Podcast: Fear, Anxiety, or Panic?

Episode Transcript

Jenn: Welcome to Mindful Things.

The Mindful Things podcast is brought to you by the Deconstructing Stigma team at McLean Hospital. You can help us change attitudes about mental health by visiting deconstructingstigma.org. Now on to the show.

Jeff: Welcome and thanks for joining us. My name is Jeff Bell and on behalf of McLean Hospital, I’d like to pass along our sincere appreciation for your interest in our educational webinar series. We’ve titled today’s segment Fear, Anxiety, or Panic.

And our goal is to explore the distinct ways that our brains respond to potential threats. Some fear and anxiety responses serve us well, of course. But when fear grows too intense, it can lead to panic attacks. And when anxiety goes unchecked, it can impair our ability to function.

So how do we know what’s what and when is professional treatment warranted? Those are among the many questions we’re going to ask Dr. Nathaniel Van Kirk to answer for us today. Nathaniel is a licensed clinical psychologist specializing in severe anxiety disorders, OCD, obsessive compulsive disorder, and trauma and PTSD.

He is the Director of Psychological Services at McLean’s OCD Institute, and Nathaniel is involved in efforts to reduce mental health stigma, including McLean’s Deconstructing Stigma campaign. Nathaniel, thanks for joining us.

Nathaniel: Thanks so much for having me.

Jeff: Now, you and I have known each other for a whole bunch of years now, and I have always admired your commitment to helping people with anxiety disorders, whether by sharing your own inspiring story or by pursuing your work as a professional therapist.

So just wanted to start with that. I am thrilled to be linking up for you with this particular conversation today.

Nathaniel: Thank you, looking forward to it.

Jeff: Well, as I mentioned, a big part of our goal today is to differentiate between fear, anxiety, and panic. So how about we start with some basic definitions that we can use for the sake of this discussion? Fear, what does fear mean, Nathaniel?

Nathaniel: So fear, a lot of times, I think colloquially we tend to use these things interchangeably and there is a lot of overlap between them, which sort of makes it a little tricky. But generally when we talk about kind of fear, we’re talking about sort of the automatic emotional response to an imminent or perceived imminent threat in the environment.

So a lot of times this is kind of characterized by sympathetic nervous system activation, that fight or flight or freeze response typically tends to think, your brain is sort of like focused on survival more than anything else and it’s usually at an immediate response to the environment itself.

And your brain’s kind of like acknowledgment that there is some threat in this environment that I need to react to.

Jeff: So that’s fear, how would you separate anxiety from fear?

Nathaniel: Anxiety is a generally a little bit more diffuse, a little bit more kind of general in a sense. Typically when we think about anxiety, we’re thinking about the kind of something that’s the anticipation of a future threat.

So we tend to think of it as a little bit more of a more generalized mood state compared to a very specific kind of hardwired physiological and emotional reaction to a threat in the environment.

So with anxiety it tends to be much more cognitive in nature, kind of a response to emotions. And in general you’re going to see kind of somewhat different physiological but related physiological experiences like tension, kind of hypervigilance, avoidance of things that are promoting that anxiety.

But it tends to be more future-oriented where fear tends to be more in response to the immediacy of the environment.

Jeff: Okay, and how about panic?

Nathaniel: And so panic is unique, right? Because it kind of like bridges the two a little bit. So we tend to think about panic as this specific type of a fear response where you have a really abrupt surge of intense fear discomfort that tends to peak within minutes, usually within about 10 minutes.

And you have both the physiological symptoms like heart racing, difficulty swallowing, chest tightness, muscle tightness, but also a lot of cognitive elements that go with it. So the fear sometimes of those physiological responses, the fear of losing control of one’s self or that something’s wrong with in one’s body.

Like, so panic attacks in and of itself are a type of fear, but they do also have those kind of anxiety elements that are sort of like future oriented and more cognitive in nature where you’re kind of running through like what is happening? What do I need to be afraid of?

One way that I tend to think about it is panic tends to happen when your body or brain kind of thinks, “Hey, there might be a threat, but I haven’t really identified what it is.” And so, it activates that fear response but it isn’t necessarily sure what it’s activating it to.

So sometimes it turns in kind of and looks inside, says “If I don’t see something in the environment but I’m having this fear response, what if there’s something inside?” And then it can kind of escalate pretty quickly.

I think one thing that’s really important, I know we’ll talk a little bit more about this, is that panic attacks in and of themself are not a mental health diagnosis or even necessarily a problem. They’re kind of just a hardwired physiological response that essentially got activated at a time where it isn’t actually useful or helpful in that moment.

And a lot of people will have a panic attack throughout their life without ever having a mental health diagnosis. So, I always like to kind of highlight that when we talk about these different kind of three different overlapping aspects.

Jeff: Yeah, I appreciate that. And we are going to zero in on panic attacks versus panic disorder and disability as well.

While we’re talking about these distinctions, there’s a very important one we need to make as well, which is between healthy anxiety and fear and unhealthy anxiety and fear, let’s start with the healthy component. They serve us anxiety and fear in our day-to-day lives.

Nathaniel: Yeah, I mean, anxiety, kind of fear, you know, even when you distinguish them, right? Fear is a basic emotion that’s hardwired into us for survival. It’s sort of, and that anxiety response in many cases is our best defense.

I always kind of joke when we’re talking about panic attacks or just anxiety that’s uncomfortable is that, you know, you want that anxiety, you want that fear response.

Especially if you’re walking through the woods and you know, a bear pops up, you want to have some physiological reaction because in a, you know, a one-to-one fight, we’re probably not going to win against a bear.

But it’s that anxiety that actually allows us to kind of be alert, be aware, mobilize all of the resources our body has with the goal of survival. And so healthy anxiety, you know, there’s a thing called a Yerkes-Dodson law that showed that there is an optimal level of stress response that’s related to high performance.

That there is this optimal level that actually increases things like creativity, focus, efficiency, anxiety is that thing that kind of spurs on those different aspects that we actually value. I think one of the biggest challenges becomes is when we start to talk about anxiety as good or bad.

And really, I love how you framed it, that healthy versus unhealthy or functional versus non-functional. It tends to be a way that thinks really good to think about it because we should have some anxiety, we want some anxiety in our day-to-day life. It’s what leads us to strive, pushes us, motivates us and also can enhance creativity and things like that as we go.

Jeff: Nathaniel, without getting us off into the weeds, I do want to ask you about the physiology of all of this. And you reference fight or flight. I know we sometimes hear about the amygdala and its role in all of this.

Can you walk us through the basic science of what’s happening in our brains with fear and anxiety?

Nathaniel: Yeah, I mean, so without going kind of too deep into like the neurology and the neuropsychology of it, but I think really what tends to be happening is our body’s sympathetic nervous system is sort of activating.

So, when we talk about fight, flight or freeze and a lot of times the freeze is sort of left off, but I always think it’s nice, it’s important to kind of highlight that freeze is actually a fairly, you know, kind of is something that happens to all of us. Just a lot of times it’s really quick so we don’t always notice it.

But essentially what happens is our body kind of kicks off that sympathetic nervous system activation. You know, your heart starts going a little bit faster, you have like might feel that muscle tightness. Essentially our body’s trying to push oxygen resources to our major muscle groups in case we do need to run or fight to survive.

And so, kind of that physiology of anxiety is really our body’s self-defense mechanism gearing up. One of the things where it gets a little tricky is that kind of like amygdala response you were talking about for fear is a hardwired response.

But sometimes our brain can sort of almost act like a fire alarm that’s not quite working when it’s unhelpful anxiety, where it’s kicking off this kind of survival instinct when there isn’t really an identified threat. That’s also when we tend to see a lot of freeze.

So, all of us as humans will freeze if we’re not sure whether we should fight or run. Our brain sort of, even if it’s just for a split second, freezes first to essentially evaluate what is the best course of survival and then fight or flight kicks in when our brain’s kind of determined in that kind of split second which direction to go.

And so, I think what ends up happening, I think one of the really important pieces is you get to feel things like muscle tension, changes to your breathing, which you know, kind of makes sense. If you’re going to run, it makes sense that you need to start bringing in more oxygen, your heart rate increases to kind of push that oxygen to your major muscle groups.

We also see some changes in your blood flow. You know, it pulls blood away from kind of the skin, so you get that kind of tingling. You know, one of the ideas behind this is you’re less likely to bleed out if you get cut if you’re fighting or running. And so, it really pushes kind of all that blood to the major muscle groups.

One of the things that you also tend to see is even kind of our core systems like digestion, for example, tends to like shut off a little bit because the joke we always talk about is that if you’re running from a bear, whether or not you digest the food doesn’t really matter because then you’re just doing the bear’s work for them if they catch you.

So, a lot of times people feel like I’ve got to go to the bathroom or I’m sick to my stomach or feel nauseous. And that’s essentially that change in blood flow but also the change in your body’s function to essentially reallocate everything to those parts of your physiology that are necessary for survival.

And with that you’ll have things like vision changes. You know, a lot of times people will say like it’s gets a little fuzzy to see things in front of me. One of the reasons, predators kind of historically tend to attack from the side. So, our vision kind of widens as we try to make sure, look for any potential threat in the environment.

So, you know, kind of on a higher order level, it’s essentially our body doing everything it can to give us any potential edge to survive against whatever threat might be there or any predator. And it’s this hardwired survival mechanism.

Jeff: And part of the confusion, if I’m understanding you, Nathaniel, is that we can be triggered by imagined threats as well that might not actually be, quote, unquote, real.

Nathaniel: Yeah, and that perception sometimes can go awry. Especially because anxiety a lot of times, especially when it becomes non-functional, is based on kind of learning experiences.

That is what we call overgeneralizing where that fear learning is no longer specific to the situation someone may be experienced it in but starts to generalize to all these other situations where that response isn’t warranted.

But they have some similarities that in the moment we’re not noticing those similarities. So, it sort of kicks off that fight or flight as if your life is in danger when there isn’t necessarily an imminent danger in the environment with you.

Jeff: So, when we’re talking about healthy versus unhealthy anxiety and fear, is there a continuum for both?

Nathaniel: Oh yeah, definitely. You know, I think the idea is sort of like when does it start to interfere with daily life functioning? So, when we talk about, you know, kind of unhelpful anxiety, it’s sort of anxiety that tends to be, you know, prolonged and out of proportion to the actual threat or the actual like necessity of the environment around you.

So essentially that anxiety response is kind of a little bit is turned up a little too high or is activating too frequently where it’s not serving its initial kind of function or purpose.

And that’s when it tends to lead to things like avoidance, the use of safety behaviors, avoiding doing daily tasks that are necessary because they’re eliciting that anxiety or avoiding going places that previously you would’ve liked to go or would’ve gone. And that tends to be sort of that line.

I always like to think that that line is sort of the functional impairment. When the anxiety starts to be kind of holding you back from doing the things that are important, that’s you want to start thinking about like is this crossing the line from adaptive or functional to unhelpful anxiety?

Jeff: Are there other warning signs, so to speak, that we should watch for when it comes to unhealthy anxiety, unhealthy fear?

Nathaniel: Yeah, I think one of those that comes up a lot is the idea of when it’s almost like hard to disengage from it. This idea of uncontrollable worry that comes up in generalized anxiety disorder for example, where you start to notice that you’re avoiding things that are important to you.

Maybe you’re avoiding kind of doing daily things that you used to do, when perhaps the anxiety is so persistent and distressing it becomes debilitating where it’s just easier to not even try to do something new versus feel that intense anxiety that comes with it.

And it sort of becomes this persistent ongoing, we talk about, you know, the, quote, unquote, timeline is six months. That’s a little arbitrary definitely, but it’s more of like a marker to think about what we mean by persistent because sometimes people have, you know, pretty difficult challenges where for a month or a really difficult month, things like that.

But when it starts to persist long term and continues to increase in severity and the amount of distress that you’re feeling to where you’re no longer able to do the task at hand because the distress is so overwhelming, that’s another good hallmark that it might be creeping into that unhelpful zone.

Jeff: So, Nathaniel, as you know, one of our goals with this webinar series is to weave in some audience questions and our audience members always ask some great questions. And this one just came in I want to talk about right now.

Are all three of these terms that we’ve talked about, anxiety, fear, and panic under a certain mental health classification?

Nathaniel: That’s a great question. What I would say is that anxiety and fear are not only a mental health classification, they’re kind of a functional hallmark of being human. And I think this also gets into the idea of what treatment is aimed at, like what the goal of treatment is. A lot of times we’re not trying to get rid of anxiety because that’s not a great thing either.

What we’re trying to do is change the way we relate to that anxiety and understand it and make it essentially make sure that that alarm system, if you will, is going off appropriately and it’s not necessarily kind of turned up, the volume isn’t turned up too high to where it gets in the way of doing daily things.

So, you know, when we talk about these three, I’d say that these three are experiences of being human. It’s when they start to kind of elevate to the level where they’re causing functional impairment, that’s when they start to come under kind of different diagnostic categories.

You know, anxiety disorders being the most prevalent. But we also know panic attacks and anxiety can also occur in relation to major depressive disorder, OCD and related disorders, trauma and related disorders, panic attacks are those can occur in all of those different contexts.

Jeff: So, we’ve touched on this, but let me put the finest point possible on this question. When do I seek professional help if I’m dealing with anxiety or fear, and it feels like it’s getting in the way of my day?

Nathaniel: I think you just kind of, you know, just the way you said it, right, when it feels like it’s getting in the way of your day, that’s a great time to go seek help. Worst is, you know, maybe it was just a really stressful time, but you can learn some coping strategies to use it more effectively across time.

I think the early intervention tends to be one of the most important aspects in anxiety treatment. We know that if left untreated anxiety can be chronic, but treatments are highly effective and a lot of the skills that you learn in these types of treatments are actually everyday skills that all of us use every day.

It’s just learning to use them a little bit better sometimes or a little more efficiently or effectively. So, I’d say the moment where the distress becomes so overwhelming that it’s hard to think about anything else or those moments where you think it might be getting in the way more than you want it to, that’s a great time to reach out for help.

Or even if you’re worried that that threshold might be occurring, go ahead and reach out for help proactively because then you can kind of learn some skills, nip it in the bud and get back to living your life.

Jeff: Let’s talk about anxiety disorders that are diagnosed. We hear about general anxiety disorder, social anxiety disorder, OCD, panic disorder, which we’ll zero in on separately.

What should we know about anxiety disorders in general? Do we have a sense of how many people have them as a part of our population for example?

Nathaniel: Oh yeah, so anxiety disorders as a group tend to be one of the most common categories or dimensions if you will, of mental health diagnoses, you know, as a group and there’s a lot of anxiety disorders within kind of that group.

But I think the last estimate, I’m trying to remember off the top of my head, you know, a lot of these, they vary somewhere between four to a 12% of kind of, you know, prevalence within a year.

And that does vary, but what we do know is that I think it’s somewhere around even up to 40% of individuals will have at least some mental health, you know, experience or challenge throughout their life.

The data that’s really kind of coming out is saying that the predictive like lifetime prevalence rate of mental health challenges that are, quote, unquote, diagnosable is actually well over half within a year. You know, so really, it’s more of a human kind of experience, if you will.

And I say anxiety sorts are one of those most common, you know, the prevalence rates vary based on study, all those type things over time. But we do know that within the US well over about 40 million people will have an anxiety diagnosis at any given time.

Jeff: Walk us through the main anxiety disorders that we hear about. Let’s start with generalized anxiety disorder, GAD, what should we know about that?

Nathaniel: So, GAD or generalized anxiety disorder is essentially characterized by, you know, a persistent and perceived as uncontrollable sense of anxiety and worry around daily life domains.

So work, school, relationships, finances, it tends to center around this daily life concerns where someone may enter into what they feel like is problem solving but then it sort of gets out of hand and they get into this spiral of worry.

A lot of times there’s a lot of catastrophizing for example or predicting like the worst possible outcome overestimating the likelihood of that worst possible outcome. But the really the hallmark of it is this kind of like just overall general kind of keyed up on edge, feeling anxious and distressed throughout your entire day for more than six months.

That’s characterized by an uncontrollable sense of worry that once it starts it’s really hard to disengage from. And that’s sort of like the hallmark of generalized anxiety disorder, sort of takes those day-to-day things we all experience and then runs with them. It’s like a snowball going down the hill.

Jeff: What about social anxiety disorder?

Nathaniel: So social anxiety disorder is really, I think the fundamental cognition in there a lot of times tends to be a fear of negative evaluation by others in social settings or kind of interpersonal interactions.

So, a lot of times it’s performance based, it’s the idea of like, I’ll make a mistake, I’ll do something wrong, I might say something weird and they’re going to judge me for it, they’re going to kind of negatively judge me or might be humiliated and I’m not sure what I would do with that.

So, it’s better to just kind of avoid those social situations and it tends to be more acute, especially with people that you’re not as familiar with. People that you trust, your close friends, family tends to be a little less intense, though it can still be there, but it really boils down to that kind of evaluative component and the fear of negative evaluation.

Jeff: All right, here’s one that’s familiar for you and me, OCD, obsessive compulsive disorder. You and I both have some lived experience in that arena.

Nathaniel: Yeah.

Jeff: What should we know for folks who are not familiar with obsessive compulsive disorder, what do you want them to know about OCD?

Nathaniel: I think the biggest thing is that, so OCD now is, while anxiety is a hallmark, it’s not the only emotion that comes up. We have discussed not just right experiences, you know, obsessional guilt and shame. So, it’s actually been pulled out of anxiety disorders into its own domain because it operates a little bit differently.

But its hallmark is essentially having unwanted and repetitive intrusive thoughts, images, urges or feelings that cause significant distress that generally tend to go against how you view yourself as an individual.

And as a result of that have really intense urges to do certain behaviors over and over and over again or mental acts over and over and over again with the hope that it’ll neutralize the distress and prevent the feared outcome that your brain is telling you might happen.

So those rituals are kind of the way to try to hold that obsessional fear at bay. Unfortunately, the more that we do those rituals, Jeff, as you and I’ve talked about before in other venues, the more you do them the harder it is to achieve that feeling of safety and certainty.

And over time they just get more and more intense and more and more extreme. But at its core it’s kind of like this intolerance of uncertainty tends to be the hallmark of OCD.

Jeff: And fortunately, this disorder and so many others that we’re going to talk about today are highly treatable and we’re going to get to that treatment process in just a moment here.

I do want to ask you about panic disorder because we want to separate that from panic attacks.

Nathaniel: Yeah.

Jeff: Panic disorders, are they considered anxiety disorders?

Nathaniel: They are, so panic disorder is kind of one of the core anxiety disorders and I think, you know, as I mentioned before, having a panic attack itself is not necessarily diagnosable but what panic disorder is, it’s sort of the hallmark of it is sort of like this fear of the fear response.

So, a lot of it is having a panic attack and then for you know, at least a month after and typically it’ll be ongoing if not treated is the idea of having this overwhelming fear, anxiety or distress associated with the idea of having an additional attack.

And because with panic disorder there tends to be recurrent panic attacks that typically come out of the blue. And so, they feel sort of unpredictable, if you will. And when we’re talking about panic disorder, we’re actually talking about that kind of like cognitive response to that experience.

The response of the fear of what’s happening to my body for example, that the overinterpretation of this physiological kind of symptoms that are hardwired into us, that are our kind of safety and protective factor as we are as humans.

But interpreting them as catastrophic or dangerous in some form or fashion as indicating that one might be losing control of themselves. And so, there’s this persistent fear of having another panic attack that leads to significant changes in behavior.

Behavior like avoidance, fear of going certain places, fear of leaving the house, fear of going and doing things without like a safety person just in case you might have another panic attack.

So panic disorder is really a fear of that physiological fear response and the consequences or implications of it that tends to come from over-interpreting the physiological symptoms as you’ve experienced them.

Jeff: Yeah, that’s a key distinction there. Nathaniel, before we get into the treatment options for folks dealing with anxiety disorders, I want to ask you to kind of walk us through the anatomy of a panic attack.

For somebody who has not experienced that, can you kind of paint the picture of what that’s all about?

Nathaniel: Yeah, so a panic attack is typically when within you kind of go zero, it’s like going zero to a hundred in under 10 minutes. A lot of times people say it’s within a minute or two or five minutes, but it tends to be a very quick onset of a lot of these, kind of, physiological symptoms that are associated with the fear response.

So, some of the hallmarks typically tend to be, you know, sort of heart pounding or palpitations, sweating, trembling or shaking. The feeling of choking sometimes can come up especially as someone’s like kind of respiration changes or increases like they start to almost hyperventilate, feeling dizzy or unsteady.

Sometimes people have chills or hot flashes, depending on kind of where they are in the panic kind of continuum or fear response continuum if you will. There’s also instances where someone can have like derealization or feeling like things are around them are unreal or fuzzy or foggy.

There’s also tends to be the cognitive symptoms of the fear of dying, fear of losing control of oneself, fear that this means one’s body is sort of turning against them and that they’re kind of at risk, at imminent risk of harm or death because of these symptoms.

We also have vision changes and kind of might feel like your muscles are tight, are tightened but are also sort of like vibrating. You know, those are kind of like the hallmark ones and a panic attack is usually four or more of those at instance that come go from zero to a hundred kind of within under 10 minutes. That’s sort of like the definition of a panic attack.

But I think, Jeff, kind of, it sounds like what you’re also asking is like what’s actually going on in your body? Is that accurate?

Jeff: That is accurate.

Nathaniel: Yeah, so I think one of the things like just to break down some of them that I think is really interesting is to think about how our body defends itself because this is where it gets sort of, you know, really if you take a step back, it’s kind of exciting how well our body has evolved to sort of protect ourselves.

Jeff: Sure.

Nathaniel: And so, you know, we talked a little bit earlier, like the heart rate increases because it’s pushing blood, you know, through your body faster to deliver oxygen to those major muscle groups so they’re ready to work when the time comes.

The sweating is essentially your body preemptively starting to cool itself, you know, because you don’t want to overheat while you’re running or fighting because then you start to feel sick and kind of lose like your ability to do that which would be bad for survival.

So, you start to sweat. But that also can lead to that feeling of chills because if you necessarily are, if this is started up and your body’s starting to sweat, your heart rate’s increasing, your respiration’s increasing but you’re not fighting or running, essentially your body takes in too much oxygen and it’s sort of pushing your blood too fast to all these places.

Your body’s preemptively ready for yourself to run but because you aren’t running, you start to get cold because you have sweat kind of developing but you’re not using it and you’re not using all that energy in that moment. The feeling of dizziness is one of those things that tends to happen when our body actually exists on a pretty good balance of oxygen and sort of CO2.

So, it’s kind of like this balancing act, if you will. When you start to take in those big gulps of oxygen to get ready to run or fight and that fight or flight kicks off, if you don’t end up using that, essentially what tends to happen is you know, that oxygen sticks the hemoglobin in your blood.

And if there’s gets too highly saturated, it starts to get sticky and has a hard time releasing it until you start to run or fight or exert that physical energy where the muscles sort of rip that off. And so, you start to get this dizziness because that balance has become skewed in one direction.

The same thing that happens if someone holds their breath too long kind of gets skewed in the other direction. And then you get that kind of like cognitive, that dizziness, that kind of fogginess that comes.

And so that’s one of the reasons why kind of changing your breathing is one of the main techniques we talk about with panic disorder to help sort of shut down that sympathetic nervous system activation and increase your parasympathetic activation, which sort of calms the body, if you will.

But ultimately what your body’s doing is just gathering resources to get ready. The other thing that tends to feel kind of uncomfortable is the chest tightness. A lot of times people will talk about, and I always ask people to just watch their body when they start to have a panic attack.

When our chest tightens, what it’s doing is pulling our arms in which is protecting our major organs. It’s putting us in a fight or defensive posture to protect of like our major vulnerable organs. And that’s sort of why all your muscles contract in that way.

You also start to notice that like maybe you can’t sit still and it’s like you’re vibrating and sometimes people will say, well, I’m losing control of my body, like my muscles are twitching nonstop. The analogy I always give is, it’s essentially like a sprinter on the starting block.

If you’ve ever looked really close at a sprinter on the starting block, you know, you ever kind of look at them maybe watching the Olympics, right? And it’s like their hands are pretty much and their feet, legs are like vibrating, their whole body looks like it’s sort of vibrating.

Kind of like The Flash if anyone’s a DC fan. You know that same idea. But essentially that’s getting their quick muscle fibers, quick twitch muscle fibers activated so they can launch on a moment’s notice.

And that’s essentially what our fight or flight does too. So the moment that our brain decides I should run or I should fight, you can go and there’s no like warm up or hesitation, but that’s also all why you get that kind of tingling and numbness if you will.

Jeff: So unless I forget to circle back to this, talk a little bit about dos and don’ts for navigating the panic attack itself. What do you want to do to best get through it?

Nathaniel: One of the best things that you can do is changing your breathing. So, you know, just in terms of like thinking about what’s the go-to.

So Jeff, like in terms of when you think about anxiety, right, what do people tend to do when they get anxious? What’s like the first thing you sort of like notice yourself wanting to do?

Jeff: Get reassurance, get comfort.

Nathaniel: Get comfort, right? And sometimes this idea that if I feel tight or my chest feels tight, that comfort can come from taking in big gulps of oxygen, right? The idea that all right, I can breathe, take deep breaths and that’s sort of what everyone tells you, right? Take deep breaths.

What we know is when you’re having a panic attack that actually isn’t always a good thing to just take deep breaths because you’re taking in more big gulps of oxygen that your body isn’t necessarily using. So what we tend to tell people to do is to do what we might call relaxation breathing.

Where it’s you breathe in for three seconds through your nose and blow out and exhale through your mouth for two seconds longer than you inhale just like you’re blowing up a balloon. The idea behind that is that it’s allows you to sort of start breathing from your diaphragm versus your shoulders.

A lot of times when we get anxious because our muscles are tightening, we tend to breathe like this and that’s can lead to hyperventilation. So we want to do sort of this, you know, I think the key a lot of times some of the research is showing that exhaling for two seconds longer than you inhale tends to be one of the keys to like balancing out, you know, the oxygen and CO2.

It allows your body to sort of reregulate and we’ll start to kind of turn down the sympathetic nervous system activation, although it’s always important to know that your body is much quicker to go into fight or flight than come out of it.

Jeff: Interesting.

Nathaniel: Well, it’s a good thing to have, right? So if you’re, I don’t know if, Jeff, if you like hiking, but the idea of like when you’re hiking, if you think there’s a bear there, right?

Jeff: Right.

Nathaniel: And then you run, you’re like, all right, I’m good. If that sympathetic nervous system totally shuts down and they’re like, all right, cool, I’m good, now I’m going to go take a nap in the, you know, next to this rock over here, but the bear is still following you, you don’t want it to fully shut down because then we’re at risk.

That’s why our bodies are designed for when you have that fight or flight response to sort of come down gradually just in case that threat reemerges, you have less to go to reactivate your survival system.

Which a lot of times is what people feel like, well, something must be wrong, I’m not calming down quick enough. I always like people to know that’s good, it’ll keep you alive.

Jeff: So Nathaniel, let’s segue into treatment for some of these disorders, anxiety disorders and others.

And since we’re talking about panic attacks, let’s talk about panic disorder. How is it treated in the long term?

Nathaniel: So one of the best kind of empirically based treatments for it is cognitive behavioral therapy or specifically there’s a protocol called panic control treatment. The idea behind it is sort of kind of twofold.

One is to do some exposure to those physiological symptoms to practice sort of like controlling, like turning on and slowing down your sympathetic nervous system sort of one sensation at a time, if you will.

We call them interoceptive exposures. It’s where you purposely elicit that kind of one or two physical sensations that you’re sort of afraid of that have become triggers of, oh no, what if I have a panic attack?

So sort of like, you know, one, if someone had dizziness is one of those for someone, we might have them spin in your chair for about a minute until you start to feel feeling similar to what it’s like when you’re having a panic attack just in that kind of like specific, you know, physiological experience.

And then we use that breathing that I was just talking about to sort of practice slowing it down. The goal is to reduce the fear of the physiology, to know that you’re not in danger when anxiety’s present or you’re having a panic attack, your body is doing what it’s designed to do. So we do exposure to each of those and that’s kind of the first part.

The other is sort of restructuring or changing the relationship to, you know, those physiological experiences where we try to notice some of the, you know, distortions or shortcuts that our brain tends to use that aren’t really helpful like catastrophizing, which is sort of like predicting the worst possible outcome.

Another big one is emotional reasoning that because I feel anxious, something bad must be happening. Using that emotion as fact versus just another form of data. You know, those tend to be, essentially what we’re trying to do is change the misinterpretation of those bodily sensations as dangerous.

So that whenever you feel a bodily sensation that’s related to it, it doesn’t kick off your anxiety fight or flight system by thinking, oh no, I felt my heart rate changed. What if I’m having a panic attack? That means I must be in danger. And as soon as your brain does that, right? Turns up that fight or flight all the way to a hundred.

And so it’s that we’re trying to challenge those misinterpretations of, oh, I noticed my heartbeat changed, maybe I’m walking a little bit faster than I was before. Oh, that’s just normal variation in being human, and having your heart kind of doing different things throughout the day.

And so we’re trying to challenge those kinds of the hyper-focus, if you will, on the physiology and over time that will break the panic cycle.

Jeff: Okay, do you mentioned exposure therapy and CBT. These are common terms we talk about in the OCD world. How does OCD treatment differ from panic disorder treatment?

Nathaniel: The biggest thing that differs is sort of a lot of times if it’s just OCD and not OCD with comorbid panic disorder, which can happen, sometimes those with OCD will have a panic attack. But usually it’s brought on by a certain trigger, an obsessional kind of trigger, something that triggers that obsessional fear.

So a lot of times we’re doing exposure to that obsessional fear and those triggers that are related to it versus the physiology itself. Now there are of course exceptions but we’re typically not going to focus as much on the cognitive restructuring because OCD really is only it’s looking for 100% certainty. 99.9% isn’t good enough.

Like when you say that, it’s like great, so you’re telling me there’s a chance. So the goal is sort of to do exposure to learn to more effectively tolerate uncertainty just like we do in a lot of other domains of our life.

I think, Jeff, when you and I were talking, right, the idea of like a lot of times we walk outside with an umbrella when it’s raining, but many times we won’t really think about the fact like I’m holding a metal or aluminum rod during a lightning storm but we just do it because we have to.

Until I said that then you know, everyone might think about that a little bit more next time it rains. But it’s that idea that we accept uncertainty every day and that’s sort of what our exposures are going towards in OCD is increasing the ability to tolerate the stress around uncertainty and navigate it more effectively.

Jeff: How does ACT or ACT, acceptance commitment therapy, factor into all of this equation as well?

Nathaniel: Yeah, so ACT has some really great research showing its effectiveness in showing that it is also one of the most highly effective treatments along with CBT. And there are similarities between ACT and CBT.

A lot of it focuses on changing the relationship to those thoughts and kind of focus on doing sort of those value-driven activities, the things that are important in your life that give you meaning even though that anxiety is there.

By reducing avoidance and changing the way that we relate to the thoughts and to our own kind of catastrophic thoughts that come in, how do we navigate them and accept that all right, those thoughts are there but it doesn’t mean I have to act on them, I can change my behavior and move forward.

And so you know, ACT is another really great treatment for anxiety disorders and OCD and has a lot of empirical and foundations behind it.

Jeff: We have questions coming in about, we have a lot of questions coming in. One of them is regarding social anxiety. So let’s talk a little bit about that as well and how its treatment might differ from OCD or panic disorders.

Nathaniel: Mm-hmm, so when it comes to social anxiety disorder, I think again a lot of the, within the anxiety disorders, a lot of the skills and strategies are actually sort of transdiagnostic. There’s a lot of transdiagnostic mechanisms that are the same across all of them.

So targeting the cognitive distortions or those misinterpretations if you will, the shortcuts that our brain takes that are unhelpful, identifying them, noticing them and then what we call challenging or restructuring them to make something more objective. And then we practice that over and over again.

And this comes in play with social anxiety disorder a lot where we’re sort of, you know, challenging those misinterpretations of how others may be evaluating or judging you or the implications of that judgment to be a little bit more objective.

You know, when you’re struggling with social anxiety disorder, a lot of times the ideas that everyone’s looking at you and judging you all the time when as humans, we also all tend to be caught up in our own stuff a lot that we don’t always even pay that much attention to those around us.

And I think, you know, there’s that kind of like filter if you will, in social anxiety disorder where only certain information is sort of focused on and all the stuff that doesn’t like fit that fear structure sort of like discarded.

So cognitive structuring and also doing is a core component of it similar to panic disorder, a little different than OCD because we’ll do things like probability estimation, like how likely is this outcome you’re afraid of and like your interpretation of its consequences.

But we don’t do that as much in OCD because OCD sort of plays by its own set of separate rules when it comes to probability. But the way I always frame it, we’re just trying to get more objective kind of approach to life and relationship to life around us.

Not trying to say everything’s going to be great, everything’s going to be good, you know, everything’s sunshine and rainbows. It’s sort of like more of the objective. There’s good and there’s bad, but I’m overinterpreting the bad and disregarding some of the good.

My goal is to sort of come into the middle to be more objective of what day-to-day life is so I can choose how to respond and how to react more effectively so that I can do the things that are important to me.

Jeff: People would like you to speak a little bit to DBT, perhaps you can define the term first and talk about whether or not it’s used in the treatment of anxiety disorders along with mindfulness.

Nathaniel: Yeah, so DBT or dialectical behavior therapy, you know, one of the core pieces that I think is used in a lot of anxiety disorders too and can be just good foundational skills is the DBT kind of distress tolerance skills.

Learning to like ground yourself effectively when you’re emotions are high and this can work for, you know, across emotions, not just anxiety, you know. And so it’s the idea of like using effective grounding skills, using mindfulness for example, which is really all about focusing on the present moment and not overinterpreting your thoughts.

So noticing them as they come and go but not getting like sucked into them sort of and coming back to the present moment or taking like an observer stance if you will, where you’re just noticing them sort of like you’re standing on a balcony and there’s a crowd below you, you’re seeing everybody but you’re not in there pushing and shoving, fighting against them.

And that’s sort of how we want to relate to our thoughts, especially when you’re anxious and those thoughts tend to come pretty rapidly, right? They’re just rapid fire one after the other. So DBT can be great foundational skills and mindfulness, we do know there’s a lot of research on that.

Doing mindfulness daily can reduce overall anxiety levels and so mindfulness is a great skill to practice. Even just five minutes a day can have huge effects long term on your relationship to anxiety. Because it is practicing disengaging from those anxious thoughts and just being in the moment.

Jeff: You know, the very specific question, how does self-harm, that is cutting for example, relate to anxiety issues?

Nathaniel: Mm-hmm, so there’s a lot of different ways it can relate I guess is kind of the preface I would give to that. And it’s very individualized, but sometimes when it comes to anxiety and like panic or feeling overwhelmed in general, self-harm can kind of seem as a last ditch way of coping.

Of, “I don’t know what to do with all this overwhelming emotion but this physical, you know, feeling, this physical pain if you will, overrides the emotional pain.” So it helps people disengage from the emotional pain, gives them something else to focus on.

And that kind of, you know, what we might call like non-suicidal self injury can tend to be this when someone feels like, “I don’t know what else to do, I don’t know where else to turn, but this seems like the one thing that’ll break me out of it.”

And so a lot of times what we’ll try to do and DBT is great for this, is learning other methods of disengaging from the overwhelmed thoughts, the cascade of thoughts and feelings and grounding into a physical sensation that doesn’t cause harm to oneself.

So like holding ice is a great example or what we call an ice dive where you fill like a, you know, a big bowl filled with ice, really cold ice water and then dip your head in it and it sort of like tricks your body to think that it’s drowning.

So physiologically it shuts down the sympathetic nervous system activation because it’s trying to conserve resources. So it’s sort of like tricking your body to slow down that like cascade of anxiety and distress.

That’s similar to what self-harm sometimes can function. And again, this may vary person to person, but when it comes to anxiety, that tends to be one of the ways we see it connect.

Jeff: We’re covering a lot of ground here and I think it can be a little overwhelming for some people. And I want to kind of take a quick step back and say, what if I don’t know where to start for finding a therapist?

What if I don’t know how to go about getting treatment? Where do you point them?

Nathaniel: I think a couple places that are really great is, you know, McLean’s website would be a first one. You know, there’s a lot of webinars on anxiety, what to look for in a therapist, how to find them, you know, the adult outpatient clinic would be a great example.

If you’re not in Massachusetts, the Anxiety and Depression Association of America or adaa.org has a find a therapist tool for those that specialize in anxiety and depression. The Association of Behavior and Cognitive Therapies or ABCT also has a find a therapist tool and it’ll list it by specialties. You can also do it through Psychology Today.

And just looking for individuals who focus on things like ACT, CBT for anxiety or do transdiagnostic anxiety treatment. Those can be great places to start because one, it gives you a lot of great, they have a lot of great resources and information, but also gives you a list of providers to start talking to.

And you can sort by area code, by what you’re looking for help with. So those are great places. If it’s OCD and related disorders, the International OCD Foundation has find a therapist tool as well. So I think those are kind of great kind of places that are sort of empirically based.

NAMI can be another one that has great resources and ways to find therapists. So those are great places to start. And then also finding kind of any book resources that you can just to read and learn about it can sometimes, like psychoeducation is always the first step in any treatment approach.

So the more you learn about it, more you understand it, the easier it’s going to be to utilize these skills effectively. So that can be another great step.

Jeff: I can tell by the questions that are coming in that we have a number of folks who are watching today because they’re interested in supporting somebody, a loved one who might be dealing with anxiety or excessive fear or panic.

Kind of walk us through their role, pre-treatment, during treatment, post-treatment. What can a loved one be doing to best support somebody with anxiety and or panic?

Nathaniel: I think when you’re first starting out, you know, prior to going into treatment, one of the things I always encourage when you’re in treatment is bring your support system into treatment. Have a have a conversation with your support system, you know, and your treatment provider.

Because what it does allow is for you all to come up with a plan together on like what words to say, how to help someone maybe utilize grounding skills in that moment. What grounding skills are most effective?

But I think when someone’s first starting out, even just validating how difficult it is and the experience of anxiety and then providing support, sometimes just being there can be one of the most impactful things for someone when they’re going through panic.

It’s just helping them ride it out and helping them, giving them something to focus on, try to have a conversation with them, use some of the skills with them and then encouraging them and helping them go through resources together to what is treatment, what does it look like, how to find treatment.

Listening to personal stories together to try to encourage someone to go to treatment. That can be a really important part to start with.

Then as you go into treatment, I definitely recommend talking as a group with the treatment provider because you also want to make sure that you know, you’re giving someone enough sort of autonomy if you will, to practice the skills on their own versus trying to make the anxiety go away for them.

Because that can sort of lead to another form of avoidance. But it’s a natural feeling as a human, right? If someone we care about is suffering, we want to make them feel better.

But there are times where that can also be ineffective and prolong the anxiety because people don’t get a chance to practice the skills and build this sense of self-confidence that they can cope with that feeling of anxiety.

So I do think having a conversation with the treatment provider and your support system together can be really, really effective. And then it can also help you kind of identify like what are things that are helpful for you to highlight for someone maybe as they’re transition out of treatment, if you notice a change.

But I think also getting back to day-to-day life after treatment is really important where kind of giving them that chance to live life again and doing it together.

Jeff: We also have clinicians in the audience today and I know some of them are looking for tools for increasing their own training, for example, in dealing with anxiety disorders and dealing with OCD and dealing with panic disorders.

Are there programs out there that can help general CBT therapists specialize a little bit more in these anxiety disorders?

Nathaniel: Definitely, I mean, I said the first step would be looking up manuals for the treatments that work. So treatments that work is a great example. There’s a lot of books out there about empirically based treatments for anxiety disorders and OCD.

And so starting with reading those to get a kind of foundation of how you tailor the skills, how to utilize them for each of these anxiety disorders, there’s also a lot of consultation groups.

So the International OCD Foundation, ADAA, ABCT, they all have professional consultation groups for clinicians that are looking for kind of consultation, supervision, a place to discuss like cases and make sure like kind of get support as they’re trying to like refine and hone those skills.

I think I’d always recommend any clinician looking to specialize, make sure to find supervision from someone who specializes already because then you have the support and understanding and guidance of someone who’s been there and that can really help give you, like, essentially give you the foundation to utilize, practice these skills in session with your clients.

So all those professional organizations are great. There’s lots of trainings through McLean, MGH, the International OCD Foundation has the Behavior Therapy Training Institute, looking for CBT or ACT based trainings from a lot of the academic institutions or kind of hospitals that specialize in mental health are great places to start as well.

Jeff: Nathaniel, let me get to some more of the specific questions that are coming in. A viewer wants to know how fear is related to PTSD?

Nathaniel: Great question, so a lot of times the way that we tend to think about it is that in PTSD there’s sort of like an overgeneralization of the fear response where someone was sort of in a situation that where there was imminent threat to their life, physical integrity, wellbeing.

And then, you know, typically I think one thing that’s important to know is that as humans, we’re always hardwired, we are hardwired to sort of recover from trauma and stressful life events.

But one of the challenges is sometimes those events kind of exceed our ability to cope in that moment and it can be hard to get back to the day-to-day life things that help our brain do that natural recovery process.

And that’s when it tends to lead to things like PTSD where you get re-experiencing symptoms because you haven’t had a chance to process or cope with the emotions effectively in that moment. And so they sort of like get stuck around.

The analogy always comes up is it’s like an over-generalization of the fear response and it’s sort of like a file cabinet where you don’t have file folders to make sense of stuff. You sort of just shove everything in it and then try to slam the door shut, every once in a while it pops open because things aren’t necessarily like organized.

And that’s sort of what our brain is struggling with in PTSD at times, where that fear sort of over generalizes over time to anything that is a reminder of that event.

Jeff: Any suggestions for managing anxiety when it prevents you from falling asleep?

Nathaniel: Oh, that’s a great question. So there is a thing called kind of CBT for insomnia, which is actually an empirically based protocol using cognitive behavioral therapy for difficulty falling asleep. And one of the parts of it is also how to disengage from worry, rumination. That’s a great time to use mindfulness skills.

So using some of like, there’s a bunch of them. UCLA Mindfulness Group has a whole bunch of free mindfulness exercises and recordings that you can download. And mindfulness for sleep can be a great, great thing when you’re having a hard time disengaging from the worry if you will, and allow yourself to fall asleep. But I’d highly recommend looking into CBT for insomnia.

The Veteran Affairs Hospital also has a great self-guided app for it that you can download that’s free to download and use. Because those are great ways to sort of break that anxiety process at night and use these skills with a little bit of like guided help as you’re going through it.

Jeff: This would be a whole separate webinar and maybe we’ll do this sometime down the road. But phobias, we haven’t talked about them today.

How do they fit into the larger landscape of this discussion?

Nathaniel: Oh yeah. So phobias are part of kind of anxiety disorder, if you will. So a lot of times when we talk about kind of phobias in their core sense, really what we’re sort of talking about is this idea of having a really intense urge to avoid and fear of where someone’s fearful or anxious or avoidant around circumscribed objects or situations.

So it’s usually very specific like certain animals, can be blood injections, of seeing blood for example. But the hallmark of it is that the kind of fear anxiety response that’s immediately induced is out of proportion to the actual risk of the object or situation.

And I will say one thing, there is a developmental element to it, like it’s natural that it, and when as kids we’re all sort of afraid of certain things. But the key is when that fear persists and becomes essentially like an immediate response to anytime you see something related to it, to that fear and it doesn’t kind of like match the developmental level, if you will.

So I think the hallmark is, it’s okay to be afraid, but it’s when that fear comes out of proportion to the actual danger and persists in that out of proportion nature over time.

Jeff: Let me squeeze in another question or two here before we wrap up, and one of them is this, what do we know about the causes of anxiety disorders?

Nathaniel: Ooh, that in and of itself could be a whole other webinar.

Jeff: We’re going to have to have you back soon, yes.

Nathaniel: So, you know, we do know there tends to be some kind of predisposition. For many of them, there are some, you know, kind of familial heritability, you know, predispositions that make someone at risk to maybe develop an anxiety disorder.

But that doesn’t necessarily, just because you have a parent maybe that has an anxiety disorder doesn’t mean that you will develop one or vice versa. Because there is a large portion of it that is essentially based on learning and watching others navigate fear, having positive experiences navigating fear, using these skills and strategies.

So we do know there are some, you know, neurobiological differences, for certain anxiety disorders, there are some kind of, you know, they’ve been looking for genetic markers, things like that.

But what we do know is there’s not one thing alone that 100% predicts an development of an anxiety disorder. There tends to be an interaction between this, you know, predisposition and learning and environmental experiences or stress.

So I think that’s always good also for parents who maybe struggle with it, that are afraid, what if my kid, does that mean my kid’s destined to have this too? Not necessarily, if you can model the skills, model the treatment strategies, it doesn’t mean that they’re going to develop it down the line.

Jeff: Let me ask this next question very broadly, and that would be, when are medications involved in the process of treating anxiety disorders?

Nathaniel: I think they always can be. The way that I always frame it for individuals is, you know, medication is sort of like a tool to turn down the volume of the anxiety to allow you to use the skills that you learn in therapy effectively until you’ve practiced those skills enough where they sort of become the automatic response or second nature.

And then many people do taper off medication, some choose to stay on it. It’s sort of an individual decision and when to start it, you know, if you feel like it would help you maybe access therapy, that’s a great time to give it a try.

Or if for some people medication alone is enough, what we do know is if you discontinue the medication, the symptoms tend to come back unless you learn those skills and strategies.

So I’d say it’s really an individual decision, but there’s nothing wrong with giving it a shot if it helps you do the other work to get back to your life.

Jeff: I wanted to save a few minutes to talk about your own personal story here, because one part of my goal with the series here that we’re trying to convey hope through is to wrap things up on a positive note to talk about the hope that is afforded through proper treatment.

Can you share a little bit about your own story, your own journey with OCD and talk about that success?

Nathaniel: Sure, so when I was in high school, right before starting high school, I developed a kind of sudden onset of OCD, you know, just in the sake of time, kind of distill it down is I had a lot of different versions of OCD, a lot of fear of harming others, fear of contamination, fear of bloodborne pathogens.

I had also had the fear that, you know, walking around I was going to get people pregnant just by touching them, which as a high schooler, I knew that’s not how it works. But with OCD that doesn’t matter. It’s the what if. And so, you know, at that time I was probably washing my hands up to four hours at a time.

I was taking, you know, four plus hour showers and almost failed out of high school at that point. Had a very wonderful principal that actually helped keep me in school. But when I finally found the right treatment, and I went through a couple of trials that didn’t quite work.

When I finally found the right clinician and treatment and did exposure response prevention and CBT treatment for OCD, I was able actually to graduate high school, get into college. And at that point I sort of decided that’s what I wanted to specialize in was what we call treatment refractory or complex OCD presentations.

And so from there about the time I was in my sophomore year in college, OCD had sort of faded into the background. It wasn’t a driving feature of my life anymore. Wasn’t even something I thought about every day. And that continued on through grad school to where at a certain point I actually started to forget what it felt like to be kind of in the fight with OCD.

At times it would pop back up and then I would use my skills and it would fade back into the background. And so from there I ended up going to get my PhD specializing in OCD and OCD treatment. And that’s been my kind of clinical and research specialty ever since.

Jeff: Well, it’s such an inspiring story and I love the fact that you kind of leaned into that fear and that you’re now helping other people navigate these same challenges that you had to go through yourself.

Nathaniel: I always say it keeps me honest. You know, if you’re doing ERP all day every day, it keeps you honest and you keep those skills sharp.

Jeff: Well, Nathaniel, thank you so much for sharing those skills with us today and your own story and all that you’re doing to help so many people with anxiety disorders and OCD. And we very much appreciate your time.

Nathaniel: Oh, thank you very much, Jeff. Thanks for inviting me. It was a pleasure chatting with you.

Jenn: Thanks for tuning in to Mindful Things! Please subscribe to us and rate us on iTunes, Spotify, or wherever you listen to podcasts.

Don’t forget, mental health is everyone’s responsibility. If you or a loved one are in crisis, the Samaritans are available 24 hours a day at 877.870.4673. Again, that’s 877.870.4673.

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The McLean Hospital podcast Mindful Things is intended to provide general information and to help listeners learn about mental health, educational opportunities, and research initiatives. This podcast is not an attempt to practice medicine or to provide specific medical advice.

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