Transcription
Anxiety. We hear a lot about it. It seems to be much more pervasive in our society. Today we're going to talk about what it is, who gets it, how to deal with it, and because it is so so common. Welcome to Talking with Docs. I'm Dr. Bradley.
>> Hi, I'm Dr. Paul Salza. We have a guest today to talk about anxiety.
>> Hi, I'm Dr. Sammy Barakat. I'm a psychiatrist.
>> Thank God. Thank God we have a psychiatrist to talk about.
>> Yes. Who are experts in anxiety. So, first thing, just know, leave, leave a comment if you suffer from anxiety. If there's something that you found helpful in your journey because a lot of people are dealing with this and and don't really know where to turn. So, we're going to try to provide you with some of that, but you can also be a valuable resource for each other. So, let's start at the beginning, Sammy. What actually is anxiety?
>> So, anxiety is a common term that we all use. Um, anxiety is something that uh helps us in a lot of ways in in some ways. We need a certain level of anxiety to perform, right? We need a certain level of stress.
>> Yeah. In order to not be apathetic, to meet our obligations, to move forward in our lives. But when anx but we start to call it clinical anxiety when it crosses a point at which it it motivates us to be productive. In some cases it can paralyze us.
>> In some cases it can overwhelm us.
>> It's almost like a survival instinct. That's where it kind of came from. And even during medical school and you would say we all were nervous about tests. So then you study harder and then you perform. But then it crosses over to that point you're like, I'm so worried or anxious or whatever that I can't do my normal stuff. And that's when it that's when it becomes a clinical problem.
>> Right? When it interferes with your social or occupational functioning, that's in all that's when it becomes an issue for us um and for people to deal with.
>> And the cliche thing is it's not even cliche, it's just that it's it's part of that fight or flight response, right? Normal anxiety is part of that fight or flight response that's kept us alive as a civilization, as as species. And you and all animals have it.
>> Yeah. And and the language we use is anxiety that's out of proportion with what would be expected given the situation.
>> Okay. So it brings us to the criteria. So someone sees their family doctor and maybe subsequently gets referred to you and then they're telling you their story or the situations where they're uncomfortable or the reason that they're to see you. What are the criteria that specifically say okay well you have this and this non-anxiety but you have this and this and this and that becomes a formal diagnosis of anxiety?
So the most common form of anxiety is called generalized anxiety disorder. Okay.
>> So generalized anxiety disorder is when people are worrying about everything and anything that comes to their mind. Work, school, family, the world, the future, anything that crosses their mind creates ruminations, anxiety. Okay?
>> So there's a cognitive part to it. A lot of anxiety, a lot of worry. Most of the time, most days of the week, it lasts at least six months. But accompanied by that are feelings of restlessness or muscle tension, a lot of physical symptoms, headaches, trouble concentrating, um getting tired really easily as a result of your anxiety, feeling worn down by it. People will talk about having trouble falling asleep as a result of their anxiety. Feeling more irritable,
>> quick to temper than they used to be.
>> Uh those are a number of the symptoms that we talk about. And again, they have to be they're not explained by some other reason. So, there are a lot of physical health conditions that can contribute to anxiety. People might be using substances that are creating anxiety.
>> But if you kind of um adjust for all of those um and it's and of course it's interfering with your functioning,
>> it's causing distress, it's interfering with functioning, that's where we cross over into considering whether it's a condition that needs some attention.
>> And it's a like you mentioned something else that's causing it's a pretty tricky thing. I remember in residency going through all our different rotations and one of the big things was trying to identify if if someone presented to the emergency room, is this anxiety or is this something going on like a heart attack or or a pulmonary ambulance or something that's causing these symptoms that's not anxiety?
>> That's an excellent point. I mean, anxiety often presents as physical symptoms.
>> So again, we're trying to get away from some is it in your mind or is it in your body?
>> The brain and the the brain is part of the body. It's all connected. But how do people with anxiety disorders often present to family doctors, to the emergency department? It's with physical symptoms, right? That doesn't rule out an anxiety, but it does mean you need to do blood work, physical exam, other investigations. Is there something else contributing to why the anxiety is happening or explains the anxiety? And certainly when it comes to panic, yes, you have to rule out those serious things. If someone comes to the emergency department with chest pain, right,
>> you can't say, well, it sounds like anxiety. It might sound like anxiety. It might be typical in presentation but you still have to rule out something more serious.
>> Yes. I'm having anxiety because I'm having a heart attack. Yeah. So I am having anxiety.
>> So it is tricky and and you mentioned panic. Now does a panic attack fall like how does that fit into the framework of anxiety?
>> So so you know we talked about generalized anxiety disorder. Panic disorder is something different. A panic attack in of itself is not an an illness or a condition.
>> People can have singular panic attacks. I remember once five years ago I had a panic attack.
>> Right. But it's it's the repeated unexpected panic attack. So you can have a generalized anxiety disorder that when it gets bad enough creates panic symptoms.
>> But you but when we talk about panic disorder, it's recurrent unexpected panic attacks kind of out of the blue.
>> I was just sitting there and all of a sudden
>> I started to feel a number of physical symptoms, right?
>> Chest pain, heart palpitations, dizziness, a feeling of choking, nausea and vomiting or GI upset all at once. It's like a wave. So, this is what I'll It's like a wave that comes over you and it peaks in a certain amount of minutes and then it kind of starts to fade away.
>> So, that's kind of the lay definition of a of what we think about when we talk about a panic attack. But, in order to have a panic disorder, you need to have more than one of those,
>> right?
>> Um, and it needs to be unexpected and it's followed by fears, right? It's followed by anxieties and fears of having another panic attack.
>> Okay? Another unexpected panic attack and a change in behavior to pro to mitigate what if I have a panic attack here? What if I have so I better not do this or I better not do that. And it starts to interfere with functioning.
>> A panic attack leading up to an event that you're anxious about is not really a panic attack. Panic disorder.
>> Yes, it's not a panic disorder. It may be the prelude to one. It may be part of another condition or it just might be a panic attack in that moment that doesn't happen again.
>> Yeah, I remember having one. I remember having in high school I had to go read in front of the class for this thing and I was just getting like just wait that exactly that before which is odd because I like public speaking the public may not like my speaking.
>> No no public speaking. So then I think I think for the average person for me as well. So then the distinction between having anxiety say for public speaking
>> versus a panic attack obviously versus panic disorder the difference between a panic attack and anxiety is the severity or the the circumstance.
>> It's it's a combination.
>> Okay. But for instance, when I talk about panic disorder, it's the unexpected part. That's what creates that.
>> So nothing to say, hey, I'm at a I'm on the topic.
>> If I'm getting a panic attack in the context of public speaking,
>> that might be a form of social anxiety disorder, a different condition.
>> If you're getting So panic symptoms can be part of a number of different conditions.
>> Panic attacks can be part of a number of different conditions. A panic disorder is when it's recurrent and unexpected and followed by the fear.
>> And I would say that anxiety also can be totally normal. Would you also not say that? Like if you're if you're a little bit nervous about public speaking, that's that's really common. That's actually not pathologic at all. It's not even anxiety. You're just nervous about public speaking.
>> If you are nervous about coming on a YouTube channel that reaches
>> many many people
>> and you're anxious that morning,
>> then that is normal. I hope
>> sharing for a friend
>> just a friend, no one in particular today. And interestingly, we actually have colleagues at this hospital that I've asked say, "Hey, I think you'd be really great on our channel. You're an excellent speed." They're like, "No way. There's no way I could get in front of the camera and be on YouTube." So, those people have anxiety.
>> We have to normalize these things, right? I mean, when I'm asked to come on something like this, it's not no problem. I love, you know, it's it creates feelings and emotions and it creates anxiety, but that helps motivate you to make sure you're prepared to what you want to talk about.
>> It makes you feel better. We feel anxious to because every time we have you on I feel like I have the thing he's talking about today. I'm really worried. It's like med school. Remember in med school you you read I have that. Oh my god I've got that. Same thing here. Every time you're like oh my god I've got that.
>> And just with respect to anxiety it is um extraordinarily common numbers in the range of 30%. Would you would you agree with that number? Like a is it more common and b why do we think it's so much more common?
>> I think it's becoming more common particularly in child and adolescent patients. There are a number of different influences on that. Different theories related to social media, related to parents who suffer from anxiety, who are not letting their kids fail, uh who are afraid to have their kids in distress, so they kind of make sure to mitigate that so that so that children are not kind of prepared for what life throws at them. There's a number of different theories.
>> Okay.
>> And that's a theory why kids are having it.
>> The prevalence of generalized anxiety disorder kind of in any given year has doubled in the last 10 years or so. Wow. So it's a significantly growing problem. Um and in terms of a lifetime prevalence of say generalized anxiety so it's around 13% at this point in our country.
>> Yep.
>> Well is it is some of is some of the increasing prevalence just because of increasing diagnosis and awareness of it or is it all you think truly more of it happening?
>> I think it's I think it's a combination of things. I think we're more aware people are hopefully as we destigmatize these conditions people are are kind of suffering less and seeking seeking care. Although I think that the delay from beginning to experience say generalized anxiety symptoms and seeking help is still years and years really for a number a number of people suffer in silence try to normalize it.
>> Um but I also think as we get more aware some we we tend to diagnose things more
>> but I I would tend to think that we're just kind of uncovering what's actually there and the world is a more stressful place than it
>> it was 10 years ago especially for young people.
>> Um
>> and even in the workplace right there's no kind of downtime. we're we're reachable at all times,
>> right?
>> Regardless of your occupation, there's kind of no nineto-five
>> uh anymore. So, I think a lot of different socioultural things are contributing.
>> Would you say that it's kind of across all kind of ages, genders, uh socioeconomic sess, but would you say that the oldest people are the ones that have the least amount of generalized anxiety? Because I feel like when I see like a 85year-old, like they got stuff, but rarely do I ever see them, you know, I got I'm really anxious. I mean, I'm not sure if that's just their generation was through a lot of stuff and they're just more tolerant. Would do you see a lot of people that are say in their 80s that also have generalized anxiety? So, it's across all ages.
>> I think that I think that is the case, but often that's that there's also biological brain changes that contribute to that
>> where people who may not have had anxiety before suddenly develop crippling anxiety and there's a there's really more of a biological underpinning to what's happening.
>> I've seen I've seen patients in their 80s that are anxious.
>> Absolutely. We have an entire older adult clinic for people with depression, anxiety.
>> Yeah. Yeah. Ger geriatric psychiatry is a recognized subsp specialty. So, so unfortunately, as we get older, we're not immune to some of these things.
>> Okay. So, the patients come to your office, you've heard the story, you've done some physical exam, some baseline, either lab testing or EKGs or whatever. You've confirmed the diagnosis, and now obviously you have a chat. And so, what does this chat look like as far as here's the options that are in front of us, and which ones are we going to try? Is there I'm assuming the algorithm is very unique depending on the patient but what's a general approach for the average what can they
>> so you take a high level approach at first right you talk you educate right so you talk about what you're recognizing why you consider it a condition that requires treatment uh you empathize with the patient's experience make sure that they're aware of what you're thinking about and then you talk about different treatments so by the time they get to me um they require the education but probably I'm going to be thinking of some medication but even before the talk of medication I'm going to be talking about self-help what are things they can do um to help themselves. And when we talk about anxiety, because so many of the symptoms are somatic in nature, that's where deep breathing exercises, progressive muscle relaxation, mindfulness and meditation, different apps that they can try. So there's a there's a number of ways that people can help themselves.
>> Okay.
>> As a starting point when they're talking about anxiety
>> and that and that's usually instigated by the primary care uh healthcare provider, do you think or
>> ideally it would be okay.
>> Ideally, it would be right. So people are presenting to their primary care provider. They're often the ones doing the blood work, doing the initial physical exam to determine, okay, there's nothing else here.
>> You know, I'm going to refer you to a specialist or and they might give some, you know, again, objective screeners, so we're in kind of evidence-based,
>> uh, measurement based care. So, screening tools to help them.
>> Okay.
>> Um, ideally, they would be providing some of that information, but I want to make sure to cover it kind of as a holistic approach to mental health. Sorry. When you say a screen, you mean like a survey like someone's going to fill out a questionnaire like the generalized anxiety disorder 7 questionnaire where they're kind of going through filling out some of the criteria, the impact on functioning.
>> Yeah.
>> Um, and what I would say is ideally those questionnaires shouldn't wait for someone I know we're kind of digressing here, but those questionnaires shouldn't wait for someone to come with anxiety to give,
>> right? Ideally, as part of your holistic primary health care,
>> when you come for your for other reasons on a one year or two-year basis, you should be getting depression screens, anxiety screens because people might people might want to talk not not want to talk about it and all of a sudden you give one of these screens and someone is,
>> you know, hitting thresholds for concerning levels of anxiety, you want to be that's that's an entry point for a discussion.
>> Can we put that we'll put that it's called the generalized anxiety disorder screening seven
>> GAD7
>> GAD7. We'll put we'll try and put a link to that in the description. The GA AD7,
>> right? You can try it people. It's online. You can try it on your own right now.
>> Pause, go try it, and then come back and watch the rest of the video.
>> And as for and then we start talking about medications. So, pharmacologic treatments. So, again, a combination of of
>> and a combination of treatments is is necessary. So, the education, the mindfulness, exercise of course can play a role in helping anxiety. And then when we're talking about medication, we're most commonly talking about medications that we also use to treat depression. Right. So the serotonin specific or selective reuptake inhibitors are the first line treatment.
>> Um there's a number of those different medications. Uh serotonin norepinephrine reuptake inhibitors. Um and a number of add-on different medications. So there's a kind of an entire toolbox available to to clinicians to use or physicians to use in prescribing medication um to go along with whatever therapy they're going to engage in.
>> Right? So they might see a therapist as well. So, not only doing some stuff on their own, taking empowering them to do some stuff on their own, but also potentially seeing a therapist to talk about the problem.
>> Really, when it comes to anxiety disorders, it's it's it's rare that just take this medication and it'll all go away, right?
>> Um, like many conditions, there's the there's the therapeutic work that needs to be done. So, cognitive behavioral therapy is the cornerstone of treatment for a number of anxiety conditions. It varies based on the type of condition, but often people ideally are in some sort of therapy to help kind of recognize the anxiety symptoms, the irrationality of them, what's the evidence for them to help kind of see the distortion that may be happening as a result of their anxiety, right? But sometimes and often they need medication to bring the temperature down enough
>> to do that other work. You need the breathing room, right? And you need to treat the specific symptoms. So yes, are there people that take medications and wow, this has magically changed everything? Of course there are. But often especially by the time they get to a hospital based psychiatrist right
>> the severity is of the level that we need kind of a multi-prong approach.
>> Okay. So it's going to be a component of cognitive behavioral therapy in addition to the pharmacologic treatments going hand inand to try and tackle this sometime can it be done sometimes with just without the medication or just the therapy?
>> Yes. in mild in in more mild conditions certainly people can get better with with just the uh
>> and CBT is really teaching them here's what you have here's what seems to be the disconnect and here's what you can do if you're feeling it the goal being obviously if you feel like attacks coming on here are some strategies that you can have to try to reduce the severity or potentially avoid that attack co that's more the behavioral part of it the cognitive part is connecting your thoughts with your feelings and your emotions so I'm feeling overwhelming anxiety identifying what what the emotions are
>> right.
>> Um, and then what are the thoughts behind that? What, you know, well, I'm worried I'm going to lose my job.
>> Okay. Well, let's examine the evidence for that in this moment,
>> right? Is this a real
>> like Yes, kind of. So, so there's a high, you know, so then you start to look at evidence for and against, right? I'm simplifying, but you know, that's what you and then even if that even if that realization in that moment brings your anxiety down 10% at the beginning, right? That is meaningful change for someone who's
>> feeling overwhelmed. So, it's a very kind of slow and uh process at first, but eventually the idea is that you train your mind to do it faster and faster and faster.
>> Okay?
>> But but in the moment when you're in the anxiety and it's overwhelming, you need to be able to reach for that those other tools, you know, grounding techniques or progressive muscle, some sort of exercises that you can do to to help.
>> Right. Okay. And so, and can we just briefly talk about the things we're not going to talk about just so because I know people are going to be leaving a comment about, oh, I have this, I have that. We're talking about generalized anxiety disorder. We talked about panic attacks associated with it. We're not really touching on post-traumatic stress disorder, anything like that, right? What what are some of the other things that this this doesn't apply to?
>> So, what what when we talk about anxiety disorders as a general cluster, we talk about most commonly generalized anxiety disorder, panic disorder, social anxiety disorder, um where the anxiety comes in the context of either a fear of being observed, right? uh doing something, fear of your interaction, how you're going to come across, what other people are going to think of you. Okay,
>> so there's a perform or performance of some kind, right? So those are three main categories for that. And again, out of keeping with what we would normally expect in any of those situations and it becomes debilitating, um those are kind of the main categories. We're now recognizing there are other conditions that used to be kind of clumped in with anxiety disorders that are really kind of separate entities, right? So obsessive compulsive disorder and its related disorders like hoarding or trickotillamania that's kind of a separate okay entity we're recognizing there are different biological underpinnings different approaches necessary still cognitive behavioral therapy but different and then post-traumatic stress the this post-traumatic stress disorder and the related trauma disorders are kind of yet another category they used to kind of all be lumped in under anxiety disorders but we're recognizing
>> they're distinct
>> they're distinct kind of categories
>> and we leave a comment about those we that's not in this video. We will hopefully get you back and talk about some of those things in other videos, but it's not right now that's not sort of the focus of this what we're talking about now. We're talking about the more common ones, not those types, the generalized anxiety disorder, the panic, the social. And where does does agorophobia fall into that? And what is what is that exactly?
>> So gorophobia is is interesting. It's it's almost as if people start to have significant anxiety and avoidance behavior in the context of being in certain situations.
>> Okay. So certain situations like uh public transportation, certain situations like large spaces like arenas or stadiums or smaller spaces where getting away would be difficult.
>> Um those are kind of some of the categories and again it's it's fear of having panic but not it's not the unexpected the fear of an unexpected panic attack. It's fear of something that may happen. So an elderly person who's prone to falls
>> may de may develop agorophobia in the context of I don't want to be stuck in a situation where what if I fall.
>> So that becomes so debilitating that they stay home.
>> I'm not going to go out.
>> They don't leave the house for fear of being in one of those situations whereby they might be overwhelmed and be unable to kind of escape.
>> So that's how they can control the situation. Just don't go outside.
>> And often that's how that how it manifests. They they stay at home. Okay. And and actually fear, you know, one of those categories is fear of leaving your house for any one of those,
>> right? And that falls into that general anxiety disorder sort of social
>> that in itself is agorophobia. That's agorophobia. But you can have panic disorder with agorophobia, right? Okay.
>> And again, this point this is an important point that you bring up that anxiety disorders are most common co-morbid meaning that
>> you don't often just have one.
>> You often they will cluster right there. It's very comorbid with depression. So people with depression will often have anxiety symptoms. You'll often have depression alongside anxiety. So, it's important to screen for all these other types of conditions because it's as it gets more severe, it's unlikely to be just one or just the other. You can have a number of different anxiety conditions at once that need attention
>> with with respect to treatment. For sure, someone's wondering and definitely wondering about their children potentially. What what is the what does the long-term treatment look like? So, is this something that hey, are we going to cure this? Is someone going to be on medication for the rest of their life? Will CBT allow them to have strategies to say, hey, you know what, now I still have it, but I can totally manage it. And obviously there's a range but like what's the what's the end goal of
>> I think it depends on the again it's very patient dependent depends on you know young kids may have significant anxiety at one point in their lives that that changes as their brains change over time
>> you can outgrow some of it potentially
>> yeah or work yes some of it will change some of it may not right the more severe the more you're going to have to manage it the general rule is what gets you better keeps you better
>> okay
>> so if you take a medication and it puts you into remission we have discussions around the risks and benefits of coming off medication later even though you're feeling great. People will say, "Do I need to take this forever?" It's really just a what are the risks if you were to stop it? Are you biologically protected? It did do something biologically versus having to be on a medication long term. Yeah.
>> But again, what I often say is we have to destigmatize these conditions when it comes to pharmarmacology. We don't ask these conditions. We don't ask these questions about hypertension,
>> right?
>> We don't ask these questions.
>> We don't ask these questions about diabetes. Yes. Right.
>> These kind of conditions. Well, when can I stop this insulin? My blood sugars will look great for a year now. like your pancreas still doesn't work.
>> So in some cases it's about
>> what for whatever reason you're prone to this condition. There may be a strong family history, a genetic vulnerability. Your mother had it, your sister has it.
>> These med if you're feeling better, these medications will help you stay better,
>> right?
>> Um and then some sort of maintenance from a therapy point of view. It may not be formalized once a week cognitive behavioral therapy, but what are the things you need in your life to keep you well,
>> right? And I know for depression I read some papers that um like mobility, exercise that kind that had great effects on depression. Is there a role for that in anxiety? Is there the same evidence that says hey you know what, regular exercise can help this condition like it can in depression for does that work for anxiety? I don't know if the research I would have I would have to check again if the research has been done around spec I know in depression absolutely in for generalized anxiety disorder there is evidence that depression that sorry that exercise can help
>> but not necessarily trials of that I'm aware of exercise alone as a treatment for a severe form of anxiety so it's you know we're talking about exercise alongside the other kind of treatments but exercise again the mind and the body are connected yes
>> so when we have talks about well exercise could help this condition well exercise should be part of everyone one's life.
>> Yeah.
>> Regardless of physical or mental health like totally agree.
>> So I don't really
>> when we're talking about you know you should start doing some exercise. It's
>> this is a never had any conditions I would say we should all be doing some it will help
>> with your mental and physical.
>> Personally I find that helps if I'm feeling anxious with something. I feel like if I go for a run or do something like that it helps because I feel like I'm bringing my physical demands up to meet my like cardiac output right now because I'm my heart's beating. I'm breathing heavy. I'm sweating. I'm stressed. If I go for a run, it's like, okay, I'm making the rest of my body match that
>> sort of.
>> And so what I would say is for most people, that's a good outlet. But if it's a significant anxiety condition, you will finish the run
>> and still be
>> and continue to be ruminating and cooking. That is the nature of that.
>> You can't outrun it.
>> There you go.
>> Tell that to Forest Gump.
>> Yeah. Yeah. I don't know that he anxiety.
>> Nobody ran a lot.
>> Surely did.
>> Um that that's an awesome summary. Yeah. And I I say the takehome for this is know that anxiety is very very common. You are not alone. That there are very real ways to be helped. So please, if you have this problem, discuss it with your family doctor. Get the help that you need and that you deserve and that's available to you. And if you like this video, please like it, subscribe to our channel, share it with someone that you think may be suffering from this.
>> And remember, you are in charge of your own health. Thanks again. Thank you so much for sharing that.
>> No, thank you for having me. there's anything we can do to help destigmatize these conditions, get people talking about them and and seeking help when they need to, and also getting our primary care community to proactively ask people, then then I'm happy to help.
>> Yeah, we generally talk about a we we take the stigma out of a lot of things.
>> There's no stigma on this channel. No stigma. We'll see you next time.