(upbeat music) - Defining anxiety
disorders can be tricky. What are anxiety disorders and when does normal anxiety become a clinical condition? Dr. Ramani answers these questions in today's episode of our
anxiety disorders series. Dr. Ramani, can you define
normal anxiety for me? - Normal anxiety is
appropriate to the situation. It's worry, it's a
response to uncertainty. If a person is facing a stressor
where there's an unknown an exam, a deadline at work, there should be some
worry, it motivates us. In fact, a normal curve that associates anxiety and performance, it
shows it's an upside down U. There's a top of that curve, you get optimized performance. That's where anxiety is sort of at this perfect mid-level. Just enough to get you off your butt and make sure you study
and your mind is sharp. So anxiety can actually enhance
performance to a degree. It sets some stakes in there, and then again, if we're
having a stressor in our life, it's appropriate to be anxious, 'cause it leads us to mobilize resources. We don't say, I got an exam, I think I'm gonna take a nap. We're like, I have an exam, I better study, I better focus. And it activates us. So that's normal anxiety,
it's appropriate worry about the things in life and that when that issues resolves, we sort of let go of some of that anxiety and move on to the next thing. If we stay in a situation
of anxiety for too long, almost like our sympathetic
nervous systems, our fight or flight, is
activated for a long time, that's not good for our health. It releases stress hormones, it wears us down physically
and psychologically. So there's a point at which when the thing we're worried about passes, that we let it go. That's normal anxiety. We all have some of it, it's what gets us out
of bed in the morning. - And so, I think there's a
lot of people that would say, or think, that we shouldn't have anxiety. Any time they feel anxious
they go ope, this is bad. This shouldn't be happening. - We're all, I mean, in the modern world, we're all going to have a little bit. I have to say, it's getting worse, 'cause now we even have anxieties around, what do you people think
of my social media posts and things that, that to me, that's actually rather wasted anxiety. It's really about things
that have to do with maybe survival needs,
taking care of your family, taking care of your job,
making sure that things are sort of running on
time, and when that's, that demand is higher, for
us to be a little anxious, like I said, it can enhance performance. But to live with no anxiety, that would be a little bit problematic,
'cause anxiety also creates a little bit of a check
and a balance system in us. It makes us aware. Self-aware and aware of others. Like, I want to make sure
I say the right thing. I want to make sure that I'm on time. Like, there's an awareness of it. When we talk about the
absolute absence of anxiety, we're actually talking about psychopathy. A person worries about, like hey, I'm willing to take your
wallet and shoot ya, because I'm not worried. You know, that's the most
extreme example of it. Obviously, when you're
just having a good day, and things are moving along, you don't need to expend that much worry. I wouldn't call it
anxiety if you're saying, oh, I want to be on time to school, you get in the car, you go. That's something you have over-learned. But, if it's a day you have
a test, and if you're late, for example, and being late
will mean you'll have less time on the test, that anxiety
might mobilize you to say, I better leave a half-hour earlier today. You might feel that little
churning in your tummy. If that enhances performance,
it's not a bad thing. - So, you're using the example of a test, and when I was in college
a lot of people said, oh, I get a lot of anxiety around tests. I did too, but it didn't inhibit me. - Right. - Are there people who can have
too much anxiety for a test? - Absolutely. In fact, test anxiety
and treatment programs on test anxiety, they're
all over universities. They're offered all the
time, and it can get so bad that the person freezes during the test, and then they don't
pass and it's not really a valid indicator of how
much they know that material. And that's heart-breaking to witness. So, there'll be all kinds of programs, including time management,
breathing, preparation, sitting in the right
part of the classroom, I mean, all kinds of techniques. But a lot of it's self-talk. - So, from a simple
standpoint, anxiety is normal and it's not bad unless it is causing you to go through some
undesirable consequences? - Yes, unless it's causing you a sense of subjective distress. You feel uncomfortable. I don't want to feel like this. Or, it's causing you
some form of impairment. You're not doing well on the
test, it's getting in the way of your relationships, people
are like, you need to stop, you're obsessing over this. Other people are noticing,
it's what we call, when it causes significant
distress or impairment, that's when we start thinking
of the anxiety as a problem. - As a disorder. - As a disorder, yeah. So, can someone have an anxiety disorder without ever have gone
through normal anxiety first. - So, the idea that when a
person has an anxiety disorder, they likely have always
run somewhat anxious. If you sort of scroll back on
the life histories of people who have anxiety disorders,
you're gonna probably see a pretty tightly-wound kid. They tended to be anxious as children. They'd be anxious about
school performance, they'd be anxious about their friends. They might be anxious about what other people think about them. So you would see a person who
probably, temperamentally, ran anxious all their lives. Now, how much of that was
inborn, how much of that they may have learned from their families, they might have had an anxious parent. Obviously to fully tease
that apart is difficult, but anxiety tends to be
sort of a life-long pattern that can get really enhanced
in adult and blow up in adulthood and become
more of a disorder, and you can see teenagers,
maybe to some degree children, who have anxiety disorders as well. - And we're gonna get into
this more in later episodes, but at any point in life we
can develop anxiety disorder? - Yes, and that's where anxiety disorders are very, very interesting
and quite different than a lot of other mental illnesses. For example, if you look at a
disorder like bipolar disorder at the age of 40,
someone's not gonna wake up and then develop bipolar disorder. That's something that would
have been set probably by their late teens,
early to mid-twenties. With an anxiety disorder,
it is quite possible that a person could develop
a phobia later in life. A person could develop
generalized anxiety disorder later in life. A person could develop panic
disorder later in life. That can happen. It's still not normative. By in large, a lot of these
paths do get set early in life, however, life happens. And let's say a person all
of a sudden experiences tons of stresses, a
divorce, the loss of a job, the house burns down, whatever happens, family member gets sick,
and it just gets all to be too much, it's
not unusual for a person to have that happen. In fact, generalized anxiety disorder, the average age of onset is about 30, 31. That's a later onset than
most mental illnesses. And that's a problem
because it averages out, there's people out there
who are having their onset later in life, 40 or 50 years of age. - Wow, the average age for
generalized anxiety disorder onset, 30, 31. - 30, 31, which is late
for mental illness. - Wow.
- Yeah. Which makes sense, life is
starting to happen, right? You're no longer a college
kid going to a keg party, you're like, oh, there's
these things called bills and I've gotta get a job,
and the world expects something of me, I'm
supposed to get married. The expectations start
ratcheting up, and that's where sort of the rubber meets the
road on the anxiety disorders. - Really fascinating, and
that makes perfect sense. I'm really excited in future episodes to dive more into that. Now, you mentioned in episode one, that anxiety is the most
common mental health disorder, and it often is co-occurring with other mental health problems. What other co-occurring diagnoses
do you see anxiety with? - Most commonly, you'll
see anxiety disorders co-occur with a mood disorder. So anxiety and depression together is a very common combination. There are theorists out
there that actually think that division between
anxiety and depression is somewhat artificial. That it's similar processes in the brain, and that, in some ways, it's
just a manifestation difference where one person might become very sad, another person might become very worried. And in fact, rumination is
often a big part of depression. So, that's almost like
difficult to tease out, but we'll often see those
two hanging out together. - What is rumination? - Rumination is when you sort of get stuck in a obsessive rut of thinking. Typically about the same thing
over and over and over again, you can't let it go. It could be something
that happened at work and you can't stop thinking about it, it could be a falling out with a friend, and you can't stop weighing in your mind. An argument you had with a partner, and you just can't break out of it. For people, it's normal for a little while to say, god, I wish I didn't say that or I wish that didn't happen, or how could she have done that? But then over time, other
stuff comes and we sort of let it go and we move forward. For a person who's
ruminating, they can't let go. And they'll do that with everything. It'll be, did I look at
that person the wrong way? Did I park in the wrong place? Do you think they like me? Did I say the wrong thing? It tends to be more self, in anxiety, it tends to be more self-blaming stuff. Did I do the wrong thing? Did I make them uncomfortable? So, it doesn't, that's where it has a very specific flavor to it, that we'd almost label as neurotic. - For how long does
someone have to ruminate for it to be considered
neurotic or too much? - Same thing. Is it getting in the way of their lives? That's where we would, you know, and here's where it gets challenging, some people ruminate a lot,
and they start withdrawing. They start keeping to themselves. They don't talk to other people as much, they cut out from their lives. So we may not even notice it as much. But people around them
might say hey, this person doesn't come around, have they called you? They're not showing up
to family gatherings. If they live with people,
they'll notice a change. So, it might be just other
people noticing changes in their rhythms, but when that
rumination gets in the way, they can't talk or think
about anything else, and it's really causing
them problems at work, with friends, family, that's
when we start paying attention. - Do you think that people
are aware that the rumination is getting in the way of their life? - I do, I do think people are aware. In anxiety disorders,
insight is very preserved. People know this is too much. They can't stop it, but
they're the first ones to say I know this is disproportionate,
and I can't stop it. And that's where anxiety disorders
can be rather paralyzing. Because the person feels
like they can't let it go. They can't stop worrying. It's a very helpless feeling. - And that would give
me anxiety, I feel like. - Yes, exactly, it's a feedback loop. It just keeps going and going
and it just sort of spirals. And that's where it's so
painful, because I think I see people, and no matter
how many times you try to give them the
counter-argument, if you will, they will, they're still sort of stuck in their interpretation of events. And a lot of the work in anxiety disorders is helping teach them new interpretations. - Now, we've talked about general anxiety. How many different types
of anxiety are there? - There are different
types of anxiety disorders. The most common are actually the phobias. And the phobias are sort of
divided into three groups. The specific phobias, social
phobia, which we now call social anxiety disorder, and agoraphobia, which is sort of on it's own,
because it often hangs out with it's friend panic disorder. Panic disorder is another
form of anxiety disorder. Then there's generalized anxiety disorder. So these disorders are all
characterized by anxiety being the key element of the disorder. The phobias have a very
specific form of avoidance associated with them. So people with phobias avoid the thing that they are afraid of. People with panic disorder have a very strong
physiological experience, which can lead them then
to pull out of life, because they're having
these panic attacks. And then finally,
generalized anxiety disorder, is sort of a wide ranging,
wide reaching anxiety about a variety of issues. But it really has to be
around for a long time, for about six months or so. So let's say a person's
going through a rough time. Their mom is sick and in the hospital, and they're worrying about everything. Who's gonna pick up the kids, who's gonna go to the hospital? That only lasts for three or four weeks, we wouldn't diagnose that as
generalized anxiety disorder. We look at it being over a
wide range of activities, sort of disproportionate to
the level of the stimulus, and very persistent. - You mentioned agoraphobia? What is that? - Agoraphobia, people sometimes say, it's the fear of open spaces. So the person's like, I
refuse to go into a field. It's not. It's fear of being in places from which escape would be difficult, help would be difficult to get, and there's a possibility that they could embarrass themselves. - But that didn't get
it's own category, right? - Agoraphobia is it's own. - It's its own section?
- Yeah, but agoraphobia almost 90% of the time, co-occurs with panic disorder. And think about it, if
a person is starting to have recurring panic
attacks, and they don't know when those attacks are gonna happen, in other words, they're
spontaneous, then what happens is they get scared, I don't want
to go to the grocery store and have this happen, I
don't want this to happen in a movie theater, I
don't want this to happen in the middle of the
warehouse where I'm at work, or at school, so what would
that person start doing? They'd stop going to those things. And one day, before you know
it, they could look up and say, I haven't left the house for months. Or, if they do go out of the house, it'll only be if somebody's
willing to go with them and stay with them and reassure them. So it's very specific, it's that fear of being in situations where help may not be readily available,
or escape won't be easy. - Wow, that sounds so difficult. - It's so debilitating,
it's heartbreaking. It's really, really heartbreaking
because agoraphobia, that agoraphobia-panic
combination can often occur when a person has a significant
stress or loss in their life so for example, someone
in their life dies, or they go through a really stressful interpersonal experience,
like a painful divorce. That can be accompanied by panic attacks, and then before you know it, that person will find themselves having almost completely
cut out from life. So, they're missing out on the opportunity for connecting with
other people, for coping, and now days, I'm gonna
be honest with you Kyle, agoraphobia's getting easier. Because people can Amazon Prime it, they can order stuff online, they can get on social media, so they can almost get that
sense of ah, I'm in the world, but they're not leaving their house, where the fear of a panic
attack always looms. - And are they aware that they haven't left
the house in a month? - Oh yeah. They're definitely aware.
- And that feeds the anxiety? - Yes, yes. - It's like, oh gosh, I haven't
left the house in a month. - And that's what so
many mental illnesses, what's heartbreaking is there sometimes can be a sense of shame, you know. And that's the devastation,
as I'll always say on MedCircle, there's
nothing to be ashamed of. These are all sort of the things
that happen to human beings and people won't leave, and
they'll sort of withdraw even more, so that's also, that can also get really really tricky, because part of being a human being is, even the little things of life. Even going on a walk
around the neighborhood starts to become very difficult. - Well, I love, I forget which
video it was that we've done, but you said that all of these diagnoses, whether it was a panic
disorder, general anxiety, social phobia, it's just the tool to find the right treatment, it's not this label that we go
hey, this is who you are now, so sorry about it. It just goes, this is the steps, so we know the steps to take after. And that gives me some stress relief. - Well the difficulty is is
that sadly in our society, mental illnesses and these
labels still carry some stigma. So if you went to the
doctor's office and they say, ah, you have a bacterial infection, you'd be like, cool,
I'll get my antibiotic, go home, go to bed, take some. But if you go and see a
mental health practitioner, and you're told you have
an anxiety disorder, social anxiety disorder,
you might feel like, you know, you'll cringe at it. It's not exactly what you'd consider dinner table conversation. And to me, whether a person
has a flu, arthritis, a stomach ulcer, or depression, they're just illnesses. - That's right. - And they're all manageable, and they don't define the person. - Well, when we were talking about, we knew we were gonna do
this series on anxiety, and we knew we would find,
or we knew you were an expert at social anxiety, and
we thought, you know, wouldn't it be great if Dr.
Ramani could find somebody who could work with this
person who has social anxiety and we could film it and blah blah, and I didn't immediately offer myself. Because I go, do I really
want to bring that out? Do I really want to tell,
maybe three million people, hey, I was diagnosed with social anxiety, and now watch a therapy
session of me dealing with it. And I thought, I have to,
because I can't be here talking about how we're
breaking down the stigma, how people shouldn't be ashamed of this, this is just a method,
and so finally I said, guys, here's the deal, and I
explained what was going on. Because I get it. I get why people are afraid, but I also understand
why they shouldn't be. - But look how, just by
coming clean, if you will, or sharing it with the world, look how many stereotypes you break. - Right. - You are willing to go on camera, and your words will
reach millions of people. That completely flies in the face of what we think social anxiety is about. So I think for people to
understand, this is not just a person who's a quivering
nerve in the corner, that this can have many manifestations, and that then people feel embarrassed, well no one's gonna believe
I'm socially anxious, I'm on TV, you know? So it helps people see that,
there's a wide range to this. I've worked with clients who are actually brilliant salespeople,
and socially anxious. - I get it! - You know, and to me, doing a sale, I would have a panic attack
if I had to sell something. But I could speak in front
of 10 thousand people. - Yeah, well I am very
excited about our session. If you wanna see that, make
sure you go to MedCircle.com and sign up and we will send it to you. Now, we talked a lot
about what anxiety is, the different types of
anxieties, what isn't anxiety? - Okay. - What is not. - What is not anxiety is,
what we call normal anxiety. Being worried when it's, being worried when it's April 14th and you haven't started your taxes. That's not an anxiety disorder, that's like start worrying, now. - Yes.
- You know. This is, it's the, you know,
two hours before a final exam and you haven't studied yet, worry. So, when you say, oh gosh,
I'm worried about my exams, I must have an anxiety disorder, no. If a person says, I'm really
afraid of snarling dogs, we're not gonna call that a phobia, okay. If a person says, I don't
want to go to a theme park, but I'm willing to go to a
movie theater, grocery store, that's not agoraphobia. So, they don't tend to be that selective. Anxiety disorders, by definition,
tend to be more sweeping. So, this idea that I'm
afraid of one thing, may not mean that you have a phobia. A person who says I don't like big parties may not mean you have
social anxiety disorder. So it really is a matter of degree, it's also a matter of
how much it generalizes. And that's when we think
about whether or not it's truly an anxiety disorder. Because what we don't want to do, is we don't want to
medicalize and diagnose and sort of label the normal responses to difficult situations,
because that's when people start second-guessing
themselves and saying, well maybe I'm broken because I'm anxious. I'm like, well you better be anxious, you're going through a lot, that's a very appropriate reaction. So that's what we always want
to be careful in all of this. - Yeah, I like that a lot, because if we did start
diagnosing every type of thing, then it also minimizes
the other diagnoses. - Yes, I think so, I think so. And I think people just
wonder how much is too much? And some people are actually living under tremendous amounts of stress. Whether it's because they're
having trouble keeping up with their income, or
they're having significant relationship problems, or
somebody who can't pay down their student debt, or
something like that. You know, those are big problems. And so, if a person's worrying about them, and then they think they
don't have the right to worry about them,
that's concerning to me, because I do think a person has a right to any emotion that they're feeling. - Yes, your right to anxiety. - Yes.
- I like that. Is there any research being
done on where anxiety disorder is most prevalent in the world? - Interestingly, in the United
States, anxiety disorders are the most common
form of mental illness. That's not the case all over the world. In much of the rest of the world, mood disorders like major
depression are the most common. - I wonder why. What's the differentiation? - You know, I wonder how much
about the American condition, I mean I think this is
a competitive society, that there may be some
things built into our culture that may foster anxiety. It could be that, also,
maybe a lower acceptability to endorse depression,
and I think many times a person enters a health care provider or a mental health care provider's office with sort of generalized medical, or psychological issues, I should say. A lot of times, they might
focus more on the anxiety, than on the sadness or something, too. But that is an interesting distinction, that it is for the United States, that the anxiety disorders
are the most common, but that's not the case
all over the world. - Is there any information on
which demographic of people may have more or less
anxiety than the other? - Here's an interesting one. One thing that has sometimes
jumped up in the literature is that sometimes people
with more economic resources suffer a little bit more from anxiety. And that may very well be,
because a big part of anxiety, is a sense of control. When your sense of control
is being nipped at, that's when you feel more anxious. And there is some belief, that
people who have chronically been living in poverty, or
have fewer economic resources, they've almost adjusted to being buffeted by the randomness of
life, and they don't feel as anxious about it, they're
like, oh it's just another, just another day in paradise, you know. And I sometimes wonder that I've, I work with students, I take students, for example, to India every year. And, we sometimes see these families living under stressors
that seem insurmountable, but what I'm not seeing a lot
of there often, is anxiety. I'm seeing other manifestations, but not the kind of anxiety
I certainly would feel, if I had the level of uncertainty that they had in their lives. So, the sense that I've had a
life where I've had some sense of control over things in my life, that means that if any of
that control's taken away, my likely response is anxiety,
because at some level, I must think that I can fix it. - Wow. Wow, I know this is so juvenile, but more money, more problems. - Amen boyfriend, amen. That's exactly what it is, That's exactly what it is. - Well, what everybody wants to know, and what we've touched on
here, but we're gonna dive into more detail on, is what causes anxiety. So that will be coming
up in episode three. Of course, you can get the full series by going to MedCircle.com, and also see our mock therapy session, very excited for that. Thank you so much for watching. You can access more
videos just like this one using the links in the description below, and remember you can subscribe
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