whole point uh dr milesberg is that we don't plan the opening that the opening is organic uh you know are you anxious about doing it without rehearsing the opening i
just think i'm gonna do awful on this podcast
Well, you know, it sounds like you have a lot of fear. You're anxious and you're not happy about what to expect with what we're doing today. And that leads us to our topic, I suppose. Anxiety.
You didn't even give it time to develop.
Well, what were we going to develop?
I don't know. I was going to act like I'm very anxious and then you were going to make me evaluate the evidence and then we were going to come up with a replacement thought.
You know, I may do a lot of behavioral activation, but I wouldn't call myself a CBT therapist. It is funny that you bring that up. I feel like people might not know that there's a sort of artificial dynamic between the two of us on this. I feel like I've been getting some feedback that I'm kind of mean to you, but maybe that's just who I am.
I got the same feedback too. My mom thinks that you're mean to me.
You're not serious. Is that true?
That is serious. Mom said. Well, it took her a while. She used to say, that Dr. Fu's not nice to you. And I said, no, it's our dynamic. He's well-intentioned. And then she started liking you.
Well, I appreciate that you were playing defense there for me, but I'm probably nicer on the podcast than I am with actual trainees. So, you know.
Your dynamic is that you're abusive to your trainees and co-hosts.
I mean, if this stuff is abusive, I mean, you kids these days should have been coming up decades ago how they used to do medical training. Okay. See, there you go.
There you go. You kids these days. All right. All right. So today we're talking about anxiety. I can start off with a little spiel. I think we have a lot of things we could touch on. Yeah, I mean, it's a popular topic.
I feel like everyone can get an anxiety diagnosis these days. And I do think that that's partially because of, first of all, anxiety burden is super common. across types of patients and psychopathology and on top of that i don't know if training around anxiety is where i would like it to be for the field what i mean we
can let's briefly touch on like what what is if you were to encapsulate the problems in a few sentences what would you say it is
Yeah, I think what I want to get across today is that anxiety is more often than not a signal or an experience associated with or stemming from other things rather than its own thing. But most people tend to think of anxiety as a thing in itself.
Okay, so that's helpful. So you think that when you see anxiety, you should see it as a signal for where you're searching for the underlying diagnosis, not as the thing in itself.
Yeah, exactly.
Okay. I think we will get there. If you wouldn't mind, maybe I'll start us off with some basics on how I view anxiety. Not in terms of what you're saying in regards to where it fits in, but just the underlying biology and definitions that might be helpful.
I think it will be absolutely helpful. Let's go for it.
There's two different interconnected concepts I want to touch on. I like making things oversimplified, so you have little... conceptual things in your brain to think of quickly. So the first one I want to touch on is the two regions that are involved in anxiety, fear, panic, and worry. And then the second thing is kind of defining and distinguishing the four interconnected things that I'm talking about, which are fear, anxiety, worry, and panic.
Because I see them used very differently and in different ways. And I think it's sometimes helpful to have them differentiated. So to start, in terms of how I view all these things, we're all mammals. Human beings are mammals. And anxiety and fear and all these things evolved as survival mechanisms. And in that sense, they're all normal things. They're not things we want to get rid of. These are all fear.
Fear and anxiety are ways to help us detect threats and danger. and then help us mobilize and do something about it. And there's a little thing called the Irks-Dodson curve. And it's a relationship between on the x-axis is arousal and on the y-axis is performance. And it's basically just saying that there's a sweet spot in that if you have too little arousal, you're not going to perform well.
If you have too much arousal, you're not going to perform well. But there's a middle ground of anxiety and arousal that you're... you know motivated and aroused enough that you're performing at a peak level and that's what anxiety is for like that little curve is showing why we have anxiety is because we're trying to get the arousal started for performance purposes yeah you
know it's something i think that you really run into if you have any history of public speaking or being a professional performer at all the optimal level of anxiety or activation I often say that the difference between physiological activation and anxiety is actually our subjective experience of it you know whether we see it as a negative thing or not obviously there's situations where anxiety is just so clear and out of whack that's a clinical problem that's not really what i'm talking about but what you're talking about there reminds me of i think it was rollo may his book on anxiety i think he mentions a very similar thing that his speaking performance his performance in general is just not as good if he has too little or too much anxiety And by the way, it's a concept that's relevant to psychotherapy too.
In a psychotherapy, this is an aside, in a psychotherapy, the patient needs to be at an optimal level of activation, not over-regulated, not under-regulated for optimal treatment.
Yeah. And I mean, you know, like these things serve a purpose. Like you said, like I can think of, yeah, lectures I given when I was super anxious and, you know, had to do grand rounds and I flustered because I was heart rate was going too much. And then there's times when no one's listening. It's not important and I don't care and I don't do a job.
So there's a, you know, there's a middle ground of like this is an important lecture, but there's not a billion people who are trying to criticize me. There's that nice middle ground. And that's what that anxiety exists for. Let's move now to the brain regions involved. And again, this is oversimplified to an adorable degree, but it's still helpful for a little conceptual framework. There's two main brain regions that I think of.
There's the smoke detector, and then there's the watchtower. So the smoke detector is the amygdala. That's the bottom part, and I'll explain that in a second. The watchtower is the prefrontal cortex, and that's the top part. So... When I say bottom up or top down, it can be a little, I get confused because it means different things in different contexts. But here I'm thinking of the bottom being like the mammalian brain, the emotional brain, and the top being the more evolved part, the cortex, the thinking part.
So the amygdala is the bottom up. That's the fear center. It's the primal part of the brain that asks one question, am I in danger? And it's not a smart part. It acts really fast. It's instinctual. Then you have the top part, which is the watchtower, the prefrontal cortex. that's the more evolved thinking part of the brain it's scanning for information it's dealing with complex information and it's making judgments and i think of it as the part that sends like the what ifs you know like what if i blow this podcast what if what are the risks of this podcast like what if what if uh i say something stupid and dr foo thinks i'm stupid it's like the part yeah it's the part kind of setting the what if questions
It's also the part that can control. I mean, not everyone gets to this point where you can have a direct volitional executive control of anxiety or sort of reinterpreting it as excitement or activation instead of anxiety. But yeah, it's a complicated area. It's funny you call it the mammalian brain. I kind of feel like a lot of people call it lizard brain. I think it's more fun to call it that way.
It's not exactly accurate. But for those of you who don't know, the brain structures are basically something like three different levels of brain tissue type that build on each other that we can trace back to different periods of evolutionary development.
I call the lizard more like the hypothalamus, like the part that's doing all the survival functions. I guess I think of amygdala and limbic cortex as mammalian.
We should defer to you on this. I'm very inexact with neuroscience because I don't exactly have a lot of respect for how well it can translate to clinical practice.
Agreed. It's a helpful little model more so than, yeah. So as we're saying, regardless of how you define it, when we say bottom up, we're saying it's the emotions and the biology triggering the cognitive thinking part. And we're saying top down, we're just saying the cognitive thinking part triggering the emotions of biology. So when we're talking about fear or anxiety or panic or worry, the key difference isn't where in the brain it happens, but how and when these regions interact.
So fear is bottom up. It starts with the alarm, and then it gets the thinker thinking afterwards, and it starts with a threat. Anxiety is top down, so it starts... Anxiety is a little bit more complicated, but... is more of the top-down process of the the what-if which sets off the alarm so it's
both the there i will diverge um i don't agree with that definition we'll talk about conceptualism anxiety later not to say that yours is not a valid one again anxiety is such a broad term and used by so many different people it just means so many different things in different contexts anyway sorry to interrupt please go on
no no no worries i'll go into a little bit more detail maybe we can figure out where you differ Um, so let me, let me go on. Fear is the alarm system. Its primary job is to protect you from real immediate present danger or perceived danger. It's when the amygdala detects an obvious threat, it kicks in your fight or flight, fight, flight, or freeze. That's where you get the heart rate, the increased breathing, the muscle tension slows digestion.
That's why you can get nausea changes your vision. So that's why I can get a little blurry. Um, The adaptive purpose is to keep you safe, to trigger your fight or flight, to respond. So it's to mobilize and do something about it. Anxiety, like I said, is to me more the top down. It's the persistent state of being alert. So it's when the watchtower is worrying about potential future threats and it's setting the what ifs that I was kind of talking about.
And it's a broader, more persistent state of distress than fear or worry. I'll talk about worry in a second. It's a diffuse, less specific, unknown future threats, whereas fear is more the immediate threat right in front of you. And it allows you to maintain vigilance in an unsafe environment. So it kind of is that top-down thing sending slow... messages to the bottom part, which slowly trickles out stress hormones.
So you feel a persistent sense of unease. So the physical manifestation of anxiety is the smoke detector being kept on low-grade alert by the watchtowers worrying. So the key here is it's a prolonged future-oriented state of unease about a nonspecific threat. And like I said, the adaptive purpose is to keep you aroused for performance. Helps you prepare for danger. A moderate amount keeps you focused and motivated.
I would have never studied in school if it wasn't for anxiety. It was when there was the test is the next day and it's like, oh my God, I'm going to fail. That If I didn't have anxiety, I would have never gotten through school because I just would have never studied. It was like when that level of anxiety got so high that it's like, I'm going to blow this.
I think that's so true. But I also think it's interesting how we as a society kind of conceptualize this, right? I said at the start, I'm not a CBT therapist, but if we talk about it not as anxiety, but as excitement, right? you know excitement of the body arousal kind of has some sexual connotations I think but if we just talk about about like nerve excitement I would have never studied if I didn't get excited well did I get excited because of the anticipation of a threat or a negative outcome yeah I did but it was still exciting right it's sort of a positive spin I think when I try to encourage
Yeah, I love that. I do something similar, but for when it comes to panic attacks, like telling yourself I'm having a panic attack is very different than telling, and we'll get to that in a second, but I'm having an adrenaline release. Like how you frame these things is really going to change how you respond to them. Yeah. it's the underlying biology is the same but the context that you put it in is going
to change how you view it that's right the watchtower is not an ai watchtower there's a little person in it and you can even get many little people in it and train them to stack a watchtower in a way that works a little better than what
you're used to uh my friend that the disney movie i still haven't seen it um inside
out hmm My friend loves that for... You mean internal family systems in a movie?
Exactly. Well, so going back to anxiety, evolutionarily, this was designed for humans to survive predators and social rejection, like being banished from a tribe, we think. In modern life, these threats are symbolic. So... The things we talked about in the personality stuff, there are threats to your identity. There are threats to where you want to be in life. There are threats to your empathy. There's threats to your relationships.
It's a lot more symbolic threats than it was how we think of why they evolved in the first place.
Well, in the interests of cultural balance, I will say there are far too many people, the majority of the world still has some very real threats on their plate day to day. So just depends on where you are.
Absolutely. I'll try to go a little bit quicker through the last two. Worry to me is the cognitive component of anxiety. It's just the, so worry is in the mind, anxiety is in the mind and throughout the body. So worry is also future focused, but it's the thought-based component of anxiety. It's the what ifs without, if you were just thinking of the what ifs without the response to the what ifs.
So it's got the same purpose of leading us to planning and action. It's what sets off the bottom-up part, but I guess I think of worry as just the cognitive component of anxiety. Then panic is the overwhelming alarm or... when we're thinking about panic disorder, an overwhelming false alarm. Um, so it's a sudden intense wave of fear that peaks within minutes and then gets better. So it's really the, the body's alarm system maxing out.
Um, you know, it's, it's when you're in a cave with a lion cornered on you and you're, you just release everything you have. It's like one last ditch effort to do something. Um, so it's an intense, abrupt episode of fear with powerful physical symptoms and it's an escape.
Oh, a quick add on on that. Sorry to interrupt. Um, Totally agree with those definitions. One thing to watch out for, though, is that when you interview patients and you're trying to diagnose, many patients will describe panic as lasting hours because they actually have a subsequent prolonged period of emotional distress and heightened anxiety that they still associate with it. But if you drill down to it, you will find that in a true panic attack, it is a spike initially, a very intense mind and body experience lasting just 10 to 20 minutes max, as Dr.
Malzberg says.
Yeah, definitely. And like these things are interconnected in that like, yeah, you can have the anxiety prolonged after the initial panic response. Yeah. So that kind of captures my, you know, the amygdala, the prefrontal cortex and the differences and how those interplay with fear, anxiety, worry, and panic, which are very similar. But I think differentiating is helpful for patients to kind of understand rather than just have this global sense of like everything's wrong.
Yeah. So I suppose then I should give the model I prefer and how that kind of informs me and soapbox a little on it. Does that sound okay? Let's do it. Yeah. So I think that my main problem is that anxiety is mostly signal, both signal of underlying psychopathology and signal of underlying thoughts, feelings, conflicts, and desires. What do I mean by that? Well... You know, a lot of people act like a anxiety disorder is its own thing, like a schizophrenia or a bipolar disorder, something like that, where there's sort of a separate medical reality to it.
And that's something that is maybe imposed upon somebody in a way that is different than who they really are, their normal self. Right. I think those conditions include things like dementias. i think it's wrong to think of anxiety disorders that way because the way we define anxiety disorders are clinical and so much of anxiety disorders come from a lot of different sources and also a part of the personality basically neurotic tendencies that has been sort of deleted out of dsm for the most part even though it's clinically and just scientifically very relevant okay so how do i think of anxiety the first thing is that i want to separate trait from state anxiety that some people have higher or lower trait anxiety they have a baseline temperamental physiological tendency towards anxiety that is probably partially controlled by genetics partially controlled by upbringing and environment and to a smaller degree controlled by volitional psychological dynamics.
And then there's state anxiety. Every person except for maybe extremely rare people and psychopaths have a tendency towards feelings of fear, trepidation, anxious anticipation, anxiety itself in response to situations. Now, if we can identify a specific cause of that anxiety, the threat response, we can call that state fear. And if we cannot necessarily identify that and the activation of the body and mind is sort of free floating for that moment, I would be more inclined to call that anxiety.
And so one more thing I wanted to mention Anxiety is poorly defined. The different pathologies are not defined well, and they overlap with a lot of different things. I think that this can be best demonstrated simply through the history of the DSM. In DSM 3 and 4, PTSD and other related disorders and OCD were considered anxiety disorders. They are now considered separate chapters, and I actually agree with that separation.
we become more certain or more clinically attentive to differences about the causes of felt experience anxiety then we can call them different things so anxiety again is a signal it's a signal of some underlying problem fear conflict unobtained desire in some cases and don't confuse it for a thing in itself
And then, you know, I think you're talking about the trader state. So trade anxiety is more the personality style. And then state anxiety is more the temporary response to current stressors. Is that accurate? Yeah, that's right.
And of course, if you're high trait anxiety, you're going to be much more likely to respond to the same situation with a higher degree of state anxiety compared to somebody with low trait anxiety.
I've heard an analogy that it's kind of like the weather. So, you know, like the climate is the trait and the weather is the state. So like, you know, Miami, Florida has a warm climate, but any day can be hot or cold within that. I don't know. That's just a little.
Yeah, that's pretty good. So I guess you might ask, what are the implications to this kind of atom splitting than doing with the anxiety concept? Yeah. i guess the clinical and personal implications i have is don't just stop at calling it anxiety find the source of the anxiety whether it's external internal or a combination interaction between external and internal factors There was one doctor's records who I combed through who kept telling patients to find the source of the anxiety.
I thought that was a good instinct. I probably wish that that doctor spent more time helping the patients find the source of anxiety, but it is a good instinct. And so in the modern DSM, what is left in terms of defined conditions that are considered, quote, anxiety disorders? Well, there's generalized anxiety disorder, which is a pretty problematic diagnosis, if you ask me, and one that gets applied way too broadly to anyone that has a lot of anxiety.
There are specific phobias, and there is social anxiety, which is basically a social phobia, and in my opinion, something that's more of a... mismatch between personality and temperament and environment development am i missing anything else in the modern dsm things are considered specific anxieties
Oh,
yes, there's the panic syndromes, which, you know, those are their own kind of thing because it's an interaction, I think, between, again, personality temperament and some kind of events. For example, panic disorder, that is acquiring a fear of fear, fear of panic and avoidance pattern on top of it. It's kind of a psychological phenomenon.
Yeah, to review that fast in terms of how my brain... Generalized anxiety is fear of multiple topics. I think a panic disorder is fear of a panic attack. Phobia is a fear of a specific stimulus. Agoraphobia is a fear of being trapped or helpless related to being in public. Social anxiety tends to be a primary fear of being judged or having... being humiliated or getting a negative evaluation in a social situation.
There's also separation anxiety, which you don't really get. I think that's more child diagnoses, but that's fear of being away.
Right. And I mean, look at this. It's strange. We separate out social anxiety and separation anxiety from dependent and avoidant personality, even though the phenomenon is basically the same. And if it persists and permeates multiple relationships into adulthood, that's when we call it personality suddenly, when really these are just issues that are present for many, many people, both to a pathological degree and to a non-pathological degree across the lifespan.
I think it's a little erroneous to separate them out personally.
And to be a little cheeky, some psychoanalysts think all anxiety is separation anxiety.
Yeah, though I wouldn't agree with that. Also, generally it's anxiety disorder. I also disagree with conceptualizing that one as simple worry about multiple different things per day. I think that's an output. I think that for GAD, we should only be making that diagnosis if we can identify a longer life course of anxiety. strong and severe neuroticism uh generalized anxiety disorder in my opinion properly should be trait anxiety uh that is of such a degree and so persistent that
it becomes disabling in some fashion now i see that diagnosis get thrown around all the time like the percentage is wild what do you think is going on there
Well, I think that people don't read the criteria or keep it in mind. I think people hear the term generalized anxiety disorder and they say, I'm talking about psychiatrists here. Okay, I've seen this all the time. They say, if this patient has a generally high degree of anxiety, they have generalized anxiety disorder. Not true, folks, not true. There are so many conditions in state or across that condition that can come with a lot of perceived and experienced anxiety with patients.
Untreated bipolar disorders, lots of anxiety. MDD with anxious distress, lots of anxiety. Paranoia in schizophrenia has not been adequately treated or worked with psychologically, lots of anxiety. Obviously, PTSD and OCD, lots of anxiety. But the source of that anxiety is different in every one of these conditions and needs to be contended with differently. And GAD, properly diagnosed and conceptualized GAD, as problematic as it is, what is it most related to?
It's related to MDD recurrent, non-manic depressive. Okay, so those are probably the more similar ones. And what is that really fundamentally most similar to? What construct, in my opinion? Trait neuroticism.
One thing I kind of struggle with, so in terms of how, correct me this, I might be wrong, how the DSM defines what's clinical anxiety is, according to the diagnostic criteria across the disorders, it's just the duration and the intensity. And for each one, the duration is six months, and the intensity is just with functional impairment, which is relatively vague. I guess I'm having a tough time because you're saying like they don't, I see a lot of people who technically do kind of meet the criteria, but I still wouldn't call them GAD.
And I'm not quite sure how to make sense of that based on what you said.
Well, it's this artifact of the DSM's philosophy, right? You know, the DSM is supposed to be ideology neutral. Yeah. The purpose of the DSM is to come up with a relatively objective and uniform criteria to recognize the known phenotypes, known clinical types. in the population, right? These are all real known clinical types, but do they reflect the same underlying cause? Not necessarily. So that's sort of what I'm getting at.
Bipolar disorders and schizophrenia don't reflect the same underlying cause either, but they probably reflect a closer group, a more closely related group of underlying causes than do the anxiety disorders. Again, why the anxiety disorders have been split up into different chapters across time. I don't know if that answers your question.
Close enough. Another thing I think comes up, and I think you kind of talked about it, and I see a lot of clinicians get this wrong, is the question of like, I'm curious your answer and then I can get my answer. And I know, is anxiety emotion? How would you answer that question? Yeah.
I'm very psychoanalytic as far as that one goes. I say anxiety is not properly a primary emotion. You could argue it as a secondary emotion. I guess I should say the difference between these. A primary emotion is something that you're capable of feeling, has a body correlate, and is present from a young age. You're capable of feeling it from a young age. A secondary emotion is some kind of a more abstract processing of a primary emotion through social and language understanding.
So I'd like to say a dog and a cat or an infant can experience a primary emotion. So most people would say, yeah, anxiety has got to be an emotion. But there are some thinkers, and I agree with those thinkers, that will say almost every primary emotion can be converted into anxiety. This is why I say look for the source of anxiety. So I would say fear is a primary emotion.
It's very, very fundamental in all vertebrates, even invertebrates, I might argue. But for it to be anxiety, I think we should reserve that term for the overall physiological activation that can happen in the body from any source.
Awesome. I think I think we completely agree on this. I think an analogy that might be helpful of isn't an emotion. Let's let's use the fruit category. Apple's a fruit. Banana is a fruit. Strawberry is a fruit. but fruit salad is not a fruit um and here anxiety would be the the fruit salad um and that it's composed of different things and it's a more abstract complex intermingling of these things and i i agree um you know like as you like to define an emotion that's the same thing i say it's it's got a trigger it's got a short duration has a distinct uh facial expression or bodily expression and has an action-oriented purpose um I think of anxiety is kind of subclassified as an affective state of fear, along with phobia, panic and trauma.
But it's kind of a more complex state that can, like you said, be a signal for every single emotion.
You know, we've been spending a lot of time on theory. I'm sure the people are hungry for treatment approach and recommendations. What do you think?
Yeah, sure. I can start us off with a little helpful model and then we can kind of go from there. Is that right? I think of there as being five primary models of treating anxiety. Yeah. The first is the biological model that's just using medications. Second is the cognitive model that's addressing thought distortions. The third is the exposure model that's addressing avoidance behavior. The fourth is the motivational model that addresses the internal ambivalence in the anxiety.
And the fifth is the hidden emotion model, more the psychodynamic model, which is addressing repressed feelings or desires. Now, these models aren't competing. They're all like valid and effective and they capture kind of different facets of anxiety.
Yeah, it's accurate. Nice categorization, not a system I thought of before. What strikes me is that each one is probably operating for all anxiety treatments that are being delivered appropriately, engaged in it appropriately. And each of them captures some aspect of anxiety disorder treatments. that the other ones don't necessarily capture. So I'm an inclusionist. I would want to integrate as we talk about all of these things into one.
Yeah, and I agree. I think it can be helpful, though, for conceptualizing your different interventions in regards to anxiety.
Yeah, definitely. I personally like to identify rough clinical types and then go with specific recommendations on each of those. i know that's weird coming from someone who is more of a psychotherapy integrative person integrative psychotherapy person but i still think that specific uh approaches at least for starting things can be more appropriate um for specific groups so i guess i would break it down to uh gad proper um dead loop avoidance problems such as panic disorder and agoraphobia and then specific fear problems such as the specific phobias and then developmental rate relational problems uh i guess those are the four major categories of things that would still classify under anxiety disorders
Maybe there could be a way that we merge our two paradigms.
Yeah, most likely we'd be able to. I don't know if we should do that on air, though. If you're willing to try now, we can. But I feel like it's going to be experimental. Maybe, actually, why don't we go through each of my four categories and you say which approach. That would make sense. Perfect. So starting with, let's say, GAD proper. What's your preferred approach?
I think that's the one that's... I mean, as we kind of talked, it's such a broad category that is capturing different patients. I think that's the one that has the least well-defined approach. And I would be thinking... I think the other three that you mentioned, I can think of specific approaches that would work for most patients. With GAD, I would be trying to categorize what kind of patient the GAD was and then...
Good point. Let me be more specific. Patients that... me specifically, uh, that I specifically would identify as GAD. That means somebody who has trait neurosis and anxiety from a very early age, uh, onset of at least some kind of dysthymic tendencies from adolescence, uh, worrying since adolescence and, uh, it ramps up, um, high conscientiousness, uh, included all the way until maybe 20s to 30s, where the worrying and anxiety gets out of control, yet they aren't diagnosable with an MDD recurrent.
That is the category I'm talking about. Think of the top 5% to 10% in the population of trait neuroticism. No comorbidities, no comorbidities. That's another thing I do with GAD. I look for another cause of anxiety first that is more plausible. And if that's the cause, that's the diagnosis, not the GAD.
To me, I think I would start with the motivational part and try to see what they're... Usually, there's some sort of resistance and that their anxiety is serving some sort of purpose, like a subconscious belief that their anxiety is protecting them in some way. I would try to bring that out. That's where I would start. And then I would probably implement the CBT kind of things, probably leaning more towards the cognitive realm.
Yeah.
That's good. It's a good approach. What's interesting is I don't think we have data or evidence or science to say what is the best approach in GAD, right? Psychotherapy is probably better long term. interesting that I diverge from this. When I see that particular clinical syndrome, I do see it as more biological. Not that the psychology is not involved, but I see it kind of like OCD where it's a biological cause, but that the psychological solution is better.
I'm more likely to use SSRIs, or second, third line agents for anxiety, high doses of SSRIs concurrent with the recommendations to engage in a proper CBT style psychotherapy, exposure and response prevention, and basically changes in how they cope. That's how I approach that particular phenotype.
You put me in a bind because I want one of our big messages to be not leading on medications, but when they've done research on the different personality traits and what responds to antidepressants, the neurotic and the ocean traits. Neuroticism was the only trait that responded better to antidepressants than to CBT. It is a personality style that you would expect the antidepressants to...
Yeah, you should give the caveat, right? I know what you're thinking. The problem is that people will just go, if medication is effective, patients and clinicians will simply lean on the medication and won't go further. That's a real disservice. You'll find a lot of true GAD people on their high dose or even multiple dose SSRIs with lost side effects, and they think that's the end of their path there, you know.
And as I always say, the medications don't solve your problems to make it easier for you to grow and change. And so even if you're going to use medications as a first-line treatment in a GAD phenotype, you are doing a disservice to yourself as a patient or to the patient as a clinician if you are not having them engage in wholesale self-lifestyle change and psychotherapies.
absolutely thank you for yeah uh detailing the the bind i felt like i was in and
then i guess we should go on to the uh dead loop uh why do i call it dead loop because it's uh you know panic and fear is supposed to lead you to some kind of a meaningful escape or uh you know progression outcome theoretically, right? In a panic disorder, it becomes that the fear of fear itself, the only thing we have to fear is fear itself, develops into a worsening cycle of more frequent and more severe panic attacks.
It is the avoidance of the panic attacks that is producing the panic disorder, not so much the panic attacks themselves. Similarly, in agoraphobia, it's the anxious avoidance that is worsening the fear response. So how would you tackle those?
To me, I have a hierarchy of the most important thing is exposure. And that's getting them to confront the thing that they fear the most through repeated exposure. Now, it would be great if we could just get every patient to go and throw... They have a fear of spiders. Let's create a hierarchy from... being in a room full of hundreds of spiders at the 100% and 10% being looking at a picture of a spider.
It'd be great if we could throw everyone in the 100% and they would respond. The problem is there's a lot of cognitive things that get in the way of people wanting to do exposure. So I have exposure as the top of the higher, like number one, and the cognitive component is number two, which the cognitive component is... getting them to do more exposure. And cognitive is addressing their distorted negative thoughts about the potential exposures.
yeah uh that's the trouble of exposures i think patients are rightfully scared of the exposures right i think there can even be produced a kind of sadomasochistic uh not sexually but otherwise uh dynamic between the clinician and the patient um this can even be helpful for extreme exposures i just think that it's pointless to try to do exposures and response prevention type treatments until the patient can accept themselves and can accept that they have learned something in the past that's not working for them and they need to learn something new so there can be a softer approach um we're not talking about ocd right now but uh there there is a workbook i like the self-compassion workbook for ocd that can address a lot of the cognitive stuff the cognitive barriers and emotional barriers that you're referencing there um Related to this, not just for the panic disorder stuff, but for a lot of the anxiety disorders, I do think that a global helpful treatment for the patients who can engage with it and tolerate it without getting worse in their state of anxiety is mindfulness practice.
And appropriate mindfulness practice is effective in anxiety disorders, in my opinion, for two reasons. First, if you do it over time, I think your state anxiety will lower. Sorry, your trait anxiety. Your trait anxiety will lower. Secondly, the ability to turn attention to neutral aspects of the present moment can be very helpful for ruminators and panickers because a lot of the time the cause of the fear or panic is not what is going on outside of you in real life in the present moment.
But it is what is going on in the mind in terms of the mind attaching itself to the past, the future or what could be.
What what do you provide for the patients? First, you mentioned the the. self-compassion workbook, is there a specific section or topic that you have patients fill out or that you implement in your appointments? And then second is mindfulness, what resources or what psycho-ed do you provide?
Well, I only give that specific self-compassion workbook for OCD in particular. In general, I think for this group, the most important thing in my mind is psychoeducation. We need to make sure that the patient has a very good understanding of the source of the panic and fear and its solution. Without the cognitive understanding of that, it's going to be hard to get buy-in to do the difficult work, the fearful work, and the emotional work that comes afterwards, which is a large part exposure, right?
So if they don't understand why we're doing the exposures and why would they... willingly subject themselves to that pain, right? It doesn't make sense. So we got to give them some kind of understanding of the disease and a hope. So having them understand that it's this cycle of avoidance that is causing the anxiety then teaches them that we need a next avoid avoidance. And then for And then mindfulness practice is part of that.
This is a key issue, though. They cannot use the mindfulness practice as a escape. If you use mindfulness practice as an escape from fear, it will make it not mindfulness practice and we'll make it another avoidance behavior which just perpetuates the problem and in terms of resources i kind of tailor it for patients some i will teach directly some simple grounding techniques and mindfulness some i will direct workbooks some i will have watched some youtube videos some i'll have use apps there's just so many resources out there these days you can pick anything that seems to strike the patient's fancy what i want them to do though is to commit to like once, twice, or three times a week, five minutes to start, a time where they're not going to be disturbed, a time where they're not usually in distress to do mindfulness practice for the purposes of doing the mindfulness practice and for nothing else.
That's outside of the psychiatric mindfulness in meditation and mindfulness circles. It's a huge concept that you don't meditate for. Your source of motivation for meditating is a huge factor in regards to your meditation practice. If you're meditating to do X, Y, Z, or like you said, the intentions are wrong and you won't progress in your practice. Um, so I like how you worded it, that, you know, people use the mindfulness as an additional avoidance thing.
Um, and it kind of gets wrapped up in the problem, the inherent problem that's going on.
Yeah. If you're doing mindfulness practice independently and you're finding yourself feeling worse or upset or distressed, uh, there's probably something going wrong. And, but that is a sign that you should seek a more direct supervision, teaching or help for learning how to do mindfulness correctly.
Now, you gave me a little bit of your spiel for teaching people what's going on with panic. Can you go into a little bit more detail? Like what is the things you say to a patient for explaining the panic, the psychoad for panic disorder?
Yeah, I basically say there is a minimum level of anxiety, panic, and distress that everyone has to have. Okay. Life is hard. Life has a lot of scary and bad things about it. There's a minimum level of suffering. Now, when you try to escape suffering or fear, uh in a very fearful or anxious way that actually raises the amount of suffering that you're going to get so what we're going to try to do here is we're going to have you get down to the minimum level of suffering that's possible for you and what's going on with your condition is that your attempts to escape or avoid the panic attacks for example where you use pack attacks is what's making them strong and frequent i can give you some medication to help with that and by the way i don't mean benzos or prms i don't use those okay it has to be other things that globally lower the level of neuroticism anxiety i can give you some medication to help with it but uh if you can get to a point where you can accept or withstand and not avoid these panic attacks that will help the panic attacks become less frequent and less intense i'm not going to guarantee they're going to go away entirely they might we're just going to find out together So that's the basic idea that I give.
And that is related to the real mechanism, by the way. I don't think that an SSRI directly treats a panic disorder. I think an SSRI basically lowers the severity of the panic disorder to the extent that the patient will automatically start living their life again and give themselves exposures without knowing it and then relearn how to live without having panic attacks.
That's awesome. And an additional psychoad I provide, I feel like it's just a different kind of, maybe a different way of framing it. Like I use my hands to show feedback loops because I think something visual is helpful. And I shake my one hand and I say, what happens is you experience a little bit of anxiety and then you start having thoughts of, oh God, I'm having a panic attack.
Something bad's happening. And those thoughts cause you to become more anxious and have an increased heart rate and increased respiratory rate. which, and then this whole time I'm shaking my different hands to kind of show the feedback loop. And then that increased respiratory, you go, oh God, I'm going crazy. I'm going to lose my mind. I'm not going to be able to handle this, which those thoughts then create more of a physical response.
And then I kind of just keep going with those back and forths to really emphasize the feedback loops and how they're really contributing to the big part of the problem.
yeah it's great uh definitely knowing about that feedback and knowing about that pattern i think is the most important thing for those conditions i'd like to gloss over specific phobias just because they're relatively simplistic and then move on to kind of developmental relation relational anxieties that's all right because i feel like it's a huge topic and i know we don't want to go too long or at least idle today Yeah.
Specific phobia, I think most of the stuff that we just said applies.
Yeah. One thing I would add is that I'm not allergic to some selective avoidance for the purposes of being functional. It just really depends on the case, right? When you have just a specific phobia, sometimes a little avoidance is okay if it keeps you running your life the way you want to. So you got to work with the patient and their values and what they want out of a treatment, I wouldn't go overboard in making sure that everyone is doing graded exposure.
That is ultimately the best way to overcome a specific phobia. Okay. Relational. Relational developmental. Big area. Right. Relational developmental. How do you approach that?
Benzodiazepines.
Everyone, that is a joke. That's a joke. That's a joke. They all want benzodiazepines. That's true.
Yeah, this this one's a lot harder. I think of this one as we see a lot of patients, you know, we're kind of talking. I see a lot of patients want treatment for these things or come in and say like they say, oh, my anxiety is terrible. And this is where I use the more the hidden emotion, the more psychodynamic oriented interventions. So here, you know, I'm thinking of anxiety as secondary to some repressed or unacknowledged emotion.
And the suppressed emotion, which in some family structures, it couldn't be expressed in the family. They, you know, they watch their parents. Their parents would never... be able to express anger um so the kid wouldn't be able to really respond to it and as a result they don't experience the anger they just experience it indirectly as anxiety or panic or somatic symptoms so there's something there's some hidden emotion and the goal is to bring it to conscious awareness um and teach the person how to express or act on the emotion constructively um So, here, in terms of, I think, a simple intervention that I commonly do is I bring out the emotion wheel.
If you just Google emotion wheel, hit images. There's one with a nice bunch of different colors. And with the patient, I say, it depends on the patient and their anxiety once I have an understanding. But I say, you know, I think I'll give an example. I had a patient who says they just have anxiety. They, you know, I'm anxious. I want, you know, let's talk about medications.
And then it turned out that they'd been going on dating apps and having a tough time with dating apps. And that there was a person who they would take like three days to respond and they were feeling rejected. And the goal was to take out the emotion wheel and instead of saying like i'm experiencing anxiety we identified that they were experiencing rejection that they were experiencing loneliness um which are emotions that are productive and that can be acted on and that you can develop solutions whereas anxiety is not before understanding that it was a signal to a different emotion there there wasn't a way forward
Yeah, that's a really great anecdote and way to conceptualize it. You know, this is the area, the type of anxiety, quote, anxiety disorder, where the Lacanian idea of anxiety as the universal currency of affect, emotion, desire is the most useful. Where I also like to emphasize is that if your anxiety problems, if the anxiety that you feel is the product of inadequate developmental progress, which again is not the fault of the patient by and large, right?
The child is not responsible for the degree of their development, their environment is more responsible. not your fault, but will be your responsibility to deal with as an adult. If the source of the problem is developmental, which is a process of relating with other people and yourself, then the only solution is going to be developmental. Another process in adulthood of relating to other people's situations and yourself.
The solution is not going to be a medication. And this is the group of patients, I think, which is most easy to over medicate and to prescribe a bunch of nonsense that is barely helping them or only helps them because it's being given at the same time as they have a therapeutic relationship. So for this group, I really try to emphasize either formally in a group or individual or both psychotherapy.
or in their just day-to-day lives or the kind of people they're spending time with. You have not had the opportunities to have healthy, safe environments and relationships maybe the same way that other people have had. This has resulted in problems with your ability to regulate and manage your emotions and also remove yourself from bad situations where appropriate. OK, so you're going to have to slowly figure that out.
It's going to be a long road, but there's hope for you here. You can improve that. I do believe that. But you'll have to start by making changes in your life, bigger changes in your life.
I feel like the relational developmental anxiety can be super permeating and comes up in like a ton of different conditions. I'm curious if you can think of any cases that kind of reflect that, like where it occurs with other anxieties.
Yeah, actually a relatively recent one. And I want to emphasize this is not a unique case. You see this kind of thing all the time. But people can absolutely have more than one of these four categories of anxiety, right? I'm reminded of a guy who was, you know, basically suffering from a situation where he's feeling a lot of anxiety. And that's all he talked about. He said, I have too much anxiety in my body.
But then if you looked at his history, it was because he was actively living in an abusive environment and that the symptoms that he was having, new onset, were not from a trait anxiety, but were basically a trauma stressor related disorder. OK, so he presents saying I have anxiety, anxiety chapter. The clinical problem appears to actually be trauma disorder. But here's the wrench in the works. He had no insight into the fact that he was actively living in an abusive environment.
and he was not willing to leave it either which to me my conceptualization of that is because of limitations in his ability to assert himself and to draw just basic boundaries of safety bodily safety uh in his relationships that's a relational and developmental problem right and so all three of those factors were intersecting in this one patient and that's a very challenging area to work with that's all i can say
Yeah, this reminds me of an axe I have to grind. There's Facebook physician psychiatry groups, and there's so many threads that are like, patient, 32-year-old female with anxiety, tried Zoloft, Paxil, Seroquel, Gabapentin, what's next? And then there will be 300 comments that's like, I really like Lamictal. Have you added a touch of... And it's just like hundreds of comments of little tips and tricks. And it's like, is no one going to ask about what's...
Is she getting... beaten every night after she goes home is she like there's no one's going to ask follow-up questions um it it feels like what is actually going on the patient stop
throwing meds ask what is really going on
Like a five sentence one liner and then just hundreds of people being, you know, I really liked, you know, just a touch of Abilify. Is no one going to ask what's going on in this woman's life?
Yeah.
Yeah. You know, I still want to do You Tell Me. I still want to be you and me, Dr. Malzberg and Dr. Pooh react to social media posts. I think they'll have a lot more popularity than this didactic stuff. But anyway, we'll move on. All right. Well, what's our takeaway here? You know, I think what people should take away is that anxiety is complicated. It might not be its own thing in most cases, that there are many different sources for anxiety and that you got to do a thorough assessment before you can make reasonable recommendations.
And you really need to understand the patient and help the patient understand their own anxiety, too, if you're going to make progress.
Yeah, a big thing that I think comes up when I'm supervising is I have to say, they're like, the patient's anxiety is higher. What medication should I use? And the thing I always hammer in is look at the diagnosis first and treat the diagnosis. Don't treat the symptom. You can't treat anxiety as this thing that we're supposed to manage with medications regardless of the cause. Really look for the underlying cause, look for the diagnosis, and focus on that, especially with the patients.
It's going to help them to conceptualize their anxiety as something different than the way they were conceptualizing it before.
Exactly. And with anxiety in particular, DSM diagnosis may not cut it, right? You might have to go on to a full-on psychotherapy-type formulation to really understand the patient's situation.
So I'll do a quick recap. So in terms of some of the things we talked about, feel free to add because I might miss some of the things you talked about. We talked about the different brain regions, the amygdala being the bottom up, the prefrontal cortex being the watchtower being the top down. We distinguished between fear and anxiety and then worry and panic. We talked about whether anxiety is an emotion and we both feel like it's not.
We went through the different anxiety disorders in the DSM, GAD, panic disorder, fear of having a panic attack, phobia, fear of a specific stimulus, agoraphobia, fear of being trapped or helpless, social anxiety, fear of being judged or negative evaluation, separation anxiety, fear of being away from an attachment figure. I talked about the five primary models that I think of for anxiety being biological, cognitive, exposure, motivational, and the hidden emotion psychodynamic.
You talked about kind of grouping patients into four separate groups being the generalized anxiety disorder, the dead loop, repetitive pattern of avoidance, panic, and fear patient, which includes panic and agoraphobia. Yeah. You talked about specific phobia very quickly and then the relational developmental anxiety.
That's right. And it's a huge topic. So, you know, if you feel like we haven't answered something, you're curious about something, got any questions, comments, likes or subscribes, please do so, including on Reddit, which I do read obsessively.
Awesome. All right. I will. I think we should do maybe medications next time.
Ooh, medications for anxiety. Can we fill an hour? Maybe. Sure. I don't see a problem with that. And it'll link to this one. Well, I think this was an okay one. What do you guys think? What do you think, Dr. Malford? I thought it went well. All right. Well, I'll see you next time.
Thank you.