What we’ve said about Anxiety

“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”

“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”

“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”

“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”

“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”

“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”

“there are two different anxiety centers in the brain. One of them is Panksepp's fear system, and the other is what he calls the panic-grief system, which is the attachment system”

“anxiety can be interpreted as an activation right as a higher level of sort of psychological energy. And if you decrease it, remove it, or suppress it entirely as you would using a benzodiazepine, that will slow or stop motivation itself”

“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”

“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”

“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”

“I go, let's try our best to not use clinical terms because it can mean different things to different people. When you say you had an increased anxiety, what did you experience? What are you referring to”

“When we talk about medication management, assess entirely for other physiological and medical causes, especially substances of anxiety”

“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”

“I do think that GAD is its own disorder in a sense, but that the criteria is too loose and that too many people are being diagnosed with it when we should probably tighten up the criteria and capture a smaller proportion of the population”

“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”

“probably the biggest thing I see is that It's some kind of mood and anxiety problem, sometimes diagnosable as a major depression, a bipolar, or a primary anxiety disorder, but often just a fuzzy mix, right? Maladaptive, self-punitive, or anxious response to not doing so well”

“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”

“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”

“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”

“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”

“If a patient can engage in therapy, I think that they should be engaged in therapy before medications. When do I use medications first? First, if they're too symptomatic, that they're not able to engage in therapy. And second, patient autonomy”

“mild anxiety can forego treatment entirely. That means that back in the old days, if you came in, people who were seeing psychiatrists were bedridden, were acutely catatonic. Nowadays, it's not uncommon for me to get patients that I finish the assessment and I go”

“a huge part of that is avoiding avoidance. And by signing that paperwork, you're promoting the avoidance”

“usually the request is a signal. for a important area of impairment, pathology that should be treated. And that's a opportunity to talk about that with the patient”

“I think that's the ultimate treatment. If you can tolerate and engage with mindfulness practice, that's going to be a fast track to lowering and managing anxiety in the long term. And if that's not working for you, a CBT style Treatment for anxiety is quite helpful”

“And then also essentially combating ruminations, worries, anxiety, and inward focus by going into outward focus. Both of these can be achieved by a more consistent mindfulness practice”

“Pull out that emotion wheel, teach them to bring out the emotion wheel and try to find the underlying emotion. There's a lot of people who - They filter their emotional world through, oh I'm anxious or angry”

“I think when you see that level of improvement, it's not the exercise. It's because they're inadvertently entering flow states. They're inadvertently practicing mindfulness”

“I do think any sort of religion or spirituality, belief in things bigger than ourselves, does an amazing thing for quelling anxiety”

“They're for temper. Temporary use, and most of the time they actually get in the way of appropriate treatment. So, uh... Most of the things we're going to be And that's what we're talking about today. Today are going to be about scheduled medications”

“Anxiety, Theory. Theoretically, is an overactive threat detection system. And if you rely on a medication And to quell that. That anxiety, you're telling your brain that I need something external to fix this anxiety”

“If you don't use a PRN, then you start to develop other coping skills. You know, like I personally, if I'm starting to feel increased anxiety, I need to go outside for a little bit. I do like to do a little bit of a Wim Hof”

“Typically, I use an SSRI. That doesn't work. I'll switch to another SSRI. We're talking augmenting agents, considering buspirone or gabapentin. If their patient's still unresponsive to, you know, a bunch of these things, you can start kind of going off patient characteristics. If there's a lot of sleep issues, I'll consider mirtazapine”

“Not SSRIs, you know, not necessarily serotonin-based medications primary because of the risk of agitating bipolar disorders because in undifferentiated patient, we don't know which is which, but just smaller things, you know. your gabapentin hydroxyzine your uh buspirone uh propranolol”

“the people who might have a little bipolarity, even if they'll never have a real bipolar disorder or have very high levels of anxiety, then yeah, going too quickly on the medication like Lexapro can definitely, uh, cause some reactions there”

“you want to start at minimum 15 in the morning, 15 at night. That's the starter dose. Now, what I do say to patients is that if this happens to make you very sedated, then cut the morning dose in half or stop it”

“Typically, it's more effective at the like 900 to 3,600 milligrams per day range. And It's important to remember that gabapentin has, quote unquote, nonlinear pharmacokinetics, which is just a fancy way of saying that like, you know, 2400 sounds like a mega dose, but significantly less is absorbed as you get to the higher doses”

“I don't love hydroxyzine, but I will hand it out because it's a low-risk medication, generally speaking. Some people just seem to like it. I think the main dividing line is how sedated you get on it. Some people just get way too sedated on hydroxyzine”

“I want to see some kind of evidence of upregulation of the fight or flight system. So I do use it for trauma disorders, and I certainly use it for echithesia because it's low risk and effective. I'm not opposed to using it if anyone wants to try it”

“I've just seen so many times patients with OCD, PTSD, anxiety on bupropion. You pull it off and they get better”

“if we are going to trial it, I recommend they try it for the first time on a weekend or something or when they have nothing to do”

“that is a method of last resort that I even placed beyond, and I will try before that, the tricyclics. And that's actually the traditional answer to what to do with someone who is having a primary anxiety disorder, who's not responding to your SSRIs, SNRs. You should be using tricyclics”

“I don't do it at all for only anxiety. I think that we have insufficient to know evidence basis for antipsychotic augmentation of primary anxiety. Again, this is not counting OCD, which has been separated from the anxiety disorders since DSM-5”

“I just really hate anything that causes withdrawal and physiological dependence for patients. I think it's an awful thing to do to somebody when there are other options, you know, um, Will I never give it? No. I remember when I was in medical school, I saw a patient who just presented for a regular medical catch up checkup”

“I don't see it as any better than the others. It's more that anxiety, people with anxiety disorders tend to have worsening anxiety and ruminations at night. So if you give them something that makes them sleepy, they're going to help them with that. And it does not have to be Paxil. It can be a little gabapentin, for example”

“people love it for the first few months and then it kind of poops out. So usually by like six months, they don't see any sort of significant difference”

“People who are coming to a psychiatrist for anxiety should be drinking at most one cup of coffee”

“if you're treating a proper ADHD, the psychological anxiety reduction far outweighs It's the minor physiological. Physiological anxiety”

“I'd like you to get used to accepting suffering. There's a minimum level of suffering and anxiety that you have to live with. And if you accept that, you won't make it worse”

“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”

“it's essentially treating the perception of physiological arousal as a threat. If you can perceive physiological arousal as non-threatening, relatively speaking, or even as excitement instead, you will be able to modulate your body response. It's not something you can do overnight”

“The side effects are going to be certain side effects are going to be as bad as they're going to be when you first start the medication. And it takes about three days for it to kind of level out. And usually about one week until you start to feel a little bit normal”