Intro: Duly Noted, a health and care podcast is the official podcast series of Duly Health and Care. Each podcast features physicians or team members discussing groundbreaking topics and innovations that help listeners reimagine and better understand an extraordinary health and care experience.

Amanda Wilde (Host): Welcome to another episode of Duly Noted, the official podcast of Duly Health and Care. I'm Amanda Wilde. In today's hectic world, it seems like more and more people struggle with mental health issues. Today, we're talking about diagnosing and managing anxiety with Dr. Steven Prinz, psychiatrist and Department Chair of Behavioral and and Mental Health at Duly Health and Care. Dr. Prinz, great to have you here. Thanks for joining me.

Dr Steven Prinz: Thank you. So glad to be here.

Host: Anxiety disorders are the most common mental illness in the US according to the Anxiety and Depression Association of America. How do you define anxiety?

Dr Steven Prinz: You know, there's so many different definitions, but I think the best definition is really from the American Psychological Association, which says anxiety is an emotion characterized by feelings of tension, having worried thoughts and then physical changes that occur from the tension and the worried thoughts. So, physical changes like elevated blood pressure, increased heart rate.

And in order to really understand anxiety, I think we just have to look at sort of this fight or flight response that occurs with all of us. So if we're exposed to a stressor in our lives, what happens is our nervous system, we have two parts of nervous system, we have a sympathetic nervous system and a parasympathetic nervous system. And the sympathetic nervous system gets you ready to manage the stress, which is great. So, our pupils get dilated, our skin flushes, so there's less blood that goes to the skin, more that goes to the heart and the muscles and the brain so we could get ready to manage the anxiety. We breathe more quickly, we get oxygen going to our muscles, which all of these things physiologically help prime the body for action and to be ready to respond. This lasts for about 60 minutes with our sympathetic nervous system. And then, after the stressful event, our parasympathetic nervous system, our relaxing nervous system kicks in and releases some neurochemicals to help.

The problem is, is what happens if someone has like continued stress, either continued instances of the same acute stress or multiple instances of different stressors, and then the nervous system responds in unhealthy ways. And that's when we see more psychiatric, psychological kind of concerns. You see more depression, more anxiety disorders. We have headaches, more physiologic concerns, like consistent elevated blood pressure, consistent elevated cholesterol.

Host: I was going to ask some of the most common symptoms of anxiety. You've mentioned some, headaches, blood pressure, heart rate. You've also said anxiety is normal, but chronic stress causes a kind of anxiety that is not normal. So, who is at risk for that kind of anxiety?

Dr Steven Prinz: I think if we look at really who's at risk, there's a couple things we should consider. One is that this is what I would call a biopsychosocial illness, meaning that there's a genetic predisposition for anxiety disorders. So, we take a look at family's history, especially first-degree relative, like parents, siblings, children. But we should look at grandparents, aunts, uncles, cousins. And so if we see that there's a history of anxiety disorders that runs in families, that puts someone at risk.

And then, we want to look at personality structure and we want to take a look at how we've been brought up to manage and deal with anxiety. So for instance, if I came from a family where my family did not manage anxiety very effectively, that we became very overreactive and we didn't think and process information appropriately, then I would learn that's how you manage anxiety situations. And then, we want to look at environment, because environment's so important too. If we're placed in an environment where it's healthy, we're not exposed to constant stress in our environment, which is often unusual, but these environmental factors play for risk as well.

So, we have to look at all three of those components and that tells us who's at risk. We know that if we look at lifetime prevalence, so lifetime prevalence, meaning that someone who experienced an anxiety disorder sometime in their life, it's about 30% of people. So, that's huge. One out of every three people are going to experience an anxiety disorder at some point in their life. Adolescences, under so much stress and pressure, we see that no matter what age range, about 30% of adolescents during their adolescence will be criteria for an anxiety disorder. So, pretty prevalent in our culture. For adults, usually we see it manifest more between the ages of 18 and 44. But again, in kids, in adolescents, it could occur at any age.

Host: Is anxiety its own diagnosis, or is it usually in tandem with another mental health condition like depression or PTSD?

Dr Steven Prinz: So, anxiety is often connected with other psychiatric illnesses, conditions. So, we say there's a high comorbid component to different psychiatric illnesses. So for instance, it's highly correlated with depression, with manic depressive illness, with substance abuse disorders. And then, as far as PTSD, which is post traumatic stress disorder, there are many different anxiety-type disorders and they often coexist with other anxiety-type disorders. So, phobias or a fear of a situation or of an object. There's social anxiety disorder where someone feels extremely uncomfortable meeting new people, feeling like they're going to be criticized when they meet new people. There's posttraumatic stress disorder that you mentioned where you experience a life-threatening event and the nervous system reacts in certain ways, trying to avoid remembering the event, even though we do remember the event. The nervous system becomes much more hypervigilant, more sensitive to sounds and stress and sensations. There's generalized anxiety disorder, that's what I call worry without reason. About 2.7% of the population has that. There's panic disorder. We have panic attacks and extreme reaction to anxiety, your heart races, we feel like we're going to suffocate, we feel like we're going to die. And then, there's obsessive compulsive disorders and about 1.2% of the population. But that involves obsessing, ruminating about a certain thought that you know is silly, but you can't stop it. And then, we do repetitive behaviors to try and manage unhealthy thoughts, even though the behaviors don't really treat the obsessive compulsive disorder, they just temporarily make the obsessions better. But these coexist together, so someone can have generalized anxiety disorder and posttraumatic stress disorder. It's unusual to just see one anxiety disorder by itself.

Host: And we've said there are different levels of anxiety. I mean, when do you know it's crossed that line and it is actually considered a disorder?

Dr Steven Prinz: The way I look at illness or disorders, I think we have to look at anxiety like on a spectrum. Because again, some healthy, normal anxiety is going to prepare us. If I wasn't anxious about meeting you today and preparing for this podcast, I wouldn't do a good job. So, I had to prepare for it because I was anxious. So, that was a good level of anxiety. But what I always try and take a look at is, does the illness or does the condition, does it interfere with day-to-day responsibilities, work responsibilities? If I continuously came late to work because I'm anxious about driving to work, so if it interferes with work responsibilities or school responsibilities for an adolescent, then it should be considered significant enough to treat. If it interferes with personal relationships. so for instance, if I had social anxiety and I didn't want to go out and meet some of my wife's colleagues from a work function that's important to her, that would cause a rift between my wife and I. And so if it interferes with relationships, we should consider getting treatment or if it interferes with health. So, for instance, if all of a sudden, over the years of my anxiety, I'm now getting consistent high blood pressure, consistent elevated cholesterol that may be related to stress, then someone should seek out treatment. So, I look at it in that regard. If it interferes with work responsibilities, day-to-day, responsibilities, relationships and health, someone should seek out care.

Host: It sounds like anxiety can really feed itself and cause more anxiety. So, what are some coping strategies and treatments you offer patients to help them manage anxiety on a daily basis?

Dr Steven Prinz: So, I'm going to give like a list of some tips that people could do, but I also want to mention that there's so many different therapies that are offered to treat anxiety disorders. And there's also medications that could be very helpful as well.

The therapies really help in the long run more effectively because you're learning coping mechanisms and strategies to manage the anxiety. The medications, the way I look at it is they allow someone to be in the here and now a little bit more so they could even work more effectively with therapy. So for instance, the medications, they help alter some of the neurochemicals that we think may be responsible for increasing anxiety. And again, this could be part of a genetic predisposition. So if we can increase the neurochemical called serotonin, we know that that could decrease and mitigate anxiety symptoms. If we could increase gabapentin, a relaxing neurochemical, that could decrease anxiety. If we could manage norepinephrine, adrenaline a little bit more effectively...

But here's some tips, and then if we want to talk about some of the therapies. So, we usually say take a time out if you're stressed. Get a massage, listen to music, learn to meditate, practice yoga, some of these mindfulness kind of activities, keeping you in the here and now, not always worrying about the future or the past;. To eat really well, to eat balanced food. There's more and more data that there's a good gut-brain connection and there's neurochemicals in the brain that are in the gut, so if we could eat more healthily. To limit the amount of alcohol and caffeine that someone takes in. We know that both of these can aggravate anxiety and can actually trigger panic attacks. Make sure you get enough sleep. We know that when we're stressed we need more sleep, and often we don't get enough sleep. Sleep regenerates the neurochemistry in the brain. And to exercise daily, you know, even little bits of exercise. Exercise releases endorphins and helps with blood pressure being managed better, can help in releasing energy. Say just to breathe deeply sometimes gets rid of carbon dioxide, help increase oxygen. And we say to have the attitude, which is easier said than done, but just to do your best. You don't have to be perfect. And I'm going to use a silly examples of something you told me when we started, "Hey, we may mess up talking, but we could edit this and make it sound better." But we don't have to always be perfect. And if we have that attitude, that could help reduce anxiety. Say sometimes just to take a break, count to 10 slowly and if you need to do that to 20, just sort of distract yourself. And then to accept what you can control and what you can't control. That philosophy sometimes helps reduce anxiety. You say humor is very good for anxiety. So, the people that you see laughing all the time, they're probably less anxious. And when we laugh, we release endorphins, which helps the brain and body feel better.

So, just a couple other things I'll say is that, you know, to try and maintain a positive attitude, throughout the day. Try and replace negative thoughts with positive thoughts. I'd just give an example. "My mom just had like a mini stroke. So, I've been spending more time with her because I'm worried about her. So even though I'm worried about her, the positive is I'm getting to spend more time with her and getting to know her even a little bit better as an adult." So, those kind of things. And to stay active, to volunteer or find a way to stay active in your community. This develops a support network and gives someone a break from everyday stressors.

Last thing I'll say is if you start to log what triggers you and you start to know yourself, sometimes to keep a journal about feeling stressed or anxious and look if there's any patterns to your anxiety, and then maybe you could intervene in that way as well.

Host: So, you do have a lot of control over what you do with your anxiety if you can get over what many of us suffer from, which is depriving ourselves or being hard on ourselves or not connecting with others, it does take some effort to get out of that. So if someone suspects they may be dealing with anxiety or any mental health condition for that matter, how does someone know when it's time to seek professional treatment?

Dr Steven Prinz: In general, if you have any mental health illness or anxiety that interferes with your day-to-day functioning and interferes with relationships and interferes with your health, really that's the time to say, "Hey, let's seek out help." And a lot of people will talk to their PCPs, because the primary care physician is often the first line of assessing and noticing something going on with their patients. But someone could schedule an appointment with a mental health specialist again at Duly, which is really neat. I mean, we have therapists, there's all these different therapeutic techniques that actually treat, or teach really, and then treat anxiety, but teach like different coping strategies, teach mindfulness strategies, teach ways to approach problems in different fashions; look at the way we automatically think about things and try and help us incorporate different ways to think about things; look at what has been successful in the past with dealing with situations. And we say use positive psychology and therapy, so that we could actually build on what has helped in the past so we could help someone move forward. And really, therapy is extremely helpful. And therapies are often short term. Sometimes within like three or four months someone learns enough skill sets to help manage anxiety.

Host: Well, Dr. Prinz, thank you so much for heightening our understanding of anxiety and looking at all these options for how to cope with it.

Dr Steven Prinz: Oh, you're so welcome. Thank you for having me. I really was excited to do this today, so I hope it helps people.

Host: That was Dr. Steven Prinz, psychiatrist and Department Chair of Behavioral and Mental Health at Duly Health and Care. To learn more about all we are doing to help humans flourish, visit us on the web at dulyhealthandcare.com. Thanks for listening.