Key moments, in order
Anxiety is more often a signal or experience stemming from other things than its own thing. Almost every primary emotion can be converted into anxiety: apple, banana and strawberry are fruits, but fruit salad is not, and anxiety is the fruit salad. So look for the source.
There is a sweet spot: too little arousal and you do not perform well, too much and you do not either. The same goes for psychotherapy, where the patient needs an optimal level of activation, neither over- nor under-regulated.
A simple model: the amygdala is the smoke detector and the prefrontal cortex is the watchtower. Fear is bottom up: it starts with a threat and the alarm, and the thinking comes afterward.
Framing changes the response: 'I'm having an adrenaline release' lands very differently from 'I'm having a panic attack'.
Worry is the cognitive component. Worry is in the mind; anxiety is in the mind and throughout the body.
Many patients describe panic as lasting hours. Usually that is the prolonged period of distress and heightened anxiety that follows, which they still associate with the attack.
Trait anxiety is a baseline temperamental tendency shaped by genetics and upbringing; state anxiety is the response to situations. High trait anxiety predisposes to more state anxiety in the same situation, like climate versus weather.
Do not stop at calling it anxiety. Find the source, whether external, internal or an interaction of both. There are many sources, so do a thorough assessment before making recommendations.
The criteria are so loose that almost anyone can fit, and the diagnosis gets applied way too broadly to anyone with a lot of anxiety. That is a problem with the DSM, not the person.
Panic disorder is acquiring a fear of fear, a fear of panic, with an avoidance pattern on top of it. It is largely a psychological phenomenon.
A quick map by what is feared: GAD, many topics; panic disorder, the panic attack; phobia, a specific stimulus; agoraphobia, being trapped or helpless in public.
We separate social and separation anxiety from avoidant and dependent personality even though the phenomenon is basically the same.
Only make the diagnosis if you can identify a longer life course of anxiety: strong and severe neuroticism.
A generally high degree of anxiety does not mean generalized anxiety disorder.
True GAD is most similar to recurrent, non-manic major depression, and fundamentally to the construct of trait neuroticism.
Anxiety can be approached through several models: biological (just using medications), cognitive (addressing thought distortions) and exposure (addressing avoidance behavior).
Another grouping by clinical type: GAD proper, dead-loop avoidance problems like panic disorder and agoraphobia, specific fear problems like phobias, and developmental-relational problems.
Look for another, more plausible cause of the anxiety first. If that is the cause, that is the diagnosis, not GAD.
Start with the motivational piece. There is usually some resistance, a subconscious belief that the anxiety is serving a purpose and protecting them.
One view sees GAD like OCD: a biological cause where the psychological solution is better, with SSRIs (including high doses) or second- and third-line agents alongside.
In research on personality traits, neuroticism was the only trait that responded better to antidepressants than to CBT.
Medications do not solve your problems; they make it easier to grow and change. That holds even if you use them first line in a GAD phenotype.
It is the avoidance of panic attacks that produces panic disorder, not so much the attacks themselves. In agoraphobia, too, anxious avoidance worsens the fear response.
Exposure is number one. The cognitive component is number two, and its job is getting the patient to do more exposure.
Exposure and response prevention is pointless until the patient can accept themselves and accept that what they learned in the past is not working and they need to learn something new.
Turning attention to neutral parts of the present helps ruminators and panickers, because the fear usually is not coming from what is happening around them right now.
If patients do not understand why we are doing exposures, why would they willingly put themselves through that pain? Give them an understanding of the condition, and hope.
Used as an escape from fear or panic, it stops being mindfulness and becomes another avoidance behavior. It works the first few times, then stops working like any PRN.
It should not be unpleasant, very effortful or a struggle. Do not thrust someone into it; it is contraindicated if they are suffering while they practice. Feeling worse during solo practice means something is probably going wrong and they need guidance.
Tell them there is a minimum level of anxiety, panic and distress everyone has to have. Life is hard and has a lot of scary and bad things in it.
We do not use benzodiazepines or PRNs for it. It has to be something that globally lowers the level of neuroticism and anxiety.
An SSRI probably does not directly treat panic disorder. It lowers the severity enough that the patient automatically starts living their life again.
Use your hands to show the feedback loop: a little anxiety, then the thought "oh God, I'm having a panic attack," and around it goes. Something visual helps.
With just a specific phobia, a little avoidance is sometimes fine if it keeps the person running their life the way they want to.
Pull out the emotion wheel and find the underlying emotion. Many people filter their whole emotional world through anxious or angry. Naming rejection or loneliness instead gives them emotions that are productive and can be acted on.
If the source is developmental, a matter of how someone relates to other people and to themselves, then the only solution is developmental.
'Too much anxiety' can turn out to be a trauma and stressor-related disorder: new symptoms from actively living in an abusive environment, not trait anxiety.
Online prescriber threads answer a short anxiety post with hundreds of medication tips ('just a touch of aripiprazole') and nobody asking what is going on in the person's life.
Look at the diagnosis first and treat the diagnosis, not the symptom. Anxiety is not something to manage with medications regardless of the cause.
With anxiety in particular, a DSM diagnosis may not cut it. You may need a full psychotherapy-type formulation to understand the patient's situation.
Each moment is a point made in the episode, linked to the second it was said. The topic links open everything the podcast has said on that topic.