Aug 23, 2022

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Mitch: Anxiety. What is it? Why do we have it? And how do we kind of cope with it? This is "Who Cares About Men's Health," where we try to give you some information, inspiration, and a different interpretation of your health.

I'm Producer Mitch, and today I'm joined with Scot. He brings the BS to our show.

Scot: Glad to be here. Can't wait to talk about anxiety.

Mitch: Right? How exciting.

Scot: Can I sing it every time I say it? I'd love to.

Mitch: Anxiety? Okay, yeah. We'll see if you commit. And to bring a bit of the MD to the rest of our BS is Dr. Troy Madsen. Hey, Troy.

Troy: Hey, Mitch. Good to be here.

Mitch: And joining us today to talk, he's back, it is Dr. Scott Langenecker. Hey, Dr. Scott.

Dr. Langenecker: Howdy.

Mitch: So before we dive too far into what anxiety is, how we deal with it, etc., I wanted to ask the rest of the team here. Scot, when was the last time you felt anxious?

Scot: Not that long ago.

Mitch: Oh, really?

Scot: Yeah. The last time I felt anxious was during my graduate studies. Working on my final project, I had to make a couple of presentations for that. I get a little anxious. I find myself getting anxious as I approach deadlines.

Mitch: Sure.

Scot: I am curious to find out . . . I've heard there's a difference between just normal . . . I just labeled it, right? And I shouldn't have done that. Just kind of anxiety out of events like that versus maybe more severe anxiety. There'd be times where I would notice I was getting a little short of breath and I just have to go, "All right. Calm down. Take a couple of deep breaths and you'd be good." I had never really experienced that level of anxiety before. Otherwise, it was just kind of butterflies in the stomach.

Mitch: Like having to talk your body down?

Scot: Yeah. A little bit.

Mitch: Okay. Interesting.

Scot: And to a past episode, that I remembered box breathing, right? That our brain and body are so tied together. Calm one down, it'll help the other. So yeah, that's my story with anxiety.

Mitch: Oh, cool. Okay. And what about you, Troy? I mean, you're in a really intense job. It's a little bit more than a podcaster. Do you get anxiety a lot?

Troy: I try not to. And it's one of those things you have to check yourself sometimes because if you are feeling anxious at work, it can be very distracting and detrimental.

But I will tell you the shift I worked just a couple of days ago, there was a point I had several patients I was trying to see, and then they just kept bringing more patients back. And it was kind of a moment where I just had to catch myself like, "Okay. Take a few deep breaths. Just go one at a time. See the patients. No rush."

It was kind of that feeling of being anxious and also feeling a little bit overwhelmed, which is funny to say after doing this job for however many years I've done it. So yeah, I definitely felt a bit of anxiety at that moment, for sure.

Mitch: That's interesting because those are both situations where it kind of makes sense, right? There's a threat, there's a stressor, there's something.

One of the things that I've been dealing with for the last year working with mental health, and one of the reasons I really wanted to do an episode and bring Scott back on to talk through this with us, is I apparently have some generalized anxiety where it's just like I'm always just a little anxious. And it has been a long journey to be able to just quiet those feelings down a little bit.

And so just to give us a little bit more perspective about what is anxiety and how do we work with it, etc., Scott, why don't we start there? What is it? What is anxiety? Because you hear people say, "Oh, I'm feeling anxious today." Is that really anxiety, or is that just a catchall term for "I'm a little nervous about something"?

Dr. Langenecker: Yeah, it's a great question. I think I'd like to start out with this concept of pain. So why do we tell kids when they're young not to put their hand on the stove? Why do we have pain receptors in our hands? It actually keeps us from harming ourselves.

And so anxiety at its core is a danger warning system in your brain. And it turns out it's a pretty old system. It developed a long time ago. Many animals have anxiety. We humans have anxiety. It's not really a fine-tuned system, and so it's pretty easy for it to go a little bit awry.

Mitch: Okay. And when you say old, it's pre-caveman? We're talking way down the line in the evolutionary line, or what?

Dr. Langenecker: It depends who you ask. But if you ask somebody who likes to be contrary, they will say an amoeba can have anxiety because it can move toward or away something based upon the danger of that object to the amoeba.

Mitch: Wow.

Dr. Langenecker: Now, obviously, that's a bit of hyperbole. We like to think of anxiety as having a little bit more sophistication than that. But that's sort of at the far end of the spectrum on what we think of anxiety, is moving toward or away things that may be dangerous to us.

Troy: That's what we need, Scott. The next book is going to be "The Emotional Life of the Amoeba: Dissecting Their Emotions and Treating Them."

Mitch: Is anxiety an emotion, or is it a biological response?

Dr. Langenecker: I would opt for a biological system or a biological response that can lead to a host of emotions.

Mitch: It's not an emotion. Your body is actually afraid or telling you, "Hey, there's danger here"?

Dr. Langenecker: Yeah. Most often, when we think of anxiety, we think of it going along with the emotion of fear, but there are other emotions that can come with it, like excitement, or anger, or disappointment, disgust. It doesn't have to be that specific.

Mitch: Before we started the interview, you mentioned that you like to think about anxiety as the tiger of the mind. Do you want to explain that a little bit to me? That sounds very exciting and interesting.

Dr. Langenecker: Sure. This is the way that I make anxiety real for patients of all ages. But it's really helpful for talking with kids too, because kids have lots of fears. Some of them are useful, some of them not so useful. As we move into adulthood, we get better at managing them, by and large. Not always.

So when I think of tigers of the mind, I think of "What is the evolutionary purpose of anxiety?" And the evolutionary purpose of anxiety was literally to keep us from eating that poison mushroom, from going out in the dark and being eaten by tigers. And so, anxiety was a good thing, right? It made us cautious. It made us think rather than feel.

And those people who were more cautious and did the thinking rather than the acting impulsively are the ones who passed their genes onto their kids. So anxiety has been preserved, and I would say even strengthened as we've evolved.

Mitch: If it is this kind of evolutionary thing, almost everyone has a little bit of anxiety, it's a biological system that allows us to respond to dangers, at what point does that become, say, an anxiety disorder? And what kinds of anxiety disorders are out there?

Dr. Langenecker: So that's a whole thick book, but the basic idea is we have anxiety. The best way I've heard it described is anxiety is about a loss of control. So control about safety, control about your social status, it could be control over a number of things.

So social anxiety is one, right? That's potentially a loss of status. That goes back to Scot's anxiety around his performance in exams and projects and so on. "If I don't do well, I may not gain the social status that I'd like, or I might lose some social status."

When Troy was talking about it, it might actually be related to danger. "If I don't find a way to manage the anxiety there, there might be some danger to me."

And then we have fears, phobias of various things.

The generalized anxiety that you referred to before, Mitch, is kind of . . . I'm going to use the word unsettled.

Mitch: Sure.

Dr. Langenecker: Things don't seem to be settled often and your brain is constantly looking for why. Why are things not feeling settled? And so it becomes generalized and you're just looking. You're looking for the monster under the bed, even when the bed is not there. That's what your brain is doing to you when you have more of a generalized anxiety.

That's just a couple. There are more complicated ones around trauma and obsessions. And I think just in the interest of time, let's get past those for now.

Mitch: For sure. It's interesting to hear that because one of the things that I've been working on with my therapist was the idea that my generalized anxiety may be connected to some childhood trauma. It might be connected to some instability in my life for a long period of time when I was jumping from job to job doing freelance stuff, etc., whatever.

But he explained it to me and generalized it, my particular case, that just I'm super-duper sensitive, right? My whole system is constantly searching for "What is danger?" And it is starting to create danger where there is none. And it would be everything from like Scot would end an email with a period rather than a smiley face. And I would just be like, "Oh, Scot hates me. He's going to fire me. What am I going to do?"

Scot: Wow.

Mitch: No, it's real.

Dr. Langenecker: Periods should be banned from sentences.

Mitch: And so it was that kind of stuff. And it's been really interesting viewing it from that side. It's not, "Hey, you're not crazy. You're just . . . Because of one reason or another, your system is hyper-wired and very responsive to these things." It's trying to protect yourself. And that gave me kind of a different, I guess, appreciation for what I was experiencing.

Dr. Langenecker: One way to think about it is our DNA is super complex and it's designed to create variability. And so if you think of trying to find the sweet spot for anxiety, our DNA is actually going a little bit high sometimes and a little bit low sometimes. And unfortunately, you and I actually end up a little bit high on that scale. And the non-therapist therapist advice here is the biggest part of managing it is actually just calling it what it is, like, "I'm high on the scale."

Mitch: And that has been, for me at least, one of the biggest changes because I'm finally able to be like, "No, you're not scared. Your body is over overcompensating. This is where you're at. Calm down." The higher brain can talk me down a little bit, which I appreciate.

Dr. Langenecker: And the trick then is if your system is super sensitive . . . If we just think about tests, there are false positives, false negatives, true positives, and true negatives. If your system is super sensitive, you're going to end up with a lot more false positives, which means you're going to feel anxious when there actually is absolutely no reason why you should feel anxious.

Mitch: Yeah. There was a day or two in therapy where I just was like, "I feel really anxious." And he's like, "You just spent the last 15, 20 minutes telling me how good your life is going. What are you anxious about?" And I'm like, "I don't know. Something is going to happen." There's a rubber band theory out there where it stretches and stretches and stretches and things are going good, things are going good, just snap it back.

So yeah, it's interesting to hear that.

Dr. Langenecker: And these are the parts of the brain that we understand the least well. There's the very simplistic way of thinking about the amygdala is looking out for threats in the environment, and it triggers a fear response. But there's a whole bunch of cortex that's actually linked in with the amygdala that's making all sorts of complex calculations about, "What's the likelihood of this event being truly dangerous? And how often has this happened before? Am I in the same environment that this happened before?"

And when we think about anxiety for humans, we have the capability of adding all of these layers to it. And that's where I think we end up with things like generalized anxiety. There's a cerebral element to it as well.

Scot: Can I try my hand at an analogy? It sounds like if somebody has generalized anxiety, their threshold for setting off the alarm system that would normally help keep somebody safe is really low, which is what you've said. And then it also seems like that then when the alarm is going off, your body is almost going, "But there's an alarm going off. There must be a problem." It's this loop almost.

Dr. Langenecker: Yes.

Scot: Would that be accurate at all?

Dr. Langenecker: Yeah. I think you're spot on the money. And then there's another element to it as well, which is sometimes you as the person are like, "Hey, the alarm hasn't gone off in a while. Is it working? Maybe I should set it off to see if it works."

Mitch: Oh, man. And it would cause me to be suspicious of people sometimes, kind of like, "Hmm, there should be a danger here. Maybe this person is my danger." Yeah, it's fascinating.

Troy: This reminds me of the smoke detector in our bedroom. I looked up at it the other day and the smoke detector is there, but it's pulled out so the batteries are pulled out. So it doesn't work. And I said, "Well, why are we doing this? The smoke detector needs to have the batteries in." So I put the batteries in.

I shower the next morning and the smoke detector goes off. I'm like, "Oh, that's right. That's why I pull the batteries out. Every time we shower, the steam comes out of the bathroom next to the bedroom and lets off the smoke detector."

So it sounds like you're saying anxiety disorder is a little bit like that, where its threshold is just too low and it senses danger from things that don't present danger.

Dr. Langenecker: Yeah. That's absolutely right. Now, I'm making light of it because we're on a podcast and we're trying to make light of it. But there's a darker side to it as well, which is people who have experienced adversity and trauma. Their brain is actually changing and adapting to that. And it's not that clever, funny analogy anymore.

That's why I use the analogy of tigers of the mind, because tigers are sneaky and tigers are dangerous. And there's a bit of mindfulness we can do with anxiety, but there's also a bit of, "Hey, this is a real thing. You went through some real trauma and your brain has changed because of it. And so then what are we going to do next?"

Mitch: So I guess going down that line, what are some of the signs that someone might notice in themselves that they might have not just the run-of-the-mill responsive anxiety, but maybe something that could use some professional help?

Dr. Langenecker: The big grab bag category we use is "Does it affect your functioning in your life?"

So, for example, if I have social anxiety and, therefore, I can no longer go on a podcast because I'm afraid people are going to send me hate mail, that's where it moves into, "Oh, boy, that's leading to some dysfunction."

If it makes me uncomfortable and I do it anyway, that's sort of in a gray category.

If I have a fear of fire in my house since I'm constantly checking the smoke alarms and making sure that the oven is off and it takes me an hour or two a day to go through those loops 17 times in the morning, 5 times at lunch, and 5 times before I go to bed, that's moving into a dysfunctional area.

So when we talk about anxiety and dysfunction, we say, "Well, does it change the way you pursue your goals? Does it prevent you from pursuing your goals?" And when it does, then it's time to get some help.

Scot: Somebody who's more sensitive or who has had trauma that's experiencing this type of anxiety, that sounds exhausting. So beyond just it impacting the goals that you're trying to achieve, does it just mentally wear you out, tire you down to a bad place?

Dr. Langenecker: Yeah, it can. So one of the things that I focus on a lot in my therapy with patients is, "Is it affecting your sleep? Is it affecting your energy level? And is it affecting your mental focus?"

So you can run into this situation where people are sleeping, but they're not sleeping well and they feel like . . . They go through an entire day, every day thinking, "I just need to take a nap." And there are actually some biological reasons for this. If we trigger the stress response over and over and over again, that stress response actually loses some of its elasticity. It loses some of its ability to recover over time.

So let me give you an example. We're going back to tigers again. I find myself, unfortunately, in a jungle and there's a tiger there, and there's a huge surge of cortisol that comes through my system to help me, probably unsuccessfully, fight against this tiger.

That cortisol surge is to actually assist me in getting more strength, more agility, to heal faster, but it's supposed to last maybe 20, 30 minutes. But what happens if that gets triggered with the tigers in your mind 50, 100, 150 times a day? That response after a while is going to get a little bit worn out.

And I know that's not a technical description, but yeah, you can end up being pretty worn out from that constant stress.

Mitch: I was. I was getting really tired, really fast and it was leading to inability to sleep, inability to work out. I just was exhausted all the time.

Dr. Langenecker: Yeah. And it ends up being a bit of a trigger for depression, actually.

Mitch: Yep.

Dr. Langenecker: Folks with anxiety are at twice the risk for depression, probably because of that very mechanism of getting hyped up so often and then getting worn out.

Troy: Certainly there the underlying issues, but how much of this, though, is situational where you do face those threats, and legitimate threats? And obviously, the easy analogy for me is just a point to my work. It is a high-stress job with high levels of anxiety just with dealing with unpredictability, both in terms of the kind of things you take care of and just the number of issues you have to deal with.

How much of that becomes a trigger for people? Or would you say that anyone, regardless of their job situation, if they're getting to that point where they're just feeling overwhelmed and exhausted by anxiety, that it truly is a sign of an underlying anxiety disorder?

Dr. Langenecker: Yeah, you've moved into an uncomfortable area here, Troy, which is I honestly don't know how you do it. I honestly don't know how ER docs and first responders and military personnel do it, and yet many do and do for a long period of time and do so successfully.

There are many people where that's just not something that they should be doing. Their body isn't designed to handle stress in that way. But I don't have an answer for why some people seem to be able to manage high levels of anxiety reasonably well.

Troy: When you talk to people in those situations, in high-stress jobs or environments, do you ever simply counsel them to say, "Hey, maybe this is more of a response to what you're facing. Maybe try something different before we recommend medication"? Is that an approach or do you usually say, "Well, clearly, this is disabling. Let's try medication and see if this helps you to work reasonably well in that high-stress environment"?

Dr. Langenecker: I think most people weed themselves out in the process of pursuing these types of careers, but there are times where that's my actual counsel to folks.

So let me give you a couple of examples. We've run a couple of projects with firefighters, and what they'll say to me is, "It's a young man's job, or a young woman's job," which is your ability to physically and mentally be agile in responding to stress just changes over time, and they find themselves less able to do that with as much plasticity as they move into middle age.

And the counsel is often exactly that. "You've had a good run of it, you've done amazing work for your community, and your body is just not able to do that work anymore, and your brain is not able to do that work anymore, so maybe let's find something else for you." And sometimes that's enough.

Mitch: For people that maybe their lives are being impacted by the level of anxiety, maybe not even to a full disorder, but if it's impacting their life at all, how do we cope with it? Is it medication? Is it talk therapy? How do we help people that are experiencing those types of things?

Dr. Langenecker: So this is the really uncomfortable part of this discussion for me, in that for most people, anxiety is not something . . . It's not like an infection, right? You don't treat it and then it goes away. It's more kind of along the lines of diabetes, which is once you have it, you probably have it for life. And then the question is how do you manage it?

And by manage it, there are things that you can do in your life: exercise, mindfulness, sleep hygiene, diet even, things that can help. But for many or for some, we have to go one step further and pursue medication. And that makes, I think, everybody including myself uncomfortable, which is, "Do I have to take these medications for the rest of my life?"

It's an uncomfortable conversation, and so that's why I like to use the analogy of diabetes, which is the medications are there to help balance out your system. You would never say to a diabetic, "Hey, let's try not using the insulin this week. Let's see what happens." We wouldn't do that. That would be a bad idea. And so, for some folks, their anxiety is just at a level right now where medication is a good idea.

Mitch: So I actually started taking some anti-anxiety meds last year, and it took a little bit to get used to them, but it is night and day for me. It feels like the system has calmed down. It feels like I can actually do some of the mindfulness kind of activities and cognitive behavioral, self-talk type stuff. And it's gotten significantly better, but it did take me a while to find a guy, a mental health person. And then on top of that, to just straight up say, "Hey, I think I have anxiety, and I think this is impacting my life."

So I think just to wrap things up a little bit, is there anything that you would want to tell maybe a guy out there who's like, "Maybe I have anxiety. I don't know"?

For me, sometimes it feels like, especially with my upbringing and everything, mental health is a mystery and a foreign language, and the people in it are not me. That's the ideology that comes behind it. What would you tell the someone out there that maybe would be curious and what they should do to address the issues?

Dr. Langenecker: So let's start with the myths right up front. These medications with titration, with maybe some switching and augmentation, they'll help about 60% of folks who have anxiety live better, more fulfilling lives. Will they make anxiety go away? No. But maybe it takes the edge off a bit. So that's the first thing.

The second thing is it does take a bit of time to figure out the best mix for you. Sometimes that's months. Hopefully not years.

The third thing I would point out is that people . . . there's a bit of machismo here, which is, "I can do it on my own. I don't need medications." And I get that. I hear people when they say that and I just ask myself a simple question, which is, "Does it need to be that hard?" And the answer is no. It doesn't need to be that hard. You can take a shortcut.

And the shortcut here is actually helping your brain to do what it wants to do anyway, which is to give you the goods, which is to make your life fulfilling and meaningful and allow you to connect to other people. And if anxiety is getting in the way, medications are worth a shot. They're worth a shot to try out.

Troy: I know a lot of people are hesitant to take medications just because of potential side effects and issues. Do you find that that's a big issue when you're talking to people about these things? And how do you work through that?

Dr. Langenecker: Oh, yeah. We forgot about that one. So the word on the street is that some of these medications might lead to sexual impotence. And yes, that can happen for a small subset of people. If that happens to you and it's cutting into your enjoyment of your life, you can cross that bridge when you get there. You can try different medications. You can stop taking medications.

Again, it doesn't have to be that hard. Try it out and see if it actually can work for you. And for many, many people, their quality of life will improve not just a little bit, but substantially.

Mitch: So if someone is, say, struggling with anxiety at any level, where do they go first if they are looking for help? Is it your PCP? Is it a mental health specialist?

Dr. Langenecker: This is where I'm going to get into a little bit of trouble, but I'm going to the data. So the data suggest that if you go to your PCP, most of the time, a PCP is going to be helpful. They're going to try and prescribe a med for you. But they're more risk-averse in that they might under-dose in an attempt to avoid some side effects, which basically means that you're trying something, but not really trying something. And so the data just show that that's the most common thing that happens if you go to your PCP.

Fortunately, there are lots of online resources to sort of verify whether or not you might be under-dosed. I know Troy is probably going to slap my wrist and say, "You shouldn't go to Google MD. You should use it as a resource to augment what you know. You should not use it as the sole source."

Troy: Yeah, Google MD kills me. Please. The number of times I hear about things people read on Google that brought them to the ER, it's just . . .

Mitch: "I've done my research."

Troy: "I've done my research. This is what Google said." Okay. Here we go.

Dr. Langenecker: But the basic idea is going to see a psychiatrist even for something we might consider minor like anxiety is fine. If you're wanting to try it, it's okay to try it in a context where you're going to get an expert to help you.

Mitch: Scott, thank you so much for answering all of the questions that we had about anxiety. Hopefully, for someone out there, that'll help them. It doesn't have to be that hard. And myself, I cannot tell you how much better I feel after getting some treatment. So thank you so much for talking to us, and thanks for caring about your health.

Dr. Langenecker: You bet.


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