Whether you're dealing with anxiety yourself or supporting someone who is, don't miss out on this vital discussion on Resiliency Radio with Dr. Jill Carnahan and Dr. Ellen Vora. This episode will equip you with valuable tools and educate you on the Anatomy of Anxiety. Subscribe and stay updated for more enlightening conversations.

Key Points

1. Anxiety can be divided into false anxiety (physiologically triggered) and true anxiety – It may be helpful to know which is bothering you
2. It is better to embrace anxiety as a teacher and allow yourself to move through the emotions instead of creating resistance
3. Caution is advised with frequent use of anti-anxiety medications as they can make the problem worse.

The Guest – Ellen Vora, MD

Ellen Vora, MD is a board-certified psychiatrist, acupuncturist, and yoga teacher, and she is the author of the bestselling book The Anatomy of Anxiety. She takes a functional medicine approach to mental health—considering the whole person and addressing imbalance at the root. Dr. Vora received her B.A. from Yale University and her M.D. from Columbia University.

https://ellenvora.com/
https://www.instagram.com/ellenvoramd/
https://www.facebook.com/ellenvoramd/?ref=aymt_homepage_panel

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Dr. Jill

Dr. Jill Carnahan is Your Functional Medicine Expert® dually board certified in Family Medicine for ten years and in Integrative Holistic Medicine since 2015. She is the Medical Director of Flatiron Functional Medicine, a widely sought-after practice with a broad range of clinical services including functional medical protocols, nutritional consultations, chiropractic therapy, naturopathic medicine, acupuncture, and massage therapy.

As a survivor of breast cancer, Crohn’s disease, and toxic mold illness she brings a unique perspective to treating patients in the midst of complex and chronic illness. Her clinic specializes in searching for the underlying triggers that contribute to illness through cutting-edge lab testing and tailoring the intervention to specific needs. 

A popular inspirational speaker and prolific writer, she shares her knowledge of hope, health, and healing live on stage and through newsletters, articles, books, and social media posts! People relate to Dr. Jill’s science-backed opinions delivered with authenticity, love and humor. She is known for inspiring her audience to thrive even in the midst of difficulties.

Featured in Shape Magazine, Parade, Forbes, MindBodyGreen, First for Women, Townsend Newsletter, and The Huffington Post as well as seen on NBC News and Health segments with Joan Lunden, Dr. Jill is a media must-have. Her YouTube channel and podcast features live interviews with the healthcare world’s most respected names. 

The Podcast

The Video

The Transcript

170: Resiliency Radio with Dr. Jill: Dr. Ellen Vora discusses the Anatomy of Anxiety

 Dr. Jill  00:12
Well, hello everyone, and welcome to another episode of Resiliency Radio with Dr. Jill! I'm so glad you're joining us again. If you've enjoyed other episodes or enjoy this episode, please stop by and leave us a review. Share it with friends or family that might benefit from this information. Today I have a special guest and a new friend and I'm so excited to introduce her. We were just talking right before we get on here about how needed the information today is going to be for our society, for our teens, for our adults, and really for everyone. Today we're talking about the anatomy of anxiety and we're going to do a deep dive with Dr. Ellen Vora.

Dr. Jill  00:46

So let me introduce our guest and then we'll jump right in. Dr. Ellen Bora is a board-certified psychiatrist, acupuncturist, and yoga teacher. I want to mention you're an MD because there are a lot of people out there calling them those doctors who aren't medical doctors. So I love that you're coming to this with a medical degree. She's the author of the bestselling book, The Anatomy of Anxiety. She takes a functional medicine approach to mental health, considering the whole person and addressing imbalances at their root. She received her bachelor's from Yale University and [her] M.D. from Columbia. Welcome, and I am so delighted to have you here today!

Dr. Ellen Vora  01:18
Thank you, Dr. Jill. I'm so glad to be here today!

Dr. Jill  01:20
So as I always start with guests and [as I] mentioned to you, I always love the story of how we get into healing professions. I'd love to hear a little bit about your journey into medicine. Was it something you always wanted to do? How did you get into medicine? And then, how did you get into functional and holistic medicine?

Dr. Ellen Vora  01:37
Yes. I got into medicine—I'm sure it was an early connection to intuition, but I was not yet aware of how my intuition was operating. I was obsessed with the brain, but I'd also been an English major as an undergraduate. Really, I was passionate about hip-hop dancing, but that did not materialize into a career. So I ended up in medical school. 

Dr. Ellen Vora  02:04

By the time I was in my psychiatry training, I already felt deeply out of alignment with allopathic medicine with what I was being trained to do. I was in these two parallel crises. One was feeling like I wasn't convinced that I was doing no harm. I wasn't convinced that I was actually helping my patients thrive. And that's a bad feeling 10 years into training and it's an expensive education. It's your blood, sweat, and tears. And to feel like maybe this has all been for naught… And “Are these tools not as helpful as we are taught to believe that they are?” 

Dr. Ellen Vora  02:04

But the parallel crisis with that was that I was really unwell and I had autoimmune markers in my blood work. I had a malar rash on my face. I was bloated. I couldn't poop to save my life. I wasn't getting a period. I had polycystic ovary syndrome, ocular migraines, and joint pain. There was so much that wasn't working in my body. I thought: “Here I am a medical student; I should know how to keep myself well.” I thought I was doing everything right. And it really took a—at the time, we used the word alternative. Now I just think it's the oldest-fashioned, most basic way to support human health. But it took a lot of alternative strategies to get myself well. Then I started applying that in my practice, and I felt more hopeful that I had tools for supporting my patients. And that has all worked together to lead me to be this radical, weird psychiatrist that I am.

Dr. Jill  03:39
I love it! What if we are actually more the norm? I know you and I believe this, but I understand every bit of your story. It sounds like [for] both of us, the intuition and that deep inside and right brain… And you have English, so you had all these creative pieces. I really think that not only women in medicine but [also] the more intuitive healers, bringing that to conventional medicine—I could just cry because it's so critical to the crisis we're having right now in our medical system and especially in mental health.

Dr. Jill  04:10

The fact that you are able to sit with a patient—I can't wait to dive into more—I so resonate with your story because I almost didn't go into medicine because it didn't feel aligned. But then I realized, “Wow, we can actually change it.” And you're doing that. And hopefully, I'm doing that a little bit too. So I already love you and the energy that you bring. And those of us who are truly healers and maybe didn't know it in the beginning, we often have that journey, right? It's our own illness. I find this with colleagues and with myself when we found those pieces where Western medicine didn't have an answer. It's wonderful if you have a heart attack or stroke, but if you have depression, obesity, diabetes, autoimmune [disease], lupus, or any of these things, we don't have the best answers because drugs are not the cure, right?

Dr. Ellen Vora  04:55
This is right. I share that appreciation of the heroics of Western medicine, [which] can really rescue you out of a bad situation. And [I have] so much gratitude for that. But we just keep misapplying it to situations where it's not only inappropriate and doesn't help someone get well, but it often leaves them worse off. So it's really nice to expand our toolbox and have other ways to support patients to gently rebalance rather than react and throw someone into a new state of imbalance.

Dr. Jill  05:27
I love that. And today, we're talking about anxiety. Now, just before we went on, I mentioned I was talking to a very high-level community leader who was talking about the crisis in mental health, especially among teens, literally every week. There was another child being admitted for suicide. You and I both see this, but let's talk first about the state of things because I think there's the pandemic, the isolation, and the social media. And then, in our talks, I could name a hundred things that are contributing, but I'd love to hear from you as the expert. What is the state of anxiety and mental health, especially in the younger generations? What are we dealing with? What are you seeing?

Dr. Ellen Vora  06:03
Yes. We were already in an epidemic and then, of course, things got precipitously worse through the course of the pandemic for a variety of reasons. And we've seen skyrocketing rates of prescriptions for psychiatric medications. Some 30 million Americans have anxiety in any given year. But I think that statistics are so intangible. And really, if you look around, we all know someone who struggles with anxiety. We ourselves struggle. We see the rates in kids. We see how kids are struggling. So I think of it as the pH of our age—that if you drop a litmus strip into this stew that we're all in, the quality of the way we experience imbalance right now and how we experience unease is something we subjectively call anxiety.

Dr. Jill  06:52
Yes. So let's go into: What is anxiety?—because I think a lot of times you have this movie. At least, even as a medical professional, I have a stereotype of what anxiety looks like, right? And your book, titled The Anatomy of Anxiety—what a great name! What is the anatomy? What does it look like? And how can it actually be anxiety but masquerade as maybe even an OCD type of presentation? Tell us [about] the many faces. What does this look like in our friends, family, and patients?

Dr. Ellen Vora  07:17
I think it can really present with such a diversity of symptoms. One person has what we would call generalized anxiety disorder. They're chronically worried and tense and they have difficulty relaxing and letting go. Whereas somebody else might have social anxiety. Or someone might have obsessive-compulsive disorder. There are so many different manifestations. Panic disorder is very common. You can have agoraphobic traits to that. But I've really moved away from my training. As a psychiatrist, we're taught to use the DSM, the diagnostic statistical manual, and it's our bible. But I've come to observe that that doesn't steer management in a meaningful way for me. And that's really the central thesis of my book: What did feel like a meaningful classification system was to divide anxiety into two types. They're what I call true anxiety and false anxiety.

Dr. Ellen Vora  08:15

I want to be really clear: False anxiety doesn't mean that the suffering is any less real. It speaks to the underlying root cause. False anxiety, which you can also think of as avoidable anxiety, is physical anxiety. It's based in the physical body. It's related to something tipping our body into a stress response. It's usually something pretty innocuous—some aspect of modern life. Maybe we're tripped into a blood sugar crash or we're sleep deprived, or we had an extra-cold coffee that day or we're hungover, or we just came out of a going down a rabbit hole on the internet. All of these can lead our body in a stress response, which we then subjectively experience as anxiety. But we would do well to identify the root cause and eliminate it. And we can move away from this. It's unnecessary suffering. We can eliminate the avoidable anxiety. 

Dr. Ellen Vora  09:18

On the other hand, we also have true anxiety, which we can also think of as purposeful anxiety. This is not something to pathologize. It's not something to suppress or try to make go away. This is actually something to honor. True anxiety is not what's wrong with us. It's what's right with us when we are able to viscerally connect to what's wrong in the world around us. And that can pertain to our personal lives, our immediate surroundings, our communities, and the world at large. 

Dr. Ellen Vora  09:45

We're in a moment right now where people are having immense amounts of true anxiety, where you are aware that there's something out of alignment and you feel that you have a role in the ecosystem in addressing that. However large or small, you know that you have to course correct or show up in some way to get things back into alignment. So true anxiety isn't something to pathologize or suppress. It's really something to learn how to listen to and honor. 

Dr. Jill  10:11
Wow! It's one of those times where there's such an aha with what you said because several things just click. Number one, when we really experience our somatic body and system, anxiety is a very normal part of being. It's literally a signal. You're saying that something is out of alignment, whether it's in our personal relationships, the world at large, or suffering that we've experienced. So I love this because I'm always helping patients go back to their bodies and actually feel because, when we can connect, we actually intuitively often know what to do next.  So I love what you're saying there. 

Dr. Jill  10:46

My other thought is that I remember years ago treating a patient with atrial fibrillation. I remember understanding that all of a sudden I had this aha years ago. Their heart was beating abnormally. It was an irregular rhythm, for those who don't know what atrial fibrillation is. But what that did was create anxiety. But it wasn't anxiety like “I'm worried.” The heart was beating abnormally and that gave a signal to the brain that something was not right. And I realized all of a sudden: “Oh! This is not classic anxiety.”

Dr. Jill  11:12

This is literally from a physiological dysfunction, right? So that's the other part of what you're saying, like, what if it's actually a signal that something is… And again, I've understood that, but you just made it so clear in how you spoke it—so eloquently, I should say. And it makes sense. And I think those listening will understand that too. Let's dive deeper into what other things physiologically can that [be]—that false anxiety you called it, right? I love that idea. Tell us more about that.

Dr. Ellen Vora  11:38
The one you bring up with AFib—that's such a perfect example because our mind is the consummate meaning maker. So if you give our body a stress response, that tracks up to the brain and it says, “Okay, we're in a stress response. Our brain's role is always to attempt to make sense of stimuli of inputs. So it sees this stress response and it thinks: “Okay, I'm anxious right now. I must be anxious because of this thing happening at work” or this interpersonal dynamic that feels uneasy. And we'll tell a story and we'll have a narrative to make sense of that physical sensation.

Dr. Ellen Vora  12:14

There's always validity to the story we tell ourselves because we do always have stressors. But it's in many ways unhelpful because what generated that feeling of anxiety was not these stories we tell ourselves, not the circumstances. It's the AFib. It's the heart literally generating a stress response or it's the hangover, the sleep deprivation, or the blood sugar crash.

Dr. Ellen Vora  12:41

So once we know that it can be so powerful and grounding to just be able to reflect in a moment of peak anxiety… I usually instruct my patients to say it this way: “I give myself permission to be anxious right now. I'm feeling anxious and it makes sense that I'm anxious right now. And maybe I need a snack.” Or “And I'm aware that I had a lousy night of sleep. Or “And I know I'm getting my period tomorrow.” And just having an awareness of the physiologic underpinnings that might be generating a stress response can be really helpful. Sometimes it's actionable. Like, if you're having a blood sugar crash, have a snack. Sometimes there's not necessarily a to-do. It might help you make different choices in the future, but sometimes it's just to take the power out of the anxious feeling in that moment. 

Dr. Ellen Vora  13:34

A lot of my patients have what's called interdose withdrawal—if someone's taking psychiatric medication. We are all slightly different with our pharmacokinetics and our unique biology. Somebody might metabolize their medication a little bit more rapidly than average, and maybe they're at a pharmacologic nadir or low point when they wake up in the morning and their bodies do for the next dose of medication. That can certainly trip somebody into panic, anxiety, feeling overwhelmed, and a dark doom and gloom feeling. We run with that and we think, “Okay, everything is terrible.” But if you can just remind yourself in that moment [that] maybe this is interdose withdrawal, then you can just know things might not be as terrible as they feel right now. This might just be my body due for its next dose.

Dr. Jill (pre-recording)  14:24

Hey, everybody. I just stopped by to let you know that my new book, Unexpected: Finding Resilience through Functional Medicine, Science, and Faith, is now available for order wherever you purchase books. In this book, I share my own journey of overcoming a life-threatening illness and the tools, tips, tricks, hope, and resilience I found along the way. This book includes practical advice for things like cancer and Crohn's disease and other autoimmune conditions, infections like Lyme or Epstein-Barr, and mold- and biotoxin-related illnesses. What I really hope is that as you read this book, you find transformational wisdom for health and healing. If you want to get your own copy, stop by ReadUnexpected.com. There, you can also collect your free bonuses. So grab your copy today and begin your own transformational journey through functional medicine and finding resilience.

Dr. Jill  15:21

This is so helpful. And it sounds like what you're saying is: Be kind to yourself. And instead of going to that place, I could just hear myself or anyone else saying: “Oh my gosh, what's wrong? Why am I feeling this way?” Which accelerates the anxiety, right? And pathologizing it, making it like: “This is a bad thing. What in the world is going on?” And I've heard patients say that too. They tell the story of that. And instead of doing that, you're actually having this kind compassion. Like, “Maybe this means I need something like a glass of water.” I had this joke with good friends and [my] boyfriend that if I ever get cranky, I'm like a two-year-old. I'd need either a nap or a snack. So I totally get that.

Dr. Ellen Vora  16:00
We are just oversized toddlers in so many ways. When I had my daughter, I had to keep a list on the refrigerator like: Is she hungry? Does she have a wet diaper? Does she need to be burped? Maybe she's teething.  Is she tired/overtired? And I needed to cue myself and remind myself. It was just a little too many things to keep track of without a list. That's why, in my book, I have this avoidable anxiety inventory because we just need a list. We need to remind ourselves, “Maybe this is going on right now,” and to just give ourselves grace and compassion in that moment. And maybe it helps us form a plan that can prevent future unnecessary suffering. 

Dr. Jill  16:36

Oh, this is such a beautiful way to look at it. I love, love, love what you're saying. What about panic attacks? Those, to me, obviously are accelerated and they're definitely driven by neurotransmitters, and adrenal and all those things. Give us a little bit of the anatomy of a panic attack. And I feel like that's another level for people experiencing that, where they might not be able to as easily talk themselves through it. What would you do or tell a patient with chronic, maybe severe, panic attacks? 

Dr. Ellen Vora  17:01
Yes. So whenever I'm working with someone who experiences panic, they always want to know, “What do I do once I'm panicking?” I like to say I'm below average at supporting someone once they're past the point of no return. There isn't a whole lot we can do at that point. Some people splash cold water on their faces or go outside and move in the fresh air. Some of my patients will do a sensory practice that really grounds you in the present moment. You name five things you can see, then you do a 4-7-8 breath. Then you name four things that you can feel, and then you do a 4-7-8 breath. And then you name things that you can smell, taste, or touch and all of this. 

Dr. Ellen Vora  17:40

And it's helpful, but I'm so much more interested in preventing a panic attack from happening in the first place. I'm a little bit uninterested in: What do you do once it's happened? It's kind of like it goes up and it resolves. That's how it's going to behave, almost no matter what you do. And that can be helpful to know if you experience panic. You're not trapped. You're not stuck. You're not going crazy. This is going to crest and then it's going to resolve on its own, pretty much no matter what you do.

Dr. Ellen Vora  18:09

So the more you can actually not be in resistance to it and you can kind of allow it, that's really helpful because resistance does tend to pour oil on the flames of panic. Whereas allowing and softening in the face of it does tend to change our suffering around it. But I'm always interested in preventing panic. And I think it's actually quite physiologic. There are, of course, always psychospiritual, emotional, and mental underpinnings. But the physical stuff is where I think we can move the needle the most, and it's preventing big peak stress responses. 

Dr. Ellen Vora  18:46

I was recently talking with someone who was getting into a panic disorder when they were using cocaine and they didn't connect those dots until a physician was like, “Do you use drugs?” And the person was like, “Actually, yes.” And it's like, ‘Bingo!' So sometimes we forget that things that put our body into a very pronounced stress response can be contributing. The fact is, here in the United States, it's common, it's cool and it's trendy to drink really significant amounts of caffeine. I have nothing against caffeine, but sometimes you just want to be conscious of how much. And I have a lot of patients who just assumed anxiety was part of their identity. That's who they are. It's how their lives would always feel until they dramatically decreased their caffeine consumption. And then it was like, “Actually, I don't have to be anxious all the time.”

Dr. Jill  19:39
Wow, these are some great pearls! I actually love that you said maybe you just leave it alone and let it crust. I found that when I really started to do somatic work and started to re-experience emotions I hadn't allowed myself, like sadness and anger for the very first time, the sadness was like a wave. By that time, I had started to understand that “I can let this go and ride the wave like a surfer,” just like you're describing. And it's going to come and go. Once I learned that, it was so much easier to deal with difficult emotions because, for my first 40 years, I just suppressed it and resisted and did not do any good things for my health. So I really like that you're saying that maybe it's actually a part of allowing and knowing. It's hard, but you will get through it. Because once we do that, whatever emotion it is, and especially panic, it really is just like riding a wave. It's not fun, but…

Dr. Ellen Vora  20:27
In many ways, everyone writes a book and then it takes a long time for the book to come out. By the time it's out in the world, you're like, “Well, I would write it a little differently now if I could rewrite it.” And one thing that I've shifted over time is that I have a very Mr. Fixit approach to mental health. And I still stand by that. I don't want unnecessary suffering for my patients or for my readers. But I also think that there's just a lot of wisdom in allowing. I think of Rumi's poem, I think it's called The Guest House: [When] sadness comes, you invite it in.

Dr. Ellen Vora  21:00

The other day, I was walking down the street. And right now we're recording this; it's October. I live in New York City. It's that time of year for me where I start to get a little bit seasonal affective [disorder]. And I was noticing the early sunset and it was cold and dark, and I felt these old feelings of sadness creep in. And I knew to identify this as related to the seasons. In the past, I've always taken such a Mr. Fixit approach to that. I thought, “Well, what's the right vitamin D amount?—and fish oil and bright light therapy.” And “Let me get some sunshine.” And I was like: “Maybe we actually need an opportunity to be sad.” It's the yin to our yang; it's the purge of pent-up grief and unmetabolized feelings. So I was like, “Actually, I'm just going to really allow myself to be in some seasonal affective disorder.” It's almost like [it's] not a problem to solve. It's actually a wave to ride that serves me on some level.

Dr. Jill  21:58
Thank you for sharing that. I think that is so helpful to me and to everyone listening, because the truth is, this is part of why Western medicine didn't quite align with both you and me. We tend to pathologize everything, right? And I am the guiltiest of all of you listening. I am the queen of pathologizing and saying, “Oh, what's wrong? What do I do?” Just like you said, I go to my cabinet, I figure out a supplement, and I figure out a biohack. I'm all about that.

Dr. Jill  22:23

However, I've just recently learned: “What if this is actually not pathology? What if there's this kindness to yourself that you can feel? It's okay to be sad. It's okay to be grieving. It's okay to have anxiety.” And it's almost like you take that little girl and say: “Sweetheart, it's okay. You're beautiful and you can have a full range of emotions.” At least for me, I grew up in a very stoic farm family where some of these emotions weren't really allowed or weren't really encouraged. So I thought, “Okay, you put on this face and this happy [front].” So it really reinforced that. And as I've grown and learned, that allowing and that kindness to ourselves with all of its phases is so powerful and healing, isn't it?

Dr. Ellen Vora  23:04

Honor to earlier times and previous generations where there was a different set of what we needed to get by. It's a privilege to be in a position where you can invite in sadness where it's not just a matter of survival. And I think that, yes, I'm in a similar position of really learning to embrace the full range of emotion. I'm grieving right now. And I just really grieve. To me, there's nothing wrong with it. I don't apologize for it. I don't even feel like this is a burden or a nuisance if I start crying in a conversation with someone. 

Dr. Ellen Vora  23:41

I actually think that crying in someone else's presence is a little bit of a gift to them because we use our mirror neurons and we all get a little dose of oxytocin. It bonds us. And crying in the presence of others—we are always so embarrassed. We think, “Oh, I'm sorry. I'm sorry.” We try to suck it back in and make it small. And I'm really done with that. I think that I just try to cry as big and fully now as whatever kind of cry my body wants to have in that moment.

Dr. Jill  24:11
All this is so good. So you wrote The Anatomy of Anxiety. When was that published? 

Dr. Ellen Vora  24:22

March 2022. 

Dr. Jill  24:20

Okay, so just a year ago. And again, it's such a needed resource. I want to be sure that if you're listening here, you go out and get that book right away. We'll link up wherever you're listening to the websites and resources of Dr. Vora. But I want to talk about you writing that book because I just wrote my own book and that is such a process of really understanding ourselves and our patients and [it's] therapeutic. What was the biggest lesson, takeaway, or thing that you maybe didn't think you were expecting that came out of the writing of the book? 

Dr. Ellen Vora  24:49
It has so many parallels to pregnancy and childbirth. You're gestating something for a while, and there are aches and pains and discomfort that come with that, and identity crises. You come up against all your stuff, all your imposter syndrome, and your perfectionism and feeling of not [being] good enough. Then you birth it into the world and it just lives on its own. It's like your heart traveling outside your body. It's very vulnerable. And you just hope that people are kind to it, that it carries out its mission in the world and [that it] has a fulfilling experience. I think that I'm starting my second book now, which similarly with childbirth, you write your first book and you're like, “Oh God, I'm never going to do it again.” 

Dr. Jill  25:32

Exactly. “I'll never do it again!” 

Dr. Ellen Vora  25:34

And then you get the inspiration—biology trumps it all—and you find yourself wanting to do the process again. But what I'm trying to do this time around more richly than the first time is really channel and pray before I start writing. So that's my process now. It's very meditative. I burn a candle. I sit in meditation. And then I basically ask for source to use me, to use my unique perspective, strengths, or insights and then to birth something into the world that will benefit the world through me. So that's the process now and it's simultaneously harder and easier. Easier because it flows and harder because I'm tackling much bigger, harder questions.

Dr. Jill  26:24
Wow. You are like my long-lost soul sister. I love every bit of what you're saying. And I really love that piece because I learned it in my first book, and for sure, [I will learn more] if I ever write another book. I'm still in the post-delivery stage, where I'm like, “Uh, not yet.” But all that to say, I really realized the best pieces came out of that [by] letting go and surrendering to the Divine and allowing that to flow through me. And stuff that I didn't even know was in me came out that was profound for myself and for the reader. So I really, really appreciate that because I feel like the most vulnerable, best, and most powerful content is in that space of complete surrender and realizing with humility how limited we are but also how vast we are with the power of the Divine flowing through. So I really, really appreciate you saying that, and it's encouragement for me for the next book someday.

Dr. Ellen Vora  27:16
Yes. I'm so excited for your book to be birthed into the world!

Dr. Jill  27:19
Thank you! This morning I had this conversation with a leader about teens. Do you see young adults and teens, or are you [dealing with] just adults? What kind of population [are you seeing]? And then, what are you seeing?—because I feel like they are maybe in a bigger crisis than any generation before.

Dr. Ellen Vora  27:39
Yes. So I am an adult psychiatrist so technically, I am not trained in 18 and younger, although many of my patients are parents. So kids are a central topic in my practice. So we've had this framework of true anxiety and false anxiety. I think that young people right now uniquely have a whopping dose of both. I do find that the younger you are, the more you're able to viscerally connect with what's wrong in the world. You're less hardened, less concretized, and [less] rigid. You can really feel injustice. You can feel it on a visceral level. So they're carrying that. And they were born into this world with 9/11, climate change, the pandemic and social media, which is an enormous one. So they're aware of what's wrong. I think that the underappreciated aspect of what it means to be young right now and the part that I feel like is more actionable and that we can do something about is the whopping dose of false anxiety that they carry. 

Dr. Ellen Vora  28:44

I think that they gestated in an inflammatory environment. I was born in 1980 so I gestated just at the end of a world that wasn't yet using high fructose corn syrup in everything and wasn't yet spraying Roundup on everything. We weren't yet engineering foods to be hyper-palatable. I think things have gotten really deranged in the last 40 some [odd] years. So these kids gestated in a womb that is endocrine disruptive, inflammatory and lacking in microbial diversity. So all of this, I think, impacts their physical health. And then foods are engineered to be hyper-palatable, which messes with your brain chemistry and also messes with how your body is depositing fat, which is triggering, especially for young females. I think that they're drinking coffee in a way that kids didn't used to drink coffee. 

Dr. Ellen Vora  29:42

But the big, big, big factor that trumps everything else is screens and social media. It's such a problem because it's so addictive, so necessary and so poisonous to the young brain on a number of different levels. If we just looked at a very biologic aspect of this, the blue light in the evening suppresses melatonin and disrupts circadian rhythm. That itself disrupts hormone production. It's even altering puberty. It's altering brain development and compromising sleep quality, which itself compromises brain development and the ability to have a good, stable mood the next day to have good, clear attention and cognitive function the next day. So all of this is big. And then there's all the compare and despair, relational aggression, and FOMO that happen with social media.

Dr. Ellen Vora  30:38

There's one other factor and this one is the most controversial and sensitive to talk about. But I say this because this will be a truth for some people and I think they deserve to know this, which is that… I'm a psychiatrist. I prescribe psychiatric medication. I know it can be helpful. I know it can be life saving. So I say this with nuance and balance. I also know that people experience adverse side effects; they experience withdrawal when they miss a dose or go off of it when they change medications or doses. All of this is a silent epidemic and it impacts young people so starkly. So I think that we have made people more mentally fragile with all of the psychiatric medication prescribing. And that's also a really big problem and there's no easy path out.

Dr. Jill  31:33
Once again, you have said that so eloquently. I just want to pause and take it in, because what a beautiful way to say that. We need to use caution and you and I as medical doctors should be the leaders in talking clearly about not only the benefits but [also] the risks, which is what we're talking about now. I think that's very, very valid. I see the same thing. I see the withdrawal symptoms in between doses and all of that that you're discussing and it's very real. What's really sad is, I think, that whether it's a pharmaceutical, not all doctors but some doctors may not be giving full disclosure. What ends up [happening] is that the patient themselves feels like there's something wrong with them, that they're not responding, or that they're having these ebbs and flows. I want to take that off of the patient and say, “We need to have discussions about this with your doctor.” You and I here are just bringing to light that there could be a piece of the puzzle that involves your actual medications. 

Dr. Ellen Vora  32:23
Exactly. And I think that that stands repeating that people do attribute all these things to themselves. They'll call something a relapse when, in fact, it's withdrawal. They'll just say, “This is just hard,” when in fact it's interdose withdrawal or a side effect. I think people just don't know how to attribute things to the effects of medication, like a child who's on stimulants and has a comedown at the end of the day and is irritable. And a family might come to me and say: “This is a problem. Why do they have such bad behavior? They're a problem. What's the right medicine to treat that?” We failed to look at the root cause—that this is a really obvious effect of a medication they're taking during the day. There are things we can do to mitigate it but we need to start with a recognition of what's happening here. 

Dr. Jill  33:13
Yes. And on this note, I'm going to bring up something that may or may not be controversial: Benzodiazepines—obviously one of the common ones that, as physicians, we're taught to use to treat anxiety. But as you and I know, there are definitely withdrawal issues and addictive issues. Tell us a little about your stance. And again, we both know there are appropriate uses for these things. I'm not demonizing them, but I would love to hear what you think about benzodiazepines—the good and the bad and the cautions.

Dr. Ellen Vora  33:38
Oh my God, the bad and the bad. I think I have a less nuanced view on benzos. 

Dr. Jill  33:43

I agree. 

Dr. Ellen Vora  33:45

I mean, I think that you can convince me they're helpful in seizures, and you can convince me that as an absolute one-off rescue from a panic attack, there's a role. But the tricky thing about benzos is that they are habit-forming. Not for everyone. It's a little bit unpredictable. But I've over the years had so many patients wash up to shore in my practice and say: “I went to see my primary care doctor. I was put on an SSRI. I was still anxious. I was having panic attacks so they gave me Xanax” or “Klonopin.” And “Just doing what I was told to do by my doctor,” being a good law-abiding citizen, “I started taking this when I was anxious,” and now they are addicted. And to me, the harrowing process of getting off a benzodiazepine is so brutal for some people. It's so damning that I don't ever think that it's doing no harm to start someone down that path. So I have not started someone on a benzo in so many years. And even just the one time I did, I felt a little bit bullied into it. It's not my truth. 

Dr. Ellen Vora  34:55

And I think that I also have so much sympathy for primary care doctors who hand these out sometimes like candy, but they have what?—8 minutes, maybe 15 minutes with a patient. Someone is crying; someone is not well in their life and you need to be able to solve the problem and send someone off feeling like a happy camper in no time. That person needs to be heard and witnessed and their false anxiety needs to be adjudicated. There's just so much that we need to do to actually support healing in that moment and it can't be done without time, training, and space holding. So they end up on Xanax.

Dr. Ellen Vora  35:28

I really think that for the people listening who are okay in their relationship to benzos, consider yourselves the lucky ones. And [there is] no need for my words. I don't want this to be a hex and make you think that it's worse than it is. But I just want to send so much sympathy to anyone who feels stuck on it, who's struggling with the withdrawal process, and who feels let down by the healthcare system that they trusted and then finds themselves in a situation that's making things worse.

Dr. Ellen Vora  36:02

And that's the last thing on benzos that I'll add: It exacerbates the exact problem we used to treat it for. So if we're using it to treat anxiety, rushing the brain with the neurotransmitter GABA, the brain, in an attempt to restore homeostasis, pulls the GABA receptors. This is part of why we develop tolerance and dependence: When you're not on the benzo anymore, you can't feel calm at a regular level of GABA in the brain. It's almost as though your brain can't hear the GABA because you don't have the receptors anymore. So we've then exacerbated the anxiety and panic by attempting to treat it. 

Dr. Jill  36:41
Wow. Once again, [it was] so eloquent and I couldn't agree more. I'm really glad you are very honest about it because I think it's a really, really big issue. And patients are very much unaware of the severity of what could happen. Like you said: Compassion to the primary doctor who's doing this because they're trying to do the best they can. But even as physicians, you and I both know we are not trained on the severity of the side effects and the withdrawal, are we right?

Dr. Ellen Vora  37:07
No. Benzos are the one exception, partly because maybe it's off-label and they're cheap and generic. But we're at least told: These are not safe for long-term use. But we're not properly told: Therefore, you can't really ever start someone on it because they create the need for themselves, and it's really hard to get off once you're hooked.

Dr. Jill  37:30
Thank you for that. And again, I know our listeners appreciate every bit of wisdom you're sharing. I want to end with a question. You may have already said something that fits this so feel free to repeat. But what is the one thing that you wish everyone knew about anxiety?

Dr. Ellen Vora  37:51
I think it really does come back to that central thesis of false and true anxiety. I want someone to basically do an algorithm with themselves where, at first, you start with the false anxiety. It's the low-hanging fruit, and it muddies the waters. You can't really know what your true anxiety is while your physiology is pinballing between a blood sugar crash, sleep deprivation, hangovers, and an over-caffeinated hormone imbalance. You need to get some of that resolved. You need your physiology [to be] stable so that you can feel clear.

Dr. Ellen Vora  38:27

And then the job really becomes welcoming in your anxiety and listening to it. It's very natural for humans not to want to be still and not to want to feel our feelings. And when we come by it, honestly, it's hard. But we have a feeling when we head towards anxiety of: “Oh no, oh no, oh no, I won't be able to handle this.” And if we actually soften into it and allow it, it's not there to hurt us. It's actually there with a loving message to help us get back into alignment.

Dr. Jill  39:03
Once again, beautifully said. I have a sign in my living room that says “Be still”. And it's just that reminder because I'm someone who moves a lot and does not like to be still. After 40, when I started somatically experiencing my emotions, I realized, “Oh, the reason for that was because I didn't want to feel.” So I think this kindness to ourselves… If you're out there listening, you're a type A, you're driven, and you're busy all the time, there's probably a piece of you that doesn't like to be still because of what we're talking about because some of this stuff percolates up. And just like you said, I want to echo Dr. Ellen: Be kind to yourself, take that time in the quiet, and let yourself feel the wave and the tsunami of these emotions.

Dr. Jill  39:41

Dr. Ellen, this was so full of wisdom and pearls. I'm super excited to get a copy of your book myself. But where can everybody else find your book and your website?

Dr. Ellen Vora  39:51
Yes. My book is wherever books are sold and it's called The Anatomy of Anxiety. My website is EllenVora.com and I'm also very active on Instagram. I'm @EllenVoraMD.

Dr. Jill  40:04
Fantastic. Thank you again for your time today. 

Dr. Ellen Vora  40:07

Thank you, Dr. Jill. I loved this conversation.