Anxiety, simplified

I thought it would be good to return to a more “bread and butter” informational psychiatry post for once.  Consider this a drastic reductionism of a complex field.

Following the prior post about avoiding benzodiazepines, many have asked — What else can I do to feel less anxious besides take benzodiazepines?

The short answer is other (safer) medications, and/or psychotherapy.

Like any other blog post, this isn’t a substitution for medical advice, since there can be causes of anxiety that require medical intervention, such as hyperthyroidism. Make sure you get evaluated properly before trying to chalk your anxiety up to a “mental” problem. Even after that, it’s useful to see a professional who can help you tease out what’s contributing to it and the options to change how you’re feeling.

Anxiety usually refers to a common cluster of symptoms, such as shakiness, sweating, heart racing, panic attacks, restlessness, and just an internal feeling of nervousness. These are physiological aspects of anxiety. They occur during an activation of the sympathetic nervous system, the “fight-or-flight” response.  What evolved to protect us from something life threatening (Bear attack!) now activates to things that feel life threatening.  And then there are of course the emotions that those sensations add up to (e.g. nervous, anxious, worried, etc), and the thoughts we think in response to them as well (“I’m dying,” “this will never end,” “there’s something wrong with me”).

There’s different anxiety diagnoses, from panic disorder to generalized anxiety disorder to PTSD (sorta). A simple way to lump them, though, is to ask if the anxious feelings go on throughout the day, or only in short bursts (situationally or episodically). Of course people can also feel a baseline level of anxiety all day with short bursts of worsening (such as panic attacks) as well.

So let’s talk about Jack and Jill.

Jack was born anxious. He was a nervous kid, and he grew up to be a nervous adult. People just wrote him off as “that’s the way he is,” so he never explored if he could do things to feel different. Now as an adult he’s nervous all day long and his new girlfriend is telling him this isn’t “normal.” Jack comes in for an evaluation wondering if it’s “normal” or not. I tell him that “normal” is less useful than thinking about the terms “common” and “’healthy.” Anxiety is common. It isn’t necessarily healthy.

I go on to tell Jack about how meds work for someone with anxiety all day long, which is to lower the baseline level of nervousness, like turning the volume down on it. But it means taking a medication every day. Usually this is an SSRI (prozac, zoloft, lexapro, etc), considered the first line medication by most psychiatrists for anxiety. It’s taken at a scheduled time, and gradually the anxiety comes down. It’s not an instantaneous fix, but it lasts.

Jack and I go on to discuss ways that therapy can also help him, from challenging his thoughts that there’s something wrong with him or that bad things will continue to happen, to practicing ways to relax, to learning to control feelings that feel out of control. He might even try therapy where he thinks about his family relations as a the “cause” of anxiety (though I have a little less confidence in that). Over time Jack feels like he has more space to breathe and think, as his anxiety decreases. It takes some time and patience, though.

Jill is a young working woman who has never had any problems with anxiety or depression, but has never been particularly introspective, either. She just moved to a new city and after hearing about the dangers of some areas, finds herself wracked with anxiety whenever she steps outside. She just had her first panic attack, and is especially worried about having more. Even worse she’s been tasked to do public talks for her new job, and has a lot of worry about public speaking.

If someone has anxiety only episodically and feels completely normal in between these episodes, they might be able to get by with an as-needed medication. These are medications like vistaril (hydroxyzine), or in the case of phobias something like propranolol (a beta blocker).

Jill and I sit down for a talk, and we discover that anticipation is a big part of her anxiety. She anticipates how bad things could be. As do many people with anxiety. In many ways this is about fearing what might happen, which feeds the anxiety itself. So we have a talk about therapy, and how an approach like CBT might be able to challenge this anticipation, and break the habit of anticipating every bad thing that might happen.

There are of course exceptions situations where meds should be used more cautiously. Such as situational anxiety. As in someone didn’t have anxiety, and then something in their life changes, and now they’re feeling so much “stress” that they’re feeling anxious. I have several patients who have been in jobs that they hate, are overworked, but don’t have an easy way to leave it. The demands on them are overwhelming, from the hours to the workload to quotas. They are in a situation without an escape. So they tell themselves that they’ll just deal with it until things change. They don’t change their job, they just hope things resolve on their own. This is not usually a successful strategy. Anxiety can be taxing emotionally, and can lead to burnout. So in this case I’m a bit more cautious about prescribing a medication. I believe in relieving suffering, but I’m upfront with the person that it might just lead to tolerating an intolerable situation, which removes the pressure to figure out a better lifestyle. So in that case it’s their choice, and I encourage to look deeper at all of their options and make sure they’re not staying in a terrible situation.

PTSD is its own animal, though I still think about it in the anxiety spectrum. I’ll be writing a more complete post on PTSD soon.

For every kind of anxiety, medication can help. For every kind of anxiety, therapy can help. Using both together can help all the more. It’s just a matter of finding the right balance for the individual, something in line with what they’re willing to try.  We want to be able to engage the parasympathetic system, or challenge the sympathetic from taking over and snowballing in a way that’s hard to break out of.  This of course then should include meditation, relaxation exercises, even hypnosis, since they can all help with relaxation.

I may include some easy exercises in future posts that can help.


How to Not Burn Out

“I just can’t do it anymore.”

People burnout everywhere, in every field. They burn out professionally. They burn out in taking care of others. I live in Los Angeles and I can understand how just driving a car can burn someone out in this level of traffic.

No one plans to burn out. Maybe they do have a little awareness that they’re going down that road, though.

We have a level of control over where we place our attention, as well as our effort. If you’re worried you’re burning out, consider preventing it.

There’s two parts, I believe, to preventing burnout.

For the first, I’d like to borrow from a simple model I first heard from Dr. Christine Moutier (a psychiatrist and former supervisor of mine at UCSD), modified a bit here. Imagine a gas tank. It’s feeding an engine. That engine is you. If the engine shuts down, you shut down.


This gas tank has a leak in it. It’s losing gas. Gas is pouring out. Eventually if we do nothing, the tank will be empty. When it’s empty, the engine stops. It doesn’t run anymore. The engine burns out.

We don’t want the engine to stop, so we need to fill the tank. It has to be filled faster than it’s losing gas. In life we each have our strategies to fill the tank. Sleep. Food. Socializing. Rest. Sex. Yoga. Watching TV. Meditation. Talking to people.  Exercise. Make a note of your ways to fill the tank, and note what others do, since one way might not be enough. One way might not be able to fill it fast enough.  It’s for your own well-being.

On the other side, look at the size of the hole that gas is leaking out of. This is the effort we put out into the world. We can try to narrow the hole, to hold back. That may be effective, to a degree. If done too much, it leads to apathy. The hole can’t ever be completely plugged up, in a normal life.

It’s not a particularly complex model, I’ll give you. Yet really smart people neglect themselves all the time. They think their tank will never run out, as if there’s a secret reservoir somewhere. Running on empty hurts the engine. So the first step is to keep the tank filled.

The second part of not burning out is to Not Overextend. We all have projects we’re asked to be involved in, whether that be something at work or even fixing up something in the house. Or maybe it’s arranging an event for family or friends. Presuming this is not a startup business that is your idea, ask yourself – how much am I putting into this? How much are the other people putting into it?

Here’s the key: If you’ve been asked to do this project by someone else, and you decide to invest a lot of time/energy in it, make sure the other person is as invested in it as you.  The plan, the approach, and if possible, the energy/time.  If you’re thinking up a lot of aspects of it, make sure the other person agrees along the way, or has as much skin in the game.

Let’s say I’m asked by my wife to plan a party for our friends. I put a lot of time into planning and arranging it, and then my wife tells me she doesn’t like what I did. I devoted hundreds of hours into the project, she devoted none. My response to any criticism she might have is anger and wanting to quit and disconnect. I would feel burned out. Such is the way when only one party in a group does most of the work, and the other critiques or doesn’t support it.

Now in many situations the division of labor is unavoidable. One side will do more work than the other. Chances have to be taken. When they are done with open eyes, though, the disappointment may be less.We can clarify the point, then, that the other party needs to buy into the plan at least. Don’t overdo it expecting the other party to be wowed by the amount of time you’ve put into it. What if they aren’t? You may end up apathetic and withdrawn. Check in with them frequently, to get their buy-in on the approach, so they won’t be surprised, and you won’t be surprised. And finally, try to discern endeavors that might not be worth the investment.


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