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Anxiety, Stress, Worry, Panic

Anxiety, in its many forms, it probably the most common thing patients come into the practice struggling with. Why? Because the lives we lead here in New York City are intense and often unbalanced in ways we can’t control. Because it’s likely that no part of all the education and training you obtained focused on coping skills. As a result, many of us, when asked what tools we used to get through the last big challenge, have no idea what we actually did that helped. (and no, ice cream and alcohol are not coping skills).

The first step in assessing and treating anxiety is to develop a more nuanced way of describing what you are experiencing. Are you experiencing your anxiety in your body, in your thoughts, or both? Do the things you are worrying about seem legitimately worry-worthy or do you feel you are preoccupied with things that don’t seem to warrant the distress they are causing? Is your anxiety due to a trauma that you lived through and the fears that it will happen again?

Anxiety Can Have Wide-Sweeping Effects on Your Work, Relationships, Parenting, and Health

We will start by understanding the “Volume” of space in your day that your anxiety takes up.

To what extent is your ability to function compromised by anxiety? Is anxiety undermining your ability to do your job? Is stress affecting your relationships? Is tension worry and panic affecting your health? Do you feel that your worries, phobias, compulsions or fears are affecting the way you parent or impacting your kids? Do you notice that avoiding things that increase your anxiety has made you opt out of going out? Being social? Networking? Traveling? Do you find that persistent health worries result in you going to doctors too frequently?

What Are Your Symptoms of Anxiety?

Next we will take a thorough inventory of the specific anxiety symptoms you are experiencing. Does your anxiety affect your sleep causing insomnia? If so, is it the type that keeps you from falling asleep or the type that wakes you up in a panic? Does your anxiety cause GI problems? Loss of appetite? Reflux? Nausea? Are you having panic attacks? Do you have rituals or compulsive repetitive behaviors that you feel you must engage in? Do you have Social anxieties, returning home after a social event to ruminate about what you did, said, wore and cringing at the thought of it? Or do you avoid social situations to avoid feeling this way?

The Connection Between Anxiety and Substance Abuse

Most people with serious anxiety have tried a variety of things seeking relief. So if you have reached for substances, both legal or illegal to try to take the edge off or to get some sleep, you wouldn’t be the first. Seeking treatment for anxiety with a psychiatrist is a good opportunity to also address any behaviors or substance use which have developed alongside. It’s a relief to find that treatment decreases your anxiety treatment, but an additional bonus may be that you find you no longer need to rely on smoking (tobacco or marijuana), sleeping pills, alcohol or other substances as much.

The Connection Between Anxiety and Food

Many of us have learned to soothe ourselves with food. And as a result, it is not uncommon to find that people with anxiety often have an unhealthy relationship with food. This can mean emotional eating, over-eating or binging. On the other end of the spectrum, some people manage their anxiety by exerting control over their food and eating habits. It’s common for anorexia, food restricting or compulsive unhealthy exercise to become worse when anxiety is high.

Why a Psychiatrist is the Best Person to See for Your Anxiety

It’s easy to ask your doctor for a prescription for anxiety, but it’s no substitute for a careful and thorough assessment to also screening for other problems that often go hand in hand with anxiety. Too many people just get a prescription from their GP or ask for a prescription for benzodiazepines like Klonopin or Ativan or Xanax. And while these medications certainly relieve anxiety in the short term, this approach fails to diagnose the root cause, and misses the opportunity to screen for and treat co-occurring anxiety related issues. But most importantly, anxiety can rob us of our sense of control. So in treating anxiety, it’s important to take that back by learning to master the anxiety and not just medicate it away.

In my practice I treat a variety of Anxiety related problems with medication, therapy or both, including:

  • Generalized Anxiety
  • Medical Anxiety or Hypochondria
  • Panic Attacks
  • Insomnia
  • OCD or Obsessive Compulsive Disorder
  • Skin picking or Excoriation Disorder
  • Hair Pulling or Trichotillomania
  • PTSD or Post Traumatic Stress Disorder
  • Phobias and the Avoidance that goes with them

Treating Anxiety at the Root of the Problem (As Opposed to Just Putting a Bandaid On It)

Many people focus on treating the symptoms of anxiety instead of looking at the cause. This means buying some melatonin instead of trying to understand what’s interfering with our sleep. Or asking our internist for something for our nerves. I believe there’s no substitute for actually understanding why you have anxiety and what contributes to it. I want you to gain insight and find sustainable solutions. Untreated ongoing anxiety can cause people to sabotage relationships, turn down great opportunities, off-ramp the careers they worked so hard for and generally miss out on much about life. Most importantly, anxiety makes you feel that it, the anxiety, is in control, not you.

The Role of Medication for Anxiety

We will discuss the two medication approaches to treating anxiety, namely preventing it with medications you take daily vs extinguishing it when it crops up with medications you take on an as-needed basis. You will learn how we decide which is the best approach for you. You will learn that some anxiety disorders can be treated with medication and simply go away, while most do best with a combination of medication and therapy for maximal improvement. In some situations, medications are not the answer. And the only solution that will provide lasting relief is to address an issue that needs to be resolved.

An important aspect of medication management of anxiety is choosing the right type of medication. Several different classes of drugs are used to manage anxiety, some are potentially habit forming and must be used judiciously, others are not habit forming at all.

In session I will teach you how these medications work and we will address the following questions: How long will it take for medications to relieve my anxiety? Can anxiety medications make Panic attacks go away? How will we know when I can stop my anxiety medications without symptoms coming back? Will I be on anxiety medications forever? Can I drink alcohol while on anxiety medications? Can I consider getting pregnant while on anxiety medications? What do I do if anxiety medications only partly relieve my symptoms?

If medications are appropriate and you are interested in trying them, I will help you make a choice that optimizes effectiveness while minimizing risk of any concerns you may have. We will thoroughly discuss how and when to start them, what to expect, and when to anticipate relief of your anxiety. We also will discuss the role of therapy in treating your anxiety.

The Role of Therapy for Anxiety

In my practice I encourage my clients to not underestimate the role of psychotherapy for anxiety. Therapy is where you can reflect on how past experiences, your upbringing, your parent’s way of coping, or prior challenges which may inform (or misinform) your assessment in the present. In my experience humans can cope with a lot. When the anxiety feels like it’s winning, its usually because of the way we are going about managing it, or the way we are thinking about our problems. Therapy is where you learn to master those coping skills we talked about, to try on different ones and emerge knowing which one’s work for you. It’s where you can reflect on the impact your anxiety has on your life and find motivation for sustained change. And while many people wish there was just a pill to make it better, a medication-only approach deprives you of a real sense of mastery over life’s stressors.

The Best Treatment for Anxiety Employs an Eclectic Combination of Skills and Approaches from a Variety of Treatment Modalities

CBT or Cognitive Behavioral Therapy

The crux of Cognitive Behavioral Therapy is the observation that our feelings of anxiety are accompanied by thoughts…and sometimes these thoughts are unproductive, exaggerated or simply false. Yet we take them at face value. That is, if we even realize they are happening. In therapy we explore why those “ schema” are your go- to explanations or predictions and consider other ways of looking at things that might not be so harsh, so scary, so unkind, so disastrous. The goal is not to convince oneself that the glass is half full instead of half empty, but rather to recognize that we may be habitually convincing ourselves of the worst case scenario when that’s only a small possibility.

CBT is an active, engaging way of doing therapy in which the therapist acts as a supportive coach, asking questions, proposing alternatives and supporting you in practicing new skills each week. This type of therapy is especially helpful in the case of insomnia, where inability to sleep generates more and more anxiety, which in turn further prevents sleep. CBT is also extremely helpful for OCD, in which beliefs about the absolute necessity of engaging in a compulsive behavior are examined and alternatives considered.


Behavioral therapy is focused on actions you can take to affect change. It is not about changing your thoughts, or having insight into why you have those thoughts. It’s more about doing something different, and practicing until it’s less frightening. Behavioral approaches can be very helpful in uncoupling troubling behaviors, such as the habit of overeating when one is distressed. Behavioral Therapy is used to help people who engage in hair pulling or skin picking to find alternative behaviors that relieve the urge and help them refrain. Behavioral therapy is the basis of using charts and rewards to motivate and stay on track. It sometimes involves identifying triggers for certain behaviors and offers alternatives so that the behavior doesn’t seem so inevitable. It is also the basis of overcoming phobias and avoidant behavior that are so common in people who have anxiety. By breaking down frightening behaviors into micro steps, and accompanying them with techniques of breathing, relaxation or mediation, you can slowly learn to partake in activities that previously caused too much distress.

DBT or Dialectical Behavioral Therapy

DBT focuses on specific tools to help you get less upset, to refrain from over reacting, to soothe and calm yourself. Sometimes when emotions come over us it feels like they are inevitable and we can’t do anything about it. But most people agree it doesn’t feel good to lose control. It’s a real asset to feel in control of regulating your emotions, to be able to tolerate distress without losing control, to identify and ask for what we need interpersonally and to get through difficult times without behaving in a way that we later regret. DBT teaches skills to put in your toolbox so that you have something concrete to do when things feel overwhelming.

Interpersonal Therapy

In this type of therapy we identify situations between yourself and the people in your life which are problematic. Sometimes our pasts have left us ill equipped to advocate for ourselves in healthy ways. Things like grief, guilt, loss or former interpersonal struggles may make us especially sensitive to some situations, may make us overreact or misinterpret. The goal here is to recognize this and learn healthier ways of interacting with others.

The good news is that anxiety disorders are very treatable and you have every reason to believe that with the right help, be it medications, therapy or both, that help is on the way.

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