ANXIETY specialty page | Engage Psychiatric, San Francisco and Pasadena

The incredible majority of clients coming to see me for their anxiety have been treated for… “anxiety”, almost always with the “standard of care”, SSRI or SNRI antidepressants. See the treatment section of this article for my thoughts on these medicines, and on broad strokes.
I interview carefully for the client’s particular description of their anxiety, so that I may take an individualized approach.

ANXIETY specialty page | Engage Psychiatric, San Francisco and Pasadena

I interview carefully for clients’ unique symptoms profiles, which can often be clustered into one or more of the nine clinical pictures described below, six of which are formal diagnoses. Those labels are just a place to start a conversation: looking for circuitry, through how individuals describe their anxiety as it has occurred over time, and observing how symptom clusters intersect with each other – perhaps also with mood, sleep, or cognitive symptoms – enables us to choose more targeted treatments, both medicines and natural options.

 

While it’s true that clients develop side effects to some of the choices we elect to try, there is never a reason to retain those choices. With a large toolkit, there are always new things to try, better solutions for the individual.

Ways Anxiety Presents

 

Generalized Anxiety Disorder –

 

Worry. In a word, that’s what GAD is about, worry and feeling keyed up – the dorsal anterior cingulate gyrus (the cingulate is the innermost part of the cerebral cortex) provides both explicit emotion regulation, providing inhibitory control over the limbic system (including structures such as the amygdala, which sharply registers fear) and top-down attentional control. It’s involved in valuation, and dislikes surprise. People with generalized anxiety disorder have a case of the “What if’s”, and when one worry resolves, another will often arise in its place. The person sometimes will say that worry is constant. There may be irritability, poor sleep, muscle tension, and trouble relaxing; take a questionnaire to see if GAD feels familiar to you, and see the National Institutes of Health (NIH) StatPearls for a lengthy explanation of GAD.

Physiologic Anxiety –

 

Heart racing, shortness of breath or chest pressure, trembling, sweating, senses growing dim, tingling or numbness in the hands, chills or hot flushing, dissociation, feeling lightheaded, or nauseous, even chest pain –
Typically I will see some of these symptoms in some cases of GAD, all cases of panic disorder and social anxiety or phobias, in some people living with sequelae of trauma, and in some individuals with OCD. Some depressed people say they only experience such symptoms when they are depressed. See if the
Zung Anxiety Inventory feels familiar to you.

Occasionally I’ll meet someone who doesn’t meet criteria for a formal anxiety disorder, but who endorses a cluster of these symptoms – it is not panic; panic arrives suddenly and usually dissipates quickly also, whereas this variant of anxiety can build over time, and persist for a longer period. While SSRI antidepressants will treat both panic and this variant of anxiety, it otherwise responds to a distinct group of tools that are more often used in people who have been traumatized. It may also improve if sleep, hypervigilance, ADHD, or other comorbidities are improved.

 

Panic Disorder

 

Panic attacks are caused by the amygdala, where fear originates in the brain, and parts of the midbrain which control our experience of pain, amongst other functions.

 

The attacks can be described as physiologic anxiety symptoms (as above) but coming on as a rush, very quickly, and usually dissipating quickly as well, within 20 or 30 minutes typically – though occasionally clients describe protracted episodes of hours or days. There may be a fear of going crazy, or of dying, or that there is something terribly physically wrong.

 

For at least a month afterward, the person is concerned about the implications of the attack, about its recurrence, or they change their behavior due to the attack.

 

Panic may occur with or without agoraphobia, where there is anxiety about being in places/situations where escape might be difficult or embarrassing, or where help might not be available, should panic recur.

  

Take the Panic and Agoraphobia Scale  if you like, and visit NIH for a more lengthy discussion of panic disorder.

Anxious graphic | Engage Psychiatric, San Francisco and Pasadena

Supporting someone who has trauma  echotraining.org

Support for someone with trauma | Cara Hoepner, Integrative Psychiatry

Social Anxiety Disorder, or Social Phobia

 

Those with social anxiety usually describe its following them back to childhood. Around 20% of all babies are born shy, and many people carry this fear into adulthood, where this primal fear that has evolutionary roots may exist in a prolonged pattern inappropriate to circumstance – with experiencing fear/anxiety or avoidance of a range of activities such as speaking on the phone, being observed at a variety of activities, or attending a gathering at which they know few people. One of my clients is socially anxious only when she has to engage in small talk, but it is fierce, she says; she locks up.

 

Generalized social phobia tends to occur in several contexts, whereas specific social phobia may only come about when one is giving a speech.

 Evolutionary models of social phobia generally see it as an issue of social ranking systems. For one to feel threatened to lose the acceptance of their tribe or its members may not seem dangerous, but from an evolutionary perspective, should one lose their tribe, they die – they are eaten by a bug, a tiger, or another tribe. What seems currently out of context doesn’t make sense to structure in the brain such as the hypothalamus, hippocampus, and amygdala, that lie deep beneath the cortex, unable to use language to calm themselves.

 

You may read more about the neural substrates to social phobia, and the NIH goes into detail about social anxiety as a diagnosis. If you are curious, complete a questionnaire on social phobia.

Specific Phobias

 

Specific phobias are similar to social phobia, but without the evolutionary roots. There is a fear that most people do not experience within the same context. Including extreme fear or anxiety, even panic attacks, when in the presence of certain animals, natural environments (e.g. heights, storms), needles or medical procedures, or situations (e.g. airplanes, elevators). I have had clients challenged to commute daily for fear of bridges or trains, who have evolved past their fear with medicine and near-daily exposure.

 

For more on specific phobias, see this NIH article.

 

 

Pressure and Stress

 

I’ve had clients who describe, even in absence of any other symptoms of anxiety, a pressure in their chest, a gripping feeling, or something electric – a hum in their gut that won’t let go. Interestingly, I’ve seen this in almost every client who has been affected by exposure to mycotoxins in their home or work environment. Many people who suffer burnout describe “time pressure” as something they can physically feel.

 

For those who feel pressure, adaptogenic herbs can make a real difference, and the blend I am most fascinated by is ADAPT-232, a blend of schisandra chinensis, eleutherococcus, and rhodiola rosea that was developed by the Swedes and the Soviets for cosmonauts in the early 1990’s. The product is still grown and produced in Sweden exactly as it was many years ago.

 

Have you experienced many stressors?

Posttraumatic Stress Disorder

 

While I devote a special section of this site to trauma, I will discuss here hypervigilance, which itself I consider a kingpin in trauma. Often it is the only anxiety symptom a client endorses, but when there are more, it is the one that can have an impact on all the others, including sleep, focus, and mood, if it is reduced or eliminated. People gain freedom of movement when this dissolves; four of my clients who were once housebound now have a richness in their life experience.

Many clients have lived with hypervigilance since childhood, never defining it or thinking about it until our conversation, as it’s always been their normal. They didn’t realize others hadn’t necessarily experienced it. These people are often expecting that the other shoe will drop, they are walking on eggshells, something could spike behind them or drop out from under them, their nervous system expects harm will occur. Because their primary caregiver was unavailable in an important way, to raise them in the world, they may not have developed a strong sense of self, and they are constantly pinging the world, asking questions, feeling uncertain.

 

Areas of the prefrontal cortex including the ventromedial prefrontal (which carries out self-related processing), dorsal anterior cingulate, and orbitofrontal cortex, connect to the amygdala in the limbic system through fibers in a tract call the default mode network, which orchestrates communication between many areas of the brain. The locus coeruleus in our midbrain is involved, producing norepinephrine, which creates the fight-or-flight response, and nightmares, that some people with trauma histories feel.

 

Early life trauma causes structural changes in the brain, including inefficiency in those tracts  connecting the prefrontal cortex and the limbic system. If these tracts are not efficient, the person cannot self-sooth, and experiences hypervigilance. For more on regions of the brain and vigilance, see NIH. They also have an overview of the diagnosis of PTSD.

Obsessive Compulsive Disorder

 

Very simply (or not so), OCD is experienced when individuals have inserted, ego-dystonic thoughts (thoughts they ordinarily would not think), that they ruminate on without wanting to, and that they may address with compulsions in order to allay the anxiety.

 

Compulsions are maladaptive, exaggerated habits. In OCD, the orbitofrontal cortex and anterior cingulate cortex become involved in cortico-basal ganglia-thalamo-cortical loops. They recruit the striatum for help with learning tasks – but in those  with OCD, hippocampus-dependent (declarative) learning overcomes deficits in striatum-dependent (implicit) learning. More on the neural basis of OCD here.

 

OCD has types, or themes, such as odd, even, or good and bad numbers, scrupulosity/religiosity, fear of harm to others (children, animals, loved ones), contamination, perfectionism, doubt, forbidden thoughts. Dr. Patricia Zurita Ona has on her website, ACT Beyond OCD, a list of 18 subtypes of OCD. There is a very good video there.

Note that in some people, OCD is caused by infection. PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections) occurs when OCD, tic disorder, or both suddenly appear following a streptococcal (strep) infection, such as strep throat or scarlet fever. The onset is usually between age 3 and puberty, and it is generally a severe form of OCD with rapid-onset. Here is some practical advice for parents.

 

Think you may have OCD? See NIH’s thorough overview, and take a questionnaire.

Health Anxiety

 

Once called hypochondria, health anxiety is a maladaptive, obsessive, irrational worry about having a serious medical condition or several. A client may feel a normal twitch in their hand, and imagine they have cancer. Nausea and some stomach pain become pancreatitis.

 

The person may be diagnosed with illness anxiety disorder, if there are minimal or no physical symptoms, or somatic symptom disorder if there are multiple or distressing physical symptoms.

 

It is unclear why individuals develop health anxiety. I have heard clinicians liken it to OCD, but I have too many times seen it resolve when a client’s generalized anxiety and sleep disorder were addressed. OCD is not so easily and secondarily addressed.

 

Risk factors for health anxiety include being middle-aged (though most of my cases have been in their 20s), and

  • Stressful life events

  • Pathologic worry, such as generalized anxiety

  • The threat of serious illness (that is not serious)

  • A history of serious illness in self or a parent

  • A family member who worried excessively about their health, or yours

  • A poor understanding of your body’s sensations, or of diseases imagined

  • A history of childhood maltreatment

  • Real history of serious illness in childhood

  • Checking one’s health on the internet often

 

The NIH has a chapter on health anxiety, and you may also take a questionnaire.

Ocean_Dark.png

How is anxiety treated with medicines and supplements?

 

There are many medicines and supplements I use in treatment of anxiety, and the choice depends on the individual’s specific symptoms profile and the circuitry that evokes, their history and experience with treatments, their medical and psychiatric comorbidities, and their priorities and desires regarding the “ideal treatment.” There is much to say, and making it relevant to the individual takes dedication in session.

Should you be interested in working with me, I will answer any specific questions you may have on our introductory call, free of charge. It is important to me that clients feel safe with and understanding of my approach, and that they are informed partners in choice.

 

I will say a few words about SSRI, SNRI, and benzodiazepine medications – and psychedelics

 

Selective Serotonin Reuptake Inhibitors (SSRI)

SSRIs and SNRIs (such as Prozac, Paxil, Zoloft, Lexapro, Luvox, Celexa, Cymbalta, Pristiq, and Effexor) are capable of treating every form of anxiety except hypervigilance. They have utility in that they cover a large amount of ground; one almost doesn’t have to be particular about the type of anxiety they are treating to hit it squarely with an SSRI. You could say these drugs could make art unnecessary within craft.

 

In some cases the medicines have been partially or wonderfully effective for clients, though they have usually caused side effects the person chose not to live with. I choose rarely to use these medicines due to their many and frequent side effects, withdrawal syndromes, and more. I prefer to interview carefully and take a targeted approach.

 Benzodiazepines

 

I utilize benzodiazepines (e.g. Ativan, Xanax, Klonopin, Tranxene) only as as-needed medicines due to their several concerning side effects and impact on mortality. 

Psychedelics

While psychedelics are not available in my practice at this time, I often receive questions. Adam Strauss wrote a one man off-Broadway show, The Mushroom Cure, about how he overcame OCD using psilocybin and other psychedelic therapies. Once used to enrich the psychotherapeutic process, psilocybin became a Schedule I substance in 1970. It is decriminalized in several cities in the US, and is in clinical trials currently for FDA approval.

How long might I take medicine?

 

This depends on the condition, and your history. Panic disorder can often be treated for six months then tapered. Generalized anxiety and OCD are often longstanding, and require protracted treatment. This is true also of social anxiety and specific phobias.

 

I have seen clients make significant progress, however, utilizing targeted psychotherapies, recovering completely from a phobias, panic, and hypervigilance, discontinuing medicine after months or a few years. People likewise make very significant improvements in their experience of internalized trauma.

What are some effective psychotherapies for anxiety?

Effective psychotherapy for anxiety symptoms is based in cognitive behavioral therapy (CBT). CBT is still practiced in its classical form, but more often practitioners are adding in or relying upon therapies that it has influenced, including Acceptance and Commitment Therapy (ACT) and Exposure and Response Prevention (ERP), as well as Relational Frame Theory (RFT).

Cognitive Behavioral Therapy (CBT)

 

In its pure form, as designed by Aaron T Beck in the 1970s, CBT utilizes a seven-column technique, in which clients list their situation, they identify and rate their mood or anxiety state, identify automatic thoughts or images that go with, list facts that support the triggering thoughts, facts that do not support them, there is a column for balanced and realistic or objective thoughts, and then a column for rating how you feel at the completion of this exercise. Classical CBT and the Thought Record can be tedious, so many therapists work this type of exercise into therapy in other ways, e.g. flashcards for automatic thoughts, with counter thoughts on the other side. CBT has also been worked into other styles of therapy over the years.

In this video, One Trick to End Anxiety, legend David Burns (Author of Feeling Good and When Panic Attacks) describes how CBT can help treat depression and anxiety.

 

 

Acceptance and Commitment Therapy (ACT)

 

Designed by Steven Hayes PhD, ACT was inspired by his own experiences with anxiety, and has six core therapeutic processes:

  • Being present, focusing here and now

  • Values: discovering what you hold important

  • Defusion: observing your thoughts without allowing them to overtake you

  • Self as context, seeing yourself as not being changed by experience and time

  • Acceptance, being willing to experience difficult thoughts and feelings

  • Commitment, taking action to pursue the important things you create in your life

In this video, Steven Hayes, describes how ACT can increase psychological flexibility and decrease suffering in anxiety

In this video, Dr Hayes describes how to manage a panic attack

 

Exposure and Response Prevention (ERP)

 

ERP gives clients cognitive behavioral technique for preventing compulsions and other responses they would normally perform in response to a troublesome stimuli, such as obsessions in OCD, fears in social anxiety, or thoughts of their health in related anxiety.

In this video, Sara Conley PhD of Rogers Behavioral Health (the country’s foremost residential program for OCD) describes ERP and its utility in OCD.

 

 

Relational Frame Theory (RFT)

 

RFT is a theory devised by Steven Hayes to be used in conjunction with ACT. It postulates that relating one concept to another is the foundation of all human language.

To see how this relates to therapeutic work, and blends with ACT, visit this description by Dr. Hayes.

In this video there is a description of Relational Frame Theory – with three examples.

 
Therapy technique for anxiety | Engage Psychiatric, San Francisco and Pasadena
 
 
 

Lifestyle Matters – the Big 5

 

Heard of the gut brain axis? Inflammation and gut health affect anxiety in a big way. Clients are encouraged to treat their bodies well, doing as many of the following as suits them. According to the CDC, only 6% of Americans have a healthy body mass index (BMI), sleep adequately, drink alcohol moderately or not at all, exercise adequately, and are never smoking. And only 12% of American adults are metabolically healthy!

Here are some possible goals:
 

1 Anti-inflammatory diet, for instance paleolithic or Mediterranean diets, including plentiful fruits and vegetables, and avoiding gluten, sugar, and dairy, as well as any food allergens.
I offer laboratory testing, to check inflammatory markers and micronutrient status – magnesium and zinc are tied to anxiety, as is the ration of serum copper to zinc.


Listen to Emily Deans and Chris Kresser discuss ancestral diet and psychiatry here.
 

2 Limit alcohol use. The National Institute on Alcohol Abuse & Alcoholism (NIAAA) defines moderate drinking as up to four alcoholic drinks for men and three for women in any single day and a maximum of 14 drinks for men and seven drinks for women per week – a cardiologist or oncologist would have very different recommendations.
 

3 Exercise – aiming for half hour five times weekly. If regular walking is what suits you, this is largely what our ancestors did.
 

4 Sleep adequately, and well – learn how to hack your sleep to improve quality. Books by Matthew Walker and Shawn Stevenson are fantastic overviews.

Have insomnia? Consider

5 I would round this out with a meditation practice. There are many types (not just mindfulness), and each may change your brain differently. I practice Vedic meditation, 20 minutes twice daily. There are many teachers, including the Transcendental Meditation corporation, and Emily Fletcher in New York, my teacher. When I started, my sleep improved, and feelings of pressure/“anxiety” vanished, within 5 days.

Books to Help and Heal Anxiety

 

Mindfulness and Relaxation

 

The Relaxation and Stress Reduction Workbook - Davis, Robbins, Eshelman & McKay

A classic – evidence-based stress-reduction strategies for busy lives.

 

Full Castrophe Living – Kabat Zinn, creator of the Stress Reduction Clinic and the Center for Mindfulness in Medicine, Health Care, and Society at the University of Massachusetts Medical School, walks you through the use of mindfulness for stress, anxiety, and pain.

 

The Stress-Proof Brain (Master Your Emotional Response to Stress Using Mindfulness and Neuroplasticity) – Greenberg

Harness neuroplasticity to rewire your limbic system and gain resilience, reducing stress.

 

 

Cognitive Behavioral Therapy for Anxieties

 

When Panic Attacks: The New, Drug-Free Anxiety Therapy That Can Change Your Life – David Burns et al

Burns, psychiatrist and adjunct professor emeritus at the Stanford University School of Medicine, teaches you more than 40 drug-free techniques to overcome every type of anxiety.

 

The Anxiety Toolkit: Strategies for Fine-Tuning Your Mind and Moving Past Your Stuck Points – Boyes

Learn to overcome rumination, hesitation, perfectionism, fear of criticism, and many other “stuck” points of generalized anxiety

 

Worry Trick: How Your Brain Tricks You Into Expecting the Worst and What You Can Do About It – Carbonell

Worry convinces us that there is danger, and some of us will get hijacked into fight, flight, or freeze mode. Carbonell uses ACT and CBT to teach you not to avoid or resist anxiety (it will push back), but to see the trick that underlies anxious thoughts.

 

Anxiety and Phobia Workbook  – Bourne

Helps those with GAD, social anxiety, specific phobias, panic attacks, OCD, and other anxiety-related issues. Used alone or with your therapist, there are many effective skills for quieting thoughts and regaining control. Has a good section on creating a hierarchy to do exposure therapy for phobias!

 

Mastering Your Fears and Phobias – Michelle Craske

Learn CBT technique to overcome specific phobias. There's a therapist guide and client workbook. 

 

 

CBT, ERP, and ACT for Obsessive Compulsive Disorder

 

Living Beyond OCD Using Acceptance and Commitment Therapy – Zurita Ona designed this workbook to help Adults living with OCD to tame their obsessions and compulsions with OCD and ERP. The website is here.

 

Getting Over OCD, Second Edition: A 10-Step Workbook for Taking Back Your Life –  Abramowitz

A guide to CBT, based on recent evidence, complete with vivid stories and many practical tools

Life in Rewind: The Story of a Young Courageous Man Who Persevered Over OCD and the Harvard Doctor Who Broke All the Rules to Help Him – by Murphy et al

“Life in Rewind is a miraculous true story of commitment and determination, darkness and hope, love and inspiration.”

Brain Lock, Twentieth Anniversary Edition: Free Yourself from Obsessive-Compulsive Behavior – by Jeffrey M Schwartz

“The definitive classic that has helped more than 400,000 people defeat obsessive-compulsive behavior – this is the first book I ever owned on OCD, and it is a classic, updated with all-new material from the author.

Freedom from Obsessive Compulsive Disorder (Updated Edition): A Personalized Recovery Program for Living with Uncertainty – by Jonathan Grayson, PhD

Freedom from Obsessive-Compulsive Disorder provides Dr. Jonathan Grayson’s revolutionary and compassionate program for finally breaking the cycle of overwhelming fear and endless rituals, including:

  • Self-assessment tests that guide readers in identifying their specific type of OCD and help track their progress in treatment

  • Case studies from Dr. Grayson’s revolutionary and profoundly successful treatment program

  • Blueprints for programs tailored to particular manifestations of OCD

  • Previously unexplored manifestations of OCD such as obsessive staring, Relationship OCD (R-OCD), obsessive intolerance of environmental sounds and chewing sounds

  • Therapy scripts to help individuals develop their own therapeutic voice, to motivate themselves to succeed

  • And much more

I'll include a podcast for those living with OCD, too – The OCD Stories – check it out!

For You HSPs

 

You know who you are – while “highly sensitive person” has escaped the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), this is a widely recognized construct – you may take the questionnaire here, and there is a book just for you – singer Alanis Morissette claims it has changed her life.

The Highly Sensitive Person: How to Thrive When the World Overwhelms You – Aron

 

 

 

On Perfectionism

 

The Perfectionism Workbook: Proven Strategies to End Procrastination, Accept Yourself, and Achieve Your Goals – Newendorp

Do you need approval and to pleasing others? Do you procrastination and become paralyzed? Are you self-critical, afraid to make mistakes, and judgmental of yourself and others? With practical strategies and real-world examples, Newendorp helps clients living with OCD, other anxiety manifestations, eating disorders, or depression to loosen unrealistic pressure and impossible standards.

 

Better than Perfect: 7 Strategies to Crush Your Inner Critic and Create a Life You Love – Lombardo

Perfectionists appear to be very accomplished, but they are often unhappy and unfulfilled. Lombardo, Shaquille O'Neal's "head coach for happiness," offers a “proven, powerful method for shaking the chains of perfectionism to live a happier, healthier life.”

 

 

Online Tools

 

Understanding Anxiety has an excellent list of online tools, treatment, and educational websites available to those living with anxiety.

 

The top 10 list of websites on Good Therapy’s roster is helpful also.

 

These online organizations are likely to update their lists with fresh content.