Understanding Anxiety Disorders – Podcast

Nicholette Leanza:

Hello, and welcome to Convos from the Couch by LifeStance Health. I’m Nicky Leanza, and on this episode, we’ll be talking with Rachael Polakoff, who will help us understand anxiety disorders. So welcome, Rachel. Thank you for being on.

Rachael Polakoff:

Thank you so much for having me.

Nicholette Leanza:

Yep. Now, we know, as clinicians, how prevalent anxiety disorders can be. I recently saw a statistic from the National Institute of Mental Health that anxiety disorders among adults in the year 2021 was 19%, so that’s a big chunk of adults struggling with anxiety disorders. So it’s really great to have you on to help us understand these disorders a lot more, so I appreciate it. So can you tell us a little bit about you and your specialty in anxiety disorders?

Rachael Polakoff:

Certainly. So I’m Dr. Rachael Polakoff. I trained at the University of Hawai’i Mānoa, and while I was there, I was trained in exposure and response prevention therapy by one of the doctors that had worked with Judith Beck, so I feel like I got pretty good training there.

Rachael Polakoff:

After that, I went to Kaiser Permanente, South San Francisco, to do an addiction medicine fellowship. And while I was working with folks with substance abuse disorders, I saw a very high comorbidity of anxiety disorders that’s, I want to say 35% comorbidity, something like that, between anxiety and substance abuse disorders, so it’s very common.

Rachael Polakoff:

And now, I’m with LifeStance Health. I’ve been with the company for almost three years, and we were acquired after a certain point, but it’s the same team for us, which is great, and we see teens and adults. I would say that my specialty is adults, but I do see a lot of teens. And when you were talking about the rates in adults, the rates in teens is actually a little bit higher, and a lot of that is because of the stress of the pandemic, which has put a lot of toll on our young people today, so I’m also very interested in helping young people through anxiety disorders.

Nicholette Leanza:

Right. That’s such an excellent point, just the toll it’s been taking on our youth in general, is so key, so thank you for mentioning that as well. And as we continue with our episode today, I’m sure we’ll talk about more tips on how to help individuals navigate anxiety, for sure. So to start us off, can you tell a little bit about, what is an anxiety disorder?

Rachael Polakoff:

Sure. I mean, a lot of people wonder, am I suffering from an anxiety disorder, or am I just stressed or burnt out? How can I tell the difference? So I would say one thing that we should talk about is the different types of anxiety disorders, because you could be suffering from one, you could be suffering from six. There’s a lot of-

Nicholette Leanza:

[crosstalk 00:03:07].

Rachael Polakoff:

… [crosstalk 00:03:07], so we have generalized anxiety disorder, which is when you feel that excessive, unrealistic worry and tension with little or no reason. And what makes it different than a stress-related incident is the duration, right, so we have a significant impairment and then it goes on for more than six months. There’s a really great inventory, the BAI, which measures this, and it’s a nice tool you can give in session with clients. And generally, what gets endorsed is, I have difficulty controlling the worry almost every day for at least two weeks, and then that needs to continue on for more than six months to get it out of the adjustment disorder zone, so basically, you’re looking at duration as a real criteria.

Rachael Polakoff:

We’re also looking at the degree of impairment. You probably know those people who are very low-level stress all the time and they may or may not have anxiety disorders, but generally, they wouldn’t meet the criteria if they’re not causing impairment in their life, right, so it’s half the cause, significant impairment in work, school, and home, so that’s generalized anxiety disorder.

Rachael Polakoff:

Building off that, we have panic disorder. Most people don’t just start off with panic disorder. A lot of them have generalized anxiety disorder first and it builds into that with a traumatic event, so that is a physical symptom. You feel that intense fear that brings on a panic attack, you have sweats, you have chest pain, and that pounding heartbeat.

Rachael Polakoff:

Moving on, we also have social anxiety disorder. This is something I see teens struggle with a lot, especially with the pandemic. We have specific phobias. I treat those a lot. Couple of ones I treat that I’ve actually been surprised how common it is, is emetophobia, so there’s a fear of vomiting or being sick. There’s a lot of fears of flying and driving, especially here in Los Angeles. I treat a lot of transportation phobias, which are very well-founded considering the accident level, and some of them are irrational.

Rachael Polakoff:

With specific phobias, again, there’s a difference between someone that just has a fear of something and something that you’re coming to a therapist for, so it has to cause that clinically-significant impairment. I had one client who had difficulty driving over bridges, and that made his commute to work in San Francisco really difficult, so along that. But for someone who has a fear of flying and really doesn’t like to fly and doesn’t care, doesn’t really want to get treated, that’s not going to qualify, you know what I mean? So again, like we’re talking about, significant impairment at work, school, and home.

Rachael Polakoff:

Agoraphobia, so this is on the rise, actually, because of the pandemic. I’m not sure the exact statistics, you might have them, but it’s about… I think there was a 10% jump, which was higher than the American Psychiatric Association expected, because I think with a lot of people, myself included, because I’m going to call myself out on this, working from home, there’s going to be more anxiety leaving the home, the fear of contamination.

Rachael Polakoff:

Speaking of that, there’s a lot of rise in OCD as well, obsessive compulsive disorder, too. So that involves a fear of something and then a ritual to prevent that fear, so if I’m afraid of getting sick, that I wash my hands 10 or 20 times a day. These rituals are pretty common too, but they can be very difficult for people to tolerate, and there’s a lot of work that goes into hiding the rituals and stuff like that.

Rachael Polakoff:

I just want to mention something off topic, but it was this thing I saw, that new Joel Cohen film, The Tragedy of Macbeth, with Denzel Washington. It’s an excellent film. But in it, Lady Macbeth, she’s washing a spot out of her hand because she killed someone and she’s sad about the blood being there. Well, that blood is actually not on her hand, but she’s having an OCD-like ritual, washing the hand to try to get it clean, to try to prevent those thoughts of murder coming, so you could actually argue that Lady Macbeth was suffering from a kind of OCD. [crosstalk 00:07:25].

Rachael Polakoff:

We have separation anxiety. This happens a lot with children, but also with teens and adults. And I’ve seen, at least throughout this pandemic, separation anxiety also get stronger with kids going back to school. I started treating a parent who had a little bit of empty nest syndrome with separation anxiety from her teens, and that involved being afraid of being away from your loved ones. But once again, the pandemic causing so much closeness, yeah, with people, and now those bonds are breaking a little bit, going back to the office, stuff like that, and now people are having this intense separation anxiety. Even students going back to college and stuff like that is very strong here, so we’ve seen a big increase overall.

Rachael Polakoff:

I just want to briefly mention too, the medication-induced anxiety disorders. So the use of certain medications or illegal drugs or withdrawal from certain drugs can trigger symptoms. A lot of people don’t know that, actually, stopping cannabis use can trigger that kind of substance abuse anxiety disorder. It’s important because clients need to be educated that when they stop abusing cannabis, which a lot of people have done throughout the pandemic as well, when they start cutting down or stopping, that can actually lead to withdrawal symptoms that include fear, lack of sleep, and stuff like that. We haven’t talked too much about sleep, but in a lot of these anxiety disorders, one of the criteria is lack of sleep, excessive worry, and racing thoughts, so with a lot of these, that’s the common ground.

Nicholette Leanza:

Got you. I think a lot with these disorders is, I think you’re emphasizing, these aren’t just everyday things. I mean, yeah, stress and anxiety is an everyday thing for everyday people too, but these go beyond just the everyday. These are very intense. These very much disrupt a person’s life. Jumping back-

Rachael Polakoff:

Yes, post-traumatic-

Nicholette Leanza:

… to panic-

Rachael Polakoff:

… stress disorder, which I was just about to mention, that’s one that we really do need to… There’s 12 of them that are pretty solid throughout the population. And PTSD is a very difficult one, so this is when you’ve witnessed a traumatic event or had a traumatic event happen to you, and then the intrusive thoughts come back and come back. And it can be very devastating, and it’s something that does not go away without treatment.

Nicholette Leanza:

Got you. The anxiety is a offshoot of the traumatizing event that occurred, for sure.

Rachael Polakoff:

Yeah, yeah. And I think we always have to think about trauma-informed care when we look at these anxiety disorders as well, so when we’re doing assessments, finding out what the traumatic events are in someone’s life, whether they were early on or in adulthood. And I don’t know if you’ve ever seen the early childhood events scale that’s-

Nicholette Leanza:

ACE, yes.

Rachael Polakoff:

Right, the ACE. So a lot of times, with anxiety disorders, someone has a higher scale on the ACE. Although there’s a genetic component to anxiety disorders, there’s also a nature… sorry, yeah, an environmental component.

Nicholette Leanza:

[crosstalk 00:10:41].

Rachael Polakoff:

So if someone were to have a traumatic event in childhood, there’s a much higher likelihood that they’re going to go on and have an anxiety disorder later.

Nicholette Leanza:

A good point. I don’t think a lot of people recognize that if you’ve been through some traumatizing circumstances in your life, that that right there might leave you more susceptible for struggling with anxiety disorders, for sure.

Nicholette Leanza:

And jumping back to panic attacks, a panic disorder, how many people a year… And I don’t have the statistics for this, but we do know people will go to the emergency room thinking they’re having a heart attack, and after a test being done that showed it’s not a heart attack, that it’s truly a panic attack, just shows how severe anxiety can be and how it can manifest in the body, for sure.

Rachael Polakoff:

Yes, had a few clients like that this year, actually, and go through cardiac workups, and they often come to us. It’s tough when they come to us because it’s not that they wanted to have a heart attack, but it’s like, there’s… If that was the case, then there’s treatment. It’s not as stigmatized. It’s quite sad that a heart attack is less stigmatized than an anxiety disorder, in my opinion.

Rachael Polakoff:

So a lot of my clients don’t want to take medication or do therapy, and what I tell them is, “Honestly, if this was a heart condition, you would be taking medicine, and what’s the difference?” You know what I mean? Or taking a different kind of medicine, and often, an antidepressant, an SSRI, can really help with anxiety disorders. I’m not a psychiatrist, but I work closely with psychiatry, having a lot of Kaiser Permanente patients, so I feel like I learned a lot from that.

Nicholette Leanza:

Are there other tips or coping skills you can recommend for people who struggle with anxiety disorders?

Rachael Polakoff:

Absolutely. The gold standard is cognitive behavior therapy plus medication. That’s going to lead to the highest level of efficacy, and I’ve also, anecdotally, seen that to be the case. When clients are on the right medication and doing therapy weekly, that is a specific kind of therapy. It usually really helps. Now, people might be wondering, okay, what can I do at home though? Can I supplement my treatment? Or maybe I’m not ready to try a med or talk to a doctor. So there are some apps that can assist with that. I’m not here to sell any apps.

These are all free apps, but one of them that I really like is called CBT Mood Diary. That’s a really good one. So what it is with CBT, you basically want to be looking at your thoughts and you want to be tracking what they are. So a lot of times, people might say, “I just had a panic attack for no reason,” or, “My anxiety suddenly skyrocketed for no reason,” but what it is, is there’s an automatic thought process going on that you have to slow down and look at, and using a tracking app can really help you.

Rachael Polakoff:

So for example, let’s say that you suddenly felt your anxiety come on really strong. Oh, it went from zero to a hundred, I don’t know why it did. Well, looking back at your thoughts, you might say, “Oh, actually, I was thinking back to the time that I was flying in the air. It was a really quick thought, but it skyrocketed me. Okay, it triggered me. What was I feeling, and what do I need to do for myself next?”

Rachael Polakoff:

Speaking of that, what is that step I can do? Meditation is really helpful. I lead a weekly mindfulness group here at LifeStance Health, and-

Nicholette Leanza:

[crosstalk 00:14:02]-

Rachael Polakoff:

… I’m a part of the InsightLA mindfulness community here, which is very important to me, and I think it’s really great for anxiety disorders, specifically. John Kabat-Zinn, who wrote a book about this, daily… sorry, Full Catastrophe Living… I almost said, “Daily.” Full Catastrophe Living, very good book about anxiety and how mindfulness can help with it. So with mindfulness, you’re also monitoring your thoughts too, and I think that’s the common ground between CBT and mindfulness, looking at your thoughts. You’re able to say, “My thoughts are just thoughts, my thoughts are not facts.” They’re able to let them go. Some good apps for meditation and mindfulness if you’re not ready to go to a group are Insight Timer, Calm, Headspace, Noom. These are all apps that I’ve recommended to my clients with good results, so there is self-help available.

Nicholette Leanza:

And I think with those apps, in between therapy sessions, to be able to be working on one’s anxiety, interacting with the apps, being mindful of their thoughts and their thinking ears and all that, goes back to CBT, but also, mindfulness skills too, that the Calm app can help with helping them soothe themselves and bring down that worry and stuff like that. So I think the apps are just so key too, for in between therapy sessions, to help practice managing anxiety and stuff as well, so all very helpful. Now, do you do specific just, maybe, stress management yourself in your life? May I ask-

Rachael Polakoff:

Yeah.

Nicholette Leanza:

… what you practice doing?

Rachael Polakoff:

Definitely. One thing we haven’t talked about yet is exercise and nutrition. That’s a very big component here, and for me, that’s really important. So I do practice yoga, I do surf and bike, and that’s one of my forms of stress management, for sure.

Rachael Polakoff:

Also, there’s things that can get your brain into that flow state, such as art, film, and music. I’m very lucky to be living in Los Angeles where there’s a very active community here, so I would say doing that. Also, being in a community is important to me and others, so I have different communities. I have a music community, a mindfulness community, and a therapist community that I connect with, and that’s been very helpful for my stress management. Of course, being a therapist, there’s always levels of burnout and stuff that we have to deal with, as you know, and I think it’s very important for us to practice what we preach. It’s a cliche, but if you don’t, it will take a toll on your work.

Nicholette Leanza:

Very, very true. I think, not only should we, as clinicians, preach what others should do, we need to be practicing it as well to manage our own stress and anxiety and stuff. I agree. Do you have any other takeaways for us to help people navigate anxiety disorders?

Rachael Polakoff:

Yeah, I would say, what’s a really good first step would be to listen to others’ feedback. If people are telling you, “Look, I think you might be stressed out, I think you might be burning out, I think you need to take a break or calm down,” that’s a good hint of, you know what, I might want to get into treatment, I might want to talk to somebody. A lot of times, it’s really hard to see the forest for the trees in terms of your own mental health, and this is true for everyone, therapists included.

Rachael Polakoff:

So I would say, a big tip would be to listen to the feedback of others. If you hear someone being concerned about you or your behavior, or saying, “Hey, you know what, you don’t seem okay, you seem like you’re really stressed out, like you’re really burnt out,” that’s a really good sign to talk to someone, because a lot of times with anxiety disorders, it’s a little bit different than depression. Anxiety disorders can sometimes creep up a little bit without you really being aware, whereas depression is more encompassing. You really feel that pain, and it really hurts, and you’re like, “I got to go in right now,” but anxiety is more of a slow boil.

Rachael Polakoff:

And oftentimes, when I see people, they’ve already come to the panic level, they’ve already come to the PTSD level. But that’s a lot of suffering and some of that can be alleviated if you were to treat a generalized anxiety disorder sooner, before it rises into that other stuff. And so, that’s what I recommend, be aware of yourself and your stress. And if it does feel like you’re worrying every day, to be honest, that’s not a happy life and that’s not a normal life, despite the stresses of 21st century world.

Nicholette Leanza:

Right, right. I hear you. My gosh, Rachael, thank you so much for all your tips and your resources and feedback on how to help people manage their anxiety disorders. Much appreciated, and I think our listeners will definitely get a lot of resources from everything you shared today, so I thank you again for being on our show.

Rachael Polakoff:

Thank you so much.

Nicholette Leanza:

Take care.

Rachael Polakoff:

Take care.