Am I Crazy, Doc?
in on Anxiety
Anxiety is often considered to be both a situation-specific occurrence and a general state of being. The following interviews were conducted with a view towards understanding the medical realities of anxiety and the current treatment modalities available. Although AWT spoke with each of the three clinicians individually, their responses have been woven together in order to provide multiple mental health perspectives in tandem.
Jocelyn Lichtin, PhD, is a Post-Doctoral fellow at the Hallowell Center, where she specializes in neuropsychology and works with patients affected by ADHD. Marissa McMillin, LMSW, is a social worker with a background in Gestalt therapy. She works with patients suffering from chronic mental illness and also provides individual therapy for more acute conditions. Wendy Wolfson, MD, is a psychiatrist who specializes in the treatment of anxiety and mood disorders. She also has a background in ADHD, and practices in both New York City and Connecticut.
Interviews: Saskia Ketz
Editors: Irene Huhulea, Xiu-Jing Shi
AWT: Can you explain the differences between a therapist, psychologist and psychiatrist?
Jocelyn Lichtin: A therapist can be anybody who sees people that need therapy, they are either social workers or psychologists. The difference between a psychologist and a psychiatrist is that the latter is an MD, a medical doctor. Psychologists can’t prescribe medication and often do either assessment or therapy.
AWT: Where does anxiety come from?
Wendy Wolfson: It comes from a multitude of places and is probably partly genetic and partly environmental. It involves many different circuits in the brain, not just an easy one that can be identified. You could be predisposed to being anxious and live in a perfectly normal family that’s very structured, you’re well taken care of and maybe you don’t ever become anxious. You can not be genetically wired to be anxious, but you live in a house with multiple stressors, no security, a lot of upheaval, and you wind up having a hard time in life, becoming very anxious, having low frustration tolerance and not being able to tolerate being uncomfortable.
JL: We all essentially evolved to have anxiety. If you didn’t have anxiety, then think about yourself in the middle of a large field way back in the day—there’s a giant lion. Anxiety saved us because it made us run away. Nowadays there aren’t lions that are eating us. There are people who argue that we’re mismatched to our modern day environment and one of the products of this is that our fears get attached to new things that don’t need to be worried about, for example the boss that is stressing us out or the email that we don’t want to send. We tend to go into our minds—it takes us away from the present moment and we dwell, usually on the future. It’s not adaptive to avoid those things the same way that you might avoid a lion.
Marissa McMillin: As humans, the way that we get out of bed in the morning is that we all have a healthy level of anxiety. The distinction is between our ability to live with day-to-day stresses in a healthy way versus the kind of anxiety that starts to interfere with living our lives. I’d like to reframe thinking about anxiety as that being the root and instead thinking of that being a coping mechanism. Our nervous system gets overwhelmed by sensory input being more than we can handle. We start to feel panicked. Anxiety is a mechanism to deal with the feelings in the body that are uncomfortable. The mind creates that whole thought process. We tend to believe it’s the thoughts that are the problem, but it starts with usually a physical feeling that we’re not tuning into. For example, we just found out that our grandmother has gone to the hospital. Immediately that creates some conflict inside us, we quickly jump to our mind and we start thinking “Is she going to be okay? Is she going to die? What’s going to happen to her? What I am going to do if something happens to her?” A few days later we feel incredibly uncomfortable and we’re still having this looping thought process. What that process did was it took us away from the initial experience in the body, physical feeling attached to an emotion. Maybe the emotion was fear or deep sadness of what it would be like to lose someone who is important to us. Maybe that created some tension in our chest or some uneasiness in our belly. Instead of staying with those feelings and paying attention to them, we start worrying.
AWT: Ms. McMillin, you mentioned the present moment. Is a spiritual path something that you are interested in?
MM: Are you asking if I’m interested in thinking about the present moment as a spiritual approach? I think it can be. I think for a lot of people it is. The idea of actually letting yourself be present involves letting go of being in control of what’s going to happen in the future. If you’re being present you’re not worrying about the future. For a lot of people the act or the practice of becoming more present can have a spiritual connotation.
AWT: The present moment is not a spiritual approach, but rather something that you communicate to your patients generally?
MM: Definitely. I think people give it the meaning that they choose. If someone chooses to make that a spiritual experience then it is what it is for them. Many people label it calming or slowing down.
AWT: Does anxiety occur more often in bigger cities?
MM: I’m not sure that’s true. People in smaller areas experience anxiety just as much as people in larger cities. It’s just that the content of the experience may be different. For example, people living in smaller towns may have anxiety that’s more around being isolated or feeling unsupported. Whereas here it’s more about feeling claustrophobic or trapped. I do imagine that there is more prevalence of anxiety and other mental health issues in this city, because the social environment brings a lot of pressure on the individual to accomplish, to be productive and to ultimately be successful. They’re always in a hurry to get somewhere.
JL: To my knowledge the literature is somewhat inconsistent on whether people have more anxiety and depression in the city versus outside. You could imagine there might be certain stresses in the city that cause people to worry. The cost of living in New York City is so much higher than other places, you are around so many other people so if you have an inclination to compare yourself to others, for example worry about what other people think, there’s more opportunity to do so.
WW: There’s a lot of competition in New York City. People work and they don’t sleep. They don’t eat well. We’re not a big outdoors city. We also live in very close quarters so we have very little private space of our own which doesn’t give us time to digest and unwind. There’s a lot of sensory overload in big cities, everywhere you go the lights are blinking, the noise is loud, it’s crowded. You walk down the street and people are touching you. You’re getting input from everywhere in your already stimulating environment. There’s just a sense of urgency that a lot of people feel in Manhattan to succeed. It’s a reality because if you want to live here you have to work hard to sustain any kind of life.
AWT: Dr. Wolfson, you have a practice in New York City and one in Connecticut. Are there different types of anxiety in a more suburban setting?
WW: Anxiety manifests itself in a lot of different ways. What’s interesting about the difference between New York and Connecticut is how people deal with it. Generally, anxiety is worry, irritability. You can’t concentrate, you feel agitated, overwhelmed and paralyzed. Sometimes people have panic attacks. Sometimes people have obsessions that they stick to. In New York it’s almost accepted to have anxiety. People are not afraid to express it, it’s not taboo to talk about. Whereas in Connecticut, people are a lot more alone in their anxiety. They maybe compensate in other ways, often more destructive behaviors like over-exercising or drinking, overeating or not eating.
AWT: What is your professional approach to overcoming anxiety?
WW: Medication comes in first and foremost if somebody is not sleeping, not functioning, breaking down at work or not able to get out of bed. Eating right and exercising isn’t going to help them. That’s my belief. Medication allows them to start feeling a little bit better. With exercise, eating right and surrounding themselves with quality people, they can then create an infrastructure that when stressors present themselves again, they have more tools to deal with them.
MM: I’m teaching people how to tune into what’s going on in the present moment and what’s going on in their bodies. Often times, there tends to be a mind-body disconnection and people experience anxiety as an extremely uncomfortable state: “Why won’t the thoughts stop? Why am I continuing to think or to obsess about this thing?” Focusing on what is the experience in your body versus only focusing on the content of the thoughts is often helpful. Learning how to slow down, how to make time to check in with themselves. There are many different ways. It could be meditation or breathing exercises. It could be journaling, exercise or trying to take a walk somewhere where you can see trees—things that cause people to take a break from the content of their intellectual space.
JL: It requires a lot of therapy or medication, it’s not easy. There are definitely things that you can do. First identify when you’re worrying. Do you notice it in your stomach, in your neck, in your back? Do you start sweating? Note those physiological symptoms. You can ask yourself if there’s something that you are avoiding—are you avoiding a place, an activity, a person? Ask yourself what you are afraid of. What is the thought that is going on while you’re feeling anxious. Are you worried that somebody’s not going to like you, that you’re not going to be able to handle the situation or you’re going to fail? Once you identify it, suss out your negative predictions about the situation. How true are they? How likely is it that you won’t be able to handle the situation? You can also ask yourself what the worst things are that could happen. The last thing is facing it. Oftentimes avoidance, which results in anxiety, reinforces worry. Facing your fears sometimes is the only way to make them go away.
AWT: Dr. Lichtin, you mentioned that it’s important to notice physical symptoms. What are other signs to identify anxiety?
JL: Many people are more attuned to the physiological sensations than to the actual worries. Start to notice those times you feel anxious and start to predict when it might happen in the future. If you begin getting stomach aches whenever you go into a meeting with clients, well, then you can predict that the next time you have a meeting with a client you may want to expect some of that and even practice some calming remedies. Try to relax yourself before.
MM: Anxiety can take the form of physical discomfort. Breathing can become strained, the chest can feel tight, there is discomfort in the stomach. There can be muscular pain that starts to happen, because of tension being stored. The upper back and shoulders are often places. It can be quite exhausting. The experience of realizing that it’s difficult to let certain thoughts go: “I’m going to let it go now and move on,” is not an easy process for someone who is experiencing anxiety.
WW: You seem to overreact to small stressors. For example going to the grocery store is such a big deal for you. A lot of times people confuse depression and anxiety, because they are interrelated. You can go to a professional and have them tease out the intricacies.
AWT: How do you see if there’s a need to act on it, rather than letting it sit and get worse?
WW: Ask yourself the question, “Am I suffering?” If the answer is “yes,” it’s time to get help. Most people have a primary care doctor and that’s always a good place to start. They can tell them “I haven’t been feeling well, I’ve been feeling irritable, I cry easily” or “I can’t seem to get anything done, everything’s such a big deal.” There are many non-invasive things that people can do: yoga, acupuncture, reiki.
AWT: You’re open to that?
WW: I am very open. I think whatever works. All these things may lower the amount of medication that somebody needs to take.
AWT: How long do you treat patients for?
JL: It depends on your anxiety. Anxiety isn’t cyclical like a mood disorder. Somebody who is suffering from depression might have a few weeks when they feel very depressed and then they come out of it. Anxiety is almost a personality trait. Even with the right use of tools for combating anxiety, it depends on the person.
MM: In my experience, anxiety tends to be something that people know that they have. It’s really uncomfortable. You hear people using the word a bit like an umbrella statement, “I’m really anxious today.” People know that something is not feeling good. Whereas oftentimes people that struggle with depression don’t necessarily know that they’re depressed, because their emotional states are muted or dull. They can detach or withdraw in some way. Being anxious is exhausting. What kind of a length of treatment might someone expect if they’re going to go to therapy and deal with anxiety? It really, really varies. I think that we live in a day and age where people would like to think that there’s a quick fix. Sometimes medication can offer the promise of that. I wouldn’t say that I’m not a supporter of that. Going to therapy and actually understanding how someone has wired their physiological circuitry, where emotions come from, how to recognize what’s happening and how to do something different—it’s a process that can take some time. At the same time people notice changes rather quickly.
AWT: Is it a mental decision to say, “I want to be anxiety free and go back to my old life?”
MM: Someone can have that desire, but usually by the time someone has realized that they need help, it has become so ingrained that it’s going take some time to understand and really work through it. I don’t think it’s as easy as using the mind.
AWT: How do you personally deal with stress?
MM: Probably by all of the things that I mentioned before. I’m a supporter of therapy. I think it’s important for people to have support and to be listened to. Many times the experience of high levels of stress that turn into a problematic anxiety, is what makes people feel trapped inside of themselves. I’ve personally been there. I tend to be someone who is on the more anxious side. Having a space, whether it’s a therapist or a partner, a friend or family member who is able to listen to you so you can take a break from spinning thoughts and start to release them. That’s really important.
JL: I like exercise. It is incredibly helpful. Research shows that it’s very helpful for reducing stress, not to mention simply improving mood and attention or reducing irritability. I go for a run when I’m stressed out. My husband also tells me to do CBT, Cognitive Behavior Therapy: assessing the thoughts and behaviors that might accompany feelings of anxiety.
AWT: Your husband does something similar?
JL: [laughs] He just hears about it over dinner.
WW: The way I deal with it is to not have any time to deal with it. There are a few things I really try to do. The number one treatment is sleep, you need to get enough sleep. A big stress reliever is exercise. I’ve been exercising pretty heavily since I’m about 30—now it’s just a part of my life. It’s difficult at times, because I have young kids and work. The other way I deal with it is I prioritize what’s important. Family is first. I keep a list of all the things that are making me stressed and choose the one that’s the most pertinent at the time. Overall as you get older you really start to understand what you should stress over and what you shouldn’t.
AWT: That was a process for you?
WW: Oh definitely. I’m not in this field because I’m unfamiliar with this.
AWT: How does one cope with friends or family that suffer from anxieties or psychological illness?
WW: I think it’s hard. The major thing for the family or the caregiver to understand is that it is an illness and that people can’t turn it on and off. You get frustrated: “Why is this person doing this and why are they so selfish?” You can only educate people. You can’t force them into doing anything. As a friend or a family member you offer as much support as you can and you can slowly approach people and say, “I notice you’re not doing so well lately, if you need an ear I’m available. There are resources to help you.” Try not to invade their privacy and if they don’t want it, give them some distance until they’re ready to come back around.
MM: It’s also important to maintain protective boundaries so that you don’t end up getting pulled into someone else’s experience and becoming worried yourself. Recognize that you’re not responsible for changing them.
JL: The effects of mental illness on the family and friends are definitely profound and underappreciated. There are wonderful support groups for family members that are run through NAMI, which is the National Alliance on Mental Illness. If you have family who is mentally ill, practicing self care is absolutely critical. You have to be able to take care of yourself as well, not just your family member. Learning to separate the person from their illness. Anxiety can manifest in rigidity. Somebody who is really anxious feels the need for things to be a certain way. They may be closed-minded to other opinions and it can be maddening for a family. “If the person cares about me, why would they insist on doing it their way? Why can’t they see my point of view?” In reality, it is somebody else’s view being almost too overwhelming. Understanding that it isn’t the lack of caring in that situation can help to understand what is the anxiety versus the person that you love. Encourage family members or friends to go for treatment if they haven’t already. If they’ve been in treatment and nothing has improved, encourage them to get a second opinion. Things don’t have to be status quo. If somebody is worried, depressed or angry, it tends to elicit reactions in others. Try your best to remain calm and supportive throughout that.
AWT: What are other emotions that come with anxiety?
JL: Somebody who is anxious may be constantly comparing themselves to others, that could make them feel envious. Another product of comparing yourself is that you feel down on yourself. Depression is a big one that comes with anxiety. Worrying all the time is really depressing, oftentimes the two go together.
AWT: Anxiety is not necessarily a new phenomenon, but it seems very present.
WW: It’s always been around. If you look back in history, people have been medicating these kinds of things for a very long time. Whether it be when it started out with opium, or Freud drinking Coca-Cola—at the time it had actual cocaine in it. There used to be a bad connotation about mental illness. One of the biggest advances we’ve made in the last decade is to bring attention to the issue.
AWT: I assume that we ourselves bring anxiety to others. Do you have a tip on how to avoid that?
WW: When you’re anxious yourself, it’s very hard to contain yourself. Sometimes those people come off as very irritable. Or they’re very internally restless; they appear shy or rude, because they’re not big talkers. The first step is educating these patients on what they look like from the outside.
JL: Anxiety is definitely contagious. It would be nice to think that we can be considerate enough in those moments of worry to not spread it to others. In reality it’s hard to keep our worries in check when they’re happening. If you’re around somebody who is anxious, you may start to feel anxious yourself. I use that as a gauge. If I start to feel anxious I try to think about where it’s coming from. I wonder if they are feeling anxious. Then I try to think about whether the worries were rational as a result. It can be tricky.
AWT: Does talking about it make it worse or better?
JL: It can be helpful to talk through worries. A friend or family member can help to identify if worries are irrational—if you’re worried about failing a test or doing terribly in a job interview. What are the chances of that happening? It’s not helpful when it becomes ruminative. You cycle over and over, in that case it can make it worse. Talking with family or friends can make anxiety worse if they are essentially providing reassurance. Somebody who is anxious may seek reassurance, “tell me it’s gonna be alright, tell me I’ll pass the test.” People who care about somebody want them to feel better. Unfortunately, that can have the effect of reinforcing the anxiety as well, because the person becomes dependent on that, and they’re not able to provide their own reassurance to calm themselves down.
AWT: Is there a cultural basis for anxiety?
JL: I think anxiety is overall something we have all over the globe. If anything, identifying it and being able to have a term for it is helpful. It allows you to reflect on it. Notice it as something that’s out of the ordinary, something that you can address. There are some cultures that talk about it more than others. I don’t think that the rate would necessarily vary as a function of whether a culture talks about it or not.
AWT: Do you talk about being content with your patients? Should happiness be a state of mind?
MM: People often feel such a pressure to be happy that if there is any little sign of unhappiness or emotional pain, people want to turn away from it. Once they start acknowledging their pain and deeper feelings that have been hard for them to express, there’s such a feeling of relief. Connecting with what’s real for them opens the door for being content in a way they’ve never felt before.
JL: Everybody has different values. Some people value family, other people value their career accomplishments as a measure of success. I agree with the statement that happiness should be a goal. I would say that that’s a value for me. We only get to live on this earth once, so I would rather be happy than not. Maybe there are people who define happiness in different ways.
MM: It’s important to focus on the process of how anxiety is created rather than only on the content of what the issues are. Anxiety is not a feeling, anxiety is an experience that is created.
WW: There’s plenty of treatment out there for people. It’s not hopeless and you don’t have to be uncomfortable. It’s easy to get help, especially in New York City. You don’t have to suffer.