diazepam (aka Valium).  These are quick acting.  They will have an immediate effect (minutes to hours) rather than weeks for maximum effect like the SSRIs and SNRIs.  However, there can also be a cumulative effect over the 1st 2 weeks (or potentially longer for some like diazepam because it has an extremely long half life of 20-100 hours).  

These can be highly addictive.  These are dangerous and potentially fatal to mix with alcohol; some patients even report synergistic effects between alcohol and the other antidepressant classes mentioned, but that combination is still safer (on average) than mixing benzos with alcohol.

Some recent research describes a possible association between long term benzo use and dementia.  This is not well understood or proven yet.  However, benzos are somewhat similar to alcohol, and even used for detoxing from alcohol.  Severe and chronic alcohol use is known to cause dementia.  Thus, it would not surprise me if benzos were related to dementia.  On the flip side, there are likely a subset of patients who do fine on small to moderate doses of benzos long term.  These can also be dangerous to mix with other addictive drugs like opiates.

Alprazolam is the most addictive in this class, partially because it’s very quick acting and with short duration.  Any quick acting benzo is more likely to lead to rebound anxiety.  This occurs when the medicine wears off.  Then, the anxiety is higher than before the medicine was taken.  This can lead to use of higher and more frequent doses, fueling potential addiction.  Because of this, I rarely ever start someone on alprazolam.  It’s extremely hard to get off of.  I almost always use lorazepam instead.

Quick acting ones will provide quicker relief but not last as long.   Long acting ones will provide longer duration of effect, and thus one might need 1-2 doses per day rather than 3-4.  Benzos are not good for the elderly (especially the longer acting ones) as they can cause sedation, falls and confusion; this class of meds is the #1 medication cause of falls in the elderly.

They work through potentiating GABA receptors.  They can also act as muscle relaxants and antiseizure meds, so may be a good choice for those with these problems as well as anxiety.  

You always want to wean off these to prevent severe and potentially fatal withdrawal.  This can happen even if you’re not addicted. That is, there is a difference between addiction and physiological dependence; physiological dependence is one part of addiction.  Even if you’re not addicted to any medicine, your body can get so used to it that severe withdrawals (and even death) can occur if you stop abruptly (that is, if you go “cold turkey”).  

Buspirone 

This is a unique medicine in its own class that treats mainly generalized anxiety, but some research shows possible synergistic effect with antidepressants in treating depression.  This is not addictive and on average much safer than are benzos.

Its mechanism of action involves effects on serotonin, dopamine, noradrenaline and GABA systems on the brain.  This does not typically have an immediate effect, but rather 1-2 months for peak effect like the antidepressants.  That being said, I have seen patients who report noting some immediate effects as well. 

Beta blockers 

These include propranolol (aka Inderal).  All use of this class is off label (i.e. not FDA approved) for anxiety.  Beta blockers work by blocking the effects of the hormone epinephrine, also known as adrenaline (mediated by actions at beta receptors).

These can be very helpful for specific types of anxiety like performance anxiety (e.g. public speaking), or social anxiety.  These have at least 2 big advantages compared to the other classes (especially benzos):  1) they are not addictive, and 2) they do not have cognitive side effects.  In other words, when some people take benzos for performance anxiety, while the anxiety is much better, their head is not clear (which then affects the task at hand which is triggering the anxiety).   

They are typically prescribed for high blood pressure, so someone with low blood pressure may want to avoid such.  They are also contraindicated in patients with certain types of heart disease like heart failure or bradycardia (aka low heart rate) or asthma.  Initial research from years ago showed these meds could worsen depression.  More recent research has questioned this association. 

Other antidepressants 

These include mirtazapine (aka Remeron), trazodone (aka Desyrel) and nefazadone (aks Serzone).  These are typically quite sedating, so are taken at night and can help sleep.  Some patients report a “hangover” like effect, but this sometimes goes away with time as the body adjusts to the medicine.  With all these meds (including the other classes mentioned) there can be immediate side effects or ones that appear over time.  Sometimes they go away with time, but not always.  It depends on the person, the medicine, and the side effect.  The general mechanisms of these are at least partially similar to the SSRIs and SNRIs (e.g. boosting serotonin), but they also work at different receptor sites in the brain.

Mirtazapine may be more calming than other antidepressants for some people.  Mirtazapine can also help appetite and sometimes is used off label exclusively for severe appetite and or weight loss.  So it is good for those whose depression or anxiety has led to loss of appetite and weight.  On the other hand, they may not be ideal for those who are overweight.  Mirtazapine does have more weight gain than most other antidepressants on average.  Mirtazapine may also have less side effects on the gastrointestinal system.  

Trazodone is so sedating at higher doses needed to treat depresion or anxiety (which ranges from 300-600 mg per day) that it’s typically used off label at bedtime for insomnia at night, or in the day for anxiety (at doses lower than 300 mg).  Any medicine that helps sleep at a certain dose may be able to help anxiety in the day at a lower dose (as long as not ovelry sedating).  Serzone is overall similar to trazodone, but not prescribed much these days.  The brand name was taken off market b/c of potential severe liver side effects, but the generic version is still available.

Tricyclic Antidepressants 

These include (but are not limited to) imipramine (aka Tofranil), amitriptyline (Elavil) and desipramine (aka Norpramin).  This is an older class of antidepressant medications.  SSRIs and SNRIs have supplanted use of these and MAOIs mainly due to safety profile (e.g. these are more dangerous to overdose on).  These may also have more cardiac risks (on average) than SSRIs and SNRIs.

These are not ideal for elderly patients because of the following potential side effects:  sedation (and, thus, falls), low blood pressure, and increased confusion.  The latter is technically called anticholingergic delirium, and paroxetine or antihistamines can also cause such.  That’s why those are also not ideal for the elderly. 

These may be a good choice of antidepressants for those with pain or gastrointestinal disease (as they are used to treat symptoms of both).  These also have a slightly similar mechanism of action compared to other antidepressant classes mentioned; the end result is that they increase levels of norepinephrine (also known as noradrenaline; and epinephrine is also known as adrenaline) and serotonin.  

MAOI inhibitors

These include phenelzine (aka Nardil), tranylcypromine (aka Parnate), isocarboxazid (Marplan), and selegiline (aka Emsam).  These are another older class of antidepressant medications.  Again, their mechanism is similar to the other antidepressant classes by increasing levels of norepinephrine, serotonin and dopamine in the brain. 

Statistically, these appear to be more effective than SSRIs, SNRIs, and TCAs.  One problem with research of these meds, however, is that there are limited head to head trials (i.e. one medicine versus another), so that’s one reason it’s hard to make a blanket statement that these are more effective than the other other classes.  Plus, certain people will respond better to one class versus the other, and despite the science, there is a trial and error approach to finding the best medicine (thus, the “practice” of medicine).  

These come with a very restrictive, low tryamine diet (avoiding certain meats, fish, cheeses and other milk products, alcohol, and foods with yeast).  That is one reason they are not used often.  There is one exception to this.  Selegeline is available in a transdermal patch.  The lowest dose of this patch does not require a strict low tyramine diet.  But if the higher doses are used, it’s vital to follow this diet.  Not adhering to this diet can lead to a severe hypertensive crisis which can be an emergency requiring you to call 911 and go immediately to the ER.  

Bupropion (aka Wellbutrin or Zyban) 

This is a unique antidepressant with activity on the dopamine system in the brain as well as noradrenaline but not serotonin.  This should be avoided in those with seizures or bulemia.  It is also approved to help quit smoking tobacco.  Case reports note reduced cravings for other stimulants like cocaine and methamphetamine.

It can also treat ADHD or ADD.  This is typically thought of as an energizing or stimulating antidepressant.  On the flip side, this med can contribute to anxiety (if it’s overstimulating) perhaps more often than the other classes of antidepressants described.  So is not often used for anxiety like the other classes.  However, it can have a calming effect on a person with ADHD or ADD. Thus, it might be a good choice for someone with a combination of depression, ADHD or ADD, and or anxiety

Cannabidiol (CBD) & Medical Marijuana

Let’s address the skeptics here first, but also look at the big picture in an unbiased way.  We clearly need more research on this topic.  Marijuana can clearly be addictive for some.  Our society has had a puritanical basis against marijauna research in the past.   It’s clearly safer on average than alcohol and benzos in terms of overdose and fatality.  Typically, overdose on these products has not ever been described as fatal.  Only very recently has a coroner said there may have been a fatal overdose on marijuana.  Even if this is not an accurate report, with the legalization of marijuana and development of higher potency strains, it would not surprise me that this does occur in time.  But for now, in the big picture, the #1 drug that kills in our society is nicotine, and alcohol is #2.  

I think we should use certain terms less (e.g. drugs, medicines, herbs), and be more scientific and less biased with our descriptions.  All these things are psychotropic substances (meaning they affect the brain in some way), which to me is a more scientific term with no positive or negative connotation.  No psychotropic is good or evil in and of itself.  It is only good or bad for a given individual … sometimes both (e.g. if it has a positive effect but also negative side effects). Some people think “natural” products or herbs are safer, which is not always true.  Many over the counter products are more dangerous to overdose on than prescription meds.  Many herbal or other over the counter products can have dangerous interactions with presribed medicines.  Whenever taking both prescribed medications and over the counter products, always double check with both your primary care physician and pharmacist that the combination is safe.  

The mechanism of action here concerns the endocannabinoid system in the human body.  Like the other classes of medicines discussed, the exact mechanism is not completely understood.  This can have various different effects including reducing seizures, anxiety, and gastrointestinal symptoms.  The first ever CBD product was approved last year for severe seizure disorders. 

I tend to refer my patients to someone who specializes in medical marijuana and CBD when other classes of medications like antidepressants have failed them.  

Tetrahydrocannabinol (THC) is another chemical in marijuana besides CBD.  Again, we need more research on all of these.  THC formulations, depending on the exact subtype, could potentially help or worsen anxiety and depression.  THC can also worsen psychosis (e.g. schizophrenia).  On the other hand, some research shows CBD could help treat psychosis. 

Another classification of marijuana uses the terms “sativa,” “indica,” and “hybrid.”  There is a partial misconception that sativas are more stimulating (and, thus, could help depression, and indicas are more calming (and, thus, could help anxiety).  Keep in mind this is an oversimplified classification system that is not wholly accurate.  A more in depth discussion of this topic is beyond the scope of this summary.  

S-Adenosyl methionine

This occurs naturally in all our bodies, and is involved in the synthesis of neurotransmitters like epinephrine.  SAMe also helps produce and regulate hormones and maintain cell membranes.

While it can have various medical uses, as far as emotional health, the main research has been on depression.  There is not much evidence showing it can help anxiety.

That being said, because some of its effects are similar to antidepressants, I wonder if it could help anxiety.  I have recommended SAMe to those with depression before with good results for some (but not all), and would be open minded to recommending it for those with anxiety.  It’s a topic that only recently has crossed my mind, which is why I have not yet been trying it for anxiety.  

Antihistamines 

These include (but are not limited to) diphenhydramine (aka Benadryl) and hydroxyzine (aka Vistaril).  They bind to histamine receptors in the brain.  Other classes of medicines sometimes have mild antihistamine effects too (e.g. some antipsychotics or mirtazapine).  Even though anything sedating can be addictive as noted above, these are typically very low in addictive potential compared to benzos, marijuana or other drugs.  Thus, they are used quite often these days (again, off label use) for patients with anxiety who have a history of addiction that are trying to stay sober.

They can also help allergies, itching, or sleep.  On that note, any medicine that helps anxiety at a certain dose can often help insomnia at higher doses.  When used regularly, especially at higher doses, these can have negative effects on the elderly.  Thus, they are not typically recommended for them.  

Antipsychotics 

Antipsychotics are not FDA approved for or typically used for anxiety disorders.  These are also not named well.  They are also referred to as neuroleptics.  These are typically approved and presribed for psychotic disorders like schizophrenia.  However, many of them are also approved and prescribed for bipolar disorders. Thus, they may be good choices for patients with schizophrenia or bipolar and also anxiety.

They can potentially have severe side effects over time including tardive dyskinesia (which is a condition that involves repetitive and involuntary bodily movements) and metabolic syndrome.

One very unique option is quetiapine (aka Seroquel).  It arguably has the least risk of tardive dyskinesia.  It is prescribed off label for anxiety, insomnia and PTSD quite often.

Antipsychotics can also help those with severe OCD, especially when traditional antidepressants or other treatments are not effective enough.  These can also have potentially severe cardiac side effects.  These work differently than antidepressants, but have some similarities (effecting serotonin and dopamine systems in the brain).  

Other (e.g. psilocybin, MDMA, & ketamine)

Like marijuana, there has been a recent bias against such research in our society.  Research on these started years ago (and arguably helped lead to research on the other classes of medications discussed), and there has been a resurgence in research of such (e.g. psilocybin and MDMA for certain anxiety disorders like PTSD).  There has also been research showing certain hallucinogens can help patients recover from addictions. 

Micro-dosing has become popular of late.  This practice involves using very small doses of hallucinogens (not strong enough for a full hallucinogenic experience) for emotional health.  However, there is limited research on this topic.  

Ketamine is being used lately for depression (but not anxiety).  An intranasal version was very recently FDA approved for treatment of depression.  Some say this may not be as effective as intravenous ketamine.  I would not recommend ketamine for anxiety, but if someone had severe depression with secondary anxiety, it’s possible it could help both.  

It’s a relatively moot point for now, as besides ketamine, the others are not yet legal to prescribe in the USA (there are some exceptions to this in those using these substances for religious purposes).  This could change in the future.  

These substances may worsen or lead to psychosis as well.  Excessive use could also contribute to worsening depression or anxiety.  A full discussion of these (or any other class mentioned here) is beyond the scope of this summary. 

– Dr. Rahul Khurana

Caffeine and Anxiety

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Caffeine & Anxiety

This blog post provides information about caffeine consumption that will be helpful for those who suffer from anxiety. The short answer: yes. Caffeine can make your anxiety worse, but that does not necessarily mean you should quit. Whether quitting caffeine is right for you, as a strategy for reducing your anxiety, depends on a number of factors - including your ability to exercise and your access to psychotherapy.

The consequences of caffeine

Millions of Americans use caffeine every day both to wake up and to keep going throughout the day. Why so many people use caffeine regularly, and end up dependent on it, is no mystery. Caffeine has a number of benefits that include increasing wakefulness, decreasing feelings of fatigue, increasing focus, and improving certain aspects of cognitive performance (in both the short and long term). Perhaps more importantly, it tends to make people feel happier, because it stimulates the release of certain neurotransmitters (such as dopamine and serotonin) in the brain - and also because people take pleasure and comfort in the ritual, routine, and sensory aspects of drinking coffee, tea, or their favorite energy drink.

Despite these benefits, caffeine can pose real problems for some people. One of the main ways that caffeine can adversely affect us is in terms of anxiety. Those who suffer from anxiety should at least consider cutting down on their caffeine consumption. Below, we’ll take a look at some of the ways in which caffeine can adversely affect us. We will also take a look at some alternative approaches to reducing anxiety that do not involve cutting caffeine.

How does caffeine affect anxiety?

There is a correlation between the amount of caffeine individuals consume and the level of anxiety they experience. In general, the more caffeine a person consumes, the more likely they are to be feel jittery and nervous, end up in a state of worry, and not be able to sleep at night. Caffeine intake can also exacerbate anxiety disorders, such as panic disorder, obsessive-compulsive disorder, and social anxiety.

Although caffeine is not the root cause of anxiety, it can make an already anxious person feel considerably more anxious. One of the ways that caffeine increases anxiety is by triggering the release of epinephrine, a stress related hormone that can intensify the brain’s normal fight-or-flight response. Caffeine can also diminish sleep quality, because it temporarily blocks adenosine transmission in parts of the brain, which in turn contributes to anxiety.

Success without quitting caffeine?

As mentioned above, caffeine has a number of potential benefits. Consuming caffeinated beverages can also be an enjoyable part of the rhythm one’s life. This leads many people, even those with anxiety disorders, to be resistant to the idea of quitting caffeine.

Quitting caffeine is unpleasant - although some would argue that it’s relatively easy. After all, you just have to stop consuming it, learn to live with the fact that you do not get to enjoy coffee, tea, or energy drinks anymore, and then brace for the withdrawal symptoms (more on those below). Holding onto the comfort of caffeine, while overcoming your anxiety, requires more work.

Two of the best alternatives to to quitting caffeine include exercising and going to therapy. Exercise, like cutting down on caffeine, is mostly a palliative approach to treating anxiety. That is, exercise can be very helpful in managing the symptoms of anxiety, but does not target the underlying causes of anxiety. However, it’s one of the most powerful palliative approaches to treating anxiety and for many it can bring relief almost immediately. Psychotherapy, by contrast, can take longer - it doesn’t usually bring immediate relief of symptoms. However, it does offer the possibility of a deeper and more long lasting change. Together, they can be a powerful approach to leading a less anxious life.

Ultimately, both exercise and therapy require time and often also financial commitments (exercise perhaps, does not require financial commitments; although it does require a body able to engage in exercise - and having the money to pay for a gym membership and a personal trainer certainly helps). This means that unfortunately, they simply are not accessible to everyone. If you have health insurance, often your insurance will cover a portion of your psychotherapy and counseling. It may also provide discounts for gym memberships or personal training. You can also check to see if therapists or clinics in your area offer sliding scale discounts.

If you are looking for therapy for your anxiety, you should spend some time searching around for different therapists so you can find one who seems like a good fit for you. The fit between therapist and client is an important variable in the success of the therapeutic process. The approach that the therapist takes is also important. Make sure that you are comfortable with the approach they are taking to treat your anxiety. Have them explain their approach to you (they’ll often do this on their website or else you can write them an email). Once you think you’ve found a therapist that will be a good fit for you, ask them for a free consultation so that you can get a feel for them. These are also good considerations to keep in mind when searching for a gym or a personal trainer.

Is caffeine sensitivity real?

Some people are much more susceptible to the effects of caffeine than others. For them, even a very small amount of caffeine can have adverse effects on how they feel and on their anxiety levels. Sometimes even drinking decaffeinated coffee is a bad idea, as it will still contain small amounts of caffeine - enough to make a big difference for someone with a pronounced sensitivity.

If you have a sensitivity to caffeine, the results of lowering your caffeine dose will be much more pronounced than it would be for a non-caffeine-sensitive person. In fact, if you have a strong sensitivity to caffeine that has gone unnoticed - changing your caffeine intake could make a world of difference.

Is caffeine safe?

For most people, yes. Up to 400 mg of caffeine is generally considered safe for healthy adults. Of course, different caffeinated beverages have different amounts of caffeine in them. A brewed cup of coffee generally has about 100 mg of caffeine, but keep in mind that the size of the “cup” is not irrelevant. 

Many individuals who consume caffeine daily will ratchet up their intake over time. After years of caffeine consumption, they may find themselves consuming espresso drinks with multiple shots in them or drinking very large cups of coffee. 

For younger people, limiting caffeine intake is generally considered a good idea. It is usually recommended that adolescents not exceed 100 mg of caffeine per day. This is the equivalent of about three cans of coke or one cup of coffee.

if I decide to quit?

Although quitting or cutting down on caffeine can be tremendously helpful in reducing the symptoms of anxiety, this is easier said than done. Many people rely on caffeine to get them through the day. Cutting back often means feeling tired and sluggish, an inability to focus, headaches, body aches, nausea, cold sweats, and even temporary depression. These symptoms do not last forever, but they can sometimes last more than a month.

Having said that, quitting caffeine is not for the faint of heart. It takes real willpower to do this - and might even require you to use some of your vacation time (if you have any) while you are recuperating from the withdrawal symptoms.

Before deciding to change your caffeine intake, you should check in with your primary care physician. They can help you make sure that cutting back on caffeine will be safe for you and can help you determine how best to do it given your particular needs as a patient. This leads me back to my disclaimer (see the beginning of the post).

Thanks for tuning in Seattle!