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Psychiatry, Education, Insight. Docs Tracey and Paul Discuss it All! Two psychiatrists — Dr. Paul E. Keck Jr., MD and Dr. Tracey Goodman Skale, MD of TMBO (Two Minds, Better than One) — illuminate mental illness, teach signs and symptoms, dispel myths, and advocate timely care and dignity. Nearly 70 years of combined expertise. DISCLAIMER: educational/general discussion only, not personalized medical advice; in crisis call the 988 Suicide & Crisis Lifeline.
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Welcome to the Two Minds
Better Than One podcast.
Docs Tracy and Paul discuss it All.
Hello, everyone, and welcome
to Docs Tracy and Paul Discuss It
All.
We're back and today I am with
my husband, Paul Keck.
I'm Tracy Scale and we are
talking about anxiety.
So anxiety affects so many people.
You probably have experienced
anxiety or someone you know has experienced
anxiety.
So we have a lot to talk about today.
Paul, I'm going to let you
kick it off.
So anxiety is a feeling we've
all had.
What we're focusing today on
is anxiety disorders.
When anxiety in various
manifestations becomes debilitating
or interferes with people's
happiness and function.
Fear is an immediate response
to a danger in our environment.
And that's adaptive in a way.
Right.
We need fear.
Very adaptive.
Almost all animals have a fear response.
It's associated with survival.
Anxiety is a state of
heightened arousal and monitoring
for fear, something that was a
cause of fear initially, but then
people start monitoring for a
recurrence of that fearful stimulus.
Again, that doesn't
necessarily mean that's a bad thing.
It's only when it becomes
protracted and excessive.
So it's like many things that
we talk about.
I mean, you can be a little
down, a little on the depressed side,
as long as it doesn't last too
long and adversely affect your life.
You can be a little anxious.
But if it gets to a point that
it's affecting your relationships,
your ability to concentrate at
work or school, then it's an issue.
Correct.
We know a lot about the parts
of the brain that are involved in
anxiety.
And these are brain structures
that are, quote, unquote, old structures.
They occur in reptiles,
mammals, all kinds of other animals,
and they all subserve or
function to recognize and trigger
an anxiety or fear response.
Do you want to kick it off?
So you're talking about the
neurocircuitry of the brain.
Exactly.
So one of the things that's a
key factor in anxiety disorders is
the amygdala.
You'll hear us talking about
the amygdala a lot.
So amygdala is essentially.
Think of it as the brain's
panic button.
You wanted to talk about some
other parts of the insula, the periaqueductal
gray.
Tell us about that.
Yeah.
So we have two amygdalas,
actually, one on each, below each
hemisphere, and they're about
the size of your thumbnail.
They're connected in turn to
something called the insula, which
also is a panic.
Center, like an island.
It's an Island.
Right.
In fact, that's, I think, what
insula means.
So the insula connects the
amygdala to something called the
periaqueductal gray and the hypothalamus.
And that's where the
sympathetic nervous system kicks
in.
The arousal.
The arousal.
And that's responsible for
defensive reactions.
So that's important.
That's an important piece.
So then the hippocampus.
That's the.
So hippocampus, when you hear
hippocampus, be thinking memory,
you know, so here the
hippocampus is involved with remembering
fear and remembering what
triggered it.
And then you have the
prefrontal cortex.
So this is more.
This is deeper brain, what
we're talking about.
And then we have prefrontal
cortex up here, more executive function.
But tell us about that.
That's the deliberate piece.
Right.
So the prefrontal cortex is
what we consciously experience.
So the amygdala doesn't really
tell us anything.
It sends the message up.
It gives signals, signals up
to the prefrontal cortex.
And that's where we experience
anxiety, fear, things like that.
It's also where we can
suppress anxiety and fear consciously.
Right.
So we're going to learn.
That's where cognitive
behavioral techniques come into play.
If we can learn how to
suppress or not so much suppress,
because that redirect those feelings.
So that's the prefrontal
cortex, the conscious regulation
of emotions.
So if you've heard some of our
other podcasts, maybe, maybe not.
So sometimes we get into more
neuroscience than others.
That's about it for
Neuroscience today.
Now we're going to discuss.
Get into the nitty gritty.
Right?
So let's kick it off.
I think, Paul, with
generalized anxiety.
You want to start with that or
do you want to do some.
Something before that?
You want to do some
generalization about prevalence?
Maybe let's do that.
Well, let me talk about
anxiety disorders as a group.
And they differ primarily in
what people are anxious about.
It can be a specific thing, a phobia.
It can be about having a panic
attack, which we'll go into in much
more depth.
Or it can be generalized.
Somebody's anxious just about
all the time, about everything.
All of the anxiety disorders
share features of excessive fear
and anxiety.
It's really what the target
is, what stimulates those excessive
fears and anxieties.
Anxiety disorders are among
the most common of all psychiatric
illnesses.
They affect, in aggregate,
about 30% of people over a lifetime
time.
So three out of 10 people will
have one of these anxiety disorders.
So many people I know have had anxiety.
And so is there a genetic
component to it?
Probably.
I think the genetics of
anxiety disorders are much less worked
out than for.
Bipolar disorder, for example,
or depression or even depression.
On the other hand, anxiety
disorders commonly co.
Occur, in other words, in the
same person with depression, with
bipolar disorder, with schizophrenia.
So it's not uncommon to see somebody.
In fact, when I was working
with a lot of physicians as patients,
the most common chief
complaint, the problem that they
identified as bringing them in
for help was depression and anxiety.
It was depression.
Anxiety, depression and anxiety.
So the two often go hand in hand.
Well, our colleagues will
often say, especially our primary
care colleagues will say,
people come in for their diabetes
or whatever, but then they're
also, by the way, I'm depressed and
anxious.
They go together.
But there's a thing with.
We'll throw in with depression
or bipolar depression.
There's something called
anxious distress.
So it could be under the
umbrella of your bipolar disorder
or depression.
It doesn't have to be a
distinct entity.
Today we're talking about the
distinct entities.
And so if you have anxiety out
there, don't think, oh, oh, wait,
do I also have bipolar disorder?
Not necessarily.
You probably have a
generalized anxiety disorder.
I asked you about genetics
because we know that bipolar disorder
is the number one most
genetically transmissible illness,
and we don't know as much
about anxiety.
But I do believe for sure
there's a nature nurture component.
So if you have an anxious
parent and if you grew up in a household
that was lots of anxiety in
it, I feel like that trickles over
to the child.
I'll raise my hand.
Primary example.
I for sure had an anxious mother.
And I look back now,
especially now being a psychiatrist,
and I am sad about it for her
because she really missed out on
a lot of opportunities because
of her anxiety that she didn't treat.
For example, she lived in Massachusetts.
I was raising my children in Ohio.
And she didn't want to fly.
It wasn't a specific fear of flying.
It was just.
She was just afraid of everything.
And what if this and what if that.
And so because that she didn't
see her grandchildren as much as
she probably should have done
and then didn't socialize as much
as she could have.
And it was all this worry,
constant worry, you know.
And so when you have a mother
that's worrying all the time, you
become a kid that worries a
lot too.
And that's one of the cardinal
features of generalized anxiety disorder.
Constant worry, constant about everything.
So this is.
You're keyed up and you're
waiting for something bad to happen
all the time.
That's a really rough way to live.
So I'm assuming your cortisol
spikes, and that just can't be good
for you physically.
We know that people with
anxiety often have headaches of all
sorts.
Gastrointestinal disturbances,
irritable bowel syndrome, you'll
hear a lot of that.
What else?
Fibromyalgia.
Pain.
Right.
Pain, vague, different pains,
and trouble falling asleep.
Mainly because it's hard when
someone's in the throes of anxiety
to turn their brain off ruminating.
They're ruminating.
And people often feel fatigued
and worn out because they're constantly
anxious.
That's a ton of work.
Yeah, it's a lot of work to be
thinking, thinking, thinking all
the time.
And often people look and feel
restless, agitated, just fidgety,
and that's all their
sympathetic nervous system.
It's the fight or flight
response triggered by anxiety and
fear.
So they're ready to bolt at
any given time.
So, you know, my practice was
primarily working with people with
schizophrenia, schizophrenic,
bipolar disorder.
But I did take for certain
teams, for example, we called the
homeless act team.
I took all comers.
So anybody that was there that
day for new to the team came to me.
So I got lots of people with
anxiety in that particular team.
And so people with anxiety
disorders made me a little anxious
because part of my technique
as a psychiatrist is I feel the energy.
That might sound a little woo
woo to you.
I mean, we're all
psychopharmacologists too, and psychotherapists,
but I also feel the energy.
And when someone is anxious in
the room with you, you.
You feel it, you absorb it.
But I would use that as a
therapeutic technique sometime.
And I would say, I just want
to tell you how I feel in your presence
right now.
And I'm actually feeling.
I feel this heightened state
that you're in, and it must be very
uncomfortable for you because
I am also feeling uncomfortable.
So let's figure this out
together how we can make you feel
less keyed up.
And I learned a lot from my
patients that suffered from anxiety
disorders and how they also
worked it through so many of the
times.
And some people needed
medications and some people didn't.
Some people, we did pure
therapy and also a holistic approach.
And we'll get into all those techniques.
Yeah, so generalized anxiety
disorder is also fairly common.
It's estimated about 3% of
people in our country will suffer
from generalized anxiety
disorder in their lifetime.
Wait, 3% only 3%.
That feels really low to me.
I'm really surprised by that.
Isolated only generalized anxiety.
Oh, okay.
Not, not with depression, with
other things.
I don't know.
It still feels low for me.
Again, that's why you're the
statistics person.
I'm not.
Because I feel like every
other person I know has anxiety.
That's kind of debilitating in
a way to them too.
Yeah.
It affects women more than men.
And as you said, the good news is.
And we'll get into treatment
in a few minutes, but it's fortunately
treatable.
Well, part of.
Besides, they're ruminating
and obsessing, but they worry that
their mind's going to go blank.
Can't concentrate very well.
Just that general sense of
impending doom.
Feeling keyed up.
Right, right.
And when you're always looking
for the things you're worried about,
it's hard to focus on the present.
Here and now, which is one of
the techniques we use is getting
people to focus on the here
and now.
Well, I have always said that
anxiety is focusing on the future
and trying to control the
future events that you can't control
excessively.
Excessively.
And you.
It.
And I, I've done that myself.
And you might have seen, you
might have experienced that a few
times.
And you're very good at
quieting that down.
You'll say, whoa, whoa, Whoa.
You're getting 72 steps ahead
of what.
Because I'm like.
And then if.
And then that.
And then what if that, this,
this and that.
Because I think in my mind and
in people with anxiety, you're thinking,
well, if I can think of.
If I play out all the
scenarios in my head and I think
of all the possible outcomes,
I can get on top of it and somehow
prevent it.
I guess it's a little magical
thinking there, but it gives you
a.
It's a false sense of control.
You know, emphasis on false sense.
It's a false sense of control.
But so anxiety.
We're thinking in the future
about things that might have, Might
happen, might not happen.
But it doesn't make any sense
to think, get worried about things
that might not even happen.
Right.
But depression tends to focus
on the past.
We tend to be going over and
over again what we should have done.
Oh, I shouldn't have said that.
I wish I hadn't done that.
If only, you know, that's how
I see it.
Regret.
Yeah.
I think it was Mark Twain who
said 85% of what we worry about never
happens.
And so it's a lot of wasted energy.
It's really wasted energy and
it can.
Lead to catastrophic thinking,
which is you start imagining worst
case scenario.
Yeah, well, I get that though,
because if you think again, it's
magical.
But it's like if you think the
worst case scenario and you try to
pre deal with that, which
again, how do you.
You can't then anything that's
not the worst case scenario isn't
so bad.
That's taken from someone.
Again, disclaimer.
I don't have a generalized
anxiety disorder, but I appreciate
what goes on with people
because I'm on the, I'm on the fringes,
a little bit of some anxiety,
but I know how to control it and
I catch myself when I go there.
I can, I know how to stop it.
And it's, it's, it's good to
be living with one of the best psychiatrists
in the world too.
That helps.
That helps a lot.
That might be one of the
reasons I married you.
So just so you know, we were.
On the car ride here, we were
talking about stopping.
Oh, well, I was asking if you
knew the technique for that.
But I did.
I do this myself.
So there's a technique and
somebody out there might remember
what it's called.
But if you're getting these
kinds of thoughts and you're like,
all of a sudden it's like
snowball effect.
It's getting bigger and bigger
and bigger.
I will literally say to
myself, stop.
Or you know, like, close my eyes.
Or if something, I'm thinking
something in my head, I can just
like shut off the thought.
And you can make your blank,
your brain go black.
And then it's almost like
rebooting a computer is how I see
it.
And you just start all over again.
Fresh, right?
Turn it off, turn it off.
Wait a minute.
And then turn it back.
I mean, you can also do things
and this will go with all the anxiety
sores, but you can also do
things like take a deep breath and
there's diaphragmatic
breathing, for example.
I might as well talk about it now.
I was going to talk about it
later, but one of the things, you
can put one hand on your
chest, one hand on your abdomen,
breathe in slowly through your nose.
Some people do various counting.
Four counts in, two counts
out, Six, however, is best for you.
But you breathe in through
your nose.
Your other hand's on your abdomen.
And then as you breathe in
through your nose, you let your belly
push out your hand.
And then you slowly exhale
through your mouth.
And you let your shoulders fall.
And let your shoulders fall.
Yes, that Helps and it just
brings you back into the present.
It also tells your mind that
limbic system, that amygdala, hey,
we're safe, we're safe, we're safe.
Yeah, it's okay to take a deep breath.
You can turn it off now.
Right, because when you're not
feeling safe, that's when people
hyperventilate.
We're getting, we're hyperventilating.
In fact, by hyperventilating
you can induce a panic attack.
Right.
For people.
And we'll talk about that.
But so by slowing your
breathing, you're right, we're telling
our brain it's okay, no danger here.
Just take a deep breath and
smell the roses.
So that's generalized anxiety
disorder, which I think is well named
because it's anxiety about
almost everything, general things.
Let's talk about social
anxiety disorder.
So tell me this, Paul, and I
know the answer, but what's the difference
between social anxiety and
just being shy?
Well, I hate this phrase, but
it's also sometimes called pathological
shyness.
It's such a fear of how other
people perceive you or are judging
you.
And it's preconceived so that
people with social anxiety disorder
avoid social interaction.
A party would be a nightmare
for somebody with social anxiety
disorder.
So they come up with all kinds
of excuses of why they shouldn't
go.
And even sometimes just one on
one interactions can be a problem.
Conversation, conversation.
And partly it's because, so
some people think, oh, they're being
snooty or being, you know,
avoidant, but it's really their own
distress.
It's not anything to do with
that person.
It's their own distress.
And you're right how they,
they think they will be perceived,
but then it becomes a self
fulfilling prophecy because the people
are like, what's wrong with
that person?
Why are they acting like that?
So having conversations with
people, public, being in public speaking
crosses a line of social
phobia and other phobias.
Public going to the bathroom
in public bathrooms is part of a
social phobia.
So people tend to, with that,
tend to isolate.
Yeah, Social anxiety disorder
is actually very common.
It's been estimated again,.
Tell us the percentage.
7% of people, lifetime.
So that's a lot of people.
That is a lot.
The other problem that social
anxiety disorder sometimes leads
to is alcohol misuse.
Because people, whether
intentionally or unintentionally,
realize that alcohol takes
away some of that social anxiety
and then they develop a.
Whole separate problem, comes
a life of its own.
So sometimes if they have to
be In a social setting, they might
drink to take the edge off,
but then that's its own problem.
Right?
Right.
How about specific phobias?
Well, as you know, Paul, I became.
Not only was I an expert on
schizophrenia, but I had sudden fame
as an expert in arachnophobia
one time, which is fear of.
Fear of spiders.
Because a local.
We would do local TV episodes
on different things, you know.
But there was something.
It was Halloween time one year
and a local TV station wanted to
talk about phobias and they
were all disclosing phobias.
And the.
I believe it was the
meteorologist had a fear of spiders.
So they came to the local
arachnophobia expert, which was me,
unbeknownst to me.
But I learned quickly of
everything about arachnophobia.
So feel free to Google it.
You'll find it on there.
So talk about specific phobias.
So we talked about generalized anxiety.
Specific phobias are specific.
And some of them may seem.
Silly is not the right word.
So if you have a fear of
spiders, how much does that really
interfere with your life?
Probably not much.
I hate snakes.
You hate snakes?
I know.
I levitate if I see a snake.
When we first moved in, the
first thing you saw is two snakes
in the garage.
And you had to deal, but you
had to deal with it.
You did and you survived.
Yeah.
See?
Are you still afraid of snakes now?
I'm always afraid of snakes,
but I seldom see them, fortunately.
And we live in Arizona now, so
you're really lucky we don't see
them because they're probably
a rattlesnake.
That's right.
But some specific phobias
could interfere with someone's life.
Example, fear of elevators,
fear of bridges.
Oh.
So.
One of my daughters had a
teacher one year that confided in
me that she was afraid of bridges.
It's funny that you said that,
but she lived in Kentucky and had
to drive to Cincinnati and she
had to drive over the bridge.
That was a problem.
You know, unfortunately,
specific phobias can often be dealt
with with behavioral interventions.
I worked with somebody who
actually, because of trauma, his
car was hit by a tractor
trailer rig.
That's scary.
And on the interstate.
And he was.
He had a specific phobia from
trauma induced about driving on the
interstate.
And his psychologist.
I wasn't smart enough to
figure this out myself.
I hate when you say that.
I don't like the self
deprecating stuff, but.
Okay, proceed.
His psychologist told him or
recommended that he get on the interstate
where he lived, get off at the
very Next exit, come back and start
practicing driving on the
interstate in small bites until he
had to cross the bridge and
get on the interstate to come and
meet with me.
And he eventually could.
So you're talking about
systematic desensitization.
Yes.
So what we would do, let's
take a spider, for example.
You know, maybe someone were
very terrified of spiders.
We might show a picture of a spider.
So somebody that's really
afraid of a spider, sometimes just
seeing a spider will induce.
Could induce panic, for
example, or a visceral response of
some sort.
People get nauseated, they get
sweaty palpitations, all of that.
We might show a picture and
then maybe a stuffed animal or a
plastic version of a spider.
And then at some point, a real
spider, but far away across the room
in a cage.
And then it's like that.
So that's hence systematic
desensitization to ultimately maybe
there's an actual spider on
your hand and that.
The whole idea is you get into
this heightened sense of discomfort.
But you and you and you were encouraged.
We as therapists will
encourage them to stay with the emotion.
Don't dissociate, don't try to
pretend it's not happening.
Experience it fully, feel that emotion.
And then you realize, wait, I
didn't die.
Nothing horrible happened here.
So that's how you get through that.
But there's another thing
that's way more dramatic than that,
and it's called implosion
therapy or flooding.
And that's pretty controversial.
But some people do it and some
people want it because they want
a quicker response, but it's.
It's harsh.
So if I'm afraid of spiders,
there's no stepwise process here.
It's somebody puts a spider on
my face, basically.
You know, again, you survive
it, but it's.
It's a hard way to go.
So that's.
That's that flooding or
implosion therapy you might hear
of.
But yeah, fear.
So common ones.
Fear of heights is actually
very common.
And the elevator piece, you're
right about that.
What are some other really
common phobias?
Fear of flying.
Fear.
Yes.
We see that a lot.
And as psychiatrists, we are
asked to give benzodiazepines or
something, which is a
tranquilizing medication.
I was just in an office the
other day.
We were talking about it.
The primary care doc said, I
only prescribe benzos if someone's
flying.
And then I only give one pill
for the way there and one pill for
the way back.
That kind of thing.
It's almost the equivalent of
A drink and just taking the edge
off.
And the fear of flying is also
about loss of.
Loss of control.
Right.
That's the whole.
Even when you have nightmares
about that, it's about loss of control.
When I was in medical school,
one of my roommates had a fear of
blood.
Oh, that's rough.
In medical school, what do you
do then?
What did he do?
Well, as it turned out, it was
only a fear of his own blood.
He became.
He became a surgeon.
Oh, wow.
Well, that's a way to deal
with it.
That's kind of a reaction
formation in a way.
Right.
Wow, that's.
That's fascinating.
Yeah.
May I ask you a question?
What?
Tell us about your.
Tell us about your.
Your fear of chicken.
Or is it a fear phobia?
Or is it just an anxiety.
What is it?
What.
What's your tell.
Tell the listening world.
What about your.
That's not a phobia.
What is it?
What is it?
So I will not eat chicken.
It's an aversion.
It's an aversion.
So what's the difference
between an aversion and a phobia?
So an aversion could lead to a phobia?
I'm assuming it could be, but
I'm not afraid of chicken.
You're not afraid of chicken?
I don't know.
If I stuck a baked chicken
breast on your lap, what would you
do?
You'd be okay.
I'd be okay.
All right.
I'm going to.
Might try that later on.
It's putting chicken in my mouth.
And it's because.
Okay, so Paul had a negative
experience with chicken 30 years
ago.
Raw chicken.
And.
And it's called Cortez's response.
And there.
People are more averse to
something that they perceived as
poisonous than anything that's.
In the animal kingdom as well.
Yeah.
So it's.
It's an overlearned adaptive
response to not eating something
that you perceived as could
hurt you.
Yeah.
Something harmful.
Okay.
Thanks for clearing me up, but.
Yeah, it's a.
It's a pain to live with me
because I can't eat chicken or any
poultry.
Any poultry.
You're right.
Anything with feathers.
That's right.
Do you want to get into panic disorder?
Yes.
Okay.
So have you ever had a panic attack?
No.
I have, but only once, and I'm
in my 60s now.
I was like, once.
Who's there?
You were there?
Yes.
You were there.
Yeah.
And it is.
But because I had never experienced.
But I had witnessed many in my
practice, I've seen people have panic
attacks.
And people in my life have had
panic attacks.
I kind of went with it.
I wanted to see what it was
like once it started.
And I realized, wait, I think
I'm having a panic attack.
Because it was just escalating
and my breathing was getting more
rapid and I was feeling
sweaty, and I knew I wasn't dying.
And then we'll talk to that.
Because sometimes, the first
time you ever have a panic attack,
people show up in an emergency
room because they think they're having
a heart attack.
Yeah.
The average person with panic
disorder, which is the illness characterized
by panic attacks, has been to
the ER three times thinking they
had a heart attack.
Well, depending on the
circumstance, if you are having these
periods of chest tightening
and sweating and impending doom and
all, you probably should go to
the emergency room because you want
to make sure you're not having
a heart attack after you've experienced
that.
They say, no, it's.
You're not having a heart attack.
Chances are it's a panic
attack the next time if you experience
the same thing.
But I kind of went with it.
Just like I delivered lots of
babies in medical school and things,
and I loved it.
But then when I was actually
having my own baby and this baby
was coming out of my body, I
remember thinking, this is really
fascinating.
I'm gonna, like.
I want to experience this
whole thing.
What this is like.
It's kind of like the panic attack.
And then.
That's a strange way of
putting it, but I wanted to.
I'm like, oh, I'm going to
experience this.
Because now I know what my
patients were experiencing.
But I saw how it really can escalate.
Like, once you're breathing,
once you start that rapid breathing,
it's really hard to take it
down again.
It's that snowball or, you
know, tumbleweed effect.
Cascading, bigger, cascading.
It gets bigger, bigger,
bigger, bigger.
And you do feel like something
horrible is going to happen.
What's happening?
And then again, I knew enough.
And you knew how to get
through that.
But my first panic attack I
ever saw in my office one day, it
was a woman who had happened
to have bipolar disorder, but it
was under perfect control.
She was great.
Everything was great.
No mania, no nothing.
And we were just having a
regular, normal conversation.
It was a beautiful day.
Sun was shining out the
window, and she was sitting in my
office, and all of a sudden
she started hyperventilating and
getting sweaty.
And I thought, I think this
person's dying and what's happening?
You know?
And I saw.
And then she Ended up in the
fetal position on my floor.
And I thought, oh my goodness,
she is having a full blown panic
attack.
And what was interesting to
me, there was no apparent precipitant.
Apparent precipitant.
That doesn't mean she didn't.
Wasn't thinking about
something when I thought she was
engaged in a conversation.
She might have had some
trigger that she never really disclosed
afterwards.
However, we were able to
determine after that event things
to watch for and things that
were triggering to her and how to
avoid those kinds of things.
But if you ever see somebody
having it's scary again, she ended
up in the fetal position on my floor.
Yeah.
I've seen people have panic
attacks and they are ugly, they're
painful to see and obviously
terrifying for someone to have.
There's a surge of fear.
That's what it is.
All of a sudden you just feel
really scared.
And it reaches its peak within minutes.
You could have palpitations,
your heart rate starts going up.
You can feel sweaty, you can
feel tremulous, you can get shortness
of breath.
Some people feel the sensation
that they're smothering.
Chest pain, nausea, GI distress.
You can get dizzy and lightheaded.
Some people feel really cold.
What, Anything else?
Numbness, Tingling.
Tingling and numbness.
Yeah, that's from the hyperventilation.
Hyperventilation leads to the tingling.
So that's what you'll hear,
you'll see.
Some people recommend
breathing into a bag.
There is something to that,
you know.
And breathing in your
exhalation is helpful.
You want to explain why that's
helpful to breathing in.
Breathing in your own CO2.
And that slows down your breathing.
Yep, it slows down your breathing.
Then you.
Some people feel.
And that what this, these
patients of mine felt that they were
feeling detached from themselves.
They felt like they're losing
control or quote, unquote, going
crazy.
We don't like that term, but
that's what people think.
What's wrong with me?
Especially if they've never
experienced anything like that before.
They feel like they must,
might be dying.
So it's a rough illness to
have if you ever experience it.
And according to the official
DSM 5tr nomenclature, panic attacks
are defined as occurring
unbidden, out of the blue, without
a trigger.
I've seen.
Yeah, there's triggers.
Too many people have had them
because of triggers.
Absolutely.
But that's what's interesting.
So it makes more sense, I
think, to everybody if you think,
oh, whatever the apparent
trigger is, oh, no wonder there was
some trauma in their life.
And it kind of Goes sometimes
with ptsd, Post traumatic stress
disorder, which we'll be
talking about a different.
A different time.
But it could be a smell, a
taste, the wind.
Right.
All of which are associated.
Right.
Somewhere, again, they're
going to bring up hippocampus.
Again, probably something
triggered your hippocampus and that
led to this panic.
But it could be, could be not.
And that's what gets extra scary.
One panic episode, one panic
attack in your life doesn't make
you have panic disorder.
Right.
It's recurrent.
It's recurrent and it becomes
a problem.
So then people stop wanting to
go outside or interact with people
because they think, what if I
have a panic attack?
You know?
And that can lead to agoraphobia.
Right.
So more social isolation.
So all these.
We're seeing that all the
anxiety disorders are kind of interwoven.
They're really related.
It's very common for people
with generalized anxiety disorder
to have panic disorder and
vice versa.
Yeah, but then you said, like,
it could lead.
Oh, so the agoraphobia we
forgot to talk about, that was the
fear.
That was one of the specific phobias.
Fear of going outside.
Right, Right.
Yeah.
Something will harm you, and
so your environment shrinks to what
feels safe and controllable,
which is usually your house, your
room.
And then agoraphobia often
leads to hoarding behaviors, which
is another thing, and we can
talk about at a different time.
It's all connected.
One of the interesting things
about panic disorder, biologically
is that you can trigger it.
Not just psychologically, but
you can trigger it either.
Well, there's an experiment
that's been done years ago in which
you take, say, 10 people who
have had panic attacks, have panic
disorder, and take 10 people
who have not, put them in a room,
and you very slowly increase
the level of carbon dioxide.
Not monoxide, dioxide.
Yeah, don't do monoxide.
And the 10 people who have had
panic attacks, it'll trigger a panic
attack.
But that's interesting because
you just said when people breathe
into the bag and you're
breathing your own carbon dioxide,
that's calming.
It is calming.
Temporarily.
That's because you don't keep
breathing into the bag.
But so.
So that's one trigger.
Another that I've actually
done research wise, because one way
of trying to figure out if a
medicine will block panic.
Attacks is to induce panic.
You have to induce the disorder.
Right.
Is with intravenous lactate.
Right.
And so again, if you take 10
people who have never had a panic
attack and give them IV
lactate, nothing will happen.
Take 10 people who have had
panic, have panic disorder.
You will trigger a panic attack.
And it's ugly.
And so why do we do that again
with institutional review board approval
and all that?
So you establish that lactate
will trigger a panic attack.
And then if you want to try to
prove that a new medicine will block
panic attacks, then you give
them that medicine and then you repeat
the experiment.
And if that drug works,
nothing happens.
Right.
So that's telling us something biologically.
And there was a study done out
actually here in Arizona 20, 30 years
ago, a pet study.
So not pets, animals.
PET scan.
PET scan.
So which part of the brain
lights up?
Right?
And this was a really elegant
study in which they showed that in
somebody who was actually
actively having a panic attack, that
only their amygdala, but their
amygdala turned bright red.
Oh yeah, it's pretty wild.
So, yeah, it's fascinating for sure.
So what do you do to avoid all
these anxiety disorders?
So, partly, let's talk about lifestyle.
What are some things you can
do to help decrease the possibility
of experiencing these things?
Well, caffeine is a very so
called anxiogenic or anxiety producing
or exacerbating medication.
I mean you can even see it.
I mean, people look literally
jittery with caffeine.
So then these caffeine pills
that are out there and all these
also these energy drinks that
are out, people need to watch out.
So teenagers are getting much
more anxiety.
We're seeing too with these,
the, the availability of these drinks.
Nicotine is another one that
can trigger.
Panic and anxiety and alcohol,
especially alcohol withdrawal.
So alcohol is confusing
because people take it because they
think that they're reducing
their panic.
But it has a paradoxical effect.
Ultimately they feel more
jittery and more anxious.
Yeah.
So prioritizing sleep, all the
good healthy stuff, I mean, good
nutrition, sleep, a movement,
you got to move your body every day.
What else?
Well, we actually skipped over
nocturnal panic attacks.
Tell me.
Well, what do you mean?
Tell me more.
So I've worked with people who
have only had panic attacks while
they're asleep.
That sounds horrified.
Let's talk.
What's the difference between that?
Sorry.
If anybody's watching, I'm
adjusting my.
I almost had a panic attack
that my top button unbuttoned.
Is that a phobia?
Is that a fear?
What is it anyway?
What's the difference between
that and night terrors?
So nocturnal panic attack and
a night terror.
You wake up out of a panic.
Attack and a night terror.
You don't, you don't okay.
Right.
So again, in some of the
people I worked with, one of whom
is a physician, he was
terrified to go to sleep because
he was terrified of waking up
out of sleep in a full blown panic
attack.
So that's probably a specific subset.
What triggers that?
Don't know.
I mean, it was very treatable
with the right medicine.
Like what.
What do you do to treat
something like that?
So in my experience, and
research supports it, panic disorder
is one of the more rewarding
problems to help somebody help somebody
with.
Because many antidepressants,
only some of which are FDA approved,
but many antidepressants, even
off label, block panic attacks.
They just prevent them.
So that's neurobiology of that
is probably not worth going into,
but that's one very effective approach.
We'll talk about therapy in a second.
Benzodiazepines are often
extremely effective too, and often
immediately effective, but the
problems of dependence and addiction
make them probably problematic.
So benzodiazepines, for those
listening some, it's Valium, Xanax,
Clonidan, Ativan.
Yeah.
And again, we would do that in
very limited, very limited amounts.
We don't.
So I have to tell you, I used
benzos more with my people with schizophrenia
than I did with my people with anxiety.
Because again, you don't want
people with anxiety to get dependent
on that.
It's like a quick fix.
We want to get to the bottom
of it, particularly through cognitive
behavioral therapy.
Whereas someone with
schizophrenia who had so much paranoia
that they couldn't go out to
go do their laundry or go get groceries,
then they needed a little bit
of something to calm them so they
could get out the door.
So I try not to rely on that.
But what are.
We can touch.
It's okay, we're going to do
psychopharmacology podcasts, but
we can talk a little bit about
the psychopharmacology.
Like, what would be an example
of something you might use, medication
wise?
Well, one of the FDA approved
medicines is a drug called Menlafaxine
or Effexor, shown to
ameliorate anxiety and block panic
attacks.
What about the other s.
Selective serotonin reuptake inhibitors
like the Zolofts and the Lexapros.
You took the words out of my mouth.
The SSRIs are usually, usually they're.
Actually, there's an opinion
in the field that SSRIs are actually
more effective in treating
anxiety than in depression, but I
think that's controversial.
Nevertheless.
Nevertheless, they're
effective in treating anxiety.
Right.
In preventing it but so if you're.
Prone to having anxiety, just
like and you get on low dose antidepressant
and it's helping and you go
off and then you get this anxiety
all back, you probably should
stay on it.
Right.
But we can also do cognitive
behavioral therapy, which is something
we want to talk about as well.
Right.
Can we want to get into that
now, please?
So cognitive behavioral
therapy, I highly recommend the book,
David Byrne's book, the
Feeling Good Handbook.
And there's the feeling good book.
And there's a feeling good handbook.
It's good for depression, it's
good for anxiety as well.
And I've had many, many people
do that workbook.
It's great.
And so in cognitive behavioral
therapy we're essentially reshaping
thinking.
So the therapists is like a coach.
It's helping break the cycle,
you know, so you identify the negative
thoughts and you recognize
when you're thinking unrealistically
or you're thinking too critically.
So we have to recognize that.
And then you challenge the evidence.
You examine the facts
surrounding your thoughts instead
of relying purely on your emotions.
So you talk about this a lot.
You talk about this whole
matter of fact.
And I like that.
No emotion associated with it.
Let's talk realistically.
So the person's going 10 years
from now, this might happen.
That might happen.
Let's pull it back a little
bit and let's look at the facts.
Let's look at the here and now.
Right.
The realistic facts.
And then you reframe.
So you reframe the perspective.
So you replace the distorted
thinking with a more balanced, objective
and logical way.
Of thinking or even distorted
or exaggerated.
Exaggerated, yeah.
That's a good way to look at it.
So the cognitive strategies
help you process and help you neutralize
your anxiety.
You reframe.
So another thing that you can
do in terms of thought management.
So these are some pieces of
CBT activities, cognitive reframing.
You can write down your
anxious thoughts and see them on
paper.
We talked about the stop,
literally rebooting yourself, stopping
the rumination.
Have you heard of this with people?
Allow.
Some of my therapist
colleagues have talked about this.
Worry time.
You give yourself worry time.
Have you heard of that?
You have.
So instead of letting the
worry spiral all day long and you're
just thinking about all the
bad stuff all day long, you actually
give yourself 15 minutes and
you schedule it.
I'm going to worry for 15
minutes and then I'm going to go
cook dinner, exercise, walk
the dog.
Then there's how about brain dumping?
Have you Heard that term.
No.
Sounds scary.
So brain dumping is journaling.
So you journal and it helps
clear your racing thoughts because
the whole idea is it's getting
it out of your head and onto paper
is what it is.
So that's just some things to
think about.
I have to say, I often have
about all disease states.
All of my patients, whether
they had paranoia and they were really
in their head, they're hearing
voices in their head, and they have
distorted thinking with
delusions, people that are in a manic
state, depressed states for sure.
And anxiety.
I often tell people, you need
to get out of your own head.
You're too much in your own head.
You're in here, you need to be
out there.
We need to be with other
people, connecting with other people,
having a sense of purpose.
When all your time is spent
behind your eyes, it's not healthy.
Right.
It becomes an echo chamber.
Oh, I like that.
That's a good way to put it.
Yeah.
Yeah.
So anxiety, like depression,
like we said, you cannot stay in
your bed with the covers
pulled over your head because you
will not get better if you do that.
But there's so many ways.
And you said anxiety is a
rewarding illness to treat because
people do get better from it.
One thing we didn't talk about
with the.
During the panic attack too,
and my.
Again, my therapy colleagues
love to talk about this is the.
The grounding.
It's a grounding technique.
So it's the 5, 4, 3, 2, 1
grounding method.
So if someone's in the middle of.
They're starting to escalate
and starting to get panicky.
You do five things that you
can see.
So you immediately stop what
you're doing, looking around the
room.
Okay, I'm starting to get panicky.
I see the fan is moving.
I see the curtains.
I see your shoe.
I see, you know, it's kind of
brings you back into reality.
The next one is supposed to be
four things you hear, depending on
what you're setting.
I typically flip that.
I do four things you touch
because that.
That's easier than three
things you hear, two things you smell,
one thing you taste.
So it just really helps.
It's another way of resetting.
Right.
And grounding yourself.
Matter of fact, here and now, here.
And now being in the present.
So we need to be in the
present for all just.
We all need to be in the
present, whether we have any psychiatric
illnesses or don't have any
psychiatric illnesses.
That's the best way to relate.
Neat trick.
If you can pull it.
But it's it's one of the
essentials of good mental health.
It is.
And that's, you know, our
phones are distractions and all that.
So it's really important that
we put our phones away and all the
stimulus that's coming there,
turn the news off.
And when you're present with
your loved one and like, we, you
know, we don't.
We're making a point of
sitting down at the table and just
the two of us, and we're
connecting and making eye contact
and just being in the here and now.
And we need to do that with
our friends and our loved ones, our
colleagues, and decrease the
overstimulation in our lives.
And if you're someone seeking
mental health treatment care from
somebody, make sure they're
present with you.
Make sure they're in the here
and now.
What's a person supposed to do
if they're not?
So, you know, you and I are
very present, and we preach that
to our colleagues, especially
our up and coming colleagues new
to the profession, about the
importance of being present.
But what if you're assigned a
provider by your insurance company
and they're not looking at you
and they're writing a prescription
before you get any words out
of your mouth?
How do you handle that?
So I once gave a presentation
to the members of the Depression
and Bipolar Support Alliance.
That's a big group.
Great group.
Yeah.
And someone asked me that
question, this is probably 30 years
ago, and I gave the stock and
trade answer, well, talk about it
with that therapist and see if
you can work it out.
President of the organization
said, fire them and find a new one.
You know what, though?
That's good if you're an
empowered person.
But a lot of people seeking
mental health treatment, they're
so stressed or they're so
depressed, they're so anxious, and
then they're with some doctor,
nurse practitioner, you know, somebody
with the credentials, and
they're intimidated.
That's so that's easier said
than done,.
You know, and it might take time.
And you should always give.
Not always, but usually give
someone initially the benefit of
the doubt.
Maybe they're having a bad
day, but.
But I wouldn't.
Yeah, but that's not your
problem if you're the, if you're
the client, the patient, it's
not your problem if the therapist
is having a bad day.
Point is, you're not stuck
necessarily with somebody who you
don't feel is addressing your needs.
Yeah, we really, we need to
all advocate for ourselves.
And again, if people are in
positions of authority at your agencies
or Your hospitals or your practices.
You need to advocate for
spending time with patients and family
members, need to advocate for
their loved ones, especially if the
person's not in a place that
they can do that.
We need to do that for them.
Is there anything else you can
think of, Paul, that we.
Well, if there's.
To try to summarize, what I
hope we communicated is anxiety disorders
are common.
They're common.
They can be very painful, but
they're very treatable.
Very treatable.
That's true.
I mean, you saw a lot of
people with anxiety disorders in
your practice, right?
For me, it wasn't as common as
my other disorders that I was treating,
but we.
I have.
You're right.
We had tremendous successes
with people.
In fact, a lot of my patients
then graduated out of community mental
health because they really
didn't need.
It wasn't as extreme as it had
been for them, and they were able
to go on with their lives and
function well.
And then they were seen in
private sector or they didn't need
to be seen by anybody anymore.
Well, this is me being a
little compulsive, but we.
We specifically decided not to
address two other anxiety disorders.
Selective mutism is one.
Typically self.
Well, we have to touch on them
now that we're saying.
So selective mutism is one.
And that typically in children.
You hear that young children,
that they.
They might even speak at home,
but they won't speak at school and
things.
And that's an.
That is an anxiety disorder.
It's treatable as well.
And separation anxiety.
Separation anxiety, often also children.
Right.
Also treatable.
So if you're going to have a
psychiatric illness, anxiety disorder
is one of the ones that has a
very favorable outcome.
And if those of you that don't
like to take.
Sometimes you can do very well
without medications and doing cognitive
behavioral work.
That worked out well.
Paul.
Yeah, I was saying to Paul,
you know, I really love talking about
schizophrenia.
I love talking about bipolar anxiety.
Not so much.
That's more your thing.
But I.
You were anxious about talking
about anxiety.
I really wasn't.
No, I wasn't.
I really wasn't anxious about it.
I'm kidding.
I was not anxious about it.
It's just I wanted to make
sure that, because that wasn't the
biggest part of my practice,
that we got everything covered.
But I think we did.
And we'll be doing a deeper
dive as well.
And we are going to get into
specific medications that you can
use for anxiety.
We just touch the surface, but
I hope that we're leaving everyone
with a sense of hope that if
you are experiencing panic or generalized
anxiety or you're afraid of
heights, there's help for you.
There's hope for you.
Don't quit.
Keep trying.
And we're going to be with you
every step of the way.
And hope your loved ones are
doing the same for you.
Anything else?
Paul?
Thank you for watching and listening.
Thank you so much.
And until next time,.