E31: 7 Domains of Anxiety

Anxiety. For me, even the word, with its Xs, it makes me anxious or a little twitchy. Most of us have been anxious at one time or another, and we've had anxiety about a date or maybe an exam. And many of us have had those silly performance anxiety dreams, where we show up at class that we haven't gone to all semester and it's the final. So I think it's pretty normal anxiety, but some women and men have anxiety every day.

So, here, in the Scope Virtual Studio, to help us with the "7 Domains of Anxiety" is Brian J. Curtis. He is trained as a clinical psychologist with a doctorate from the University of Utah, and he's the founder of Honest Sleep, which is a telehealth-based group practice specializing in the assessment and treatment of chronic insomnia disorders in adults.

Dr. Jones: So, Brian, welcome to the Scope Virtual Studio, and we're so glad to have you here. Well, let's jump right in and chat about it right now. How would a psychologist actually define anxiety?

Dr. Curtis: Yeah. So if we look at the rather large book that psychologists, also psychiatrists, other mental health professionals use in mental health diagnoses, which is the fifth edition of the "Diagnostic and Statistical Manual of Mental Disorders," which is DSM-5, really the core features of the various anxiety disorders are going to be excessive fear and, unsurprisingly, anxiety.

So fear is defined as an emotional response to real or perceived threat that's imminent here in the moment. Whereas when we look at anxiety, that's defined as an anticipation of a future threat. So there's going to be overlap between both of them, fear and anxiety. They're both about threats to the wellbeing of ourselves or others.

Dr. Jones: Are people born with anxiety.

Dr. Curtis: It's a really, really interesting question. So we have kiddos, and you can see differences in just temperament either as a parent, or if you have seen young children, but there is research.

So in psychology, famously, there's this strange situation/paradigm the psychologist Mary Ainsworth pioneered where you can see differences in how infants . . . they have different attachment profiles. So how anxious are they when the mom leaves the room? Do they cry? Are they comforted when she comes back? So that's one thing that you can see in 9-month-old or 12-month-old toddlers, but also this growing literature on even going to things like epigenetics.

Dr. Jones: I was going to hope you would talk about that. And if you didn't, I would. What happens in the mother's emotional environment when she's pregnant can prime the brain for a certain reactivity in the fetus. And certainly, there's pretty good data in mice and rats, and I think some good data in humans. Can you talk about that a bit?

Dr. Curtis: Yeah. So, again, epigenetics, this is . . . Epi, it's on top of/above genetics. So we're talking about these biological processes that alter gene expression, but they don't change the DNA sequence itself, the actual order of those nucleotides. But this is things like methylation, non-coding RNAs.

But as you mentioned, research in rats has indicated that the way that the mom rat rears her kiddos can result in a whole bunch of effects, one of which is kind of altered reactivity in that HPA axis in the brain, the hypothalamic pituitary adrenal axis, which has these downstream effects, things like cortisol, anxiety. It can change how these rats end up coping with stress down the road.

Those are the animal model in rats, but also research in humans in particular with the anxiety disorders has focused a lot on DNA methylation, so adding those methyl groups on top of DNA.

And in things like panic disorder, the lower methylation of certain genes, like the mono-immune oxidase promoter, we've observed these lower methylations in these patients. And that finding has been replicated.

But also in something like social anxiety disorder, you see lower methylation. In this case, the gene for the oxytocin receptor you see in patients with social anxiety. And that's been correlated just in non-anxiety humans with an increase of cortisol response during stressful tasks and also increased amygdala reactivity in neuroimaging. So a really rich literature that I'm actually just scratching the surface of, but there's a lot there.

Dr. Jones: Well, I think we are all going to be afraid when something really scary is going to happen, but a healthy brain will allow us to come down pretty quickly, and we don't carry on with this fear on and on. The ability to come back to baseline is a sign of a healthy brain so you can carry on with your life, and some folks really have a difficulty with that.

And not to blame it all on the moms. I think there may even be some work in rats on sperm, guys. So if you have a male rat who is scared while he's making his sperm, it turns out that his offspring have more reactivity when they get scared and they don't come down as fast.

So I don't want to blame it all on the moms being scared. I want to just share the burden of epigenetic phenomena to men and women. Just saying, Brian. I'm just saying.

Dr. Curtis: Trust me, we are on the same page with that. Absolutely. As a father, I think I'm very much aware with, if not epigenetics, my, let's say, successes and shortcomings on a day-to-day basis and how that's impacting our children. So, yes, we're on the same team.

Dr. Jones: Right. Well, can people develop anxiety when they didn't seem to have it before? They were cruising along in life and something happens and now they're chronically anxious?

Dr. Curtis: Yeah, absolutely. So one example that we can see is in the case of the type of anxiety of a specific phobia, right? So let's say you love dogs. I love dogs. But you're out, let's say you're running in the park, and all of a sudden a random dog just comes up and it bites you. So you love dogs. But now, that park, that bite, maybe you have a little bit of a fear of dogs. You didn't avoid them before, but you notice you're avoiding that park.

Over time, you might avoid walking around the neighborhood. There are maybe some big dogs there. Weeks go by, maybe we don't want to leave the house that much. We're more socially isolated. We're not inviting our friends over who have big dogs. And so this can kick off this cycle, whereas we were fine before and nothing was kind of there. But in the case of a phobia, that can happen.

But like you were mentioning too, there are other aspects. Maybe generalized anxiety, this more free-floating worry, that seems to have more of that kind of genetic predispositions, but the environment plays a very significant role as well.

Dr. Jones: Is there a difference in the prevalence between men and women? Are women more anxious? As women we're always surveying or surveilling the environment to keep our kids safe, to keep our families safe. Do men and women have a different incidence in anxiety, or men just don't . . . it's not manly to talk about it?

Dr. Curtis: Yeah, both of those are really interesting. And so it turns out that when you look kind of across all of the anxiety disorders, they tend to occur more frequently in females than males. And that has approximately a two-to-one ratio.

So some of the research has shown that if men or women carry a lifetime diagnosis of any anxiety disorder, women tend to be more likely than men to also be diagnosed with a second anxiety disorder, not just one. Also, comorbidity with things like bulimia, major depressive disorder, these are also known to affect women more than men on average.

If you flip that, men with a lifetime diagnosis of anxiety disorder, they've been shown to be significantly more likely to be diagnosed with things like ADHD, substance use disorders.

And so, like you mentioned, are women more likely than men to seek help for anxiety? Is this a cultural thing that it's okay to talk about? Do we feel shame? Some research shows that there may be a more tendency for women to experience negative emotions like worry, guilt, depressed mood, and that can then bleed into some of these other disorders as well. But as you know, this is very complex. There's genetics, there's environment, there's society. Yeah, there's a lot there.

Dr. Jones: Aren't we wonderful? We're just wonderful, complicated people.

Well, we talked about primary emotions, and I think of those emotions where they have a physiologic response, then often the physiologic response is on us before we can even label the word that we're feeling. Can you talk about the physiologic responses when people are anxious? Maybe we can talk about just anxiety and then you can help me think about a panic attack. Just what are the physical signs of it?

Dr. Curtis: When we think about the physiology, these kind of symptoms, we just mentioned generalized anxiety, and this is that kind of excessive anxiety, worry that tends to be chronic, difficult to control the worry. But there are these kind of classic physiological symptoms that we ask about and that we can assess what's going on there.

So one of those is restlessness, kind of feeling keyed up, feeling on edge. Easily fatigued. If you find that during the day, you're kind of so stressed out you notice you're carrying this fatigue. Muscle tension is a big one. It's kind of that chronic clenching, oftentimes tension headaches. We see that difficulty concentrating, irritability. Sleep disturbance is also a pretty common symptom to see there with anxiety disorders as well.

Dr. Jones: Well, look, can you talk about an anxiety attack?

Dr. Curtis: Yeah. So anxiety attacks or panic attacks, as opposed to that more kind of chronic, you see this for six months, it's tension, it's fatigue, panic attacks or anxiety attacks are very abrupt. They're very sudden, this kind of intense fear, intense discomfort. And we're not talking about months. With panic attacks, we're talking about it reaches its peak within minutes.

And so some of the physiology here, increased heart rate, sweating, it can be trembling, shaking, shortness of breath, feeling like you're choking, nausea, stomach upset, feeling dizziness, numbness. For some people, it's fear of losing control. They think they're going crazy.

And these sensations can be so intense that often people report that they feel like they're dying. They think this is very much a heart attack. If you've ever had one or experienced one, it can be extremely unpleasant and very scary.

Dr. Jones: Right. Well, you spend a lot of time and you have a great clinical interest in sleep. How does it manifest in their sleep? Do they wake up with panic attacks, or they just can't get to sleep, or all of the above?

Dr. Curtis: Yeah, kind of all the above. So nocturnal panic attacks, you see that in people with panic disorder that they wake up and it's almost out of the blue.

But in certain anxiety disorders near and dear to my heart, generalized anxiety, which since childhood, this is something I've dealt with, sleep disruption is one of those things we look for. So difficulty falling asleep, difficulty staying asleep once you do fall asleep, and restlessness, or unsatisfying sleep, those are one of the symptoms. And research indicates that around 60% to 70% of people with a diagnosis of generalized anxiety disorder also report difficulty sleeping.

You can also flip that to the other side and look at individuals with insomnia and what you see there. Things like pre-sleep worry anxiety in that pre-sleep period, both in the mind and in the body, that's very, very common. It has really straightforward treatment implications for what to do about that that are pretty powerful and they can be life-changing,

Dr. Jones: But how do family and friends help someone with anxiety? I had an anxious kid and it was tiresome to try to talk him down, knowing that I couldn't explain away . . . The thing that he was anxious about didn't always make sense, and sometimes I would lose my patience. So how do families help and not get in the way of someone who's struggling?

Dr. Curtis: Yeah, it's a great question, I'd say. Are you the only parent that's . . . No. I mean, for me too with our kiddos, having myself and Megan with our kids, we both are . . . we have this kind of anxious-driven tendency. And so this is something that I've been dealing with too over the past seven years.

Things that you can do is just notice that this is common. The prevalence here, this is not a rare thing. And anxiety is very adaptive. There's that sweet spot of we don't want too little. If I didn't have a little bit of anxiety, a bit of butterflies, I wouldn't have prepared that much for this podcast, right? I might not have . . .

Dr. Jones: Thank you. Thank you, Brian.

Dr. Curtis: You're welcome. But it's that sweet spot. If I was too anxious, that's when we can start dipping into, "We're spinning our wheels. We're not doing what we need to."

With kiddos, knowing that this is normal, and so being able to validate that, right? And if you notice that maybe they're struggling, they're really tense, their sleep is suffering, I'm just asking, "How are you doing?" Really open-ended questions. "What are you experiencing?"

We know this, and we see this clinically. There's something so powerful about a person being able to put a name to what they're experiencing. "This feeling is this. There's nothing wrong with me, but this is this thing called anxiety."

And so, ask. And if you ask, listen. That really supportive, nonjudgmental approach of hearing them out. And if they're asking for help, you can offer. But sometimes kiddos, and adults as well, we just want to be heard and validated. That's one thing we can do.

And if this gets to the level where maybe treatment or something clinically or more help is needed, normalizing it. No need for stigma. We have some great tools out there, and this is just part of our human condition.

Dr. Jones: Oh, that's helpful. It's my impression as a boomer, young people, people in their 20s and 30s, are experiencing it much more, or their parents taught them the word, so now they say it. But do you think social media makes anxiety worse, particularly for women?

Dr. Curtis: You can say, "Kids these days," Kirtly. You can say whippersnappers. So, definitely, even my own personal experience with this . . . And you can just check in, dear listener, if you're on social media. I mean, how was your anxiety before that came about? And then after, how do you feel when you're on it? There's been plenty of research. A review article last year looked at the influence of social media on things like anxiety, but also depression, psychological distress.

And as combined, the findings are suggesting that increased social media use . . . we're not just on there to bond and connect with people, but when we're using it to a significant degree, that is correlated with increased psychological distress.

And some mechanisms here that have been pointed to. As you mentioned, particularly with teenagers, particularly teenage females as it's turning out, problematic social comparison, comparing ourselves to other people. And we're only seeing these snapshots in 30-second clips of their life, but this might lead to envy. This might lead to anxiety, and this in turn can lead to things like depression.

Dr. Jones: Oh, this has made it all the way up to Congress in terms of whether Facebook is a source of mental illness, chronic anxiety for young women. And I don't know that I have enough information to know, but the photos that people put up there, they never show themselves in their worst like most of us see in the mirror. They show themselves to be something different. So I could see being anxious or envious or struggling, but they keep looking. It's addictive. People keep looking.

Well, where can people get help? In-person therapy is very expensive and time-consuming with travel and parking. It's hard to get help for this. So talk to me a little bit about online therapy for anxiety.

Dr. Curtis: First, it's really important. It's very important to know what the evidence suggests are effective interventions for anxiety disorders, because this will then directly inform your search for where to go about getting help.

Just to preface with a large number of controlled trials, it indicates cognitive behavioral therapy, or CBT, is the first-line treatment option for a number of anxiety disorders. If there's avoidance, things like avoiding feared situations, or phobia, bringing in exposure, actually facing that fear in systematic ways, these are the most evidence-based interventions that we currently have.

With that background, as you mentioned, in-person therapy, yes, it can be expensive, but also you're getting in the car. If you're a parent, you're getting the sitter or you're doing all this, you're driving, you're parking. And so this online therapy or telehealth, doing psychotherapy remotely using HIPAA-compliant audio or video, can be a really great option for a number of reasons.

First is that the research done on outcomes between telehealth and face-to-face tend to find similar outcomes. They're equally effective on average, and often patients report increased satisfaction with telehealth because it is more convenient.

And also, access to providers, especially if you're in a rural area, or maybe you have difficulties that it's hard to find a specialist, or it's hard to find somebody with that training, telehealth can really increase access to providers that might be outside of your geographical location.

Dr. Jones: Yeah. Well, I have a sib who's just really busy and he's online all the time for doing some of his really important work for the pandemic. He wanted to get some therapy, and he actually found somebody online and it's been really helpful for him.

I think if there's one great thing that that pandemic offered for us, it's telehealth. It's the ability to get some help without having to drive a long way and find a place to park and not have to dress up for it or all that kind of stuff. I think it's been helpful.

So let's talk a little bit about structured breathing and self-calming. There are new data from mice looking at why structured breathing actually works to turn down noradrenergic drive from the brain. So it's not just woo-woo. It's real stuff. So can you talk about that? Not woo-woo, real stuff.

Dr. Curtis: Yeah, the non-woo-woo, real stuff. Yeah, this is really understanding your physiology and being able to use these actionable skills to do something about anxiety or stress when they're in the moment.

The listener can play along and, Kirtly, you and I can do it now. But if you just use your index finger and if you go to the side of your neck, you can feel your heart rate there. Just notice it right now. If you can feel that kind of pumping, just at rest, as we're breathing normal. See if you notice any difference, just breathing normal as you inhale and exhale.

Dr. Jones: I'm calming down. In fact, I'm going to fall asleep here.

Dr. Curtis: Hopefully not falling asleep.

Dr. Jones: Keep going, Brian.

Dr. Curtis: It's kind of hard to tell any difference potentially if it's just normal breathing, but now we'll try a little experiment. So keeping your inhale the same, just at a comfortable rhythm, perhaps even inhaling through your nose, but on the exhale, the outbreath, let's breathe out of our mouth. Almost imagining that we're breathing out through a straw, our lips slightly pursed, kind of like we're slowly blowing out our birthday candles, slowly emptying out our lungs on that outbreath.

And then once the lungs are empty, just breathing in once again normally through the nose at that comfortable rhythm. And then we'll just repeat that together a few times, again, with our finger on our neck. Let's just pay attention to if we notice any difference.

So inhale through the nose, and then out through the mouth slowly, in through the nose, and then out through the mouth one last time.

Okay. What did you notice there, Kirtly?

Dr. Jones: Well, my pulse goes down. My pulse goes down, and I can't really think about anything else except doing that. So whatever [inaudible 00:21:05] going around and around in my head goes away because I have to pay attention to my breathing, but definitely, my pulse goes down.

Dr. Curtis: That's beautiful then. So the pulse goes down, and you can just be curious about this. Often, we see that on the in-breath, that's wired up to that fight or flight sympathetic part of our nervous system. So our heart rate can kind of increase, but on that prolonged outbreath using a slower exhale can kick in that parasympathetic response. We can see the heart rate kind of slowing down. And as we repeat that, we are using our physiology to slow the heart rate.

But as you mentioned, too, when we think about anxiety, we think about worry. By definition, we're in the future. We're planning. We're actually not mindful. We're not in the present moment. And so as we focus on the breath, we do these structured breathing, we're in the moment, right? We are not thinking about tomorrow, the podcast with Kirtly, the exam we have coming up, the presentation at work. It's just about our breath. And so in the moment, this can be a very useful strategy.

And also, we use this in insomnia, in that pre-sleep period, kicking in this parasympathetic response. It can be a really powerful tool. I use this quite a lot as well, as somebody who also has struggled with insomnia for quite a long time too. It's a really useful tool.

Dr. Jones: Well, I think there's structured breathing where you just breathe in and breathe out, but it's breathing out through the straw. It's breathing out with a little bit of pressure that seems to particularly kick in parasympathetic drive. It's not just breathing out through your nose or mouth. It's breathing out through the straw that, for me, lowers my blood pressure the most.

Well, we know that there are medications that doctors can prescribe, which can be very useful, but we also know that people medicate themselves often. Can you talk a little bit about that?

Dr. Curtis: Yeah, absolutely. So, as you mentioned, I mean, there are medications that your provider can prescribe. Due to the positive benefit or risk balance, SSRIs, those selective serotonin reuptake inhibitors, also SNRIs targeting serotonin and norepinephrine, these are the first-line medications for anxiety disorders.

Benzodiazepines are also prescribed, things like diazepam, lorazepam, but they're not as recommended because of adverse effects like dizziness, fatigue, impaired driving skills, these kind of things.

And then there's self-medication.

It is interesting, though, that current evidence suggests that about 50% to 90% of patients with anxiety disorders are currently being treated with benzodiazepines, so quite a lot of people chronically there.

But as you were saying, Kirtly, we can also self-medicate. So we're feeling anxious, we don't have a prescription, or maybe our prescriber won't write us a prescription, and so we turn to something like alcohol, substances.

And in the moment, they definitely can decrease our anxiety. These are an anxiolytics, these are sedatives, but the long-term consequences both of medication use and substance use . . . When we think about alcohol, there's the obvious adverse potential for something like addiction, tolerance, and everything that goes with that, danger to yourself and others if you're driving.

But a really key thing to understand about the things we do to manage anxiety is asking ourselves, "Are we avoiding anything?" If we're avoiding the anxiety, what is the function of that?

And over time, if we keep reaching for the medication, if we keep reaching for the alcohol, ultimately what the research suggests is that's preventing new learning from happening. So we don't allow ourselves the opportunity to find out, "Can we tolerate the anxiety in the moment?" Are all dogs going to bite? Is this podcast with Kirtly really this stressful? Or can we actually do something about it?

But this constant avoidance. It doesn't have to be meds. It doesn't have to be alcohol. It can be very subtle. But that tends to be one of the functions of medications of self-medicating when we think about anxiety disorders.

Dr. Jones: Yeah. Well, in the environmental domain, are there environments that make anxiety worse? I will say I live with someone who probably looks at the air pollution indexes several times a day and does not go out, gets a little anxious when it's bad. Are there other kinds of environments which are worse for anxiety? Noisy? Polluted?

Dr. Curtis: There you go.

Dr. Jones: I would think so.

Dr. Curtis: I think you would be right so. Yes, air pollution, but like you're mentioning, the knock-on effects there. Not going outside. We're more isolating ourselves. Increased noise, social chaos, all these things can impact our anxiety.

Interestingly, increased heat, social crowding, all of these can bump up anxiety. But what's really, really interesting, and it's a common finding, is it's not necessarily the heat or the noise or whatever it is. It can more be our perception of "Can we control the environment?"

So we can deal with heat if we feel like we have the ability to maybe turn down the temperature, to control the noise. And so can we do something about air pollution? Well, maybe not. We have minimal control. But what can we do?

And so the implications there, really being aware of what we can and can't control in our environment, can really have a dramatic impact on how we experience what comes up next. So if we can control it, awesome. Do that thing. Change that. If we can't, maybe something more like acceptance might be in order.

Dr. Jones: Yeah. I think I've had one panic attack in my life, and it was being in an airplane stuck sort of on a runway, not being able to get pulled back, and it was getting hotter and hotter in the airplane. Because the power was off, I couldn't adjust airflow. And I started to get very anxious. I mean, my heart was pounding. I was getting sweaty. I couldn't control it. And I think I've had repercussions, some little echoes of that.

And this only happened once in my life, but now when I'm in a hot airplane and I can't control the airflow, I can feel, "Oh my gosh, I've had this before. I'm going to practice my breathing. I'm just fine here. Nothing is happening. We haven't even pulled back." But it was really quite startling the first time it happened.

Well, how about our environments that make it better? The Japanese have this term called "forest bathing." That doesn't mean you're naked in the forest, but going for walks under green environments some people think can help people with their anxiety.

Dr. Curtis: Yeah, definitely. And the research tends to support that as well. So visiting green spaces, being out in nature, exposing yourself to natural environments. We can think of, "What would that do?" A, we are getting out of the house. We're being exposed to sunlight. There is less . . . When we talk about maybe electronic use or clutter, social congestion, we are out in nature. The evidence supports that that tends to have a neuromodulating effect.

Dr. Jones: Neuromodulating. I love that word, but that's a big word.

Dr. Curtis: That's right. So just decreasing anxiety to feel more relaxed in the moment. So green spaces, natural environments. But also when we think about when we are indoors and we can't get out, what if we're at home? What if we're in an office environment? Some research indicates that just decreasing clutter, making things feel organized. Again, that sense of control. Not being over-controlling, but there's something we can do about it, right? So decluttering can be one thing to decrease anxiety.

But a big theme here, too, is really just to test this out. Evidence has shown certain things can be useful, but you weren't in that study. And you're a unique human, like we all are, so finding that sweet spot for "Does going outside help you? What works in your everyday life?" can be great strategies moving forward.

Dr. Jones: Yeah, there's some research from the University of Utah, I think it's the Sociology Department, that looked at videos, like walking in a pretend video in a green space. So if you couldn't get out or you live in a place where there is no green space, just walking through a virtual green space seemed to calm people.

But let's talk about the spiritual domain. Well, kind of. I want to talk about courage. How would you define courage, Brian?

Dr. Curtis: How would I define courage? So I think the simple way is really putting ourselves out there doing something that we assume or we know, "This is difficult." This could be dangerous, this could be difficult, but we're actually going to face that. We're going to face some difficulty, to face some anxiety or discomfort, even though we know it's going to make us uncomfortable.

Dr. Jones: Right. Well, I think of the Cowardly Lion. Not everybody was raised on "The Wizard of Oz," but the Cowardly Lion was extremely anxious. But he could pull himself together to act for the benefits of others. And I think that is, for me, the demonstration of courage, when people know that they are putting themselves in emotional or physical harm's way, but to help someone else, they step up.

Dr. Curtis: Yeah. "Wizard of Oz," that was my number one. Cowardly Lion, absolutely, near and dear to my heart.

Dr. Jones: Yes. But people with generalized anxiety to get up and go to work every day and find it in themselves to help others actually defines courage. But it also is a way that they can treat their own anxiety. Being part of something bigger than yourself helps release neurohormones that can often be self-affirming, being part of something bigger than you rather than the natural tendency to become small, to shut out, shut out, shut out. To have the courage to take that step is often one of the biggest first steps to managing your difficulties. That's my take on it.

Dr. Curtis: Well, I would say not only your take, but that is the center of the center of the bull's eye in terms of the clinical approach, which is those things we're avoiding. That airplane that we felt trapped in, claustrophobic heat, being able to not miss that flight to go out there.

If you are socially anxious, putting yourself out there and giving that presentation or talking to that group of people, because it's important to you. This is the life you want to live. I completely agree. That is courage, that is strength, and that's a beautiful thing.

But anxiety is uncomfortable. And this is a human response that we want to avoid things that are uncomfortable. But being able to do it anyway, that is center of the bull's eye in terms of what'll help us decrease that anxiety over the long term.

Well, that's a perfect segue to our "7 Domains of Anxiety" haiku. I want to offer many thanks to our clinical psychologist, Dr. Brian Curtis, for our conversation about anxiety. The "7 Domains of Health" topics are meant to start a conversation with people you know and love about how you can help yourself and others.

We'll end with the "7 Domains of Anxiety" haiku.

Your mind lies to you
Take deep breaths and hear the truth
You are brave and strong