Podcast: Taking Back Life From Anxiety’s Grip
In this episode, Dr. Lisa Coyne discusses ways to identify anxiety vs. stress, talks about proven methods to offset our anxieties, and discusses strategies to help our loved ones—and ourselves—navigate having rational and irrational fears.
Lisa W. Coyne, PhD, is an assistant professor of psychology in the Department of Psychiatry, part-time, at Harvard Medical School, and is a senior clinical consultant at the Child and Adolescent OCD Institute (OCDI Jr.) at McLean Hospital.
Jenn: Hey everyone, welcome to Mindful Things.
The Mindful Things podcast is brought to you by the Deconstructing Stigma team at McLean Hospital. You can help us change attitudes about mental health by visiting deconstructingstigma.org. Now on to the show.
Hello, good afternoon, good morning, or good evening wherever you’re joining us from. If you’re joining us live or for the recorded session, thank you for joining us. And I hope that wherever you are, you are doing well today.
If this is the first time you’re joining us, I’d like to introduce myself as Jenn Kearney, the digital communications manager here at McLean Hospital. And what I’m about to say is going to sound kind of weird because I’m actually really excited about today’s session. It’s weird to say, because you don’t really want to have anxiety, you don’t want to suffer from it. You don’t want to know people who are, but it’s about 275 million people around the world that suffer from it, and about 40 million in the U.S. And strangely enough, only about 36% of Americans that have symptoms of anxiety or having an anxiety disorder are actually receiving treatment. That’s a lot of people. So, there’s a really good chance that either your part of that population, you know somebody who is, or kind of an amalgamation of both.
So thankfully with people like Lisa, we don’t have to suffer silently. Dr. Coyne is a psychologist, senior clinical consultant at the Child and Adolescent OCD Institute at McLean Hospital, otherwise known as OCDI Jr.
Lisa, I’m going to kick it off by just asking, how do I know if I have anxiety?
Lisa: How do you know if you have anxiety? Well, I love all of the stats that you cited. And another one is that one in two people over the course of their lifetime will struggle with anxiety. One in two lifetime prevalence rates. So that’s pretty amazing.
So how can you tell if you have it? Guess what all of us have it, and that’s on purpose, because anxiety is something that we need to keep us alive. And it’s something that is...And I’ll break it down into what its pieces are. But I think your question really is more about like, when is it a problem for me, right? So, what I’ll do, is I’ll give you kind of a longer answer. Let me define what we’re talking about first, and then I’ll tell you when it gets to be a problem.
So, anxiety has three components. It has an emotion, physiological reaction or arousal, and it has your thoughts about it, okay. So, we as organisms, right, have a nervous system, an autonomic nervous system. And because we are occasionally required to escape or avoid danger, we have part of our nervous system that just reacts without any thought at all, because it needs to react really quickly.
For example, if you’re a mammal or your rabbit and you see a lion, or if you’re me and... Well, we have turkeys, we have a mama Turkey and three baby turkeys in our backyard at the moment. And whenever they see me, they immediately react, okay. That’s the part of your nervous system that addresses that as your sympathetic nervous system, okay. Which mobilizes you to escape or avoid threat. And that mobilization involves activating you, right? It increases your heart rate. It makes your blood rush to your extremities. You might notice sweating, breathing quickly, and it helps you move quickly without thinking, okay.
We also have a part of our nervous system that calms us back down and that’s our parasympathetic nervous system. And we can talk a lot about the threat-soothing part of our nervous system, if we talk about compassion focused work in a little bit.
So, the reason we have anxiety, and that’s one piece of anxiety. So, let’s start with that. The other piece is that comes with usually a feeling of fear, okay, or dread. And the third part of anxiety, the experience of anxiety is our thoughts about it. And this is where things get a little tricky, okay.
Now it’s important that we feel anxiety to help us avoid threats. The problem is our threat system is so advanced and it’s so embedded in our languaging ability as organisms that it can get over-inclusive and it can teach us that we need to avoid everything, including things that may never ever happen in our future, right. So, if I feel, for example, like I am going to give a talk and fail at it. I will feel intense anxiety imagining that, right? So that’s an example of how our thoughts, our cognitions are wrapped up in anxiety.
So, when is anxiety a problem? Well, it’s a problem if it gets in the way of you doing the things that you love and that you care about in your life, okay. If you find yourself avoiding more and more things so that you can avoid the experience of anxiety, that’s a problem, right? So, we define it in terms of what we call functional impairment, which is just a fancy way of saying you can’t do this stuff that you really love and that you really care about in your life.
So, for example, true story. Most people when they have anxiety, it usually runs in families, right? And so, it runs in my family as it does in many. And at the beginning of my career, I used to have panic attacks, giving talks all the time. And I avoided giving talks for years, even though it was necessary for me to give talks, to grow my academic career. I used to ask the students to do it for me. That stopped when I realized that if I kept avoiding this, I couldn’t do the things that I cared most about. And so, I started to say yes to the talks and face that fear of anxiety. And we can talk a little bit more about that, as we answer the questions, ‘cause clearly I’m giving you a talk right now and you’re all making me anxious (laughs). Well, but not too bad. Jenn’s very soothing.
Jenn: I have to admit, I was definitely anxious to start doing these webinars because I-
Jenn: I’ve had a constant fear of public speaking, and I knew that the only way for me to get over it was to actually just tackle it head on. And it’s taken a lot of the box breathing exercises those in for four, hold for four, breathe out for four. That kind of stuff has been really helpful for me. But yeah, when I said, how do I know if I have anxiety? I’m like, well, how do I feel every time I put the camera on to host another webinar? (laughs)
Lisa: A better question is like, if everybody has it or one in two of us are going to have a clinically meaningful piece of it, right. The question is, when does it get in your way and when does it not, right? Because here’s the thing, what if it’s not necessarily the anxiety, that’s the problem. What if our willingness to feel anxious when it most matters to us to do the thing that makes us anxious, right? So, like, does it matter to you to do these talks, Jenn?
Jenn: Yeah, I mean, I think it’s really important. ‘Cause I think that, mental health education is something that I’m such a strong advocate for. I’m definitely supportive of it, yeah.
Lisa: Right, and so I often will find myself asking this question, like if I feel anxiety about something, I’ll kind of pause, notice that and think, well, am I willing to feel anxious if this allows me to move in a direction that I really, really care about, right? And mental health advocacy and dissemination of evidence-based treatment is really at the heart of what McLean does and certainly I of my own values. So, the answer is, yes, I am. I am willing to be anxious and also do the webinar. And I know it’s probably the same for you.
So that is what we call psychological flexibility, right? So again, not necessarily about the anxiety itself, but it’s about what do we choose to do when we’re anxious and how does that help move us forward in our lives or how does it hinder us? So, it’s just a slightly different way of thinking about it.
Jenn: So, if you were to, I know that that was a really long and thorough answer for what anxiety is and what anxiety feels like to people. How would you define it if you had 30 seconds to explain it to a kid or a lay person? How could you convey that same expression about what anxiety might be?
Lisa: Intense feeling of fear and discomfort that you feel compelled to avoid. And then avoidance gets in the way of you doing the things that you really love in your life, and it’s unhelpful. How’s that?
Jenn: That is fantastic. So, when looking into treatment for anxiety, how might it differ from person to person, especially if we’re not all feeling the same type of anxiety all the time.
Lisa: So, I think that one of the things that’s important to notice is that, people’s anxiety does differ, there are different kinds. Individually, like yes, treatment should be tailored to each individual, of course. However, at the heart of all of the treatments that are the evidence-based treatments for anxiety disorders is what we call exposure therapy, okay.
And what that means really, is increasing your willingness to feel anxious, so that you learn that anxiety, even though it feels uncomfortable is not dangerous or toxic. And in fact, our bodies were built to feel it, okay. And to learn how to do the things that you care about, that matter to you, even when you’re anxious. And so, it’s moving you towards that psychological flexibility.
So, at the heart of any, and let me kind of give you some examples. So, for example, fear of heights, fear of spiders, does it matter to you to be able to sit out in the lawn and play with your toddler even if there might be spiders? If the answer yes, you will feel anxious, and there might be spiders and maybe one crawls on you. Are you willing to experience that in the service of that thing that you care about? So that’s called exposure therapy, right? Spacing your fears with willingness and openness to feeling those things that show up in the presence of a trigger.
OCD, right. Are you afraid that, you might get contaminated if you touch something, right? And is that a fear that you have to over wash your hands and I’m not talking about COVID, I’m talking about, over blown fears about things, right? If it means you can win back some freedom and flexibility in your life, are you willing to resist that compulsion of ritual that goes with your OCD, and specifically with OCD we call that treatment exposure and response prevention. It’s very important and it is the gold standard treatment for OCD. And as we mentioned, you can learn a lot more about that at the International OCD Foundation Conference.
Trauma, let’s think about trauma, right? Many of us have traumatic events in our histories that are very painful and that show up in all sorts of ways in our lives today. And so, working with a therapist to go back through the trauma and allow yourself to walk through it and let yourself process this feelings, prolonged exposure, right. ENDR, there’s narrative approaches to trauma. All of those are evidence-based strategies for that. So that’s really important.
Let’s think about sometimes people engage in...really unhealthy and unhelpful coping strategies in the face of anxiety, like self harm, for example, as a distraction. Dialectical behavioral therapy, or radically open dialectical behavioral therapy are two options for those types of things. Those involve radical acceptance of what you’re feeling and the choice to really notice if you are, say in wise mind or emotion mind, and how to choose a more adaptive behavior, right, while allowing yourself to feel.
So, each of these is about turning towards the things that are hard and learning how to navigate them. What’s helpful when you do those treatments is finding a therapist who helps you go at your own pace, right. And really honors your choices in how to do that. I think that that’s really critical. But the core, even though you might individualize the treatment, the core is exposure therapy. Another way to say that is cognitive behavioral therapy, but really specifically it’s a form of cognitive behavioral therapy. It’s really important to understand that. And that that’s what you need to look for.
Jenn: So, when looking for a therapist, because I know that you had talked about when working with one, are there any particular questions that people should be asking about to see if they treat anxiety?
Jenn: Or are there any specific like certifications or education background they should know?
Lisa: I’m so glad you asked that. I’ll talk a little bit about OCD first because, there’s a really long history of folks with OCD having trouble finding care and they will, if they don’t ask good questions, they may not know really how well versed their therapist is in specializing in anxiety or OCD.
So, I would ask questions, like, what kind of therapy do you use for anxiety or OCD? Do you do exposure-based therapy? Can you describe an example of an exposure that you might do with a client? What percentage of your practice involves individuals with anxiety or OCD or trauma, okay?
And really like be—if I could say one thing to people listening—be good consumers and do not feel bad about asking these kinds of questions. It’s really, really important. We get lots of referrals from folks who have had care that wasn’t quite right for anxiety, and that’s why it’s really important. Don’t ever feel guilty for being a good consumer.
Places that you can learn more, right, would be IOCDF, AADA, so the Association for Anxiety and Depression, the American, I can’t remember what, like exactly the acronym, but that’s an organization all about treating anxiety and depression. And then for children, division 53 of the American Psychological Association has a website called effectivechildtherapy.org. And you can research what are evidence-based treatments for these issues. Okay, so there’s lots of good stuff out there and there’s lots of information, but certainly be a good consumer and it really is hard to find good care. So, I think work with your insurers too to find out who on their boards actually treat anxiety disorders and OCD.
Jenn: I think it’s really important, the point that you brought up about being a good consumer, because a lot of times, if you’re trying to seek care and finding a therapist, you have to go through a screening process and it almost feels like you’re being interviewed, but don’t hesitate to flip the script and ask the questions that you need so that you have the right information to be with the people that would be most helpful to you too.
Lisa: And I recognize too that if you’re feeling anxious yourself, that’s going to be an exposure for you to advocate for yourself, with somebody who you are nervous about. And so, making a space for that anxiety and ask yourself this question, are you willing to feel uncomfortable if that means you can find the best care for yourself, your partner or your child or your relative? And if the answer is yes, go ahead and move forward. I think that’s really important.
Jenn: And speaking of partners, one of the questions that came in makes me think that my partner is actually on here (laughs). So, the question is, my spouse has severe anxiety and makes me feel anxious because they’re anxious in certain situations like driving, being in an unsafe neighborhood or meeting new people. How do I detach my own reaction from my partner’s anxiety?
Lisa: That’s such a good question, and it’s such a hard question. I don’t know if this person’s partner is receiving care, but I think having a really genuine, kind and compassionate conversation about, it’s hard for me as your spouse when I notice that you’re feeling anxious. And I’m wondering if maybe, getting some help might be an option. I’d be happy to go with you. That would be the first thing.
And then the second piece, I think is just noticing when you feel pushed around by your partner’s anxiety and really kind of trying to keep your feet on the ground and noticing like, that you can make your own choices, even if they’re feeling very, very anxious. And one of the things that happens in families when you have an individual with anxiety or with OCD, is what we call accommodation, right?
So, what this person is describing is something that’s not unique to them. You’re not alone in experiencing that. And it’s something that happens. It’s one way in which a family members, anxiety or OCD can reshape the family pattern.
And the other thing to understand about that is that even though you may feel compelled to make things easier to protect your partner or your child from that anxiety, ultimately what that does is it feeds the anxiety, right? And so learning how to, at the beginning, at least to stop accommodating and saying, I’m so sorry, you’re uncomfortable with that, but I’m going to go ahead and do it anyway, or I’m not going to actually make any adaptations to my own behavior. I know you’re anxious, and I’m not going to do that. I think that that’s really important.
And then with kids, gradually, especially with treatment, encouraging them to engage in bravery-based behaviors instead of safety seeking behavior, or supporting their safety seeking behaviors. So, like if you’re anxious about going to talk to those other kids at the playground, I know you can do it. And so, the couple of ingredients that are helpful with that is empathizing, right. Being really compassionate and understanding that this person’s, this anxious person’s experience is their truth, right. Now, don’t be dismissive, that’s not helpful. And don’t be punitive for sure, that’s really unhelpful, but like understanding their perspective is their truth, and also they can be brave and you have confidence that they can do that. So those are two pieces that are really helpful, in being supportive to a family member that has anxiety. So maybe that’ll be helpful.
Jenn: So, I know that they...This person had asked about anxiety that stemmed from certain situations. How do know, is there any way to tell if your anxiety is genetic or whether it’s environmentally induced or not, and would that actually affect treatment?
Lisa: So, the first answer is, no (chuckles) One way you can, I mean, anxiety is heritable, right? So, like anything, or like most things it’s polygenic, there’s lots of things that contribute. And we can’t really ever, it’s like a false distinction to kind of say, genetics, environment, they’re separate. They always interact, right. And so, they’re always together. So, if you have relatives with anxiety, you’re probably more likely to have anxiety yourself.
And that’s something that we know, in my clinic and the McLean OCD junior also, that when we work with kids with anxiety or OCD, it’s not at all out of the realm of possibility that a parent be struggling with something very similar, okay. So that’s something to notice.
Is it harder, and does it affect the course? Well, it depends. It depends on whether folks are really aware of it and how, when you’re anxious, if you’re engaging in lots and lots of avoidance, right. Which is really the heart of the issue with anxiety. It depends on awareness, willingness and motivation to change those things as a family.
What I will say is that when we treat children and adolescents, if we don’t also educate parents about how best to support, right. Given the new set of behaviors of bravery based behaviors that kids are going to come home with, it’s more of a risk that the kids will go back to baseline and start showing more avoidance at home and at school and in other areas as well. So, I think, yeah, you can’t really separate out genetics from environment, they go hand in hand. It does run in families, it’s heritable. And it’s important to work with the whole family when you have an anxiety issue.
Jenn: So, when it is environmental, so like things that are out of our control, whether it’s a way that somebody else is acting or the question was actually COVID specific. Do you have any advice for facing those fears and anxieties that come up when something like a pandemic is basically out of our control?
Lisa: Yes, the first thing is, that’s actually the answer is embedded in the question. And the first thing is, to acknowledge this is something that we’re all experiencing and is beyond our control. And to really normalize anxiety is a perfectly appropriate response to the COVID situation and to the uncertainty of it all, right.
And so, the next thing I think would be, this is made more complex by the conflicting sorts of guidelines we’re all getting from different places, in the government, state, and federal, and town and all of that, right. And all of the individualized decisions in school districts about whether people are going back to school and what will that look like? And is it going to be a hybrid? So, I think making a giant space for all of that uncertainty that we are all in this together, and we are all feeling is very important. Don’t beat yourself up for feeling anxious about it.
It can be really hard, I think for people to not have a plan and know clearly what’s the next step and how do I keep my family safe? So, to the best that you can stick to evidence-based and science-based guidelines for what to do, right. Social distancing of six feet, wearing a mask, that keeps other people safe from you and hopefully they will also be wearing masks. Minimizing your interactions, all of those kinds of things.
So, I think for families, and if you’re supporting other people who are anxious, making a space for people to feel anxious, ‘cause that’s a really normal response. And yes, sometimes it does lead to, for people who are struggling with anxiety, of course, it’s going to lead to, more anxiety, right. And just really kind of sticking closely to what the science-based guidelines are and not overdoing it, right. So, if it’s 20 seconds is how long you should wash your hands with soap, you don’t need to wash your hands for 20 minutes. So those would be some examples.
Jenn: So what would be your, I don’t know, top three favorite de-escalation techniques that you teach patients or clients, especially things that we can take away from, walk away from this session with something tangible you can apply.
Lisa: Right, and so that’s an interesting question because when I think of de-escalation, right, I’m not sure what that person’s referring to because when I think of it, I think of violent, aggressive behavior, not anxiety, right.
Jenn: Yeah, I mean, this person can please feel free to provide for us clarification.
Lisa: Yeah, please do add more.
Jenn: For me, when I am anxious, for me, de-escalation is kind of talking myself back from that ledge or from an anxiety spiral, which again, please feel free to provide the clarification.
Lisa: Yeah, sure. And I want to caution people also about thinking, “Oh my gosh, I’m anxious and I must make it go away.” Okay. And for example, there’s this idea that we can really control how we feel and we can kind of meter it and we can kind of titrate it for ourselves.
We’re not really in charge of our emotions and our thoughts. And sometimes it can be counterproductive to try and control them, right. Imagine it like this, if I’m anxious, I’m super, super anxious and that’s all I’m focused on. It’s kind of like, I’m in the water and I have a beach ball and I’m going to try and push it down and I’m going to work, I’m going to put all weight on that beach ball and push it under the water. And I’m going to keep trying to push it under the water. And when I lose it, it’s going to pop up and it’s going to skyrocket into the sky, right. And then I’m going to have to catch it again.
Meanwhile, I’m at the beach, and the only thing I’m focused on is this darn beach ball. I’m not noticing, hey, it’s a beautiful day. It’s really sunny outside. I’m with my friends, we’re having a bonfire on the beach, whatever the story is, okay. So, lots of times when people get stuck with their anxiety, it’s not, again, it’s not because of the anxiety itself. It’s because of the strategies we use to control it. And the evidence-based treatment exposure, right, is the opposite of that. It’s increasing our willingness to allow ourselves to feel frightened or to feel anxious.
Now, that being said, there are some strategies that I can tell you about for if you feel like they’re absolutely necessary, for example, in the middle of a panic attack, okay. And one of them is called grounding, alright. And one of the components, as you know of anxiety is what we think about anxiety. And so panic occurs in a couple of situations. One, is when we’re hypervigilant to physiological changes in our body, right, like I notice my heart rate is quickening. Does that mean I’m going to have a panic attack? Or I noticed that, I’m starting to feel flushed. Does that mean I’m going to have a panic attack?
And if you have panic, you know that there’s kind of thought spiral that begins to happen, right. Like, Oh my gosh, I’m going to lose it. I’m going to have a heart attack, I might die. Or I might, lose my mind, I might go crazy. All of these really, really frightening thoughts can show up, okay. So, this is the point where we might be able to intervene, right. By noticing, bringing your awareness just to the present moment with your five senses, it’s called grounding.
So, noticing my mind is starting to spin here and I’m starting to have all those anxious thoughts. So what I’m going to do is I’m just going to first of all, notice what’s in the room around me and I’m just going to see if I can bring my awareness to those things, okay, that’s the first thing. And that simple act can be useful. When you have a panic attack to just be aware, I know I’m panicking, this is really terrifying and I’m also going to be okay, okay? So that’s something you can do, but again, treatment is allowing yourself to have those experiences. And I know that’s a tall order having had panic, right. That is a very, very scary thing to think about. And I promise you, I promise you, you can do it. It’s really important to know that.
Jenn: And I know you lightly touched upon one area, anxiety makes you think that it’s beyond anxiety and it’s just something more, could you provide any additional insight into when anxiety makes you think that a minor health symptom or something that’s likely to be a minor health symptom into feeling a bit more catastrophic because, I mean, your chest gets tight from anxiety and panic, but that’s also a hallmark symptom of a heart attack.
Lisa: Right, exactly. And I think that’s really an important distinction to make. So if you have a history of heart conditions in your own life, or if it runs in your family, that’s worth getting checked out, but it’s not worth getting checked out many, many times over and over for reassurance, right?
So, health-related anxiety, whether it’s in the context of OCD or just frank, health-related anxiety, which is something that we also are familiar with in my own family, it’s a really hard thing, right? And it goes like this, you feel a funny experience in your body. You notice a change, you’re hyper vigilant, meaning extra watchful for those things. And then you check, you ask for reassurance, you call a doctor, you go to Web MD, please don’t go to Web MD. You go to Google and it begins this constant cycle of, “Oh gosh, this is happening.”
And when people are worried about things like heart things they’ll avoid things like physical activity, like anything at all that might like, raise the heart rate and things like that. And so, if you find yourself in a pattern of, I’m noticing something scary, I’m checking, checking, checking, seeking reassurance, avoiding, and this is really becoming a central focus. That’s probably something that you would benefit from some help with, right, from an experienced provider.
And so, I think doing the reasonable things, and checking out, like, do you have a heart condition, right? And when we get these kinds of patients that are referred to our clinic, one of the first things we do is have you checked with your doctor? Do you have a clean bill of health? Okay, then we can do your anxiety treatment. But we always want to rule out, at least initially, that this is not a physical issue. That help?
Jenn: So, the next question is, I feel like somebody took this right out of my brain. Is it common to have more heightened levels of anxiety with family and friends? And if so, why?
Lisa: It depends, that could be anything. Is it common? I suppose it depends on you as an individual and what your family and friends are like. Sometimes when people have social anxiety, yes, It’s really common to have heightened anxiety around social interactions. I also think that, for most of us, we have a slightly different base we put on outside of our homes, than we do with our closest and most trusted family members.
So, are you more likely to express your anxiety in different ways with your family? Probably, yeah, and that’s really common. We’ll commonly hear people say, “Oh my gosh, I never knew so and so was anxious,” but their family’s like, “Oh yeah, of course,” right? Because we show that side, when we’re more willing to be vulnerable, lots of times with our family and friends. So, I think that’s important. Sometimes that can be a good thing too, because it can give you an outlet to actually really talk about things that are hard to talk about, if you feel less willing to be vulnerable outside.
Jenn: It certainly, it helps with reduction of stigma too, in your social circles as well. So, anybody who is silently struggling will feel disarmed and may actually come to you for help, which would be really beneficial in mental health education and advocacy.
Lisa: I want to say something about that too, because that, like the fact that there is such stigma around feeling anxious, honestly, like that’s one of the reasons that I disclose, when I do these talks, because it’s really important to understand that we all have anxiety, it is a normal human emotion, and that if one in two of us is going to experience this in their lifetime, my goodness, right.
Jenn: It’s not flipping a coin.
Lisa: Yeah, exactly. It’s not a weakness, it’s a part of life, right. And I think the more we make a space together to really talk about this and allow this in the community, the more people are going to actually get help for it. If they need that and be able to work on building lives that they care about and really love.
Jenn: So, we did have somebody ask, our daughter has a mental health diagnosis and is often afraid to leave the house for fear of running into classmates, is this normal anxiety, and could this turn into agoraphobia?
Lisa: So, keeping in mind that we’re not giving medical advice, remember the rule of thumb for when anxiety becomes a clinically significant or a clinically meaningful issue, does it get in the way of everyday functioning? And if there’s a pattern of avoidance, that’s becoming more entrenched, that’s a flag for me. And that is something that I would actually look into, right, especially if you care about being with people.
If the person’s like perfectly happy being at home and doesn’t really have a need or desire to be connected with people, right. And is functioning well in every other area, then maybe it’s a personal preference. But if you’re seeing an increasing and widening pattern of avoidance, such that the person is avoiding routine activities, is not making friends, is starting to feel lonely and isolated and is not, starting to avoid things in school. Yeah, it can actually, continue and yes, it can, I don’t know, nothing is causal, right. But certainly, it can lead to things like school refusal and avoidance so, yeah.
Jenn: We’ve had a couple more questions about comorbidities. Somebody did ask, is there a relationship between anxiety and ADHD?
Lisa: That’s a really interesting one. We get that question quite a lot and to tell you the truth, they can be comorbid and it’s really hard to tell them apart, functionally, because when you’re anxious, it’s hard to pay attention. We all know about the Yerkes-Dodson curve, right? Where at kind of moderate in levels of anxiety, that’s your peak attention. But if you have no anxiety or really high anxiety in either of those situations, it’s really hard for you to have optimal attention to things.
So sometimes people do have executive functioning issues and also anxiety, and they are separate. But sometimes what is... Difficulty paying attention and concentrate is sometimes mislabeled ADHD, when it’s really just, it’s anxiety or if you have OCD engaging in cognitive, what we call cognitive rituals, which are things that people do in their heads, say to themself or visualize, right. To mitigate some sort of uncomfortable or a anxiety provoking experience.
So yes, they can be comorbid, and one can be mistaken for the other. It’s a tricky question. So, the way to tell, right, would be to get an assessment from a skilled psychologist who’s also involved in diagnostic interviewing, right? And who can give you an evidence based structured clinical interview that helps you choose those things apart. A neuropsychologist can also do that, and that’s exactly what they do. And they’re available for children and adults, really important.
Jenn: I know that you had lightly touched on task avoidance, and what happens-
Lisa: Oh, task, T-A-S-K?
Lisa: Oh yeah.
Jenn: So, if somebody is afraid to even get started on something, because they’re afraid of failing, would you classify that as anxiety? And if yes, how would you deal with that fear and anxiety being coupled?
Lisa: Well, that’s a really great, I love that question. So, I think that that’s an experience that’s very common and it’s also something that’s very, very present in perfectionism. Perfectionism cuts across a lot of different things, including anxiety, OCD, depression, et cetera, right. And to break down that issue of like, it’s hard for me to start things or I’m avoiding starting things ‘cause I’m afraid of failure.
One thing that’s important to do is to step back and notice how amazing our minds are, right? Our minds are so cool that we could experience a future that may never ever happen. And it can have real physiological effects for us in the moment, right. So, if I imagined, “Oh gosh, I’ll never be able to do that or I might fail at that.” I might feel anxious right here and now, even though that future may never, ever occur, right? So that’s the first thing, is to kind of marvel at how wonderful our minds are and what a double-edged sword they are, because they allow us to plan for the future and think abstractly.
And when we avoid and when we kind of indiscriminately listen to the messages that they give us, they can hold us back. So, thing two, that you could try is really notice, like first step back and notice you’re having a thought, right? Number two, ask yourself, am I willing to experience this thought? Of course, not the real thing, just the thought that this could happen and also take a step in this and do this task, which might be very, very important to me, right?
And so, I think the thing that is most, I guess, or that this has in common with anxiety is there’s an uncomfortable experience that we’re having. And the rigid response is, I’m going to avoid that thing so I don’t have that emotional experience. Anxiety works the very same way. I feel really anxious so I’m not going to do that thing. And again, exposure really, even in this situation, is, am I willing to have this uncomfortable experience, if it means I get to do this thing that I care about?
Jenn: I did just want to say, we have about 10 minutes left in the session. And I want to try to get through several questions that we’ve had about, when people feel like they need to speak to somebody or seek professional help. One is, how common is postpartum anxiety and how do I know what’s normal for anxiety versus when I need to speak with somebody?
Lisa: Yeah, okay. How common is postpartum anxiety? And I’m embarrassed to say, I don’t know the exact stats on that and I know that it’s prevalent. And I know that people are learning more and more about it because we have known about postpartum depression for a really long time. And now, just in the past, maybe, five or 10 years, we’re starting to talk about postpartum OCD, right. Which is something that people experience as well.
And so postpartum anxiety because is, I would suspect is also fairly prevalent. So I don’t know the rates of it, but what I would say is, if you’re experiencing it, if it’s causing you, if it’s impairing you in some way, and if it’s causing you significant distress to lead into the next question that you had Jenn, yes, I would certainly seek help and see if you can talk to someone about it and learn some skills.
And if I might actually suggest a resource to learn more, especially about this approach that we’re talking about, I’m going to talk a little bit about the work of Susan Orsillo and Liz Roemer, who are research scientists and also clinicians in the Boston area, who do evidence-based work using acceptance based approaches to anxiety. And one of the books that I routinely give out in my practice and we refer for parents, adults, young adults, teens is “The Mindful Way Through Anxiety.”
You can get it on Amazon, it’s not that expensive. And it’s a lovely self-help book with some data behind it, and it was developed... It is an evidence-based kind of approach to generalized anxiety disorder and worry. So that’s one way to start and you can learn a lot, even if you do something like that to start learning, like, how do I think about this? What do I do about this? That’ll give you a taste of the approach. And then if you feel like that’s something that’s a fit for you by all means, go ahead and talk to someone.
Jenn: So that actually ties really nicely into the next question of, is there a role for meditation and mindfulness in treating anxiety?
Lisa: 100% yes. Yes, there is. When you think about it, if we are working hard at avoiding feeling anxious, that’s the opposite of really mindful awareness and exploration of what those feelings are and how they work and all of that stuff. So yes, meditation and mindfulness are useful not necessarily to ameliorate or change anxiety, but to give you an alternative to avoidance behavior and to just allow it as a part of the human experience.
And just to extend that a little bit, another approach that, is very, very useful for anxiety is compassion focused therapy, which is and also, a cognitive behavioral therapy. And it involves lots of meditation and mindfulness and lots of awareness and self-kindness and holding yourself gently when you’re feeling anxious, rather than beating yourself up for feeling too anxious, right. And what that does, that kind of practice of self-compassion, right? Especially when you’re feeling anxious or stressed in any way is to engage your sort of self soothing system, right?
‘Cause we talked about the threat system, the fight or flight system, and now we’re going to think about like the sort of, self-soothing situation, which allows you to make better decisions about what you want to do in the next moment, rather than avoidance.
Jenn: So, somebody did ask, that they’re, based on fight or flight response, that their spouse’s anxiety actually displays as being extremely angry and bullying. And as a result, their anxiety level stays high because they’re not sure what’s going to come next. And while they’re not sure that they’d be willing to explore treatment, do you have any suggestions for them?
Lisa: So, the first thing that comes to mind, is I hope that this individual is safe and keep safe if there’s any sort of aggression, violence. And we know that in the face of COVID, there has been an increase in domestic violence. So that may or may not apply here, but I think it’s worth mentioning. Yes, anxiety can manifest as anger and it’s unfortunate that, that individual, and I’m assuming the spouse is not willing to go for treatment, but I think-
Jenn: Yes, it seems like they don’t think that they’d be willing to explore treatment.
Lisa: Yeah, so I think, for the spouse, for the other person, who’s the target of some of this anger, I would encourage you to get your own person to talk to, to help you work through some of these issues, to set some boundaries with your spouse, to ensure your safety with your spouse. And also find ways of having conversations, maybe brokered by that provider that you yourself see to help your spouse hear about the impact of his or her behavior on you and on you as a couple and on you as a family. I think that that’s really, really important.
Jenn: Do you think that acupuncture would be a good treatment for anxiety?
Lisa: So, there’s not an evidence base for that. And so, I wouldn’t...If we’re going to talk strictly about evidence-based approaches, I think that, you have to go with kind of what we know. And I mean, I think people explore lots and lots of things. So, I wouldn’t, my worry is, when we start to talk about sort of more holistic and further afield approaches that may have been used for thousands of years, I want to make sure that’s an adjunct to actual evidence-based treatment. If that’s something in addition that might be useful by all means try it, but don’t let it replace actual evidence-based care, very important.
Jenn: So should this individual that I’m reading their question, should they worry that their daughter has always had social issues, making friends, she sees it as unfortunate that they don’t have friends, but they seem okay just being home and doing their own thing. Would that be a social anxiety?
Lisa: Again, it depends, if it’s not causing tons, if it’s getting in the way of sort of, launching into the world, there’s...Sometimes kids who do have social anxiety issues can become school refusers or are school refusers. And we actually work with quite a lot of that in McLean either in the MAMP program or in OCD junior, and even in my own clinic.
But sometimes people come in different flavors, right? Some of us are really gregarious. Some of us are introverts and I think making a space to meet your kiddo where they are, and really kind of having a clear eye look at, is this really impairing or causing them significant distress? Or is it more that, I’m really worried because maybe I’m gregarious and I am uncomfortable with them kind of being more insular. I mean, it really depends. I think again, the two questions are significant distress and impairment across many environments.
Jenn: I think we have time for two more questions. I think one of them actually would be really useful for them to hear more about impairment from the environment. So this individual had a lot of childhood trauma and as a result, as an adult, they have severe anxiety with, they feel like they must protect their own children, which are fully grown children and their grandchildren, but their adult children get aggravated with me because what they perceive as fun, this individual sees is dangerous and they’re unsure how to relax and enjoy. And also, I think this is really valuable. They try to put on a happy face for the outside, but on the inside they’re a wreck, do you have any advice or help?
Lisa: Oh, I do, and thank you so much for that question, and my heart is going out to you right now. So, I think, understanding that anxiety as, when people have experienced trauma in their past, right. When they’re anxious right now in the present that trauma history shows up. So, it’s like that history showing up in the moment and directing their behavior maybe in ways that are perceived like as this person’s family experience.
And so I think working with a clinician to address that past trauma and find ways to notice it for what it is in the moment and then choose, how do I build my relationship, or how do I keep a healthy relationship with the people in my family now, is going to be important. But I think noticing that like when we have trauma from the past, it can show up in the present in all sorts of unhelpful ways, that guide our behavior and organize what we do in ways that are not great. So, I think that’s important.
Jenn: But last but not least is, how can we encourage ourselves, our clients and our community to tap into and trust intuition, amid dealing with anxiety when making decisions and in thought processes?
Lisa: Wow, that’s a really big question. Can you read that, again?
Jenn: Yeah, how can we encourage ourselves, our clients and our community to tap into and trust our intuition, amid dealing with anxiety when making decisions and in thought processes? I figured this would be a good one to end on.
Lisa: Anxiety at the heart of it is information and it’s information that our mind gives us to avoid or escape a threat. And so, I think kind of stepping back and noticing, right, not from our minds, but kind of from our more, trial and error sort of behavior, right. Is what I’m doing in the face of this anxiety useful? Does it serve me or does it constrain me? Is it making my life bigger and more flexible and more joyful? Or is it locking me up in a cage? I think, really noticing that is important.
And I think I wouldn’t call this intuition, but I would think about letting the things that you think that you hold most dear, the things that are most important to you, guide your behavior rather than letting the need to avoid, or the urge to avoid feeling anxious guide your behavior. So, I would say connecting with your intention, right? And notice, am I doing something ‘cause I’m scared or am I doing something because I care about it. And it’s going to build my life in ways that I really, really want. So, I’ll leave it at that.
Jenn: Lisa, thank you. As always, you are like an encyclopedia of endless knowledge. You are amazing.
Lisa: She’s saying I’m a nerd, basically, but I’m happy to nerd out with you all- (both laugh)
Jenn: Absolutely, from one nerd to another, thank you so much. You are the highlight biweekly for me, for my job.
Lisa: So lovely to see you.
Jenn: Thank you to everybody. Make sure to breathe, wash your hands and not only be nice to others, but just be nice to yourself.
Lisa: Thanks for all the great questions. Thanks for all the great questions.
Jenn: Thank you everybody.
Lisa: I hope you guys all have a good couple of weeks.
Jenn: Take care and we’ll see you soon, thank you.
Lisa: See you soon, bye.
Jenn: Thanks for tuning in to Mindful Things! Please subscribe to us and rate us on iTunes, Spotify, or wherever you listen to podcasts.
Don’t forget, mental health is everyone’s responsibility. If you or a loved one are in crisis, the Samaritans are available 24 hours a day at 877.870.4673. Again, that’s 877.870.4673.
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The McLean Hospital podcast Mindful Things is intended to educate about, encourage compassion around, and reduce the stigma related to mental health and wellness. This podcast is not an attempt to practice medicine or to provide specific medical advice.
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