Psychotherapist Nica Selvaggio on LGBTQIA Mental Health

An Interview with Psychotherapist Nica Selvaggio

Dominica (Nica) Selvaggio, LMHC is psychotherapist at Seattle Anxiety Specialists, PLLC. Nica has experience working with clients on a wide variety of issues, including anxiety disorders, eating disorders, substance abuse, sexual orientation and gender identity, acculturation and systemic oppression related to race and gender, trauma and PTSD, mood disorders, personality disorders, self-harm, relational issues, and attachment struggles.

Jennifer Smith: Hi, thanks for joining us today for this installment of the Seattle Psychiatrists Interview Series. I'm Dr. Jennifer Smith, Research Director at Seattle Anxiety Specialists. We're a Seattle-based psychiatry, psychology and psychotherapy practice specializing in anxiety disorders. I'd like to welcome with us today, Dominica Selvaggio, who is one of the psychotherapists at our practice. Nica has worked as a therapist for roughly a decade in the Seattle area and works with adults and adolescents aged 13 and older. Before we get started today, can you tell our listeners a little bit about yourself?

Nica Selvaggio: Yes, and thank you so much for the introduction, Jen. I'm really excited to be here talking with you today. That's always such a broad question. I never know where to start, but I guess that is the place to start that from a very young age, I was diagnosed with ADHD, and so my inability to pick where to start is a reflection of what I deal with in my brain. I love being a neurodivergent therapist because it brings a sense of understanding and compassion for folks who struggle with this sort of tangential thinking or not knowing where to start, that I find really, really helpful and I just get a lot of joy out of it.

So all that to say, I'm your local ADHD therapist. I'm originally born and raised in Chicago, the Midwest, and I've been in the Pacific Northwest for most of my adult life. I did spend three years living in Hawaii, and that was a really life-changing experience. And ultimately, I came back to the Seattle area because this land really has my heart.

Jennifer Smith: Wow.

Nica Selvaggio: I always describe myself as someone who's incredibly creative and just a lover of nature.

Jennifer Smith: That's great. And so you moved to the Seattle area from Hawaii. So what would be your favorite parts of the Seattle area, or just Washington as a whole?

Nica Selvaggio: It's the land, it's the mountains, it's the water, the plant life, all of it. I always say because of growing up in the Midwest that I was raised in corn and concrete. So when I moved to the Pacific Northwest and saw these huge mountains for the first time, even after a decade of being here, I'm still in awe. Yeah, I just really, really love the landscape.

Jennifer Smith: That's great. What is it that got you interested in being a therapist?

Nica Selvaggio: Big question. There's this storyline of The Wounded Healer that I think a lot of us are familiar with, that archetype of someone who has gone through their own experiences of pain and suffering, have tended to them, and then turned that compassionate attention outwards towards others who are struggling with similar wounds. My story as a therapist is not so different from that. I became interested in working in mental health out of necessity of caring for my own mental health throughout my life.

I'm a former foster care survivor and an adult adoptee, and so I had exposure from a very young age to some of the suffering in the world and in my own world and experience. So walking that path has really led me to wanting to provide a hand to hold for other folks on their own paths.

Jennifer Smith: Wow, that's really fantastic. Thank you for sharing that. What areas or disorders do you specialize in, besides ADHD?

Nica Selvaggio: Well, I got my start working in the clinical world specializing in eating disorders. So the bulk of my career was spent working in high acuity treatment centers, inpatient level residential, partial hospitalization, intensive outpatient, and working with folks who struggle with things like anorexia, binge-eating disorder, bulimia, ARFID, avoidant restrictive food intake disorder, which is often accompanied with neurodivergence. And when you work with eating disorders, you work with everything.

So people often think of eating disorders as being about literally food and body, and while those are absolutely components of a person's experience with an eating disorder, it's a symptom for an underlying issue. And often what underpins eating disorders is trauma, depression, anxiety, huge contributing factor, and other ways that the brain is sensitive. So for example, someone on the autism spectrum might really struggle with their sensory experience with food, be labeled with having an eating disorder, when really, it's something that's going on in a sensory way for them. It's not accompanied by cognitions and things like that.

So that's the bulk of my experience and I could talk about that forever. But because I'm an ADHD person, I have a million interests and my path has diverged many a time from that foundation of working with eating disorders. So through that work, I found my way into the somatic world in treating trauma because trauma is a huge underpin of most folks with eating disorders. And I got my foot into somatic experiencing, which is working with folks more so through the visceral felt-sense experience of trauma held in their bodies and helping them to let go of it rather than talking the story to death, which can be re-traumatizing for folks at times. Absolutely has some value in reclaiming our narrative and making meaning. However, I found working in the body to be a lot gentler.

Through that world, I found my way into psychedelic assisted therapy. I did a fellowship last summer in Jamaica, working with mushroom assisted therapy, and I've done a couple of trainings in San Francisco for ketamine assisted therapy. So that is a world I'm very interested in. And then gender and sexuality. So I'm non-binary. My pronouns are she/they, and working with trans folks, working with gender sexuality came out of working with eating disorders as well because those populations tend to struggle with eating disorders, body dysmorphia, those sorts of things at a much higher rate than the general population.

Jennifer Smith: Wow.

Nica Selvaggio: And then from there, add in interest in couples work, sex therapy. So a little bit all over the place, but a really strong foundation underneath all of it.

Jennifer Smith: Wow, that's fantastic. And basically that means you can help a lot of different people, which is really great. Your online bio notes that you've been trained in several evidence-based approaches. Can you let our audience know what those are?

Nica Selvaggio: Yeah, and I'm noticing in myself through this interview, I'm talking very fast and not breathing very much because I'm oriented to my own body. I'm going to take a moment and just take a deep breath before I answer you.

Jennifer Smith: Yeah, absolutely.

Nica Selvaggio: Thanks. And if anything-

Jennifer Smith: Oh, I was just just saying-

Nica Selvaggio: Yeah, go ahead Jen.

Jennifer Smith: That's great for our audience to see too. You need a moment, take a moment. There's nothing wrong with that, and I think we could probably all do that at times and we just don't, unfortunately. And then we feel awful.

Nica Selvaggio: Well, we're not really given permission to in our culture and our systems that we operate in.

Jennifer Smith: Yeah, which is unfortunate.

Nica Selvaggio: Yeah. Which ties into that question a little bit about what evidence-based therapies I work with. Most of them I learned when working in treatment settings. So in a lot of eating disorder treatment centers, the foundation of the treatments are evidence-based therapies such as dialectical behavior therapy, DBT, which was developed by Marsha Linehan, and that was a therapy originally developed to treat folks who struggle with extreme emotional dysregulation who are feeling suicidal or are diagnosed with borderline personality disorder. So these extreme swings of mood and inability to regulate.

Off of that came... And that approach is really good for folks who are... The temperament under controlled. So under UC versus OC, under controlled versus over controlled, so more impulsive behaviors, you're going to see things more expressive. You might be able to tell I'm more on the UC side. DBT is great for that. And then on the other side, you've got OC, over control. Those folks are going to have higher levels of generally OCD type thinking, more restricted, flat affect, much more wanting to control their outer experience because their internal world feels so chaotic that it reflects on the outside. In those folks, you're going to see things more like anorexia, restricting behaviors, much more flat affect.

RO-DBT, radically open DBT came out of DBT to help over control folks. So those are two different therapies, even though they have the same name in them, but essentially they're both skills-based therapies that are laid on the foundation of mindfulness and some of our Eastern inspired practices. So as well as another evidence-based therapy that's used a lot in treatment centers, ACT, acceptance and commitment therapy by Stephen Hayes. But these therapies are really trying to bridge the worlds of that grounded mindfulness foundation with concrete skills that people can use to actively change the behaviors that are causing them distress in their lives.

I love a lot of those therapies so much because they work, they can really shift things quickly. I often use those in conjunction with therapies that maybe don't have as much of a robust research base because they haven't had the time or the funding or whatever it is, such as somatic experiencing and more experiential therapies. I went a little bit all over the place.

Jennifer Smith: Thanks. And what about your treatment approach? What's that like?

Nica Selvaggio: Yeah, so I was trained in a clinical mental health counseling master's program and the foundation of my training and program was person-centered humanistic therapy. So for folks who don't know what that means, my foundation of who I am as a clinician, as a counselor is very much through the egalitarian lens of I am not an expert in your life. You are the expert in your life and I'm coming here to join human to human to witness and perhaps equip you with skills that you need in order to change the things that you're wanting to change.

That said, that's the foundation I weave in depending on what a person needs after collaborating with them on what sort of therapy they're interested in working with, all different kinds of approaches. So again, the somatic work is a huge part of my work, bringing in the body. I also do a lot of parts work, internal family systems, and for folks not familiar with that, that involves accessing the different parts of ourselves that are often in conflict. Everyone has different aspects of self that they might connect with at different times. The part of me that's doing this interview with today is my manager part, right? I'm going to present my best self today, but maybe my inner child part is like, "This is scary. I don't like talking in front of people that I can't see." That's an example of parts work.

Who else? Again, super interested in growing more in the psychedelic assisted therapy world. It's really profound powerful work that can really jump start a person's journey, but not to be used without caution and a lot of discernment and support. Yeah, it's just different for everyone.

Jennifer Smith: That's fantastic. I'd like to go back and talk about one of the areas that you can help clients with, and that's regarding their sexual orientation and gender identity. And I was reading on The Trevor Project’s website that they offer 24/7 free, secure access to counselors for young people who are LGBTQ. In a nationwide survey that 41% of LGBTQ people age 13 to 24, so the younger range, seriously considered committing suicide in the past year.

So clearly something's going on here that's severely impacting this population's mental health. So I just have a few questions regarding this, that maybe you can shed some light on.

One is, what types of issues does someone usually struggle with regarding their sexual orientation or gender identity?

Nica Selvaggio: Yeah, I love this question. Thank you for asking this. And first I want to name... I always experience a lot of heaviness in my body when tapping into the sense of powerlessness or hopelessness that comes in for a person to feel like the best option is to end their life, that they've exhausted all of the avenues and this is the best way to escape the pain that they're experiencing when that becomes the option in their brain. This is for so many different reasons and ties to what a lot of folks in the LGBTQIA+ community struggle with, which I want to differentiate that struggling to know what your sexual identity is or your gender identity is, is not in and of itself a pathology or an issue that someone's struggling with.

What people are struggling with is how the systems in the world, how our culture, how our families, how our religions, how all of these things reflect our worthiness of access to resources, safety, the right to use the bathroom in the public. Our daily lived experiences of oppression are the issues that we struggle with, not the fact that we are part of the rainbow community.

So that being said, because of operating or living in a system that... And I can give so many examples of it's February 1st and how many anti-trans legislation bills have been pushed forward this month in January alone? The visceral, physiological, emotional, spiritual, psychological response to being faced with that. Those issues can look like suicidality, that can look like depression, that can look like anxiety, that can look like a nervous system that's chronically stuck in fight, flight or freeze because they're in survival mode because the world is reflecting to them that they're not safe.

Things more classically associated with folks in the LGBTQIA community are things around identity formation. How do I know who I am? How do I put a word or a label to who I am? Do I even want to do that? Is there even a necessity for me to come out and name myself as such? Where do I fit in and belong in this LGBTQ community? How do I move through the world in the straight world? A lot of identity formation issues in that. And again, that's not an issue of pathology in and of itself. Culture's response to that question is the issue.

Substance use is often higher. Again, this is a way of coping with all the things that I've named and eating disorders and body dysmorphia tend to be much higher incidences in the trans and LGBTQ community.

Jennifer Smith: Wow. And eating disorders too, they're often highly correlated with suicidality, correct?

Nica Selvaggio: Yes, yes. Can be. Not all, but yeah, they tend to be.

Jennifer Smith: Wow. Another question I had is often when you're doing paperwork now for a medical provider or surveys, they ask about someone's preferred pronouns. And can you talk a little bit about that, preferred pronouns and how can that affect someone's mental health? Why do they matter? Why do pronouns matter?

Nica Selvaggio: Yeah. Yeah. And I love how you changed the sentence at the end. Why do pronouns matter? Because even the language of preferred can insinuate that it's someone's choice in terms of... Okay, how can I put this? If you knew that the sky was blue and someone came up to you and was like, "You're nuts. The sky is not blue. I see yellow, and you are bad and wrong for thinking that the sky is blue. How could you?” Take it a step further: “You're going to a bad place because you think this sky is blue."

And then I said to you, “Well, you just prefer it to be blue.” Is that a preference or is that just what you see? So a person's preferred pronouns implies that it's an actual preference, when in reality, it's just their lived experience. And so when someone is vulnerable enough to even name their pronouns, even if we don't understand, even if we think the sky is yellow, the reason it's important is because it indicates a level of belief that that person understands and knows themselves better than we could possibly know, their internal experience.

Jennifer Smith: Right.

Nica Selvaggio: It indicates respect for their beingness, and it creates a level of safety for that person who may have moved through many different systems in their life where it was not accepted or not safe for them to use the pronouns that fit for them.

Jennifer Smith: That's fantastic. Thank you. One anecdote that I wanted to share is that in our practice, we were trying to decide internally, "Should we all put our pronouns in our signature block?" And I'd say one-third were gung ho for, "Yes, we should." One-third didn't care. And there were other people who didn't want to, and one of the members of our team said, "Maybe we shouldn't do this, because if a person isn't comfortable saying what their pronouns are, we're forcing them to either disclose their pronouns or force them to put stereotypical pronouns that you would think that they should be.” And for me, that was really eye-opening.

So for that reason, I went on the bandwagon of I'm not putting pronouns. That way, if someone else didn't want to, they didn't feel like they had to as well.

So I thought that was really interesting, that pronouns can really mean so much to a person and just... Yeah. So thank you for explaining that, that it really does matter.

Nica Selvaggio: Yeah, absolutely. And I love, thank you to that person who brought that point up because that's always what I like to... Oftentimes when we're trying to show up as allies in support of a community that we're not part of, it's easy to misstep and to do things out of good heart and good intention, but ultimately can contribute further to harm. And the pronouns in the bio or in your email signatures requirement is one of those ways where it's like, "Oh, we're trying to help normalize it for everyone." But again, you don't know who you're requiring to out themselves or to live falsely.

Jennifer Smith: Right. That's fantastic. And that's why part of the reason that we do this series is to help educate people and just explain things. Thank you.

Nica Selvaggio: Yeah, thank you.

Jennifer Smith: Yeah. So what can you say to people who simply might not have any understanding or have confusion about what we've just been talking about and just don't understand the distress that some people might have about identity or orientation or pronouns? Why is it a big deal?

Nica Selvaggio: Yeah. I always come back to why do we need to understand? I don't even understand myself. Why do I need to understand another person's experience for their experience to be legitimate and valid for them? I don't. In fact, it's often impossible to try. I can do my best, but I can't ever fully step into another person's experience. And so we don't actually require understanding. We require respect and compassion, just to be believed. Right? And you can compare this across many different experiences of identity. I will never know what it's like to walk through the world, say, as an Arabic man, I don't know what that is.

Jennifer Smith: Right.

Nica Selvaggio: It's not for me to try to understand. It's for me to listen and believe and provide respect. So first throwing away that word understanding, we don't need to understand. What I would say is have you... I would invite folks who really just don't get what the big deal is about to reflect on if there's ever been something in their own life that was really important to them, that they really cared a lot about, but that was dismissed or diminished, or they were told that they were foolish or crazy even for caring about that thing.

And we can do this together too, but just to take a moment and really call to mind that feeling, that memory and see what happens inside. So I notice immediately I start to contract, I start to constrict, and I start to want to feel small and to hide myself. Other folks might have a different experience. Maybe they feel angry, they want to fight back. There's no wrong response here. Just notice how do you feel when you're invalidated, misunderstood, and told that you're wrong to care about the things that you care about? Generally not pleasant.

So when we show up in that way, we're often perpetuating more of the same for people around us. If we've experienced that, then we're going to put that out on others too. Like, "Well, I had to conform. I had to shut down this part of myself, so how dare you not do that?" Right? We face a lot of anger from folks oftentimes as a result of that. Yeah. And what would the world be like if we had more spaciousness for those pauses to actually feel into, what am I reacting to in my not understanding? Am I being reminded of a time that I didn't feel understood? How can I show up in a more compassionate way?

Jennifer Smith: That's great. Thank you. Our final question, which I'm a little bummed to say because I thought this has been great. Do you have any words of advice or anything else that you'd like to say to our listeners today?

Nica Selvaggio: Be gentle with yourself. Working as a clinician, as a counselor, as a therapist, through some of these major world and global events that we've been experiencing collectively over the past decade, something I've noticed in the broader populations is that levels of fear are very high. Anxiety is very high, which makes sense. And levels of burnout, feeling like we just cannot continue on are very high. Levels of trauma and secondary trauma are very high.

In the midst of all of that, I want to invite all of us to both stand in the center of honoring and witnessing our sacred human struggles together, and also find those spaces in which things feel a little bit lighter, or we can expand more and access things like rest and pleasure and resilience, and that both of those things need to coexist in order to show up in a more whole way. So gentle, gentle, gentle, gentle. Show up when you can. Rest when you can.

Jennifer Smith: That's fantastic. Thank you so much, Nica, for finding time to speak with us today.

Nica Selvaggio: Thank you for having me.

Jennifer Smith: And for our listeners, if anybody is interested in scheduling an in-person or telehealth appointment with Nica, you can do so and self-schedule at seattleanxiety.com. Thanks again and have a great day.

Please note: The views expressed by the interviewee are for educational and informational purposes only, are not meant to diagnose or treat any condition, and do not necessarily reflect the views of Seattle Anxiety Specialists, PLLC.

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Editor: Jennifer (Ghahari) Smith, Ph.D.

Psychiatrist Peter Reiss on Psychiatric Medication Management

An Interview with Psychiatrist Peter Reiss

Peter Reiss, M.D. is psychiatrist at Seattle Anxiety Specialists, PLLC. Dr. Reiss specializes in the treatment and medication management of anxiety related disorders.

Jennifer Smith: Hi, thanks for joining us today for this installment of The Seattle Psychiatrist Interview Series. I'm Dr. Jennifer Smith, Research Director at Seattle Anxiety Specialists. We're a Seattle-based psychiatry, psychology, and psychotherapy practice specializing in anxiety disorders.

I'd like to welcome with us Dr. Peter Reiss, who is one of the psychiatric providers at our practice. Peter has extensive experience with psychiatric medication management and has worked in multiple levels of care in the Seattle area, including inpatient, outpatient, partial hospitalization, and residential treatment programs, as well as in the psychiatric emergency room.

Before we get started today, can you tell our listeners a little bit about yourself?

Peter Reiss: Yeah. Hi, Jennifer. Thanks for having me, and inviting me for this interview series. As you said, I worked in quite a few places before I started working as an outpatient psychiatrist here. I took a slightly different route than the traditional way of, "What do you do when you start working after residency?"

I initially started working as a locum tenens, which includes more short-term contracts. I was doing six months to a year at different kinds of levels of psychiatric care. It just gave me a way to see what kind of psychiatric jobs I like, and it gave me an opportunity to see what the mental health resources are in the area. And, just gave me a chance to see what I could see myself doing in the long run.

Jennifer Smith: That's great. I think, like you said, to have all that different exposure probably makes you a really well-rounded psychiatrist. I think that's fantastic. Great.

Peter Reiss: I did think that. It just gave me a little bit more opportunities to really see what different acuities look like on different levels of care.

I wouldn't change a thing, so I'm very happy I did it this way.

Jennifer Smith: Fantastic. Just to let our listeners know a little bit more about yourself as well, what are your favorite parts of the Seattle area or Washington as a whole?

Peter Reiss: So, the first time we came to Seattle, I just immediately loved the area. I do think that it has this very special kind of culture. I love how it combines the urban and the nature, and just the fact that there's so much to do. Especially in the summer, with festivals going on. And, even the winter, I mean, people do complain about, or some people say we have particularly bad winters, but, in the middle of winter, it's 55 degrees, and you can go hiking or do whatever if you're okay with a little bit of rain.

Jennifer Smith: The saying is "It's not bad weather, it's bad clothing," or something like that. Right?

Peter Reiss: Well, I think our weather is our best kept secret.

Jennifer Smith: Yes.

Peter Reiss: Not as bad as people say.

Jennifer Smith: Exactly.

Peter Reiss: Or, have the reputation.

Jennifer Smith: Right?

Peter Reiss: Yeah.

Jennifer Smith: Exactly. That's great. And, what is it that got you interested in becoming a psychiatrist?

Peter Reiss: So, I didn't start out in medical school wanting to be a psychiatrist. I did keep my options open. I was leaning more towards primary care, internal medicine, possibly emergency medicine. I always knew that psychiatry and mental health is important, and that it's kind of very ubiquitous anywhere you go in medicine.

I didn't think about psychiatry a whole lot until my third year in medical school when I had my real introduction to psychiatry, where I went to the psych ward and other psych facilities for my medical school rotation. And, I just immediately loved it. I liked how it's just slightly different than other fields of medicine. It kind of forces you to think more outside of the box. It doesn't necessarily follow the standard algorithms that we have in medicine. There's a lot more nuance and room for interpretation, and it's probably the least well-understood specialty in medicine as well. So, I did the fact that there's just so much more that potential will change in the specialty in the near future hopefully.

Jennifer Smith: That's fantastic. One question that we're often asked is, "Should I see a therapist or should I see a psychiatrist, or both?" And, can you explain the difference to our audience why should someone see either of these two professions?

Peter Reiss: Mm-hmm. Yeah. So, we do have quite a good variety of mental health specialists for anyone wanting to see treatment for any mental health problems. The two options, generally, are to see a medical doctor, so a psychiatrist, or see somebody who'll focus more on non-pharmaceutical management, which would be a therapist, which would typically be clinical social workers or psychologists by training. And, it sometimes comes down to personal choice what people prefer.

I would say, if somebody's psychiatric symptoms are fairly mild, they might need to see a psychiatrist. So, not everybody would be necessarily a candidate for psychiatric medications.

Psychiatrists themselves rarely practice psychotherapy anymore. It used to be different. We are trained in psychotherapy. We do go through all these different didactical trainings, how to provide different modalities of psychotherapy, and it used to be much more prevalent back, really, back in the seventies, eighties, up to nineties, where many psychiatrists were still offering psychotherapy. But, mostly due to our insurance landscape, it really has changed that that responsibility has fallen more to clinical social workers and psychologists who are very, very qualified to provide that training. And, they're really specialized in all these different training modalities, since there's just so many of them. So, somebody who has PTSD is getting different psychotherapy than somebody who has an anxiety disorder or depression.

And, it's really hard for a therapist to be very good at all of these therapy modalities. So, I think sort of the specialization among the different therapies works very well, and it's great to just share that professional space with all these very qualified therapists that we work with.

Jennifer Smith: Wow. Have there been times when a patient will come to you and you realize this person probably doesn't need medication - do you refer them to therapy? Does that ever happen?

Peter Reiss: Oh yeah. That is quite common.

I mean, I would say, in the majority of cases, probably at least a trial of medication might be helpful, just for the patient to engage better in psychotherapy if symptoms are just a little bit too severe at that time. But, for a lot of mild cases of the anxiety and depressive disorders, often starting with therapy alone might be a good option.

Jennifer Smith: Okay, fantastic. In what ways can someone's mental health impact their physical health?

Peter Reiss: So, that's actually a really good question. I think most people do understand the connection between chronic medical conditions causing psychiatric symptoms to worsen, but it's really also the other way around. So, I mean, for example, most psychiatric disorders, whether it's anxiety disorders, whether it's depressive disorders, trauma, excessive trauma responses, they typically cause physiological changes as well. Things like, for example, chronically increased stress hormones, like cortisol. And, that can have an impact on immune function, it can increase somebody's risk for cardiovascular issues.

And then also, indirectly, somebody who has low executive functioning, low motivation due do psychiatric issues, is less likely to take care of themselves and engage in these kind of activating behaviors that tend to improve one's mental and physical health.

If somebody, for example, is less likely to engage in things that are good for social connections, that leads to loneliness. And that, in itself, leads to worsening mental health and physical health as well just due to increasing chronic stress and things like that.

Jennifer Smith: Oh, wow. So, when they say, "Mental health IS health," it really is true.

Peter Reiss: Oh, it is absolutely true. I mean the two... It's not only that it's just in your head, right? It does cause real physiological changes, whether those are directly caused by mental health issues or indirectly.

Jennifer Smith: Right. Can you talk a little bit about your treatment approach?

Peter Reiss: So, I emphasize a lot of psychoeducation, making sure that I meet my patients where they're at, and also give them as clear information about what's going on for them to make the best informed decision.

Sometimes, maybe, they have a particular treatment modality in mind, particular medications or whatnot. Just, trying to understand what their idea is, where they're coming from. So, our treatment goals might be different; we might not always agree, and that's not necessarily wrong. But, giving them as much information as I can for them to make the most informed decisions, that's very important to me.

Then also, I tend to put a big emphasis on always reassessing... Just, speaking specifically about medication management, to reevaluate the need for a particular medication. Sometimes, patients come to me having been on one medication for 10 years. We don't know if they still need to be on that. We don't need... Maybe they need to be on something different. We need to reevaluate what, really, each component of their treatment is really doing, if it still has any effect on their mental health. Sometimes, less is more with psychopharmacology.

I do always want to do check-ins, even with patients who have been on a long-term medication, "Is that really necessary, and what can we do about it?"

Jennifer Smith: That's really great that you work with a patient. And, it sounds like you strive to just get the optimal dose and really not put things that are not... Meaning that you don't do unnecessary things.

Peter Reiss: Right, because each medication could not have side effects; it could have unwanted side effects; or, something else that the patient might not know about. So, they're still... Psychiatric medication's still among the safest medication in medications in general, but we shouldn't take it lightly to have somebody on long-term medications generally.

Usually, it's not a problem. We just have to do it the right way.

Jennifer Smith: Right. And, what type of disorders do you specialize in?

Peter Reiss: So, the disorders that I see here in the clinic are fairly standard, the average psychiatric disorders, including the depressive disorders, wide variety of anxiety disorders, including OCD and different kinds of phobia. We do see ADHD patients here in our clinic as well, patients with PTSD and more trauma-related issues, and also different levels of functioning. So, there's many of my patients who are really doing well, especially on the surface. They're able to do their day-to-day activities. And then, there's patients who are not doing well at this time, who might not be able to have a job right now. So, it's a big variety of different psychiatric issues that we're dealing with, but also, different, wide variety of patient needs.

Jennifer Smith: And, let's say that I was going to sign up for an appointment with you. You are a medical doctor, so of course, I would have to complete the intake paperwork so you have an idea of where I'm coming from, what medications I'm on, my past history. So that's, I think, pretty standard. But, after that, I have no idea what to expect. So, what can I expect in the first session with you? What would we do? What would we talk about?

Peter Reiss: Mm-hmm. Yeah.

So, after a patient signs up for an appointment, there's the initial intake. That can be done either here in my office, in person, or it could be done remotely. There's always those two options. On most days during the week, I have those two options available.

The first session is just gathering a lot of information, getting to know the patient. And, that typically takes at least 45 minutes to an hour so we are clear on establishing a diagnosis, getting enough information about the patient's medical background, mental health background, social background. And, the last part of the initial meeting... Well, there's initially the psychiatric interview, and then, we kind of talk about what we're going to do.

And, if there's any disagreements, or the patient might need a little more time to think about these different options, we might talk about... Besides different medication options, we might talk about potential referrals for therapy as well to see if there's somebody who might have that particular therapy skillset that the patient needs, whether that's in our office or outside of our office.

And then. If the patient decides to be a patient with us, there would be a follow-up appointment to check in, within usually two to four weeks or so. Depending on the acuity, really, and if there's any problems.

Jennifer Smith: Okay. And, that actually leads to my next question regarding follow-ups. So, at our practice, we have a form of concierge care. Can you explain what that is to the audience? And, how does it differ from a traditional practice, and what are the benefits that our patients may have?

Peter Reiss: Mm-hmm. So, the main difference with concierge care is really that it's a subscription-based access to our services.

In a traditional setting, patients would have their appointment and then schedule follow-ups, and then, essentially, the difference in payment would just be that they would pay for each follow-up appointment. But, a subscription-based model of concierge care, it's really that patients pay a monthly subscription for, essentially, unlimited access. So, they can have one appointment, they can have two appointments; they have access to their psychiatrist via messaging system or email. It just makes it easier for us to respond in real-time to any issues that might come up.

It also helps us to see who is continuing care at a regular interval. So, sometimes in outpatient psychiatry, it becomes a little tricky, because patients might be partially lost to follow up. They might not show up for an appointment, so we're not sure is that patient still patient with us, right? But, with a subscription model, we at least know, "Oh, that patient actually wants to continue, and that patient will continue with their follow-up appointments."

So, I think it helps with patient retention in the outpatient setting.

Jennifer Smith: Great. And, I think one thing that I've noticed from the administrative end is that, because we essentially cap the number of patients that our psychiatrists will see, and you've kind of alluded to this, that our patients really can have unlimited access, to a degree, because you're seeing X amount of patients and not thousands of patients. So, there's just more time that you can give each of your patients, which I really think makes more specialized care as well.

Peter Reiss: Mm-hmm. Yeah. So, our overall patient numbers are lower than you would see in a typical outpatient clinics, which helps with just the time that we give each patient. We're not necessarily back-to-back.

I mean, there's some days where we see more patients than other days, but it just feels a little bit more... It feels a little more less time pressure, to give that extra time as well, whether it's directly during the appointment or to communicate with the patient through our messaging system and hone in their treatment that way.

Jennifer Smith: Wonderful. So, our final question, do you have any words of advice, or anything else that you would like to say to our listeners today?

Peter Reiss: So, the main thing that I probably would say is that, to somebody who's starting out with their mental health recovery, really seeing that they want to get treatment, it initially seems very daunting, but I do want to say that it does get easier when somebody is actually establishing care and is getting the help that they need.

And, oftentimes, we often forget to check in with ourselves, especially when we're in treatment, making sure that we're really doing well, that we're not just doing okay, that we're really thriving and flourishing. And, that can mean different things to many people, obviously. But, often, what suffering from a lot of mental disorders and mental illness does to us, we're losing the sense of self-worth and almost like forgetting what our normal... We're getting used to this normal baseline of functioning and being. And, sometimes, it becomes difficult to keep track of what our purpose is in life and what we can do to thrive.

So, don't settle for any less when it comes to your mental health. That would be my main advice.

Jennifer Smith: That's great. Thank you so much for your time today.

If anyone is interested in scheduling an in-person or a telehealth appointment with Dr. Reiss to discuss psychiatric care and medication management, you can self-schedule at seattleanxiety.com

Thank you again, Dr. Reiss, we appreciate your time.

Peter Reiss: Thank you, Jennifer. Good seeing you.

Please note: The views expressed by the interviewee are for educational and informational purposes only, are not meant to diagnose or treat any condition, and do not necessarily reflect the views of Seattle Anxiety Specialists, PLLC.

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Editor: Jennifer (Ghahari) Smith, Ph.D.

Psychologist Andres De Los Reyes on Adolescent Social Anxiety & ADHD

An Interview with Psychologist Andres De Los Reyes

Andres De Los Reyes, Ph.D. is a Professor of Psychology at the University of Maryland. He's an expert in the field of adolescent psychology, social anxiety and ADHD.

Tori Steffen:  Hi, everybody. Thanks for joining us today for this installment of the Seattle Psychiatrist interview series. I'm Tori Steffen, research intern at Seattle Anxiety Specialists. We are a Seattle-based psychiatry, psychology, and psychotherapy practice specializing in anxiety disorders.

I liked to welcome with us today, Psychologist Andres De Los Reyes. Dr. De Los Reyes is a professor of psychology at the University of Maryland in College Park, as well as the Director of the Comprehensive Assessment and Intervention Program. Dr. De Los Reyes is an expert in the field of clinical psychology. He's published over 100 articles, including “When Adolescents Experience Co-occurring Social Anxiety and ADHD Symptoms,” “Links with Social Skills when Interacting with Unfamiliar Peer Confederates,” and “Multi Informant Reports of Depressive Symptoms and Suicidal Ideation Among Adolescent Inpatients.”

Before we get started today, Dr. De Los Reyes, could you please let us know a little bit more about yourself and what made you interested in studying social anxiety, ADHD, and other mental health issues among adolescents?

Andres De Los Reyes:  As you mentioned, I've been at the University of Maryland for some time now, about 15 years. In that work, I spent a lot of time thinking about the most accurate ways of assessing various kinds of mental health concerns with a particular emphasis on those concerns, where when we try to get a sense of symptoms and associated impairments... Obviously, because we're often assessing children and adolescents, we're seeking input from not only the clients themselves but also significant others in their lives, like parents and teachers and sometimes peers. We focus our attention a great deal on those domains, where when we ask these questions, we oftentimes get very different responses depending on who we ask. That's a common byproduct of assessments of social anxiety, of ADHD.

The work our group has conducted, and the work of many other labs all over the world, really have led us to believe that although there may be some circumstances where these assessments are telling us different things because perhaps one or more of the informants aren't nearly as useful reporters as they might be, under the grand majority of circumstances, when we administer assessments to understand things like ADHD and social anxiety, we're often using well-established instruments, and we're also often asking people, informants, who mental health professionals have relied on for decades to assess behaviors. So under a variety of circumstances, there may very well be reason to believe that rather than these differences in results reflecting something artifactual about the measures we administer and the scores we obtain from these informants, it might be actually something really important. In particular, the specific contexts where adolescents, children might be experiencing concerns like social anxiety and ADHD.

It turns out that in both of these circumstances, in both of these domains, social anxiety and ADHD, the symptoms and associated impairments can move around considerably across various social environments that impact the lives of those we assess, the peers with whom they interact, the teachers who are serving as instructors in their classes, the parents who look after them and in fact are often initiating their services. So, I tend to choose domains like ADHD, like social anxiety because I think not only are they places where these discrepancies and results happen often, but if we learn more about these discrepant results, then we also learn more about the actual domains themselves.

Tori Steffen:  Right. Wow. That's really profound. I can definitely agree with you there how it's important to understand the differences, especially when assessing for the two of those domains. So, thank you for explaining that for us.

Well, getting down into basics about our topic, what age range describes an adolescent?

Andres De Los Reyes:  A very wide one. Even just a definition of what counts as an adolescent is a topic of considerable debate among mental health professionals, among developmental scientists. Adolescence can begin within some definitions as early as 12 or 11, and can stretch out as far as, within some definitions, the early adulthood years. There may be various factors that one might consider when thinking about where adolescence as a developmental period begins and ends.

But germane to the work that we do, we tend to focus on what some scholars might consider the mid- to late-adolescence period, so that period between the ages of about 14, 15, 16, 17, where developmental research and theory would posit that the people we're trying to assess are undergoing significant amount of changes in their biology, in their social environments. They see a lot of new environments, novel environments they oftentimes are not necessarily accustomed to encountering earlier on in development, like the development of romantic attachments, the development of time spent outside the home, outside of the immediate observation of caregivers who, as I mentioned previously, are often initiating care.

So we think of, like I mentioned before, social anxiety and ADHD as a great place where the assessment issues we care about happen. On top of that, the developmental peer that we focus these assessments on will oftentimes create additional complexities that require further elaboration and interpretation. That's where a lot of our work essentially seeps from, is trying to figure out within the traditional approaches we use to measure domains like social anxiety and ADHD, what additional things must we think about and be developmentally sensitive to when we're trying to apply our traditional assessment tools to assessing these specific domains in this particularly complex period of development?

Tori Steffen:  Right. Yeah. Definitely a lot to consider when defining an adolescent. So, that all is very important. Could you explain for our audience what social anxiety is?

Andres De Los Reyes:  The typical definitions of social anxiety revolve around several different kinds of core features of the condition. One of the big core features is an intense fear or apprehension. Under some circumstances, when the fears are really high in avoidance of social situations of various kinds, interacting one-on-one with somebody, even just going up to somebody and asking them for information or directions, like if you're going somewhere you don't really know where to go, giving presentations in a structured setting like a classroom or an adulthood in a workplace... But one of the common, core denominators that cut across all those situations is that among individuals who experience social anxiety, there tends to be a particular fear, apprehension, avoidance, of unfamiliar scenarios, scenarios that appear novel that haven't been encountered all that frequently, and where people might not have a lot of practice in navigating those situations effectively.

That's one of the big things that we think about when it comes to assessing and understanding social anxiety within adolescence, because like I mentioned before, you have these situations, these scenarios that as you enter the adolescence period you don't have a lot of practice in. One of the big ones that we focus on is in those scenarios where adolescents feel like it's one of their tasks to engage with people they don't know very well, particularly their own age, and try to develop bonds of some kind: friendships, romantic attachments, and then in both those places that unfamiliarity is something new to them, especially when you consider the fact that a lot of these unfamiliar interactions with people your own age are happening where your caregiver, somebody older than you isn't looking over your shoulder to see how things are going. You're doing a lot of this by yourself.

Tori Steffen:  Mm-hmm. Right. Okay. That definitely makes sense, that a lot of uncertainty and fear might be present.

Could you explain for us how adolescents typically experience social anxiety, and would you say that there's any big differences in symptoms among adolescents compared to adults with social anxiety?

Andres De Los Reyes:  This is something we've struggled with a great deal, and it bears some relation or implication to how we diagnose the condition among adolescents, children, and adults. I can focus specifically on the sort of diagnostic considerations you have within one of our predominant systems, the Diagnostic and Statistical Manual of Mental Disorders, now in its fifth edition.

In the current edition, there's a distinction between the kind of social anxiety that manifests consistently across situations across contexts. So, for many clients there's this sense that the symptoms and their impairments: fears, the avoidance, the apprehensions, are there when you are ordering food at a restaurant and interacting with coworkers and trying to meet new people. You see it everywhere. That can be contracted with at least one other form of social anxiety that we tend to see in clients, and that is those scenarios, those instances in which clients appear to be experiencing symptoms and impairments that manifest in a specific kind of context.

In the Diagnostic and Statistical Manual of Mental Disorders, the DM, that context is typically characterized as a performance-based context, some kind of place where there's a lot of structure and you have a sense of what it's like to give a presentation in front of a group, you know what the rules of engagement are: You have to make eye contact; you have to enunciate; you have to be able to answer questions effectively. What we've been learning in our work is that although adolescents can experience that kind of context specificity that has a look and feel of what you see in adults, we also see at least one other kind of specific form of impairment and where symptoms arise. And that's when adolescents are engaging in the social scenario where the rules of engagement are kind of stripped away. There's no manual to figure out how to navigate parties effectively. There's no how-to guide on the right thing to say when you sit down next to someone on the first day of school. You probably think that you should be friendly, maybe say hi, but what else do you do after that?

So, that lack of structure in our work leads us to believe that although adolescents can experience those kinds of patterns that we tend to see in adults, the symptoms and impairments can manifest in lots of places or in one specific place, we have reason to believe that maybe it's worth considering the notion that because of the novelty inherent in the social experiences that adolescents often have, that even just being placed in a situation where you don't know the rules of engagement can produce the same kinds of symptoms and impairments that we see in that context-specific subcategory that you said that we already have in our diagnostic manuals.

Tori Steffen:  Right. Okay. That's good information to know, the importance of novelty, especially for adolescents. So, that's really interesting.

How are the issues of social anxiety and ADHD and adolescence connected? If the two issues, let's say, that they're co-occurring in an adolescent, does that have more of a negative impact?

Andres De Los Reyes:  In our work, we tend to see that it does. It's a phenomenon that fascinates us. The reason why is because there are a lot of different kinds of features of all of our disorders, all of our diagnostic categories. They all have their own lists of symptoms. What they also have are what we call associated features, or there could even be risk factors depending on whether or not their presence brings about the condition. But many times, when we're thinking about treatment, we're thinking about those aspects of functioning that might not be symptoms, but they could be implicated in how conditions are maintained. It's kind of like whatever started the engine, an associated feature might might keep it going.

One of those features that cuts across many conditions, but in particular social anxiety and ADHD, is a concept or domain that we call social skills: those behaviors, those elements of how you engage in social situations and make a difference in whether or not you're able to make friends and influence people, and not only make friends, but also maintain those friendships over time. We know that in both ADHD and in social anxiety, one of the key areas of impairment is in friendships, in how many friendships you've initiated or developed, and the maintenance of those relationships over time.

The key distinction that many of us encounter when it comes to social anxiety and ADHD is that although there's those associated features of social skills and friendships in both of the conditions, there's reason to believe that those features might arise in these conditions for very different reasons. So, for adolescents who experience social anxiety, they might experience social skills issues in part because of the avoidance. They experience apprehension, fears about engaging situations. They might not engage in situations where they could get opportunities to make friends nearly as much as other kids who don't experience social anxiety. The consequence of that might be kind of the same thing as you missing out on going to the gym for a few months, a muscle here or there atrophies, and then you get back to the gym and you say to yourself, "I can't lift nearly as much as I used to."

That avoidance might have the effect of perhaps overall reducing fears, so if you don't enter into a situation that you find stressful, you're going to experience less stress maybe, but at the cost of not being able to have opportunities to do positive things that might actually even help the anxiety down the line. So, that avoidance makes a big deal when it comes to social skills and associated impairments in developing and maintaining friendships.

With ADHD, there's reason to believe that within that condition, the social skills issues associated impairments of friendships have less to do with avoidance and perhaps a bit more to do with the fact that among many children and adolescents who experience ADHD, the hyperactivity they might experience might be seen by peers as aversive and perhaps make it less likely that they might want to engage with them in the future.

Now, if it's the case that someone's experiencing both social anxiety and ADHD, are perhaps experiencing social skills issues and associated impairments with building and maintaining friendships for different reasons, and those two different reasons are encapsulated in the same individual, so not just the avoidance, but on occasion, the hyperactivity kicks in; you create some kind of aversive interaction with somebody, maybe they don't want to associate with you as a friend. That might be one of the reasons why we're seeing what we're seeing, at least in our own data, that when adolescents experience heightened levels of both of these conditions at the same time, they tend to be experiencing more of these social skills issues in direct observations of how they interact with same-age adolescents.

That's the neat feature of the work that we do. We collect the symptom data the old-fashioned way by asking a bunch of people about what's going on with the adolescent or how they are thinking, feeling, and behaving, and whether or not those symptoms tell us that somebody's elevated in social anxiety and ADHD. But we're looking at those combinations in relation to how the adolescent actually behaves in our laboratory when we create scenarios that have the look and feel of everyday social interactions between themselves and somebody that we lead them to believe is a same-age peer.

Tori Steffen:  Okay. Yeah. That definitely makes sense. It sounds like really interesting work that you guys are doing to figure that out.

Well, one of your articles mentions that the presence of social anxiety and ADHD can have a negative impact on adolescent social skills. I know that you kind of explained how they might show up symptom-wise. Could you explain for us the impact on social skills in an adolescent?

Andres De Los Reyes:  Going back to this notion that adolescents experience social anxiety might have fewer opportunities to engage socially with people, typically their own age or other people. If they avoid those scenarios, then by construction, they're going to get less practice building the kinds of competencies that we know are instrumental in being able to have healthy relationships with other people. When's it appropriate to make eye contact? When is it appropriate to avert your eye contact? When is it appropriate to initiate a conversation? Is it okay to say hello to somebody when you're having a very deep conversation with somebody else? When is it appropriate to end the conversation and maybe go somewhere else, interact with somebody else? All these kinds of skills, we develop them whether we know it or not, oftentimes through trial and error. Most of us don't read a guide about how to be socially skilled before we go to a party. That's just not what we typically do.

Over time, we figure out what's worked and hasn't, and in that respect, among many of us who can be considered as socially skilled, those kinds of skills are kind of like a really good app on your phone. They fit into the background after they all make sense. So oftentimes, in our interventions for both social anxiety and ADHD, although the approaches we might take to improving social skills might differ, the outcomes have the similar kind of look and feel. We're trying to build up your competencies to be able to make friends and influence people, but the routes you might get there might be quite different.

Tori Steffen:  Okay. Yeah. That definitely makes sense, how it could have an impact there.

Have any significant differences been found in your lab work for prevalence of social anxiety and/or ADHD among girls versus boys?

Andres De Los Reyes:  We don't tend to see too many big differences in our work as a function of gender, but it is just one sample. One thing I can say is that some of the gender and the gender-related issues and how we diagnose these two conditions, depending on the condition, reflect either variations in rates as a function of gender or in features. So as an example, when you assess ADHD in the general population, so outside of a clinic, you tend to see a bit higher rate, 2-to-1 in children, maybe 1.5-to-1 in adults in the direction of males tend to be diagnosed more often than females. But in ADHD, you also tend to see that females are more likely than males to experience symptoms that have more to do with inattention, so difficulty in maintaining attention relative to males. Again, big average differences that we tend to see in research.

In social anxiety, historically what we've tended to see is a gender difference that might manifest in the general population, but once you get into the clinical circumstance, it doesn't tend to be much of a difference, much of a gender difference at all. But what you do see is a kind of variation in the other diagnosis, somebody might meet criteria with as a function of gender. Among females who are diagnosed with social anxiety, they tend to experience a greater number of depressive, bipolar, and anxiety sort diagnoses, whereas males who are diagnosed with social anxiety tend to experience diagnosable conditions that are more externalizing sort of in nature, so oppositional-defiant disorder, conflict disorder, alcohol dependence and abuse or dependence and abuse of illicit drugs.

That latter group, people have been interested in that group for a long time, that combination of social anxiety and substance use disorders. One of the hypotheses people have is what they call a self-medicating hypothesis, this notion that perhaps one of the reasons why people might use substances in the context of something like social anxiety is as a coping mechanism, like a means to reduce your arousal or apprehension to then enter situations and manage them more effectively.

Tori Steffen:  Okay. Yeah. That's definitely interesting to know, and sounds like maybe there's a few gender differences, but overall as far as diagnoses go, not super significant in the differences.

Well, another area of your study classified participants in groups of low social anxiety or ADHD and then high social anxiety. What might the main differences in the severity of symptoms be between the two groups?

Andres De Los Reyes:  The interesting thing about the groups that we observed in our own data is that the group that could be characterized as high social anxiety symptoms, high ADHD symptoms, differed from that other group that could be characterized as low social anxiety, high ADHD, and specifically in those social anxiety symptoms. But where they didn't differ much at all is in the level of ADHD symptoms.

The same is true for that other group that was high social anxiety, high ADHD, and high social anxiety, low ADHD. That group as well might have differed on the level of ADHD symptoms, but not in the level or severity of social anxiety symptoms, which made us pretty excited in that one of the problems or one of the limitations you have to overcome when you do this kind of work is sort of ask yourself, when I think about grouping individuals this way, is the group that's showing concerns on two different domains simply just a more severe form of clinical presentation, or are they just a more severe client when it comes to the symptoms? Is that all I'm looking at that? That it's a 10 to 5 difference on one versus the other? If so, what's the point?

But what made us really excited was that, at least from a symptom severity standpoint, we didn't see differences in those groups that are elevated on one versus another versus elevated on both. What it looked like to us was that these groups are different from each other, from something other than raw symptom count. There's something else going on here, and it might have implications for understanding the phenomenology of the actual clinical presentation.

Tori Steffen:  Wow. Yeah. That's a great finding to come by. Yeah. Thanks for explaining that for us. That's definitely an interesting finding.

Well, actually another finding in your study linked social anxiety in ADHD through impairments or behaviors in adolescents. Can you explain that finding for us a bit?

Andres De Los Reyes:  Yeah. We thought it was important to do. In a lot of our studies, we make an observation, we might find it interesting, but we want to scrutinize it a little bit more and probe it. One of the things we wanted to probe with regards to the findings of this particular study was this notion that maybe the social skills issues that we're seeing, the differences among these groups, are isolated to just this kind of interaction. Do we have any data that sort of speaks to the possibility that these differences might have implications for impairment issues we might see outside of the peer context?

It turns out that we had a survey, the work and social adjustment scale for youth, that provides us with a broad sort of index of psychosocial impairments germane to mental health functioning or at least behaviors that might be indicative of mental health concerns. We were able to essentially replicate the finding we observed with the behavioral data, that when you look at overall indices of psychosocial impairments, that same group, that high ADHD, a high social anxiety group, tends experience overall more psychosocial impairments than the other groups in our sample.

Tori Steffen:  Okay. Definitely good to know as far as what to expect in the experience.

Well, clinically speaking, what psychotherapeutic treatment methods might work best for an adolescent with, let's say, co-occurring social anxiety and ADHD?

Andres De Los Reyes:  The good news with regards to both social anxiety and ADHD is that there are well-established interventions for addressing social skills issues in both of these for these conditions. So, social effectiveness therapy, a form of social anxiety behavioral treatment developed by Deborah Beidell and Sam Turner and colleagues, seeks to focus on improving social competence within children and adolescents experiencing social anxiety and for that matter, adults as well. There's a version of social effectiveness therapy that is developmentally modified or tailored for adults experiencing social skills concerns stemming from social anxiety.

There's a variant of that kind of intervention that's broadly thought of or referred to as social skills training that has been tested for many years among children and adolescents experiencing ADHD. My sense, and this is not something that that's been tested formally in a controlled trial or treatment study, is that addressing these co-occurring issues might involve trying to first assess the associated impairments within a client experiencing both of these concerns at once, prioritizing figuring out which one might be more impairing, and then on the basis of understanding where the priorities lie, which of these might be getting in the way of building social skills competencies in most, starting with one of these two intervention protocols, and then moving on to the next protocol if it looks like further addressing these needs is warranted.

The interesting thing, and this is another thing that hasn't been tested yet, what we tend to see in the treatment literature goes like this: If you try to address anxiety or you try to address ADHD and you're successful in doing it, you'll see reductions in the thing you're targeting, reductions in anxiety, reductions in ADHD, but you'll also tend to see reductions in mental health conditions that are related but conceptualized as distinct from those conditions. So, we tend to see that if we see a reduction in anxiety and we targeted anxiety, we also tend to see a reduction in depression; try to address ADHD and successful reducing ADHD, you're also likely to see reductions in oppositional-defiant disorder or conduct problems or what have you.

The interesting thing here that I don't think has been tested is this idea of if you treat social skills in one of these domains, both lying, by the way, in very different spectra ADHD being a more externalizing-related condition versus than a more internalizing condition like anxiety, might in those circumstances, you see the rare occurrence of seeing a reduction in social anxiety and a concomitant reduction in ADHD, specifically because the core feature that cuts across both of them is social skills.

Well, might this be one of those rare circumstances where you would see a reduction in two distinctly conceptualized diagnostic conditions? That's a question that I'd be intrigued to see somebody probe, and maybe they have the data to probe it in one a large-scale data set of sorts. But suffice to say, that the good news is there are these two classes of interventions available to address both of these conditions, and what might be required in a clinical scenario is figuring out which one to target first and then monitor symptom response to intervention across sessions and then figure out at what point might it make sense to transition over to addressing social skills in their domain versus continuing on with that same one.

Tori Steffen:  Right. Okay. Yeah. That's really good to know, good information, especially to know that treating one issue might actually help the symptoms of another, which is really good information for a researcher.

Well, while all these treatment options are best and ideally done under the guidance of a licensed mental health professional, what are some things that adolescents can do on their own to potentially reduce or lessen some of those symptoms of social anxiety or ADHD?

Andres De Los Reyes:  It's important when you're experiencing these kinds of issues to become a good detective of how you're thinking, feeling, behaving. If you start noticing that it's kind of hard to build the kinds of relationships that you really want to have because it is true, and this is the interesting thing about social anxiety and ADHD for that matter, is that when you avoid these situations or you have difficulty maintaining friends, that doesn't mean that you don't want to be in those situations; you don't want to make friends. Quite the contrary. I mean, the research on social anxiety suggests that avoidance doesn't equal, "I don't care." There's that weird push and pull where you don't want to go into that situation, but you actually do really want to have friends. You actually do really want to maintain a healthy relationship, which is a universal feature. It's the rare person that doesn't want to build these kinds of relationships, because they're healthy and they feel good, and being able to have fun conversations and lean on people when times get tough, those are all things that the majority of us value.

So, if I was experiencing these kinds of concerns, I would sort of start asking myself, “What might be getting in the way? What are the things that I notice about myself when I know I want to go meet that person? I know I want to go. I know I really would love to be friends with that person, but I just can't get there.” What seems to happen before I get there? That isn't to say that you need to become your own therapist, far from it. But I think the interesting thing is to think about what information can I start gathering about myself, that once I get there, once I think I have the information I need, I can reach out to somebody who can help me: my parents, a counselor at school, someone who can guide you towards the people who have the experience, the expertise to help you make a meaningful change in your life.

Tori Steffen:  Right. Awesome. Yeah. That's really good advice. So, thank you so much for sharing that.

Do you have any final words of advice for us or maybe anything else that you'd like to share with the listeners today?

Andres De Los Reyes:  Do you have any questions about our work or are interested in learning more? I can be reached on Twitter with the handle @JCCAP_Editor, and feel free to reach out to me at my email address adlr@umd.edu. Thanks so much for finding this work interesting enough to listen all the way to the end.

Tori Steffen:  Perfect. Yeah. Thank you so much for sharing your knowledge. Definitely a lot of good advice and just good things to know about social anxiety and ADHD in adolescents, so we really appreciate you taking the time to enlighten us.

Andres De Los Reyes:  Happy to do it. It was a lot of fun.

Tori Steffen:  Yes, definitely. Well, thank you so much again, and thanks everybody for tuning in, and we will see you guys next time.

Please note: The views expressed by the interviewee are for educational and informational purposes only, are not meant to diagnose or treat any condition, and do not necessarily reflect the views of Seattle Anxiety Specialists, PLLC.

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Editor: Jennifer (Ghahari) Smith, Ph.D.