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“Anxiety is a lot like a toddler. It never stops talking, tells you you’re wrong about everything, and wakes you up at 3 a.m.”  I’m not sure who wrote this quote, but it feels right to me. We’ve all had anxiety, and probably all recognize that anxiety can be a force of action or growth but can also spiral to quickly take over our lives and our sleep. How, though, do we navigate anxiety and help our patients who may end up in the anxiety spiral that becomes so hard to get out of?

On today’s podcast, we’ve invited Alex Gamble and Brianna Williamson to talk to us about anxiety. Alex is a triple-boarded (palliative care, internal medicine, and psychiatry) assistant professor of medicine at Stanford. Brianna is one of UCSF’s palliative care fellows who just completed her psychiatry residency. 

We start by defining anxiety (harder said than done), move on to talking about when it becomes maladaptive or pathologic, and how DSM5 fits into all of this. We then walk through how we should screen for anxiety and how we should think about a differential.  Lastly, we talk about both non-pharmacologic and pharmacologic treatments.

It’s a lot to cover in 45 minutes, so for those who like to take a deeper dive, here are some of the references we talked about:


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Moderators Drs. Widera and Smith have no relationships to disclose.  Guests Alex Gamble and Brianna Williamson have no relationships to disclose.

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Eric 00:09

Welcome to the GeriPal podcast. This is Eric Widera.

Alex Smith 00:12

This is Alex Smith.

Eric 00:13

And Alex, today’s show is causing a little bit of dread in me, a little bit of anxiety. Cause that’s our topic today. Alex, who do we have on with us?

Alex Smith 00:24

We are delighted to welcome another Alex, Alex Gamble, who’s a psychiatrist, internist, and palliative care doc at Stanford. Alex, welcome to the GeriPal podcast.

Alex Gamble 00:33

Thank you so much.

Alex Smith 00:34

And we’re delighted to welcome Brianna Williamson, who is a psychiatrist and palliative care fellow here at UCSF, and she’s in the office with me. Briana, welcome.

Brianna 00:41

Thanks. Great to be here.

Eric 00:43

All right, so we’ve got a lot to cover on this topic. I have so many questions, and I promise we’re going to get to the management of anxiety and serious illness. But before we do, we always have a song request. Alex Gamble, do you have a song?

Alex Gamble 00:58

It’s three little birds by Bob Marley.

Eric 01:01

Why did you pick this song?

Alex Gamble 01:03

Well, Brianna suggested it under the title don’t worry about a thing. We clarified the name, and hopefully it’ll be somewhat self explanatory. But I think it’s a really beautiful jump off meditation for the topic, both in how we approach it, think about it, and invitations out of our anxiety.

Alex Smith 01:21

It’s great for the people watching on YouTube. I forgot my guitar. So you’re getting me on the keyboard playing an organ version. This is like the super happy version. Three little birds.

Eric 01:31

We like to think about the baseball version.

Alex Smith 01:37

(singing) “Don’t worry about a thing cause every little thing gonna be all right singing don’t worry about a thing cause every little thing gonna be all right rise up this morning smile with the rising sun three little birds perch on my doorstep singing sweet songs of melodies pure and true singing this is my message to you hoo hoo.”

Eric 02:23

I love that version. I love the organ. We’re getting a little 7th inning stretch. We’ll play a little bit more organ.

Alex Smith 02:28

Maybe we’ll put that version on the live version.

Eric 02:31

I think that would go on both. Alex. This is good with the organ. All right, well, let’s jump into the topic at hand. Let’s talk about anxiety. Alex Gamble, what is anxiety? I call the dread. Is that the right dread?

Alex Gamble 02:54

You know, dread is certainly a sense, I think, a lot of people experience when they’re experiencing anxiety. You know, the. The first thing I think we always have to acknowledge when we’re talking about mental states is that we have a lot of different kind of frames and theories, but deeply, we don’t understand even what consciousness is at a fundamental level. And so I think there’s a lot of different ways that we’ve come to conceptualize and talk about anxiety. There are biological models where we talk about, you know, different neuroscience, neurotransmitters, and pathways that are sort of involved.

But often what we’re talking about is this experience that we can describe physically inside of our body, the sensation that we’re having as we’re anticipating that things may go wrong or badly in some kind of way. So it tends to be future oriented and tends to show up as a physical sensation in our body. Something I’ll often point out to patients is, you know, how do you identify your emotions? Because the experience tends to be fairly consistent. It’s not that a bright red flashing light goes off in my brain that says anxiety. I’m having a bodily reaction. I’m having a sensation inside of myself. It may be chest tightness, it may be my heart racing, it may be feeling sweaty. But it’s this physical sensation that comes along with these ideations. Right.

Often kind of anxious thoughts that tag along and that this sort of experience, in aggregate, we call anxiety. But again, there’s lots of different ways we can think about it. I think it just depends on what we’re trying to accomplish. But in general, some anticipated bad thing in the future that gives us this sense of anxiety. I’m interested to hear if Bri has anything to add to that. That idea or that definition.

Brianna 04:34

Yeah, I think one of the really important points that you mentioned, Alex, is that we’re really trusting other folks on their self report. I think what happens so often is we, as clinicians, or we as humans in the world, hear someone else explain or say, I’m anxious about. I have anxiety. And we jump to a lot of conclusions about what that means for that person. So I think understanding the definition that the person in front of us has in relation to the word that they’re using is a really good jumping point, because we make a lot of assumptions in medicine and even in palliative care, hopefully trying to be more informed around our communication. A lot of room to learn what the person in front of you means when they say that.

Eric 05:22

And then it’s one of these, I guess, for a lot of symptoms, like, we’ve all become breathless at some point in our lives. We’ve all had pain at some point of our lives, anxiety. We’ve all had anxiety more so since I think, Covid, for a lot of us, this seems to, like, be a bigger part of our lives. I wonder, is there a place where it becomes, like, normal, not pathologic or maladaptive? How do you think about that spectrum?

Alex Gamble 05:55

Yeah. So I think you touched on something that’s really important, which is that anxiety is a universal experience. It’s something that all of us experience at one time or another, and it can show up in different kinds of ways. So we have this classification system for different kinds of anxiety, so we can try to study it and say something meaningful about the way that we treat it. But fundamentally, you know, swinging back to what Bri said, like it in the end, is like this ultimate subjective experience. This is one of the challenges, I think, in talking with people about anxiety, is our ability to communicate to each other. That’s also a skill.

And we come to each other in different capacities, with different capabilities to even describe what we’re having, right? There’s a condition they say is alexithymia, the inability to describe our emotions. And so there’s all these kind of challenges that are inside trying to communicate about what’s happening. I think when we start to think about where are we encountering pathology, right? If you look in the diagnostical statistical manual, right, the sort of handbook for diagnoses, most of the diagnostic criteria are in some important ways kind of arbitrary, right? They’re defined as pathological when they’re causing disruptions to kind of normal activity, right? When they’re getting in the way of living our life and doing things that we want to do, if we sit with that for just a second, what we see is that, boy, there’s a ton of variability there, right?

Because I might be able to cope and manage in one situation with the skills and supports that I have, and with those same skills and supports, and another situation kind of come unraveled. So it’s not only subjective, it’s also context dependent, right? So somebody with a severe anxiety disorder where they just struggle to even think about leaving the house, if they’ve got somebody who’s there with them all the time, who has all the time in the world to sit and try to stabilize that anxiety with them, to help them calm themselves down, who maybe is trained with tools to help them recenter and find calm, who maybe has medications on hand that could help calm some of those physiologic sensations they’re having, might be able to help them get out the door and out to the store and walk with them and be processing that whole experience. Right. And in that way, that experience that they’re having of that anxiousness is not incapacitating because they have this high level of support to get them through. That same person having that same experience without any of those supports might be totally debilitated, unable even to leave their home or do any of their basic activities.

And so it speaks to, again, how do we conceive about things as being pathological? I think about this broadly as when is it getting in the way of our life? When is it interfering with our ability to do the things we want to do? When is it robbing us of our freedom? And that’s, I think, kind of our notion and conception of pathology.

Eric 08:47

Is there a time duration? Because, I mean, I’ve certainly had periods where, you know, for several days, my anxiety kind of flares up, I have difficulty sleeping, which interrupts how I actually work and be able to do things that I need to do. And then that often passes, like, for depression, we think, like two weeks. Is there at similar duration part with these anxiety disorders?

Alex Gamble 09:14

I really love that we’re kind of unpacking sort of the practical issues with things like DSM, right? So, absolutely. The DSM definitions of so many different conditions are not only function based, but also time based. But I think in practice, what we find is there’s a huge array of experiences that people are having, right. If somebody has all the symptoms of, in your example, depression, right. Somebody has a severe depression, but it only lasts for 13 days. Were they not suffering, are they at less risk to have recurrence of this?

Does that not matter? And so in the practical application of meeting people where they are, who are experiencing something that’s causing them to suffer. Right. I think the strict adherence to the time base and those definitions often can be less helpful or can be an impediment, can get in the way. I think I certainly have had a lot of friends and colleagues in internal medicine who are so fearful that, oh, if I get this definition wrong, I’m going to cause some harm. And so they stay away from the conversation altogether. And again, to touch back to that really insightful comment that Brie added at the beginning of this discussion, it’s really about understanding this person and the experience that they’re having and kind of where they are inside of this. So if we look at the strict diagnostic criteria, yes, there are kind of time based components to that.

The question I would ask is, how helpful is that in our clinical practice? Is that getting in the way of us deeply understanding where our patients are the people that we’re serving, where they are, what experience they’re having, how that might be creating suffering in their life. And thinking about how we can get into that space with them and meet them in that space.

Eric 10:57


Alex Smith 10:59

As Alex was talking, it reminded me of a concept that may be familiar to our geriatrics listeners about disability and ableism. And that so much of, like, the disability movement. Has really tried to push on this idea that there’s only disability. Because the built environment is not created in a way that allows people who have functional impairment. To move as freely as people who do not. And so there’s that big interaction, as you were talking about, about the environment, their social circumstances. And, you know, adaptive mechanisms. And whether they have disease that is negatively impacting their quality of life and function. There wasn’t a question there, but I did want to ask, like, how do you actually ask about this? Like, as a clinician, do you say to somebody, do you feel anxious? Is that a useful question?

Alex Gamble 11:54

It can be. It depends. Right. So, as we mentioned earlier, people come to us with different skills in lots of different ways. And one of the skills that we could think about. Is their ability to notice their own internal environment. To notice what they’re literally feeling. And then their ability to express and talk about that. For some people, they have a lot of language about anxiety. They have read about it. Right? We live in a time now where Psycho speak is everywhere. It’s on TikTok. It’s online.

So people may come with a lot of language. Sometimes teasing out what they’re actually experiencing from what they were reading or kind of projecting or internalizing can be an added layer of challenge. But so, absolutely, for some people, just asking about, do you feel anxious? Do you get anxious? Can be really helpful. They understand what the word means. They’ve tied it to their own experience. And that becomes a good entry point into hearing about what it is that they’re experiencing. So we can start to enter that space and start to understand and think about what they’re really struggling with. Some people, that does not fit at all. You know, there’s lots of people who. Their. Their background, their culture. Does not have a strong element of emotional description. Or has not been welcomed into the space. Right.

So can think about lots of people I’ve encountered who have a lot of ability to express anger and very little ability to express sadness. Because the life that they lived, the space that they grew up in, talking about sadness or other kinds of emotions other than anger wasn’t welcome. Right. I’ve had patients say, I grew up in a culture of machismo, you know, where you can be angry, but you can’t cry. And so they have a really overdeveloped ability to express anger in lots of different ways but have a real hard time connecting with or expressing other kinds of emotion. And so sometimes it shows up in different ways. People will describe behaviors or being stuck. I think when we’re asking people about sleep, sleep’s a little bit more straightforward, right? I’m sleeping or I’m not. So you can say, how are you sleeping? They say, I’m not sleeping. And, you know, you’re asking questions, is this initial middle terminal insomnia? And for initial insomnia, often that’s a good place for anxiety to show up because bedtime for many people is the only time in the day where they don’t have something else going. It’s the only time in the day where they are laying quietly in the dark with their own thoughts. And that’s a really rich place for anxiety to show up. Anxious thoughts to show up.

Alex Smith 14:14

I’ll tell you when I ask patients, do you feel anxious? Sometimes they’ll be able to respond, and other times they say, what do you mean? Like, Brianna, how do you answer that? If somebody says to you, what do you mean?

Brianna 14:26

So that’s a great question and probably one of the reasons that I rarely ask, are you anxious? Because that means such different things for different people. And as I think Alex Gamble well said, there’s no one size fits all, as we know this from communication folks in the Jerry pal world. But I usually try to understand people’s verbiage of what’s happening for them, what’s happening for them in the midst of learning about a serious diagnosis, what’s happening for them in a world that we’re worried about being pathologized and being given another diagnosis of anxiety on top of that, how even introducing that word could make someone worry that we’re going to throw more medicines at them or tell them that they’re maladaptive or poorly coping.

And I often, in kind of an act way, acceptance and commitment therapy type way, try to bring it into the body. I think Alex Gamble said it really well, that for a lot of folks, this really looks like bodily sensations, and for a lot of folks, it looks much more like what’s happening in their mind. And so I tend to ask people what’s happening for them, especially in terms of coping with this potentially new diagnosis or ongoing diagnosis or new bad news, to better understand the verbiage that they use and then dive into that experience for them a little bit more, which I think pulls out, potentially pulls away from the concern that we’re gonna hand them another diagnosis or tell them something else is wrong with them and instead invite an opportunity for their experience in a way that we can pivot to ways to cope, for ways for me to sit there with them and bear witness to how challenging this is. And I think that’s a wheelhouse we in palliative and Jerry maybe even feel more comfortable with. And so I think learning from the person in front of us what it’s like for them in their own verbiage can be quite a powerful thing.

Alex Gamble 16:26

I think that’s so deft. You know, I think being aware of sort of the stigmatization and being thoughtful about, you know, with this person that’s in front of me might I want to work my way into this in another way. I think it also points out something that’s really helpful about the fact that we are having a human experience, we’re encountering patients. And so I think there’s also, you know, we can often anticipate in the conversation we’re having that some of these topics might provoke anxiety, or we’re asking them about things that are happening in their life that that a reasonable person might feel anxious about and so normalizing that and inviting that into the conversation. Right. If they’ve said they had a traumatic experience receiving a diagnosis. Right. And they’ve described it that way, that we can sort of hold up there and recognize and notice that and ask them what that was like for them. And in this way, we start to collect their own language. Right. We start to find out how are they thinking? How are they feeling? How are they describing it?

Because one of the things I think is so interesting, you know, as we go on experiencing more people having the experience of serious illness and traversing that landscape is that they don’t all have the same experience. You know, some patients describe experiences that sound really traumatic, and they’re totally good. And when you learn more about them and talk more about them, you see, oh, they’re. They’re bringing so much coping skill and processing and deafness to the experience they’re having from their earlier life experiences. And so it’s really remarkable. And I think that’s really kind of the process we’re in as we’re encountering each person is we’re learning about their capacities, their coping, their skills, and sort of finding out, like, what is their experience, what is their language? Where we can then also start to think about, and how can we help them with this? How can we help them? Where might there be deficits inside of this space that we can actually apply ourselves to and help them keep moving forward?

Eric 18:15

I remember you gave a talk at ACP meeting. I remember you brought up something called the bathe technique. Yeah, I’ve heard that’s a way to, if I remember correctly, a way you can actually bring up some of this stuff with patients and empathize with them.

Alex Gamble 18:33

Yeah, absolutely. So the bathe method was sort of a purported. I want to give credit where it’s too. I was introduced to Bathe by another Bay Area palliative care, Alex. Alex Ablesmith, on his website, had a good kind of description, in summary, and I thought, boy, this is a really nice tool, because the design, the idea was to sort of bring a therapeutic intervention into a time contained environment, which the primary care clinic certainly is. And so bathe is an acronym. It stands for background affect, trouble handling, and empathy. And so it, in a really concise, tight way, affords us an opportunity to kind of connect with patients empathically and I think get into, as we’ve been talking about getting into their space. So background is a simple question, like, what is going on in your life? Opening up an opportunity for them to describe what it is that they’re experiencing. What are they encountering, what difficulties are they facing?

Affect is asking something like, how do you feel about that? So eliciting their emotions in an open way, trouble, then asking, what troubles you the most about this? So for them to identify where their difficulty or challenge is handling, how are you handling that? Which I love, because it’s an invitation into recognizing that they are probably already coping with this in some way, or perhaps struggling with that, which can afford us an opportunity to think about how we might help or connect them with resources. And then lastly, empathy. That must be very difficult for you, right? Just a simple empathic expression so we can both get a deeper understanding about what they’re struggling with, afford them an opportunity to practice communicating and actually saying the thing out loud, allow us to recognize and be in a human moment with them about it, and to recognize that emotion. So a really nice, concise technique that could be deployed in any encounter, in any space, even if we’re time limited, and really try to help build that connection with our patients, inviting their experience.

Alex Smith 20:28

Into the encounter, lest our listeners be confused. That is the fourth Alex mentioned on the podcast. We have me, Alex Smith. We have Alex Gamble, our guest, and we have alexithymia I think I heard. And then we have Alex Sablesmith, and this is his bathe method. Great. Thank you. Just keeping score here.

Alex Gamble 20:46

Good count. Appreciate that.

Eric 20:47

We’ll have a link to the bathe method again. It’s a mnemonic. Bh, a t h e. Hopefully we’re pronouncing it right, too. I love that. I wonder if we take a bigger step back then. So, you know, as we think about the spectrum and people’s own history, kind of how long it’s been going on, how important is it to think about, like, the different buckets of these diagnoses that DSM five put people in? And how do you think about it as a psychiatrist? I’m going to turn to Brianna first for this one because she actually gave our team a talk on anxiety disorders. And I loved kind of how she was, like, thinking through these different buckets.

Brianna 21:26

Yeah. Thank you. You know, it’s a great question, and I think one of the, I think, really important questions that we ask all the time in medicine is why? And yet sometimes when it comes to psychiatric disorders or sensations in folks bodies, we sprint ahead to the finish line. And so in terms of, am I looking to put a DSM diagnosis to someone? I wonder why? What would be the benefit to myself, or hopefully for them to add a DSM diagnosis?

Eric 21:58

I think for the coding, your encounter with a diagnosis.

Alex Smith 22:01


Brianna 22:01

Right. Am I looking to Bill? Am I looking to give someone a pill? Have I started my interaction with that desire to pathologize the person in front of me? And if that is the case, I guess another. Why. Why am I doing this? Right. What is at the base of this for me, when I think about in the palliative realm, I think of myself as hopefully a tool for some mitigation of suffering, if nothing more than to sit and bear witness to the person in front of me suffering, and how I can just hold space for that? I think the concern when we jump in with a desire to diagnose or pathologize, we very often inadvertently deny room for what someone needs most, which is sometimes to just be sat with and told that we’re not afraid of their anger, their sadness, their trauma, their grief, even their anxiety, that maybe there’s room for this. I think six steps down the way might be ways to help mitigate some of that anxiety. But I think we often start there.

Eric 23:10

With what anxiety doesn’t necessarily like. Anxiety could be helpful. Correct. It’s a motivating force in some ways.

Brianna 23:19

Absolutely. And I think so often when we hear the word anxiety, and I’ll steal a phrase from Alex Gamble. We think of it as something to be fixed. We walk in, and our first question is, how am I going to take this away from you? And exactly to your point, Eric, that there are many situations where anxiety is quite adaptive. It’s really important. If I didn’t have anxiety about a cavity, I would never go to the dentist. That is, in fact, the only thing that gets me in that terrifying chair. Right. And so I wonder what it is that predisposes us to look for.

Eric 23:56

Well, to be honest, most of the time, I am not making a diagnosis of panic disorder or generalized anxiety. I am seeing it in the patient’s chart. PTSD work with veterans, a lot of PTSD. And I wonder, like, how, when you think about these different buckets of diagnoses, especially for somebody like me who does not do psychiatry. Like, you know, I think about PTSD for, like, our veterans, but I’m usually not the one making that diagnosis. And how should I think about, like. Because it can be important to think about how people are coping with their illness. Like, briefly, how should I be thinking about each one of those disorders and what it looks like?

Alex Gamble 24:41

Yeah, I think, again, it gets down to this question that I think often, as internists, we’re not often handed a good answer to the question of, like, what is my relationship to the DSM?

Eric 24:51


Alex Gamble 24:51

And I think that space that that’s in, a lot of people fill it in with, like, if I don’t have this thing memorized, I shouldn’t be messing with it at all and have just kind of this broad awareness. I think there’s two ways that I think about that are helpful for us to think about this. The DSM, in part, its purpose is to define a population that can be studied. So we put those cutoffs, and I asked the question earlier, how helpful are those cutoffs in clinical practice? In a study, they’re very helpful. If I can define a population, then I can study it. And principally, what I want to do is study treatments and see whether or not they work. That’s how we can say, does this type of therapy, does prolonged exposure therapy help for people with PTSD?

We need to define PTSD, put in an intervention, and then we can see what that is. And so we could say, from a clinical standpoint, the degree to which somebody seems to adhere to that population, then what we know about its treatment is likely to apply, the less they adhere to that clear definition. We might have to be a little bit more open about this treatment may not work for you because there are elements of what you’re experiencing that don’t fit that neat box. I think that can help that conversation. The other way I think that DSM can be helpful to us is if we do not have thousands of hours logged with people with mental illnesses where we have direct experience of kind of the variety of experiences that occur within that space. Schizophrenia, bipolar disorder, PTSD. It can give us a helpful guide to what kinds of things those people experience so we can open that door up for us in a helpful way. In terms of the average practitioner, the need to clarify in between those things.

The need may not be very high if what we are encountering is something that feels like anxiety, that seems to be extremely distressing to the person we’re working with, to the point where it really, this needs a specialist help, that may be as far as we need to go with it, and getting them into somebody who can clarify the diagnosis because they’re going to make a finer treatment decision, right. They’re going to decide what kind of therapy am I referring? Referring this person to delineating between PTSD and specific phobia would be really important for that.

Eric 27:03

How do you think about the different medical conditions? Because we see a lot of anxiety. People who have severe COPD and are breathless. The breathlessness can cause anxiety. The anxiety can cause breathlessness. You see anemia and all these different conditions can cause anxiety. How do you think about. Because that fits more in, like, the medical model now, how broad should our differential be when it comes to this?

Brianna 27:30

I think it should be as broad as we think about something like pain. I think very rarely do we hear someone’s in pain and we don’t think to ourselves what’s going on underneath that. What causes have I ruled out what’s on my differential? And for some reason with anxiety, I think often we hear that word and we rush to the DSM, we try to look through the criteria, and it’s really tempting, right? Because that’s a word, kind of a buzzword. We’ve got a whole section in the DSM, anxiety disorders. But exactly to your point, Eric, it often is anxiety inducing. When I hear that I have a serious illness that might end my life, that is a very human response, and it’s a very human response when I can’t get a breath of air in to be worried about what. What’s gonna happen or how uncomfortable that is. So I think, to your point, keeping a really broad deferential when we hear that word allows us to address the person in front of us, inquire more about what’s happening for them before we jump to a solution like an SSRI, which we see happen all the time, as soon as someone throws out the word anxiety.

Eric 28:37

Well, since you brought up treatment, I’m gonna jump treatment. I’m not gonna jump to SSRI’s or benzos quite yet.

Alex Smith 28:44


Brianna 28:45

Thank goodness.

Eric 28:46

When you think about, like, you have somebody in front of you who’s been dealing with anxiety, and not just, like, you know, over the last day since they got their diagnosis, is starting to impair their ability to function. How do you think about non pharmacological approaches, or maybe even in the people who just have a shorter, maybe less complicated anxiety, but it’s still impacting their sleep? How do you think about that non pharmacological approach to anxiety? And is there anything I can do with my own meager powers, aside from prescribing somebody a benzo?

Alex Gamble 29:25

I would start by recognizing that your powers aren’t meager. That often. One of the most powerful interventions we have is presence. The decision to make space in a clinical encounter, to invite in someone’s emotional experience, particularly their anxieties, is really powerful. You know, what we see in the literature is really clear is that more than the specific type of therapy someone engages in, the main predictor, the primary predictor in the ultimate success of therapy is the therapeutic alliance, is the connection that they have with their provider. The things that you do, giving people time to describe what they’re experiencing is powerful, is therapeutic. Right. Often one of the pieces that causes so much suffering when we’re feeling anxious is this thought that, like, this is unmanageable, this is totally overwhelming and. Right.

Often this underlying belief, like, and if I share this with anyone, it will be a disaster. Just experiencing. Saying out loud a thing I’ve been holding inside and seeing someone be able to calmly hold space with me that they don’t panic, that they don’t freak out, is therapeutic. You don’t have to have thousands of hours of therapy training to do that for someone. Right? Just doing that, just opening up their experience, just exploring that with them, because what begins to happen, they begin to see this is not what it has grown into. In my mind, if people are being debilitated by their anxiety, often they’re already down this path where there’s an architecture that’s grown up around them. They have this physical experience, and there are thoughts and sensations, and it’s gotten deep. It’s a lasagna of suffering. Right. It’s all these layers of bad stuff and just starting to unpack that, just starting to see, oh, this is a discrete experience.

This isn’t everything forever, right? And I’m not going to collapse. I don’t have to collapse under the weight of this, because ultimately what we want is, as Brianna said earlier, anxiety is not a problem that has a solution. It is a universal human experience, and it can be helpful right, in the right circumstances. If it’s run amok and it’s keeping me from being able to do anything, that is a problem. And the experience I’m having may be powerfully distressing. When people have panic attacks, they often say, I feel like I am dying. And they mean that they turn up in the emergency department because they think they are experiencing a medical emergency. To touch on that, the question about the differential, it should be broad, because they could be having a medical emergency. They could have a pulmonary embolism that might be life threatening without attention.

We should take their report seriously. We should think about it with our good background and training and explore it like we would anything else. And if we’ve ruled out dangerous things at the end, what we’re left with is someone who’s still having a horrifying, overwhelming experience, who deserves to be treated with kindness and dignity and respect. And that was a common experience I had in my psychiatry training, was being called to the ER to see someone who’d come in with panic. All the dangerous things had been ruled out. And they’re like, now we want them out of the ER, but they won’t leave. And recognizing that communicating with people about what they’re experiencing is a procedure, and it’s often not a complicated one, just making time, educating them about the medical things that had been ruled out, to speak to that terror that’s happening inside of them in that moment, and then talking about, this is a problem. This is a serious, real problem.

This is not just all in your head, or rather redefining all in my head as an important place where important things happen. Right. Every experience I have is mediated up here. So if I’m experiencing something up here that warrants attention, and we have a way to attend to that, getting people connected to clinic, to therapy, to treatment, that can be really helpful and in many cases, life saving. Right? Giving people their life back, especially if they’re in a place where their anxiety has taken so much from them.

Alex Smith 33:21

Observation and a question. One of my early mentors, Susan Block, who’s also like Alex Gamble, trained in internal medicine and psychiatry, used to say that getting back to what you said about the therapeutic alliance and the importance of it, and being able to sit and be present with them in the room and talk with them about their anxiety, opening up a space, a safe space to discuss it, is therapeutic and is, like, where we should be starting. She said much the same thing. And also on the other end of the spectrum, you can imagine there are practitioners who are so concerned about that anxiety, they can’t face it, and so they don’t open that up. And the message that it sends to those patients that this is so distressing that even my doctor has to, like, run out of the room because they can’t deal with this anxious.

Eric 34:11

The doctor’s anxious.

Alex Smith 34:11

It must be.

Alex Gamble 34:12


Alex Smith 34:13

Even worse than I thought. This is. This is horrible. So that’s my observation. And my question is, like, are there some people for whom it’s disabling to talk about the anxiety, to open up that box and dwell in it or be in it, examine it, discuss it, and for whom? Maybe we shouldn’t be talking about it too much? And are there warning signs about that? I wonder if that has happened in your experience?

Brianna 34:44

I think what you said was really powerful just then. Alex Gamble and Alex Smith, both of you speaking to this importance of presence. I’ve heard often when we run to a code, the first pulse we should take is our own. And I think that that’s really true in engaging around the idea of anxiety with the person in front of us, and that it takes a lot of emotional work to do this type of care. And part of it is interacting with our own anxieties, our own desire to fix, to make go away, and how important it is that we come with an ability and potential comfort, with just sitting and an inability to fix. We do this really well in other realms.

This is hard to do with anger, with anxiety, with some of these, like, seemingly less palatable emotions. And so, directly to your point, when we skirt away from them, when we pretend that they don’t exist, what we may have handed someone is an idea that this is intolerable, and no one’s gonna accept this for you. And so actually worsening anxiety by pretending that it doesn’t exist. To your other point, there are things that are buried, some traumas that are buried really deep below layers. If this is the one and only time you’re going to see someone and you’re encouraging them to open up about the biggest trauma that ever happened in their life, and then you’re going to leave, maybe feel like you’re going to abandon them and never revisit it again, that’s cause for concern, too.

So I think it’s a really astute point to be thoughtful about when and how we’re opening these really tender moments. And I hope not just about anxiety, but about a lot of these really vulnerable and precious spaces that folks invite us into, that we spend a little bit of time checking our own pulse, being potentially and hopefully a really grounded presence in the room for them, and being really thoughtful about how much and what we open, somewhat using our own wisdom as a guide, but also trusting the person in front of us. If someone, if you ask about anxiety and they say, no, never, I don’t want to talk about it, is that the time to probe further? What is your relationship? What will be the follow up? I think trusting the person in front of us is also really important about how much to push and how much to just create space and see what’s filled there.

Alex Gamble 37:08

I think it touches on something.

Eric 37:10

It touches on.

Alex Gamble 37:11

We’ve touched on so many things that I think are so rich and really important. One I think definitely is the recognition that we may stray away from these discussions because we’re worried it’s going to trigger our own anxiety. And I think that’s a really important question for all of us to interrogate, is recognizing that these spaces we’re in, they are anxious spaces. And what are we doing to build our own capacity to be spacious and hold that space? A way we can think about someone who’s experiencing anxiety is they crave containment. For a lot of people, anxiety is about the loss of control or the fear of loss of control. And so they want to be able to have some boundaries and some space around that. If we’re going to open this space up, as we said, can be very therapeutic. We have to be able to contain what’s going to come into that space.

If we’re worried that we won’t be able to do that, we may shy away from it, and that can create these many problems. And so it’s worth us investing for ourselves in building our capacity and holding that space with each other, with our patients, and has a lot of potential benefits. I think the other part of that is looking at the way that we open these conversations is that we can, knowing that we may be touching on something that could be very sensitive. Starting the conversation in that way is saying, hey, these, the things that we’re going to talk about might bring some things up for you. I always want you to feel comfortable and safe in this space. If I ask about something that’s feeling unsafe or you don’t want to get into, just let me know, and we can talk about why it might be important for me to know about this, that I can serve and help you better, and I can better understand how I can best work with you and show you that respect, in effect, restoring that control. The recipe for anxiety often we’ll talk about with folks is it’s this perception that there’s a mismatch between the size of the challenge we’re confronting and our ability to sort of cope with it, that the gap in between those two measures is the space in which anxiety grows for things like cognitive behavioral therapy. That’s exactly what they’re going to do, is explore those two perceptions. Because often we’ve overestimated the size of our challenge.

And if it’s smaller than we thought, we may see that, oh, our ability to manage this is actually well met, or we may be underestimating our ability to cope and manage, or might be both. I don’t have to overwhelm the challenge. If I can just meet it, then I can feel more in control and much less anxious. And so thinking about what are ways that we can restore someone’s sense of control, recognizing they can’t control the anxiety, but they can work on developing their ability to recognize it and work with it and work on their response to it.

Eric 39:47

Can I ask about the control, the anxiety? Because I feel like, especially in Covid and post Covid times, there’s a lot of apps out there, a lot of talks about breathing techniques and mindfulness as a way to deal with anxiety. Is there a role for that?

Alex Gamble 40:04

Yes, absolutely. Definitely. I think there’s no question. That’s the question is, what is the right role? Right?

Eric 40:12


Alex Gamble 40:12

And so one thing I think is, as we’ve been talking about anxiety, you know, we’re speaking from a place where our presumption is that anxiety is going to be there. Right. Well, I’ll often say to patients, I’ll say kind of silly, sort of maybe obvious things like, you know, they’re called feelings. Cause we feel them, they’re not called choosies. We don’t choose them. Right. They just occur. And in large part, we don’t have a choice over what we think either. The classic example being, if I say to you, don’t think of a pink elephant, the first thing that pops in your mind is that pink elephant. Right. So if I don’t have control over my thoughts and I don’t have control over my feelings, what can I say I have control over.

And we might say, well, my response is, and I can choose where I’m going to rest my attention. When I’m overwhelmed in an anxious moment, if I’m having a panic attack, if I’m having all these really scary thoughts, these very intense physical sensations, it becomes very difficult for me to manage my attention, to rest it back to something else that might. Might be more helpful for me than staying caught in a doom loop. Mindfulness exercise is one of their very many benefits. Is it affords me an opportunity when I notice that I’m going into the loop to pull myself back out of it. When my therapy, one of my therapy mentors, Lillian Dindo, taught us a five senses exercise where you just kind of progress through your five senses. So you sit quietly in a room, notice five things that you can see. Their color, their shape, their texture. Four things that you can hear. Maybe a fan in the background, a dog barking outside, the sound of your own breathing.

Three things that you can feel. So maybe the chair underneath me, my shoes on my feet, the air passing in and out of my mouth. Two things I can smell, one thing I can taste. As I cycle through these things, what I find is I’m suddenly extremely present. I’m back in my physical body. I’m out of the anxiety loop. The question I immediately asked Lillian was, but the anxiety is still there. And she said, yes, but now you can choose whether you want to go back into it or if you want to do something else. And so these really simple techniques, five senses, exercises, square breathing, you know, they’re these really powerful techniques that we can use as sort of an escape lever that when we find ourselves in these kind of patterns, that for many people, that’s the disabling part, right? Is like being stuck in a pattern that’s so distracting.

Eric 42:30

And I love that, too, because sometimes. Sometimes, I don’t know, you kind of cry. I’m not sure, crave the anxiety, but it’s like an itch. You have to keep on scratching. And when you’re in that loop, sometimes you just want to go deeper and deeper and deeper.

Alex Gamble 42:45

And now we’re getting healthy. Absolutely. Well. Well, it’s serving a purpose, right? And we don’t have to get deep, too deep into behaviorism, but every behavior that’s repeated is being reinforced one way or the other. So a question we can ask for these things to come up is, what purpose is that serving for us? Right. For most people, that’s going to be the work in deep therapy. But that is a question I think that we can sort of explore and look for. Are there other things? Are there other ways we could respond that restore our sense of control or address that deep need we have that aren’t so destructive or aren’t disabling our lives?

Eric 43:18

As we think about this, we’re thinking about the non pharmacological treatments, ways of getting out of this, this loop. If you want to get out of this loop, Brianna here asking the whys, what’s the role and when do you think about pharmacological treatment, antidepressants, benzos? Briana, cool.

Brianna 43:40

This is a really good question, and I think very much depends, clinician to clinician. I’ll give maybe my kind of still young in my career, learning it all point of view, and then I might bounce it over to Alex as well, because I’m curious his take on this. I think there are absolutely a role for pharmaceuticals in specific instances. I do think that we reach for them really consistently instead of spending the time presence space to acknowledge the importance of what is that itch that we’re scratching with the anxiety? Where is this coming coming from? Do I believe that your anxiety is intolerable? Do you, am I handing you an escape lever?

Do I think this is an escape lever? And is it really? Or is it just a diversion technique? Instead of sitting in presence and finding more flexibility, mental emotional acceptance around something that’s admittedly uncomfortable? I think we talk often, again, kind of back to this pain metaphor, that often our approach is not to get someone to a zero out of ten. It’s to find a way to make the pain manageable, to allow other things into our lives that make our lives worth living, that add to this quality. And I think the same kind of thought process can be true in anxiety. I believe we’re really quick to throw a medicine at something instead of asking that why and understanding the deeper effect. And I think that the why can be helpful in terms of determining what medication might be most appropriate. But I think three steps before that, we often miss the importance of what’s actually happening for the person in front of us and how we encourage mental flexibility, emotional, maybe even spiritual flexibility in ourselves, in the person in front of us, before we just throw a medication.

Eric 45:44

Well, I guess, is there a role for a benzo to get somebody out of the loop? Alex, what do you think about that?

Alex Gamble 45:52

Yeah, so, definitely, I think in a Jerry Powell context, we have to be extremely cautious when we’re talking about benzodiazepines, because we certainly are talking about a really high risk population of folks. And so in a risk benefit analysis, we’ve got to think hard about, okay, this is substantial risks. This medication can pose really substantial risks to these folks. What is the risk of untreated anxiety? Right. Like, is it going to be dangerous? It can certainly be disabling. Is it going to be as dangerous to them as an episode of delirium, as a really bad fall? I think often the answer is no, which is not to say that the anxiety is not engendering suffering and does not need attention, but I think it’s to temper our enthusiasm for using high risk medications with issues that have a variety of other approaches. So, like Brianna said, I would really echo just recognizing that as we’ve talked about, inviting it into the space can be therapeutic.

It can also be an opportunity to reconnect people with their coping. One of the nice things about taking care of people who are in their 5th, 6th, 7th, 8th decade of life is that they’ve probably gone through a lot of really tough stuff, right? If they had jobs, they’ve lost jobs, they have lost family members, they have lost friends, they have suffered terrible losses, and they found ways to work through those things. So I think a great question is, when you faced other big challenges in the past, how did you get through them? What’s getting you through now? Who do you talk to about these things? A thing that I think is really under recognized is especially in like an internal medicine context, in a primary care context, you may be the first person that they have ever revealed this internal thing to. And that was something I saw, like in my med site clinic. A lot of these guys had serious anxiety, mood, PTSD, and refused to come see the psychiatry clinic. And it was having the beginning of the conversation with me who they saw as their internist, but who could hold that space and it was safe for them to talk about. That in itself was really powerful. Being able to say to someone, I think talking about this more would help. And we just proved that it can be talked about. Someone can listen to you, someone can make you feel heard, and then let’s bridge that to somewhere else. Like those can be really, really powerful.

I don’t see those written up in a lot of papers, but I see the power of those in the clinical encounter. Is that just pointing out what we just did? Hey, you just talked about it. You seem less anxious. Right. If we can help them talk through it and contain it, people often immediately feel better pointing out that, hey, having a place to talk about this and process this is powerful. It they don’t, they may not need a therapist. They maybe just need to talk to their sister. They may say, like, well, I don’t want to weigh Maggie down. And recognizing that, you know, Maggie’s worried about you, and knowing what you’re worrying about and having the ability to hold space for that might really help Maggie, too. Right? Reconnecting us with this web of people that we’re inside of, with our ability to reconnect a process through these things. Not everything needs a medication. Not everything needs a therapist, and yet medications can be really helpful. So to not dodge the heart of your question, you know, where we see that people are having a lot of distress, where it is causing a lot of debility for them, the medications can definitely be helpful. SSRI’s, in general, are first line because they tend to be lower risk. That is not the same as no risk. So there’s increased risk for falls, increased risk for fractures. Sidh is not a small matter in an older population. Like, these are all things that we have to think about.

Eric 49:23

And SSri’s versus snris versus the mic has been of the world.

Alex Gamble 49:28

SSRI’s in general are the first line recommendation because of the side effect profile. So snris tend to have more side effects and challenges. There may be cases, though, where we say, well, there’s other potential benefits. Right. We think about our chronic pain patients where SNRIs may be helpful. SSRI’s don’t seem to have any impact on chronic pain. So we may say, well, there’s a little more risk here, but there’s more potential benefits, so we want to try it. I think the way that we talk about treatment really matters. I think it’s so important that we set these expectations the same way we do when we talk about pain. If we’re going to start someone on an opioid, we want to be really clear about how are we going to know this is working?

What are we looking for? Right. We’re not looking to extinguish your pain. We’re looking to make it manageable. When people benefit from an SSRI, they don’t stop having anxiety. The anxiety tends to success with SSRI’s tends to be that it’s less intense and maybe less frequent. So if I’m having panic attacks, maybe they’re happening less often, maybe they’re sort of less intense. What’s going to help me the most is coupling that with something that’s going to help me build my skillset, my repertoire, to be more robust with that. And that’s the other place where the medications seem helpful is when we look at medication alone versus medication plus therapy. Medication plus therapy is superior. The way I talk about that with patients is, again, we don’t understand what consciousness is, but it does seem that our biology plays a role. These medications seem like they help us, us make new connections. Part of what we’re doing in therapy is kind of refiguring the connections in our brain. We don’t have to understand it for that to be working.

And Ssri’s seem to help with that. There’s something about increasing the availability of serotonin that seems to help with that process. Conversely, benzos plus therapy, less effective than therapy by itself. If we think about what’s happening, benzodiazepines work on the same part of our brain that alcohol does. And this is what I’ll often counsel patients. So people will say, oh, that liquid courage. That anxiety that I’ve got in the bar to go talk to that attractive person over there melts away when I have a couple shots of whiskey. Right. We’re both subject to the other side effects of that. That it can be disinhibiting, can increase risk for fall sedation, respiratory depression, but it’s also severing that connection. If my goal is to become more resilient and capacious, I have to be experiencing anxiety to do that. If you’re cutting off that pathway and I stop experiencing anxiety, I can’t improve it in the long run, you might give me a worse problem, because what I’ve set now is a context where the only way and the expectation for my anxiety is that it be extinguished. Now I’m becoming anxious if I don’t.

Eric 52:04

Have access to those pills spiraling bigger.

Alex Gamble 52:06

And bigger, bigger and bigger.

Eric 52:08

Okay, last question, because I want to be mindful of the time you also brought up in the ACP talk, something about, like a second 2nd chair in the room or something in clinic. Can you briefly describe what you said during that ACP talk? Yeah.

Alex Gamble 52:22

So I talked about, when I was practicing inpatient psychiatry in my first job, I would meet patients in my office, and there were three chairs in the office, and I would. Often, when we were talking to folks with anxiety, I would ask them to guess why the third chair was there, and they’d have good guesses. Oh, another patient, another staff member. And I would say, no, the third chair is for my anxiousness, because I actually have experienced panic attacks for a lot of years. And like anybody with panic attacks, they can show up unexpectedly. They can be incredibly intense. Like most people with panic attacks, it’s a strong physical sensation for me and a lot of intense thoughts. In that case, like, you can’t help this person. You need to get out of here, let somebody else try to help them and figure it out. Because right now, something bad is happening inside of you. In the moment that my panic shows up up in a clinical encounter, I have to make a choice, and that is, am I going to respond to my own doom loop that’s going to distract me, carry me away from what I’m hoping to do?

The reason I’m in this room is to help this person that’s in front of me. If I’m going to succeed in that, I need to have enough space for whatever shows up inside of me, including a panic attack, and be present to them. And so I would say the third chair is for my anxiety. If it shows up, I don’t want it to be in the way of what we’re doing. I want to welcome it into the space. Notice that this is going on inside of me, and maybe later, at a better time, I’m going to turn my attention to this and think about, why are these showing up now? Because as you said earlier, eric, it usually is tied to something else. What I normally find when I’m having more episodes of panic is I’m not sleeping well, not taking care of myself, I’m not exercising enough, I’m drinking too much caffeine. Right. And it’s a signal to me from inside of my body that the great choices this big brain is making are not serving it well.

Eric 54:07

I love that story, alex. Loved it back then, love it now. Brianna, I want to thank you, but before we end, Alex, I think we’re going to go back to the baseball game. Don’t worry, be happy.

Alex Smith 54:21

(singing) “Don’t worry about a thing every little thing gonna be all right singing don’t worry about a thing cause every little thing gonna be all right rise up this morning smile with the rising sun three little birds perch on my doorstep singing sweet songs of melodies pure and true singing this is my message to you.”

Eric 55:07

Alex, Brianna, thanks for joining us on this Geripal podcast.

Brianna 55:10

Thanks so much.

Alex Gamble 55:11

Thank you so much.

Eric 55:12

And thank you to all our listeners for your continued support.

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