How to think about, and treat, anxiety -- a nearly universal condition

Host Amber Smith: Upstate Medical University in Syracuse, New York, invites you to be The Informed Patient, with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. The U.S. Preventive Services Task Force recommended that all adults under the age of 65 be screened for anxiety.

It's a disorder that often goes undetected in primary care. Today I'm talking about this with Thomas Ringwood. He's a nurse practitioner of psychiatry and behavioral sciences at Upstate. Welcome to "The Informed Patient," Mr. Ringwood.

Thomas Ringwood, NP: Hi, Amber. Thank you so much for having me today.

Host Amber Smith: This recommendation comes at a time when it seems like many people have been more anxious than usual because of the pandemic, but anxiety was an issue even before COVID-19.

Is that right?

Thomas Ringwood, NP: Well, Amber, I'm glad that you've framed the question in this way for several reasons. What I want to point out is that if we screen adults for anxiety, we are going to find that 100% of adults have anxiety.

It's an absolutely normal human emotion that a hundred percent of us will experience at one time or another, so I think language is important here. When we say, are we screening for anxiety? it's a common thing that we're going to pick up in everybody. And this is different, of course, and the difference does come up in the language of the recommendation. This is a different thing than an anxiety disorder, so I don't want to trivialize an anxiety disorder, but I want to point out that language, saying that we're screening for anxiety, we're going to turn up a lot of anxiety.

The second thing is, you put it in the context of the COVID-19 pandemic. And this is something I think is important, too. I read an article in The New York Times not too long ago that I thought really was pertinent here. And the author talked about a term -- they call it reification. And they talk about coming up for a scientific explanation or an objective explanation for a political or power arrangement. The COVID-19 pandemic, I think, illustrates this, and so does this so-called mental health crisis or anxiety crisis that we're in the middle of right now. And you said this when you asked the question: This was a problem before COVID-19. Sure, of course.

So, in reification, the effects of a political arrangement are seen or framed as an objective reality about the world. If we look at the way things are today, I would say that there's a reason that people are anxious, instead of "Are we in the middle of an anxiety crisis?" Are we looking at something else here?

So, one way to think about it is if it's an anxiety crisis, then it's the responsibility of individuals or health care providers or therapists to figure out a solution to the problem. Whereas if the anxiety might be a symptom of some other problem, well, that's a different story, isn't it?

One way to think about this is we live in a time where the two major political parties in the United States can't agree on anything. We're in the middle of drastic changes in our climate. We are in the middle of a vast distribution of wealth to a very small percentage of our population. Formerly secure Industries that led people to a reasonable quality of life have evaporated. And there's an erosion of our social safety net. And then we can think about another path to a secure lifestyle, a college degree, that's not even a reality for most people anymore. It's a ticket to debt, that's for sure. but it's not a ticket to maybe a middle-class or reasonably comfortable way of life. And these are all political and power arrangements here in the United States. And for me, I would say, well, no wonder people are feeling so anxious.

And then, of course, we throw on a global pandemic on top of all of this, which is frightening in and of itself. Here's an illness that we don't understand that well, that spreads very quickly, killed lots of people, is still a problem, but it also exposes a lot of these other sort of power arrangements that we have here in the United States and around the world.

And then to turn around and say, "Oh, it's a mental health crisis. You know, everybody's so anxious. We need to figure out a solution to this," it sort of obscures the problem. So, going back to what I was saying about anxiety being a normal human emotion, it's a signal that there's something wrong.

And that's why we all feel anxious, and we can choose to focus on the symptom, or we might consider what it might be about. So that's sort of a long way of answering the question. I would say yes, that it was here before the pandemic, and the pandemic has certainly exposed more of it, but at the same time, it's important to pay attention to the difference between an anxiety disorder and anxiety as a normal human experience.

Host Amber Smith: So when does anxiety turn into or become a disorder? Because if I understand you correctly, a lot of this is normal, what we're feeling ...

Thomas Ringwood, NP: Sure.

Host Amber Smith: ... the anxiety ... Because there's a lot to be anxious about. When does it become a problem?

Thomas Ringwood, NP: I mean, if we look at the DSM (Diagnostic and Statistical Manual of Mental Disorders), which is the classification of mental health disorders, if you will, what the main criteria in all the anxiety disorders are, is it has to cause impairment in your function, right? We all get anxious. I was anxious about this interview, but did I not come to work today because I was anxious about the interview? No. So, you know, my anxiety about the interview isn't preventing me from coming here and doing my job and taking a break and talking to you. So an anxiety disorder, there really does have to be impairment in your social, occupational life.

Again, this goes back to if we're screening everybody for anxiety, we're going to find a whole lot of anxiety, but if we screen for impairment, we're looking at something different.

Host Amber Smith: Does anxiety or anxiety disorders impact a person's physical health?

Thomas Ringwood, NP: Yes. Long-term anxiety can make us sick in many ways. So one thing to think about is an increase in stress hormones like cortisol, and this can have all sorts of negative health impacts. We can gain weight, it can cause coronary artery disease, insomnia, things like that. It can absolutely take a toll on our physical health.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast with your host, Amber Smith. I'm talking with Upstate nurse practitioner Thomas Ringwood about anxiety.

Let's go over the symptoms of anxiety disorders. How would one be diagnosed?

Thomas Ringwood, NP: It would be a careful interview about symptoms, and again, there would have to be impairment. So that's the main diagnostic criteria. Some symptoms, like if we're thinking about something like generalized anxiety disorder, we're thinking about a lot of worry, you're worrying all the time. It occurs most of the time across lots of different situations, and it has to be present for at least six months, so it does have to be going on for a long time. The person has to have a difficulty controlling the worry. Nothing you do seems to make it any better. And then the worry or the anxiety has to be associated with other symptoms, so feeling restless, keyed up, getting really tired all the time because you're just worried so much, having a hard time concentrating on things, feeling like your mind's going blank, like you just can't function or get the right answer to something, feeling irritable or tense and insomnia, having a hard time sleeping.

So those are symptoms of a generalized anxiety disorder. And then some of the other ones you would see. like a panic disorder: You have a panic attack, and then you're worried about having a panic attack, and that would be a panic disorder. Or a social anxiety disorder, where there's a lot of the same sort of apprehension, irritability, worry, things like that. But it really occurs specific to social situations.

Host Amber Smith: How are general anxiety disorders treated?

Thomas Ringwood, NP: The treatments with the most evidence for a generalized anxiety disorder is a combination of antidepressant medications and psychotherapy. So again, I would go back to, if somebody's having anxiety, it's a symptom that there's something wrong.

So think about it like your house is burning down, and the smoke alarm is going off, and the smoke alarm could be thought of as anxiety, and there's approaches here. We could just say, "Well, we just need to address the symptom, which is the anxiety. We just need to turn that symptom off." And, of course, you can try to do that with medications, but I would really liken that to I'm laying there, trying to go to sleep, and my smoke alarm's going off, and I'm thinking, "I just need to shut that off so I can get some sleep."

So when thinking about treating anxiety, what's wrong? Why is the anxiety here? What is it trying to tell us? Do we just want to turn it off? Or would we want to explore what it might be about?

So that's my practice, is I try to work along with people to figure out why are they so anxious, what it is about, because it's a signal that's built into all of us, to try to tell us something about ourselves, our relationships, our environment: There's something wrong.

Host Amber Smith: Have you had patients who successfully managed their anxiety, and if so, can you tell us how they did it?

Thomas Ringwood, NP: Yeah, lots of patients, patients that are curious about what it might be about and make an effort to discover what is wrong and then to address whatever they discover is wrong, tend to get better.

one thing that I find frequently is, anxiety is the signal that we feel like we're all alone, and I guess this is another function of what I was talking about with reification, is a lot of us live in an awful lonely society, and the more distant we get from people, the more anxious we get, because we're social creatures.

And if it was, I don't know, 10,000 years ago, and we were out in the woods, and we got separated, we'd be anxious because we know we need our group to survive. And I think that that is still built into us. If anxiety wasn't there to tell us something, it would've been selected out by evolution a long time ago.

One thing that people find is being in good, healthy relationships or having friends or doing things, that helps with anxiety. Other people, they have trauma that they need to address in therapy, and that helps with their anxiety. Other people need to take better care of themselves, and they figure this out, and they start to eat better, sleep better, things like that.

So, yes, I would say it's very treatable, and it's a condition that people can absolutely recover from, like an anxiety disorder, if they're willing to be curious and work on what they discover is going on.

Host Amber Smith: I'm wondering, you mentioned antidepressants. Can those be effective for someone if they don't have a relationship with an established therapist?

Thomas Ringwood, NP: I mean, antidepressant medications are only so effective. There was a big trial of antidepressants called the Star*D trial (Sequenced Treatment Alternatives to Relieve Depression Study), and it shows that antidepressants have about a 30% effect rate, so they're just not very effective medications.

It's not to say that they don't help, because they absolutely do, but I would say antidepressants alone, we're addressing the signal, and this is with, again, with any medicine that we're going to think about. It can address the signal, so it can absolutely help with the maybe overwhelming feeling of anxiety or the mood that might come along with it.

It can help your mood, but is it really going to help you get to why you might be so anxious? No, a pill isn't going to do that. Antidepressants and other medicines that are prescribed for anxiety can help the signal, but again, I think this goes back to the idea of reification is you can think of, OK, now we've addressed the symptom, but the symptom's there to explain that there really is something wrong, and a pill just is not going to help with that.

As far as therapists being in short supply, that's true. And there are long waiting lists. One thing to consider is there's other resources, I guess, in the community, and things that come to mind are 12-step groups or things like 12-step groups.

So these are groups of people with some common trouble, and they get together, and they share, in their words, their experience, strength and hope with each other, in order to address what's wrong.

This functions in two ways. One, it gets a group of people together, which is often a nice feeling and does help with feeling anxious. And two, it gives people. a platform or a space to talk about what's wrong. So, of course there's 12-step groups for substance-use disorders, but there's also 12-step groups for people that come from dysfunctional families and things like that. There's other groups in the community here that are a little more general, so they're like sort of trauma-based groups or just groups for somebody that they just need to come and talk to somebody. So there's a sort of free or accessible resources in the community for people that maybe can't or don't want to go talk to a therapist.

Host Amber Smith: Do you think primary care providers in general are equipped to screen for anxiety?

Thomas Ringwood, NP: I think, primary care providers are equipped to screen for it, but I know that primary care providers are just so busy, and I think this is true of lots of people in health care. You're just so busy, and it is hard to do all the screening as a primary care provider that you have to do and address what the patient's there for in five minutes. I guess this goes back to the power structure or the culture structure here, is that a lot of providers are seeing a lot of patients and not a lot of time.

And they have to now screen for anxiety, which of course they're equipped to do. We can all ask basic, interview-type questions, but are they screened to really delve into what might be wrong? No, they're not. They don't have that time.

And then this comes back to are they equipped to prescribe an antidepressant? Well, of course they are. Are they really set up to successfully monitor how effective that medication is over time? No, probably not. They can screen, they can maybe prescribe, but with everything else they have to do, how effective is that going to be? I really don't know the answer to that question.

Host Amber Smith: That Preventive Services Task Force recommendation was for adults up to age 65. Why are adults over the age of 65 not recommended to be screened for anxiety?

Thomas Ringwood, NP: What I read in the document was that they just didn't find any evidence that there was going to be any benefit from that. So I don't know if this says anything about people over 65. Maybe it does, maybe that generation handled things differently or has closer social connections or something, and they're less anxious. From my day to day practice, I would say that's not true because I treat many older adults who are terribly anxious and depressed.

Host Amber Smith: This same Preventive Services Task Force recommended earlier that adults of all ages undergo routine screening for depression.

How often do you see depression present in someone with an anxiety disorder?

Thomas Ringwood, NP: So in my practice, I tend to mostly think about them as a related condition. If we look in the DSM at the symptoms of a major depressive disorder, anxiety is a symptom of being depressed. And the treatment is the same, it's the antidepressants and therapy. That's the gold standard for treating a depressive disorder. I tend not to split them into two separate disorders. I tend to mostly just see it as depression. And I also am a big believer in some thinking that was developed by a lot of different people, my mentor Brian Johnson (Upstate psychiatrist and pain medicine specialist) is one.

But there's an animal researcher, Jaak Panksepp. There's anotherneuropsychoanalyst, Mark Solms. And they talk about "affective neuroscience." So Jaak Panksepp, one of his concepts about anxiety is that it's an instinctual system that's built into us and that it's there to cause us to feel anxious and worried when we're cut off from other people.

But it's not sustainable. It's not sustainable to be anxious and in that heightened state for very long. If we go back to you and I being in the woods, and we get separated, it's not going to do me a bit of good to just freak out, freak out, freak out. I need to conserve energy. So we can think about depression. Depression is a shutdown, so it's not going to do me any good to be anxious, anxious, anxious, anxious. I can do that for so long, and then I fall into a depression. So I think of these sort of as a continuum. I treat them the same because really the treatment is the same, and I just say that they are definitely related.

Host Amber Smith: Let me ask you, what you would say to someone who listens to this, who feels like they're struggling with an anxiety disorder and don't know where to turn. What advice would you have for that person?

Thomas Ringwood, NP: My main feeling is this: I want people to know that having anxiety is like having a pulse. It's a normal human experience. It's an indication that you're alive.

I worry about a tendency to pathologize normal human experience. And, you know, that's why I think language is so important. So I get frustrated when I see stuff in the news or in the paper about a crisis of anxiety.

Anxiety is normal. If you're feeling completely overwhelmed and like you can't function, that is the time to seek treatment. And I would just encourage a curiosity about what it might mean.

The other thing I want to really send the message is that anxiety is a function, and our current mental health crisis, as it's labeled, is a function of a power arrangement in our society and that it is normal to feel anxious about everything that's going on. And we also live in a time where it's like you can't even seem to get away from it. It's in your face all the time, and, sure, it's normal to feel helpless. COVID, of course, highlighted this, but as you said in the beginning of the interview, this was going on before COVID.

So, are we just in the middle of some epidemic? Or are we noticing that lots of people in our society are feeling anxious and what might the reason be for that? That's what I would hope to send the message. So if you're feeling totally overwhelmed, it's normal to feel overwhelmed. If you need help with it, the right thing to do is to call and talk to somebody about it and get the help.

Host Amber Smith: Well, Mr. Ringwood, thank you so much for making time to tell us about anxiety.

Thomas Ringwood, NP: Thank you, Amber. I appreciate you having me on.

Host Amber Smith: My guest has been nurse practitioner Thomas Ringwood from Upstate's department of psychiatry and behavioral sciences. "The Informed. Patient" is a podcast covering health, science, and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at upstate.edu/informed.

This is your host, Amber Smith, thanking you for listening.