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

What Causes Anxiety?

What causes anxiety?

This essay provides a perspective how anxiety can emerge from the interaction of perceptual and neurological processes, and explores how this understanding can help us to overcome it.

What we don’t know about anxiety… 

Anxiety is not just an uncomfortable emotion, it is also often a confusing one. The confusions that surround anxiety can exacerbate it, can cause it to snowball. When we do not understand why we feel anxious, or what to do about it, we may become increasingly anxious about becoming anxious. Anxiety feeds on confusion and uncertainty.

Too much of the information that is available on anxiety fails to explain how anxiety comes about, and as such does little to dispel this uncertainty. The most common way of explaining why people get anxious is by appeal to situational triggers. Now, this is not an unimportant part of the story about why we get anxious, but it is certainly not the part that is mysterious to those suffering from anxiety. Most anxiety sufferers do not need anyone explaining to them that certain situations make them feel more anxious. They get it. They also tend to have a pretty good grasp on what those situations are.

Usually, mention of the mechanisms by which anxiety comes about are entirely missing from discussions on the subject. This is forgivable, seeing as anxiety is both physiologically and psychologically quite complex. Furthermore, most of those who write in a public format about anxiety (e.g., in blog posts or magazines) are not clinicians (psychologists, psychiatrists, etc.), but are instead people sharing their experiences of dealing with anxiety - something that is of course also quite valuable and which has an entirely different aim.

In what follows, I want to give a sketch of the mechanisms that conspire to bring about anxiety. This will not be a complete sketch and will not be without exception. However, it will be thorough and general enough to give you a sense of what's happening when you're experiencing psychogenic anxiety (anxiety with a psychological origin). Note that while most anxiety symptoms are psychogenic, some anxiety symptoms are somatogenic (arising from a physical rather than a psychological cause). Because of this, you should consult your primary care physician if you experience anxiety symptoms. They will be able to help you determine if your symptoms are the result of an underlying medical condition. Setting somatogenic causes aside, however, we can turn our attention to how the brain, in collaboration with other parts of the nervous system, manages to generate anxiety.

The Autonomic Underpinnings of Anxiety

Your autonomic nervous system plays an important role in the emergence of anxiety, so much so that certain of its behaviors are often conflated with anxiety - even sometimes by psychologists. Now, the autonomic nervous system is automatic (“auto-”), meaning that it does its own thing (you do not get to just pick and choose when it does what it does), and lawlike (“-nomic”), meaning that there are very few exceptions with regard to its behavior.

Your autonomic nervous system is split into two sub-systems. There is the sympathetic division (sympathetic nervous system) and the parasympathetic division (parasympathetic nervous system). These two subsystems are in a kind of competition for resources, meaning generally that when one is more activated the other will be less activated.

Parasympathetic system activity is often associated with calmness and relaxation. The parasympathetic system plays an important role in a number of processes, many of which we might think of as vegetative - things like digestion, automatic breathing, sleeping, and the physical aspects of sexual arousal. The sympathetic system, by contrast, is often associated with alertness and excitation. When we are in a state of sympathetic activation we may experience increasing heart rate, constricted blood vessels, increased blood pressure, pupil dilation (and tunnel vision), perspiration, as well as muscle tension and twitching.

As sympathetic activity increases it can lead to parasympathetic deactivation. Because the parasympathetic division controls digestion, this can bring with it a shutdown of digestive processes, leading to symptoms such as dry mouth, loss of appetite, and even nausea. Other symptoms of parasympathetic deactivation include “forgetting to breathe” (a shutdown of automatic breathing and a need to start breathing intentionally), difficulty becoming sexually aroused, and difficulty falling asleep. This transition can even lead to increased (sometimes unintentional) urination and voiding of the bowels.

Because sympathetic activation is often experienced as a kind of discomfort, habits can easily form as a means of repressing it. Usually, these are habits that stimulate a countervailing parasympathetic response - for example, eating food, drinking alcohol, and engaging in autoerotic activity (i.e., masturbation).

Now, a lot of these features of sympathetic activation are recognizable as symptoms of anxiety. And because of this, there is a common error that gets going right here. It is easy to look at sympathetic activation and say “That's it. That's anxiety!”, but we should resist this temptation. Because although sympathetic activation plays an important role in anxiety, it is not itself anxiety. And it is not just that sympathetic activation is not anxiety… it is not even an emotion, not in itself anyway - although it does play a foundational role in a number of emotions including anxiety, anger, and excitement. 

The Role of Perception in Anxiety and Other Emotions

With sympathetic activation identified as a necessary ingredient in the emergence of anxiety, we are left with two questions. First, where does sympathetic activation come from (what triggers it)? And second, how does this activation lead to anxiety? The answer to both of these questions is perception - but that needs quite a bit of unpacking.

Perceptions are the primary triggers of sympathetic activity - specifically, perceptions of challenges. Here, challenges can be conceptualized as gaps between the way things are and the way they should be - gaps that are at least in principle bridgeable - even if only by very rickety bridges. Sympathetic activity increases as perception of challenge increases (in terms of quantity, significance, complexity, and so forth).

If you have a lot of sympathetic activity, that is almost certainly because you perceive lots of challenges. You see challenges within challenges, and challenges within those challenges. Sometimes, you might feel overwhelmed by all of these challenges - you might feel like you are drowning in challenges. And at the risk of sounding pollyanna, I want to suggest that this is a very good problem to have. After all, the fact that you are perceiving so many challenges tells us that you are really quite perceptive. Your perceptiveness, in turn, is mostly just a function of intelligence, creativity, and functioning sensory organs. This is a set of assets, perhaps some of your greatest assets, that have somehow managed to become a liability - again, perhaps your greatest liability.

With the path to sympathetic activation laid out, we can turn our attention to how it becomes anxiety. But because anxiety is an emotion, we should first ask ourselves “what is an emotion?” This is a psychological question that, much like the question of anxiety, does not get the consideration it deserves. In part this is because it is often difficult to answer such an abstract question in a way that is not just trivially circular (as in: “it's how you feel.”). A good initial answer turns out to be quite simple, but surprisingly unintuitive.

Emotion is an ever present part of our experience. Just as a sentence is always said in some tone or other, we are always in some mood or other, always experiencing things from some emotional state or other. Even a Spock like “absence of emotion” is still technically an emotional state - a subtle, pervasive, and unrelenting calm.* Now, our emotional state is much more complex than Spock’s - we might simultaneously feel anxious about certain things, calm about others, angry about some things, sad about some, and so on and so forth. An emotion is a way of perceiving ourselves in relation to something, and we are in relation to very many things.

Our emotional state is determined both by which of these relations we are bringing our attention to and how we are bringing our attention to them. This second piece is crucial because it means that our emotional response to something depends on how we perceive it - not just that we perceive it - and there are a number of different ways to perceive sympathetic nervous system activation. This activation is the foundation, the somatic referent, for the anxious and fearful family of emotions. However, it is also the foundation for other high energy emotions, including anger and excitement.

*Anyone who has actually watched Star Trek will know that Spock's emotional life is much more complex than this caricature - but it is a helpful caricature nonetheless.

Anxiety - Too Much of a Good Thing

The crux of the issue is that there are those who suffer from a lack of life and those who suffer from an overabundance of it. 

The dull and the depressed both suffer from a lack of life in their own way. Dullness carries with it a lack of sympathetic activation because it is grounded in a lack of perceptiveness… meaning fewer challenges are perceived, and even when they are perceived their full gravity and complexity is usually not apprehended. Depression also rests on an, albeit temporary, inability to perceive challenges. But here it is not perceptiveness that is wanting. The difference is more nuanced. In depression there is an acute awareness of gaps, of distances between the way things are and the way things should be. But in depression, many of these gaps seem unbridgeable. And if they can't be bridged, they don't show up as challenges… only as occasions for sadness. When what is wrong seems like it cannot be made right, actions become pointless for us - at the limit, everything seems pointless: getting out of bed… bathing… living. Nothing is off limits. 

However, it is not in the lowest depths of depression that one is at the highest risk for suicide. Most dangerous is the beginning of the ascent out from these depths. For it is here that one is beginning to see more gaps as challenges - it is here that energy again comes back, that the potential for action returns - it is here that sympathetic activation begins again in earnest. 

In the face of challenges, sympathetic activation gives us this energy, a kind of life, and it is up to us to figure out what to do with it. There is much at stake here. For if we cannot embrace it, if we reject this energy, this life, it will not just go away. It stays there, coursing through our veins. Without an outlet, it stagnates there, sours, and rots. Turned inward, that energy becomes a liability and a source of profound misery.

What Causes Panic Attacks?

Perception of challenges increases sympathetic activation, and in anxiety our sympathetic activation is experienced as a kind of challenge - as a problem that we need to do something about. We see what is happening in our body as a roadblock to overcoming many of the other challenges in our lives - often in proportion to how important those challenges are. This makes anxiety unique among challenges. It is a kind of meta level challenge that has its fingers in all the other important challenges we face. In this way it takes on a seriousness, a weight, through which it exacerbates itself. 

When we see sympathetic activation as a challenge, our sympathetic activation increases. Again, this is because sympathetic activation is tied to perceptions of challenge. This increase in our sympathetic activation in turn also increases our perception of the challenge. It is a vicious circle. As it turns, we increasingly begin to feel that things are going to be difficult or uncomfortable. As we watch our sympathetic activation increasing - and with it our anxiety - we may worry that it will continue to increase. Again, this makes the challenge appear even greater. With such a great challenge on our hands we will be tempted to try and understand, not just its trajectory (which at this point seems dire), but also its origin. Such a profound set of symptoms can seem like it demands a profound explanation - for example, that we are having a heart attack - that we are dying.

Anxiety, and at the limit panic, comes as if out of nowhere - feeds on uncertainty, feeds on ignorance, feeds on itself.

Archetypal Lessons from Anxiety

There are a number of archetypal lessons that crop up for us once we see what's happening in anxiety. For example, notice that the hero and the coward are neurologically quite similar. What ties them together is their perception of challenges - challenges that others around them, more neurotypical individuals, might not notice. In response to noticing all these challenges, they are saddled with heightened sympathetic activation. One of them experiences this activation as an asset, as readiness for action, as excitement - as courage. However, the other experiences this same sympathetic activation as a liability, as an inability to act, as anxiety - as cowardice.

Perhaps the most salient perceptual difference between the hero and the coward, shows up in their locus of control. The coward experiences things as happening to them, as being changed, while the hero experiences themselves as the source of this change. The coward experiences the world impinging on them, while the hero sees themselves as impinging on the world. Cowards feel powerless. They feel vulnerable - like things are out of control. The transition from coward to hero is experienced as a loss of one's powerlessness.

Similarly, we notice a kind of neurological similarity between predator and prey. When prey is in the presence of a predator, its sympathetic nervous system is activated. By design, the prey experiences this activation as anxiety, as a profound discomfort that tells it that it needs to run for its life. The predator also experiences sympathetic activation in these situations - that is, whenever it is in the presence of prey. However, the predator does not experience anxiety. Quite the opposite. The predator experiences their sympathetic activation as excitement.

The Short-Term Goal of Therapy

Anxious individuals often assume that the best course of action is to try and feel more calm. They want to be more like Spock when faced with a stressful situation - cool under pressure. However, this is just one alternative among many. There are a number of ways to experience something other than anxiously and calmly. This isn't a criticism of anxious individuals. Far from it. We all do this. Our cultural understanding of anxiety frames the issue in this way. 

When we feel anxious, it is normal to feel like prey, as if a predator is bearing down on us. What our anxiety seems to be telling us is that we need to escape. And although we might dream of being magically transported to safe space, free from challenges - how prey might feel if they were transported to a perfect garden, full of abundance, without a predator for hundreds of miles - we also dream of being able to handle these stressful situations without having to escape. Our highest dream is one of being able to go through these situations calmly, without having a strong emotional response to them. 

While these are attractive visions, they both fail to respect lived psychological realities. We cannot feasibly escape from the things that are provoking our anxieties - nor can we “just snap out of it” or “just calm down”. These visions are unhelpful, tending only to produce an onslaught of additional negative emotions such as shame and depression when we inevitably find ourselves unable to make them a reality.

It is important to emphasize that this Spock-like image of how we should behave in stressful circumstances is a kind of culturally constructed norm. That anxious people should be calm, and that becoming calm should be easy; these are some of the most widely held beliefs about anxiety. Again, this is an attractive image, but it is also a false image - one that, like the fantasy of a world free from challenges, fails to correspond with human psychology.

The actionable lesson that falls out of this understanding of anxiety is that excitement is often an easier emotional space to access than calmness. By reframing what is ahead of us as exciting rather than as threatening, we can begin to feel less anxious. Similarly, by reframing what is happening in our body during moments of sympathetic activation as energy or excitement, rather than as anxiety, we can come to feel less anxious. 

Accessing this perspective, a vision of ourselves as capable, a vision of ourselves as free from vulnerability - this is what is required to transform our emotional life. Unfortunately, this is not an easy task. Sometimes individuals can manage this reframe on their own, but often psychotherapy is needed. This is the short term goal of psychotherapy for anxiety - to help individuals transition from anxiety into excitement. 

The Long-Term Goal of Therapy

The long term goal of therapy for anxiety is calmness. How this is achieved has less to do with reframing and more to do with investigating deeply rooted beliefs, interpersonal tensions, insecurities, and so forth that may be generating a distortion in their view of the world and of themselves - a distortion that exacerbates their perception of challenge and keeps them in a chronic state of heightened sympathetic activation. 



Thanks for tuning in Seattle!

On the Anxiety of Parenting

[This was originally written as a letter of advice to friends, but it occurs to me that someone else might benefit. If you don’t like what I’m saying here, ignore it and move on--there’s nothing less edifying and pointless than people debating parenting.]

Rather than being very long-winded and monopolize your time in conversation (well, we can always do that too!) I thought I’d just sketch out some random thoughts as the two of you begin on this great adventure.

One thing I definitely have to get out of the way here is that, yes, my kid did commit suicide. We know this. This could either color things as “here are the horrible mistakes to avoid” or, perhaps, why should we listen to anything he says? What could constitute a more disastrous failure? And rather than just ignore that elephant, I should say: despite all kinds of understandable irrational guilt, I don’t really think my son’s death says much of anything about me as a parent. Lots of teenagers flirt with the idea and even make half-hearted attempts, and I’m inclined to think the success of his attempt was a fluke and thus the whole thing was something of an accident, like being hit by a car. He had issues, but I think they had more to do with other factors.

After getting off to such a cheery start... I do think that I made some mistakes, and that they are very very common mistakes. I don’t know if they are entirely avoidable through prior awareness or not. Also, some people will say that what I’m considering mistakes now were never mistakes at all. I guess the short version is: take anything I say with a grain of salt, which I don’t really need to say because you would anyway. As they say, your mileage may vary. Most of what follows won’t be relevant, if ever, until much later.

I guess the first thing I would say, one of the more superficial things, is this: people attracted to libertarianism often have issues with authority, and rightly so. So much of adult life involves people wrongly treating each other like parents or children, with unfortunate political, and not just political, results, that it is tempting to overgeneralize and conclude that because adults ought not to model their relations on parent-child relations, that therefore parents and children shouldn’t either. From this, some people get the idea that it’s important to never approach a child as an authority figure, to always treat them with respect as if they were little adults, to always offer reasons for everything you do, to (to whatever degree possible) not coerce them in any way.

Gradually over time I became convinced that this was a mistake, and a mistake that has roots in a deeper mistake (the “I’m going to fix my childhood by doing what should have been done to me to someone else, my child”--more on that below probably). I don’t know if one can generalize--children may have different temperaments which make different things work for different children. But in the case of my oldest, explaining why things had to be a certain way by using reasons created a tendency towards sophistry and a lack of self-discipline. He didn’t just take the reasoning on-board the way an adult would, but rather took it as a sign of weakness that could be pushed back against, a sign that you could talk your way out of things.

In short, it didn’t work. And the tendency to want to try to make it work was rooted in my own false belief that exercising authority, setting limits without argument or consent, etc. was necessarily arbitrary and hostile just because my parents (my father) had been. But firm, fair and consistent isn’t tyranny, isn’t necessarily destructive. The more confident you are with your own authority, the more your limit-setting can be cheerful, without anger, consistent, etc. I suspect, though I’m not sure, that when a parent does not seem to really exercise authority, this creates a certain anxiety in the child, that you aren’t really taking responsibility either, can’t be relied on. Part of being an adult means “we’re on our own.” But to send the message to the child that the child is on their own is a kind of abandonment in a way.

Anyway, this is the part of my experience that I think will strike people as most controversial, and so take it with a grain of salt. Because I was afraid of doing anything negative, I often avoided doing things that were positive, and providing structure suffered as a result. Short version: you’re in charge! That’s OK! If you’re fair in the exercise of your authority, they won’t blame you for it later. I always think of this in connection with this wonderful moment in Talladega Nights (great Will Ferrell comedy) where the two kids, who are hilariously awful (one of them is screaming “Anarchy! Anarchy! I don’t know what that means but I love it!”) come up against Granny when she says “I am declaring Granny Law.” Something about her tone when she says that seems perfect to me, not angry, just clear and firm. So: declare Granny Law.

The second thing, or maybe second and third things: to the extent that we are dissatisfied with how we are raised, we harbor an unconscious fantasy of correcting our childhoods by being better parents than our parents were. But there’s something subtly wrong with this fantasy, because it depends on the idea that your child is really you in disguise. If they are, then you are unconsciously trying to raise the child to achieve results for yourself that have nothing to do with the child qua real and separate person. Initially this can motivate you to be wonderful, being the mother or father you never had, but the whole drama falls apart if the child does not assume his or her role of being you. Eventually this can lead to a kind of resentment that leads to anger and conflict. If the child does things that undermine your efforts to fix your own past, you can get angry with them for not cooperating.

By contrast, if you are not trying to fix your own past, what they do or do not do can be interpreted in light of what’s best for them. It’s difficult to explain this without drawing on the terms “selfishness” and “selflessness” in a way that won’t go down well with Rand fans, but the problem here is not selfishness, it’s narcissism. If you over-identify with the child, it can make you extremely solicitous of their welfare, which at first seems good, but when they get older and start to define their own identities, their individuation can seem like a betrayal because they are refusing to play their own role in your own drama, the role of you made young again.

This thought occurred to me this morning, and it will sound really really weird! But ideally you should treat a child the way you treat a pet... but a pet who is gradually transforming into a human being. We care for our pets, but we don’t identify with them, we do not look to them for validation, we never say “after all I’ve done for you, you turn on me now?” In fact, sporadic irritability aside, no one is more patient than a pet owner who just got bitten or scratched by a pet... because it doesn’t mean anything other than what it is. It is, in a sense, easy to care for pets because we can’t identify with them fully, can’t look to them for validation, etc. And when all those things are taken off the table, you can just do what is best for the pet, which is what you’re supposed to do with them... and then take pleasure in watching them thrive and grow.

This is all related to another thought, or perhaps it is a version of the same thought: parenting is not a contest. No one is keeping score. It’s not a performance in the eyes of someone else. There is some tendency to drift into a kind of second-handedness in parenting. But if you’re trying too hard to be a good parent because on some level you feel like you are being judged, it can get in the way precisely of being a good parent. Again, it’s tempting to talk about selfishness and unselfishness here, which is not quite what I’m getting at. Parenting is, ultimately, not about you. It’s about the child. It is the activity of helping someone become a human being in their own right. This is related to the fantasy of correcting one’s own childhood: if parenting were about correcting your own childhood, then it’s about you, not about the child. Seeing it as the task at hand, rather than proving something to yourself about yourself actually makes you do it better... and then later you can pat yourself on the back for being awesome. There’s something about trying to be awesome which undermines itself here.

There’s a thing that happens to a lot of people, and which doesn’t happen to some people, and which the culture does not like to talk about: many people experience an emotion in relation to their child that is just like “falling in love” with a romantic partner. This is absolutely normal... but the complete absence of it is absolutely normal too. Don’t stress about it either way. The being-a-parent thing is going to be happening in any case.

This is something of conventional wisdom, but it’s really very true and tremendously important: the best thing you can do for a child as a parent is to live well yourself. All the time you are around them, you are modeling behavior, and they assimilate far more from example than from instruction. If you take good care of yourself, they will imitate that, and do well as a result. A big part of this is, do not for a minute think that, now the child is more important than your spouse. Having a great relationship with your spouse is one of the greatest gifts you can give, because the child will model their own relationships on that. Also, it is tremendously reassuring to a child to know that they are in an environment suffused with love. It doesn’t all have to be directed at them. They benefit enormously from seeing love in action, from seeing happy parents. So if there is any temptation to think, now my relationship must take second seat to this child rearing stuff, except in the most trivial and obvious senses, resist that. The child loves the fact that you love each other, learns to love from that, and feels infinitely safer knowing that.

Named one of the best online anxiety publications

The Seattle Psychiatrist has been selected by feedspot as one of the best anxiety blogs on the web – and we’re just getting started, so stay tuned!

The Most Anxious Time of the Year

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The most anxious time

Exploring why the holidays reveal our deeply rooted anxieties... and how we can make them a bit less miserable.

Happy Holidays

The holidays are supposed to be a joyous and relaxing break from our lives. They are meant for spending quality time with our family members, away from the stress of work and other obligations. They are supposed to be "happy." However, this image of the holidays is often more comical than accurate. For those who suffer from anxiety, the holidays can prove to be one of the most challenging times of the year.

There are a number of reasons for amplified anxiety during the holidays: long standing tensions between family members stand to be rediscovered; old ways of thinking get triggered and lead us to feel and act like past versions of ourselves; the extra expenses at this time of year compound one another. These and other issues often conspire to make the holidays remarkably stressful. 

It is no surprise then that January and February are two of the busiest months of the year for therapists and counselors. After the holiday lull, the therapists in Seattle experience an influx of calls from those seeking to do something about anxieties recently rediscovered through holiday gatherings. The interest is often so great that many therapists and counselors end up with packed schedules by February and have to create waiting lists for new clients. 

Choosing to go to therapy is a good option for many. However, it is a long term solution - something certainly not intended as a short term fix to the intensified stress and anxiety of the holidays. Below, we will look at some reasons why the holidays are uniquely stressful and discuss an effective mindfulness based strategy for dealing with the attendant anxiety in the moment.

Interpersonal Tensions

Anxieties are often driven by unresolved interpersonal tensions. These tensions usually arise between individuals who play important roles in each others’ lives. Not surprisingly, they are most commonly found between parents and children, between romantic partners, and between siblings. These tensions take time to develop, but can stay entrenched for decades if they are not addressed in good faith. This helps explain why many interpersonal tensions are carried over into adulthood from childhood and adolescence. 

Close proximity and time are the primary factors involved in bringing out these tensions. When we spend substantial amounts of time with the important people in our lives, we set the stage for these tensions to be revealed - or developed. 

Reverting to Old Patterns

The holidays can also trigger old ways of thinking, feeling, and acting. These patterns may remain dormant for years, but are able to manifest automatically in the right settings. This is because the neural pathways involved in producing these thoughts, feelings, and behaviors are often still in place - requiring only the right situational trigger to activate them.

This helps explain why so many people feel like they are reverting to their “high school self” when they return to their hometown for the holidays. Familiar surroundings and familiar people are the most common triggers for this phenomenon. At the limit, for those who have become comfortably adjusted to a new way of life in a new place and around new people, reverting to old patterns in this way can produce an identity crisis.

Everyday Anxiety Triggers

While the above phenomena play an important role in explaining why (often deeply rooted) anxieties get revealed during the holidays, other more everyday reasons for increased anxiety are also frequently at play. These everyday triggers of anxiety include being in social settings (especially those in which one might feel judged), being in places with lots of sensory stimulation (noise, light, etc.), dealing with strains on financial resources, being away from work, travelling, and so forth.

For example, socially anxious introverts often find themselves facing a dilemma during their holiday gatherings. Attending these gatherings can mean several hours, or even days, during which it seems unacceptable to bow out and take some “me time.” They feel increasingly uncomfortable, but are often not willing or able to extricate themselves from the situation out of fear of being judged.

At most other times during the year, a socially anxious person could easily excuse themselves and leave. However, during the holidays they feel trapped. This feeling of being trapped manages to come along also with the other triggers listed above. That is, during the holidays, these triggers are relatively unique insofar as they are all more or less inescapable.

A Holiday Mindfulness Practice

Although it can be difficult, making room for yourself during the holidays is a necessity. If you can, take a break from the festivities, take some time for self-care, and try to show yourself a bit of compassion. Like most people, you probably love doing certain things during the rest of the year. To relieve stress, it can be helpful to identify and try to make room for these same things during the holidays. For some, this is going on a walk and listening to their favorite album. For others, it can mean physical exercise, meditation, reading the paper at a coffee house, journaling, and so forth. The point is to do something that you like, at least momentarily, instead of carrying on only doing what you think you should be doing.

Even if you can’t get away, just stepping back internally from your distress can be helpful. What does it mean to step back internally? The idea here is to remind yourself that, when you notice that you're feeling stress or emotional discomfort, that you can improve how you feel if you adopt the right approach toward your discomfort. An example of this approach is laid out below:

To try this, first see if you can find the discomfort on a felt level - as a bodily response to the situation. Notice not just that you are uncomfortable, but try to step back from that discomfort and examine it. Notice that it has a particular character that you can appreciate by detaching yourself from it. You can focus on it like you might focus on a particular color or texture. Try to view these felt sensations of discomfort, as they arise in your body, as if you were observing them from a distance. Try to notice and be curious about them. Let yourself appreciate them rather than trying to "do something" about them.

If you want to go even further with this approach you can incorporate some mantras (mental scripts). I’ll provide three that typically work well. When you’re ready, say to yourself slowly, in your head if you have to, the following three mantras in order.

First: This is a moment of suffering. This is difficult. This is tough. This is not easy.

Second: Suffering is part of living. It is common to all of humanity. Many other people feel this way. We all struggle in our lives.

Third: May I be kind to myself? What do I need? May I accept myself as I am? May I give myself the compassion that I need? May I forgive myself? May I be strong? May I be safe?

Finally, and especially if you're having trouble doing the previous part, imagine that a dear friend or loved one had a similar difficulty as you. What would you say to this person? See if you can offer the same words, the same message, to yourself.

Feel free to adjust the three mantras as you find it helpful to do so.

Other things that you can incorporate into this mindfulness practice are 1) telling yourself the situation, what it is that is happening in concrete terms; 2) realizing what you're feeling using words that really get at what you feel; 3) uncovering self criticism by looking for "should" language - for example: "I shouldn't feel this way"; 4) trying to understand yourself by asking “why might a good person feel this way?”, “why might it be okay to feel this way?”, and so on; 5) having the feeling. That is, just letting yourself have it. Let it flow through you. See if you can reduce the sense of tension by accepting rather than fighting it.

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Check back at seattleanxiety.com for more articles about anxiety and about what you can do to make a meaningful difference in your own life.

Working out anxiety

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Working out anxiety

This blog post is about the use of exercise to manage anxiety symptoms. If you suffer from anxiety and are looking to do something about it, this post may be for you.

The Basics

Easily one of the healthiest and most effective ways of dealing with anxiety is exercise. But how does it work? The discomfort felt in anxiety is tied directly to cravings for certain neurotransmitters. Exercise releases these neurotransmitters - and this is just one of the ways that it works to relieve anxiety. Exercising regularly also changes a person’s physiology, and makes them less prone to anxiety even on days that they’re not working out.

Exercise can take considerable willpower, but it gets easier over time. The next time you feel anxious, try engaging in some form of exercise before resorting to a less healthy coping strategy. Even just going for a walk can help. Hiring a personal trainer or teaming up with a fitness buddy are also great ways to stay motivated.

When thinking about anxiety, it can be helpful to adopt a pragmatic perspective. Know that there are a number of different reasons why any one person is anxious - and that a number of interventions can be used to help manage and/or treat the anxiety. Of course, understanding why anxiety has become such a problem is important, but equally important is figuring out what we can do about it.

There are a number of proven ways to manage anxiety symptoms. In the last blog post, we explored how lowering one’s daily caffeine consumption could lead to feeling less anxious. Today’s post will focus on exercise, and what it can do to lower your level of anxiety.

impacts & causes

The triggers of anxiety are as numerous and as different as the people who suffer from it. Fingers have been pointed to everything from formative experiences (including traumas) that are carried forward from youth, to cultural phenomena such as the widespread use of social media. The recent presidential election, stressful relationships, excess caffeine use, and many other things may play a role in maintaining and bolstering anxiety.

Anxiety disorders (those diagnosable levels of anxiety for which we have labels) affect more than 40 million Americans, making anxiety the most widespread mental health issue currently facing the United States. An even greater number of Americans, although not diagnosable with any anxiety disorder, still suffer from anxiety and could benefit from effective interventions. This is because anxiety makes it difficult to enjoy our lives and it also hinders our ability to function at work, at school, and in every other sphere of life. 

Both the personal and professional costs of anxiety are staggering. The global costs of untreated anxiety, in terms of workplace productivity alone, are estimated in the tens of trillions of dollars each year. The personal costs are, of course, impossible to quantify, but are equally serious. It boggles the mind to try and think of all of the job interviews, first dates, crisis situations, and so forth that have been soured by the symptoms of anxiety.

treatment & management

According to the most prominent theory in Psychology about anxiety, our anxiety is the result of the way we perceive and think about the world around us. This seems pretty straightforward. But notice that if this theory is right, then stressful situations do not actually make people anxious. Instead, people become anxious because they interpret situations as stressful, threatening, etc. 

Therapists working from this cognitive perspective will work with their client to create changes in the way they perceive their world - and thereby help them get rid of their anxiety. However, therapy is not accessible to everyone. For those who are not comfortable seeing a therapist, or who are unable for financial reasons to see a therapist, there are other options available. Exercise is among the best of these options.

benefits of Exercise

Because prolonged stress and anxiety have so many negative ramifications - including decreased ability to focus and concentrate, increased levels of fatigue, and poorer overall cognitive function - there are a number of benefits one can expect from including exercise in their daily routine. More sleep and better sleep quality is one of the easiest ways to measure benefits. Furthermore, all of these symptoms are connected. Notice that improving sleep quality will in turn yield a host of related benefits, including less frequent or less severe anxiety symptoms (precisely because poor sleep quality, especially a lack of REM sleep, can often play an important role in maintaining high levels of anxiety).

But why is working out such an effective approach to managing anxiety? When we exercise, our body produces endorphins - a group of hormones that have an opiate-like effect on the body. These endorphins produce a sense of calm that can ease anxiety throughout the day and can help us get to sleep at night. These natural “painkillers” are a healthy alternative to self medicating with substances such as alcohol. 

Exogenous substances (such as alcohol), have a tendency to disturb the brain’s electrochemical homeostasis and can lead to greater anxiety symptoms over time - both from withdrawal and as a result of chronic use. Working out releases endogenous anti-anxiety substances (such as endorphins) and is a better long term strategy. Over time, through a regular and rigorous exercise practice, we can put our brains in a better position to weather anxiety symptoms even when we aren’t able to make it into the gym.

Keep in mind that more intense physical activity can lead to a “runner’s high.” This is a state caused by a larger than normal release of endorphins in response to vigorous aerobic exercise. However, in order to feel the effects of endorphins, and to benefit from their anxiety easing potential, a more moderate approach to exercise will often be preferable.

There are many different ways to exercise, so it will be helpful to experiment. After trying your hand at different kinds of workouts (cardio, weight-lifting, yoga, etc.), you will get a sense of which workouts have the most impact on your anxiety and which fit the best into your life. Typically, exercise regimens that require the greatest level of physical exertion, and that can be performed regularly, will have the greatest impact on anxiety symptoms. 

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Check back again at seattleanxiety.com for more articles about anxiety and what you can do about it.

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!