S1E9: Anxiety Breakdown 2: When it goes wrong and how to control it

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Transcript S1E9

This is It’s Like This podcast with your host, Dr. Uejin Kim, a dual board certified child, adolescent and adult psychiatrist. If you want more understanding and control on mental decisions and options in your life, this podcast might be for you. By providing fun analogies, real stories, and empowering messages, I want you to have the tools to live your best life and thrive.

In this episode, we're going to be continuing the discussion of four elements of anxiety. And I'm going to narrow it down to two elements of anxiety that are most problematic. And then I'm going to give you three good questions for you to consider to start your mental health journey so that you can control this anxiety. Another aspect to kind of break down, you know, what is differentiating factor between anxiety and anxiety disorder? Okay, there's two things that goes wrong and anxiety that most likely leads to anxiety disorder. Number one is threshold. And the other one is compensatory behaviors. And the reason why these two elements are most commonly problematic is because they're personal. So, everybody has different threshold, and everybody has different compensatory response. So, it's individualized. But fortunately, these are the two areas that we can control. So, think about it, we cannot control the trigger, we cannot control the fight-or-flight response, that's just programmed in our body system. But threshold, and compensatory behavior can be changed. So, there's a hope there. Anxiety becomes problematic when our threshold sensor becomes broken. So, remember, threshold is, you know, everybody has a different threshold, and the threshold can change over time. But when it misfires and sets off the response very frequently, because our threshold sensor is broken, then it starts to go off not only in threatening situations, which is helpful, but also in non-threatening situations. And this is usually when other people, you know, describe that person as that person is obsessed or worried about nothing, or everything.

Let's think about this, why is a broken threshold sensor a problem, and there's two aspects of that. And number one is sustainability, when your threshold of threat or fear is very low, you know, fight or flight responses sets off more frequently and for a longer period of time. So imagine if you're worried about, you know, brown bear, and if your threshold is so low, that anything brown or anything that resembles like a bear or even a teddy bear sets off a fear response, fight-or-flight response, then how many anxiety attacks are you gonna get, you know, in a week, you know, versus a person who has, you know, threshold only for brown bears in the forest? A lot often,. And know that, you know, whenever the fight-or-flight response is off, you are still running away, like it’s a real bear. So, every episode is like you're running for your life. And imagine running away from a bear not only for a few minutes, but for years. Can you just imagine how unsustainable that is? At a certain point, even your essential organs like heart, lungs, and your muscles will not be able to sustain that level of intensity, and your body will start to decompensate. And imagine into state you haven't nourished your body or digested anything slept or rested or even went through the healing process. So, this is why life with anxiety is a life of pure brutal survival and escape, you’re always on the run, you’re always on the edge. It's very, very tiring. And this is why when the threshold sensor is broken, and you're going off on fight-or-flight response on regular basis, your body and your brain cannot sustain that. Now second problem with broken threshold sensor is that it’s also contagious. So, you were at first worried about brown bear but now is polar bear, grizzly bears, and black bears, and they're all over the world. Every time you encounter another painful or threatening situation, the anxiety starts to expand and the list of things to avoid, things you can't do, things should be prepared for start to grow and grow and grow. So, for example, if you have social anxiety disorder, your anxiety only pertains to social settings. And then you encounter another “bear” or a cancer diagnosis. Now you have new bears to watch out for, like your health, and of course health of everyone else you love. So, when the sensor is broken, not only are you setting off the fight or flight response frequently and for longer duration, it’s also contagious. And it doesn't only get limited to one sense of threat, it’s sensing threat in every situation and every aspects of life. So, for me, as a psychiatrist, it is not uncommon for me to see a patient who initially had more specific anxiety and worry, but develop into more generalized anxiety tendencies. The second aspect of anxiety that was more problematic is compensatory behaviors. You know, the examples of hyper vigilance, avoidance, hyper arousal, and mind racing, right? So, the goal of compensatory behavior was to minimize the probability of the threat and it was to gain the sense of control over your environment. Compensatory behavior is very helpful. It contributes to your surviving and has evolutionary benefits so that you don't go into another threatening situations again, but this becomes a problem when the goal is no longer to minimize the probability as much as possible, to abolishing any signs of threat. This extreme goal of compensatory behavior is what makes this problematic. Reality is that is impossible to be threat or pain-free in life. You know, we have plenty of sayings, you know, life gives you lemons, and that's a euphemism of like, very crappy situations, you know, in life. And that's the reality and it’s impossible to know all the possible future threat or pain. But if the goal of compensatory behavior is to abolish any current or future threat or pain, it’s going to drain you to the ground, because you're spending all the current energy and time for possible future threats. And the compensatory behavior. Remember this, this avoidance, mind racing, you know, hyper arousal, and hyper vigilance is not just something that is checkmark done, it takes a lot of effort and energy. So, a compensatory behavior is going to start to take over your life. So, imagine, like you’re hamster running in a wheel away from an imaginary predator behind you, you're going to be running and running and running. And you're not going to really get much out of it. Because like we said, the reality is that it’s impossible to abolish any and every threat and pain in the future. And this is another way that anxiety starts to take over your life. You know, I had a patient with generalized anxiety disorder, and she has a three-year-old son, and this three-year-old son, a bit of friend at a daycare and, and she was so worried that he will do it again. So, she shared a story with me one day, that she saw her son about to hug another kid. And then she stopped him, because she thought that he will bite another child again. And we kind of talked about it and our goal was for her to be a parent who allows her son to hug whomever he wants, without, you know, fear of all the potential consequences. So, if I were to break it apart, you know, the trigger and the compensatory behavior in this scenario, trigger was her son getting close to another friend with open arms. And she saw that, and the thalamus collected all the evidence of possible threat, set off the fight or flight response. Now, the threshold was really low because her son getting close to any other peer, his peer was a trigger. So, through therapy and through exposure, we will need to increase our thresholds so that our threshold is increased to the level when the toddler is getting to the friend, ready to bite, or only when the toddler is getting close to appear when he’s really upset. So that will be an appropriate threshold level. That should be our goal. Now, compensatory behavior in this case was hyper vigilance, always on the lookout for what the toddler is going to do. And hyper arousal, being on edge and at this time pulling the son away. It was a physical response to the threat. So, an appropriate compensatory response along with, you know, recalibrating the threshold would be decreasing the level of hyper vigilance and hyper arousal whenever she’s watching her toddler play with other kids. And in the name of love, anxiety drains life of those around you. And I'm sharing this not to guilt trip, a person who's already suffering from anxiety. But also know that this is a little bit. This is why mental health is a little bit bigger than individual problem. And this is why it's so important to get help is so important to call it for what it is, and get help for it. Because not only do you deserve control, and life that thrives, but people around you deserve to see you thriving. So, I just want to kind of share this message to encourage you, you are worth everything. Well, I know that you don't want to live like this. And you don't need to live like this. So now I'm going to be asking you some practical questions to escape the cycle of anxiety. And I've kind of broken into three parts. So, number one is count the cost. So, question is like in the gain of attempting to know any and every bad thing or pain and being prepared for it, what did you or what are you losing? So, in the gain of having somewhat certainty of future, you know, by running the what ifs for running the worst-case scenario, what did you lose? And in the gain of everyone having a good opinion of you, what do you lose? Every mental decision has a benefit and a cost. Anxiety tricks you into thinking, if you know all the what-if situations, if you know all the bad things that are gonna happen and prepare for it, you will be good. But actually, that's not true. And again, of that you are losing something, you are losing your life being present, and in current moments with the people, you love people who care about you. You're losing a losing battle, there's impossible to know everything. But somehow you spend all the energy and resources you have to be prepared for anything. So always know that there's cost and benefit of every mental health decision in your head, and count the cost of anxiety in your life. And I like this exercise because at a certain point you will decide this is not worth it. Number two is acceptance. Are you willing to accept that you cannot know everything, or prepare for every single thing life throws at you? Are you willing to accept that maybe that was never your job. So, a lot of times anxiety makes us live in the future, and live in fear of everything, because you cannot control the future. And that is a very thing that you're trying to control. But let's shift the focus from future to present. Anxiety sometimes, you know, when you're spiraling down, and you get in the cycle of anxiety, and you're trying to control the future or other people and you cannot, there's a sense of hopelessness, right? And because of the impossibility of your desire, but the reality is that you're not really powerless, you actually do have power and control over your life. But that is in the present, not in the future. And you can try your best in making the best choices in the areas that they you have control over? And are you willing to accept that that is good enough for you. So, an example like this, I mentioned in a previous episode, is a serenity prayer. And this was a prayer that is done usually by, you know, Alcoholics Anonymous and other anonymous groups. And it goes like ‘God, grant me the serenity to accept the things I cannot change, courage to change the things I can, and wisdom to know the difference.’ So, this is kind of emphasizing that they are things that you cannot change, but they are things that you can change, and it really takes wisdom and maturity to know the difference. So, are you willing to accept the things that you cannot change? Are you willing to accept things that you can? And are you willing to accept that it's okay to just change what you can? And number three is about imagination? What would it look like to be free from anxiety? What would it look like to only get the benefits of anxiety? But let go when anxiety becomes detrimental? What would it looked like to be aware and engaged in the present? What would it look like to run, have fun, and be spontaneous? So, I liked this exercise because when you visualize you, the same person you, without the burden of anxiety, you start to visualize, I think I can do that. I think I can be happy with that. And I liked this exercise. Now bonus question is kind of like and what would it take for you to be you without anxiety, what do you have to give up? What is holding you back? What is motivating you to change? And why is it worth it? And are you ready to make those changes. So, in summary it’s like this anxiety manifests by different elements trigger, threshold, response, and behavior. And not all anxiety is automatically a disorder, it becomes a diagnosis when it affects your level of function. And it starts to expands to different areas of your life. And the two elements out of the four that are most commonly problematic are threshold and compensatory behavior. And threshold becomes an issue when threshold of threat is so low and assess of the fight-or-flight response more frequently, and for longer period of time, because it's not sustainable way to live, and it’s also contagious. And compensatory behavior starts to become problematic when our goal is not just minimizing the threat, but abolishing any future threats. And this becomes a problem because it's impossible to do that. And I shared, you know, three questions. What is anxiety costing you? Are you willing to accept the things that you cannot control and accept the things that you can control? And accept that that is good enough? And are you willing to imagine you being you without anxiety? Are you willing to imagine the freedom? Again, anxiety is something that I personally struggle with all the time, and just know that you're not alone, and that there's no good and bad, you know, mental health issues? You know, anxiety in itself had a very beneficial evolutionary benefit. The whole point is, is we need to maximize the benefits of anxiety and fear, minimize the disadvantages of anxiety. So, I hope this podcast episode was helpful for you. And thank you so much for all the feedback that I've been getting. You think that how I explaining CBT concepts and mental health is so cool and helpful. So, thank you so much. And let me know if there's anything else that you want to listen to, you can email me at restorepsychiatrymd@gmail.com. You can record on the SpeakPipe link below and just kind of tell me what you want to know more of. In the next few episodes, we're going to be exploring some of the flavors of anxiety, like different flavors like perfectionism, mom guilt, you know, social anxiety and what to do about that. So, I hope you stay tuned for the next few episodes. And thank you so much for being here, and I'll see you next time.