On anxiety and all its states – part II

Volunteer: In the month dedicated to mental health awareness, I spoke with Bianca Vătășescu, clinical psychologist, psychotherapist, and career consultant, about anxiety – what it is and how it manifests. You’re listening to the second part of the episode.

“What do we do if we have a panic attack?” “I recognise what I’m feeling.” “How can I help myself if I’m on my own?”

Bianca: Either I call 112, if that helps me – and many people do feel much safer when they reach out straight away for specialised help. Or I try to acknowledge that I’m having a panic attack and that nothing catastrophic is going to happen, and in a way I try to take care of my own body. By that I mean I start doing breathing… well, breathing techniques: inhaling and exhaling, but slowly, so as not to heighten my anxiety. Because if I keep inhaling and exhaling very, very quickly, I might actually increase my state of anxiety instead of releasing it from my body.

Another technique would be to try to focus on other things – meaning that, no matter how anxious that moment feels and how strongly I experience the panic attack, it can help to look around me and start identifying things. For example, I might count five things I can see, try to smell, say, three flowers I notice in the garden, and so on. Little exercises like that, to find anchors in the external environment, can shift my focus from my current state to what’s outside, helping to calm both my mind and emotions. Other techniques might be things like standing up and sitting down several times, so that once again my focus is on my body rather than the moment itself – and afterwards I can consider reaching out for specialised help.

Volunteer: If we happen to witness a friend having a panic attack, how can we help them?

Bianca: Most of the time, it’s important simply to reassure them that we’re there for them and that they’re safe with us. Again, the things we’ve mentioned so far can be used just as effectively here. I can try breathing together with the other person and show them how to breathe, or I could try to draw their attention to different things around them, saying something like, “Let’s count together,” or “Let’s look over here together…” In a way, the idea is to shift their focus away from what’s happening in that moment and towards their surroundings.

Volunteer: And if they ask to be left alone, is it better to respect their decision, or should we stay with them and use the techniques you suggested, for example?

Bianca: I was wondering whether they might actually ask to be left alone, and yes, they might, if they don’t feel comfortable being seen by other people while they’re experiencing a moment of intense anxiety. In that case, our presence could actually make things more difficult. If I’m having a panic attack and I don’t feel at all okay, and I see you standing there, it might make me even more frightened by the idea that I’m exposed and that you can see what I’m going through. So, yes, it’s okay to respect their wishes. At the same time, if we see someone having what appears to be a panic attack and we don’t know whether it’s actually a panic attack, a heart attack, or something else, ideally we should make sure they’re okay and that they’re not in any immediate danger.

Volunteer: I was reading about this technique of breathing into a paper bag, this breathing exercise where you breathe into a paper bag. Is it actually effective? Does it really work?

Bianca: It’s the same breathing technique I was telling you about. The idea is simply to focus your attention on something, so you can breathe into the bag. The important thing is how quickly you breathe, though, because it’s exactly what I was saying before — if you breathe very, very quickly, you’re only going to make the hyperventilation worse, and it won’t help you in that moment. I suppose it might help some people simply because they’re focusing on their breathing and, in a way, no longer paying as much attention to how they’re feeling, but I find it hard to believe that it helps very much. The point is, if you do want to use a bag, at least breathe into it slowly.

Volunteer: How much can we manage anxiety on our own?

Bianca: One way of managing anxiety is by connecting with other people. If I’m feeling anxious and I don’t really know what’s happening to me, it can help to talk to people I trust. In other words, I can tell them what I’m going through and see whether they’re feeling the same way. And, especially in the context of Covid, it’s perfectly okay to talk to friends about it, to have someone validate my feelings of uncertainty, fear and insecurity, to realise that other people are experiencing the same things, and in a way, to help normalise what I’m going through. Another approach is using stress-management techniques, and there are lots of them — you can find many of them online, although some are more effective than others.

In any case, when it comes to anxiety, one factor that can trigger or fuel it is stress, so anything that helps reduce stress can clearly help with anxiety as well. As I said, there are also relaxation techniques. Exercise can be very helpful for both depression and anxiety, because it helps the body process emotions in a different way. Getting enough sleep is more than important because it helps the body function normally and keeps the brain working properly. Irritability is also less pronounced, so it’s important to stick to a regular sleep schedule.

At the same time, it can help to reduce your intake of caffeine, nicotine and alcohol, because all of these can make anxiety worse. Caffeine can make you feel more agitated, nicotine can also contribute to feelings of anxiety, and alcohol can actually increase anxiety or lead to a dependence that, I assume, no one would want to develop in the context of anxiety. Another approach is to challenge irrational thoughts, starting with assessing the level of anxiety. This is something that can be done with a professional: if I think I’m experiencing anxiety, I can see a specialist, assess exactly how severe my anxiety is, and find out whether it falls within a normal range or not. Then there’s assessing our cognitions—in other words, looking at whether the thoughts we’re having are adaptive or maladaptive, whether they’re helping us in the situation we’re in or making things more difficult. Again, this is something that can be assessed during a consultation. Another useful approach is becoming more familiar with the problem. If my anxiety comes from not understanding what’s happening, then I can say, “Okay, let’s understand what’s happening. Let’s find out more about anxiety. Let’s see where my anxiety might be coming from.” For example, in the context of Covid, this could mean understanding what the virus actually is, how it manifests itself, how much of an impact it has, and how I can live my life once the pandemic is over. Having more information can help a person feel more secure, and becoming more familiar with the problem can help them develop different strategies for managing the situation more effectively.

There are also techniques such as mindfulness, as well as avoidance and exposure. This is a CBT technique where you can gradually help someone with anxiety confront a real-life fear, such as a fear of heights. You can gradually reach a point where you’re no longer afraid of heights, but the process is taken step by step, either in real life or through virtual reality. There are special headsets that can put you in different situations, allowing you to gradually become familiar with and confront the fear, so that when you eventually reach the height you’ve been gradually working towards, you’re no longer as afraid because you’ve been exposed to it repeatedly, but in smaller doses. It’s quite an interesting technique.

Routine and setting aside time for catastrophic thoughts can also help. This means that sometimes it can be useful to establish a routine where you’re not anxious all day, but instead give yourself permission to let those thoughts come up at a specific time. Of course, it won’t work at first, because the anxiety will still be there in the background all day and will, in a way, run wild. But if you stick to a routine and, say, give yourself half an hour at five in the afternoon to be as anxious as you like, over time you’ll find that you have more and more control and no longer need to manage it in this way. That said, all of these techniques can work if you practise them on your own, but they tend to work much better when combined with medication and therapeutic support, when you practise them with a therapist and then repeat them at home. It’s very much a long-term process.

Assessing our coping abilities means assessing how well we can adapt to a situation or not, because we often tend to think that we’re much more anxious than we actually are, or that we’re not managing a situation as well as we actually can, and of course, the final approach is seeking professional help.

Volunteer: What medication is available for anxiety?

Bianca: Anxiolytics are generally recommended, but the most… actually, it’s recommended that you see a psychiatrist rather than taking them as you please. Medication isn’t always just anxiolytic medication, because the assessment may reveal other underlying issues, and a psychiatrist is much better placed to know what to recommend. Another form of treatment that can be used alongside medication or on its own is psychotherapy, and I’ve noted cognitive behavioural therapy as a good option because it’s a form of therapy that works quite well for panic attacks.

Volunteer: If we think about the current context of the pandemic, what does anxiety feel like now?

Bianca: Certain traumas or other problems have become more pronounced, and anxiety can manifest itself in different ways. So, whether I already had obsessive-compulsive disorder or not, it’s clearly become more pronounced now. I might start thinking that I’m going to become contaminated at any moment, and all sorts of obsessions and compulsions can develop. So, instead of only washing my hands when I come home, I might wash them five times within ten minutes, and over time, this will become apparent. It’s clear that many people are likely to develop a disorder, or at least obsessive-compulsive tendencies, now. Of course, it depends on each person’s personality and on what they did or didn’t have before.

Another example would be anorexia nervosa, because someone who has suffered from anorexia in the past might now, as a result of the anxiety they’ve been experiencing lately, stop eating altogether because they’re worried that all their food could be contaminated. Another direction this could take is social anxiety, in the sense that I might stop leaving the house altogether because other people could infect me. Again, it depends on each individual person and whether they’re predisposed to developing social anxiety; it doesn’t mean that everyone is going to develop it. Then there’s panic disorder. People who have experienced panic attacks in the past may or may not find that their attacks become more intense now, especially since many people who used to feel safe going to hospital no longer see hospitals as a safe place. So there’s clearly the fear of, ‘What do I do if I have a panic attack?’ There can also be delusional thinking, in the sense that if certain people were already predisposed to delusional thoughts, these may have become more pronounced now. And as you know, the internet is full of conspiracy theories. Then there’s hypochondria, which has also become much more pronounced for many people. Suddenly, everyone seems to have every illness and every symptom of Covid-19. For many people, it is understandable that hypochondriacal tendencies might become more pronounced during this period, but many will later need to address these tendencies in therapy.

Another example would be somatic symptom disorder, which in a way goes hand in hand with hypochondria, although not necessarily. Somatisation, or psychosomatic symptoms, is when I think I have an illness but also experience physical symptoms, so, for example, I might start getting a headache because I’ve been thinking about something far too much and clearly stressing myself out, and I start thinking that there’s something wrong with me, well, with my head, or, I don’t know, my hand starts hurting and I focus so much on the fact that my hand hurts that, at some point, I start to feel discomfort in my hand and think that… There are also lots of allergies that are psychosomatic, in the sense that they have more to do with stress than with a genuine allergy.

And finally, there’s post-traumatic stress disorder, because I’ve seen some interesting studies recently looking at the Chinese population, and they’ve identified quite a significant post-traumatic… post-traumatic shock, because it’s a bit like what happens during war. In other words, after any collective trauma, post-traumatic stress can occur, and there are many people who will be left with post-traumatic stress after this experience. And I wanted to open up this whole discussion because I’m trying to normalise things in a way. It’s okay if I’m feeling all of this; it doesn’t mean that I’m going to remain highly vulnerable afterwards. But allowing myself to experience the anxiety now, and allowing myself to acknowledge and become aware of some of the thoughts I’m having — not necessarily delusional thoughts, but simply certain thoughts and emotions — is normal and actually very helpful when it comes to managing them later. It’s much better to allow myself to experience them appropriately now and then let them pass, rather than deny them now and have them come back with much greater force later. And in a way, I’d like to open up the discussion about the fact that emotions are almost like visitors — we have them, and it’s okay to let them pass through rather than keep them at the door and allow them to become increasingly aggressive.

Volunteer: So, when these emotions come up, is it good to allow ourselves to feel them, and will they go away on their own?

Bianca: Yes, in the sense that if we’re okay with our emotions and start allowing ourselves to experience them little by little, they won’t become so intense, and people are generally afraid of their emotions because they haven’t known how to manage them up to this point and expect that, once they come in, they’ll all come rushing in at once. And sometimes they can all come rushing in at once. The idea is to let them in gradually, so that they don’t overwhelm us or end up controlling our lives in one way or another.

Volunteer: We still have some questions about this whole idea of positivity and saying, “Everything’s going to be fine”. If, for example, you tell a friend, “I’m not feeling well”, “I’m having these thoughts, I’m scared”, and they always respond with, “Everything’s going to be fine, it’s all in your head, it’s nothing”, you know? How much does this kind of discourse actually help, and how much does it, on the other hand, hide certain things and stop you from looking for answers in a specialised setting, so to speak? I mean, if I’m having these obsessive thoughts, am I not going to end up seeing a psychologist, seeking treatment or getting a psychiatrist’s opinion because “it’s all in my head”, “it’ll pass”, “I can control them”, “it’s within my power”, you know?

Bianca: People are generally afraid of suffering, in the sense that if we see someone who is, I don’t know, extremely sad, we say to them, “It’ll pass,” when really it’s more like, “I’m not comfortable with your suffering, so I don’t know how to hold space for it, and that’s why I’m telling you, ‘It’ll pass’, because I’m not comfortable talking about it with you.” And, you know, in a way, it’s a problem for both people, and this comes from Romanian culture, which doesn’t really encourage people to express their emotions. Emotions are still somewhat taboo here. It’s not really considered okay to allow yourself to be sad or to allow yourself to be angry. And, in fact, more recently, all these different parenting approaches have been trying, in one way or another, to show how important it is to experience our emotions in a healthy way and to create a space where we can do that. But at the same time, there are still some remnants of this attitude, and we’re not entirely comfortable talking about our problems in a setting like that. We tend to choose our friends for having fun rather than for that kind of intimacy where we can talk about our problems, the thoughts we have, and the emotions we’re experiencing. And it would actually be good to have that kind of space, because when I tell you that I’m not feeling well, I might actually be hoping that you’ll tell me you’re not feeling well either, so that we can normalise it—like, “Okay, we’re not feeling well in this situation, and it’s not just my problem.” Or, “Okay, I’m not feeling well either, let’s look for help together.” Or, “Okay, you’re not feeling well and I am, but I’ll help you find some support.” Or even just, “I’ll be here with you.” In a way, that would probably be the best approach: to actually ask other people what they need, because they might simply need us to be there. They might not want to talk, or for us to try to change the subject, distract them, tell them they’re crazy, or just brush it aside, because that’s not how these situations are resolved.

I was thinking we could also talk a little about this idea that everyone thinks anxiety is something bad. From an evolutionary perspective, it’s actually an alarm signal. If I’m worried that my life might be in danger at some point, I’m likely to take fewer risks. For example, I might not drink alcohol and then drive, I might cross the road more carefully, or engage in all sorts of behaviours aimed at seeking safety. In other words, anxiety actually helps us stay safe.

Volunteer: If, say, a parent has an anxious teenage daughter or son, or a teenager who has all the symptoms you mentioned earlier, and perhaps they’re also becoming depressed, how much is it up to that person to ask for help, and how much does it depend on the parent, if we’re talking about a teenager? How helpful is it for the parent to step in and say, “Look, would you like us to talk to a psychologist? I think you might need some help”? Or does it have to come from the person who’s actually experiencing it?

Bianca: Generally speaking, when you go to see a therapist, the parent clearly has to give their consent. As a minor, you can’t just go to a therapist on your own because you need your parents’ permission. I think the conversation needs to come from both sides, in the sense that if you’re a teenager and you’re experiencing certain things, it’s okay to tell your parents, or at least tell a responsible adult who can point you in the right direction. At the same time, if your relationship with your parents isn’t particularly good, then problems can arise again, because anxiety in a family that isn’t particularly connected can, in a way, also have a genetic component. Perhaps the parents themselves are struggling with certain disorders, or perhaps they have anxiety themselves and that’s why they don’t really talk to their children. Or it could be anxiety caused by — or not necessarily caused by, but intensified by — the hormonal changes that are typical of adolescence. That’s why it’s important to seek help, because a psychologist might, for example, tell you that it would be a good idea to see an endocrinologist, or perhaps a dermatologist if your anxiety is, I don’t know, related to acne, because it can be caused by many different things. We tend to put the label of anxiety on it, but it can actually have many different variables. Teenagers can experience insecurity for all sorts of reasons in their lives. Their relationships with friends are constantly changing, they have much larger and more varied social circles, and drug use can also significantly increase anxiety. It’s not okay to use drugs, and they can even cause anxiety, as well as delusional thoughts and all sorts of other disorders that may emerge alongside drug use, but that’s a different discussion. On the other hand, a teenager can go to the school psychologist, who can probably find a way to talk to the parents and help them get the necessary consent. And again, if the situation at home is particularly difficult, a social services assessment may be carried out. If the teenager has absolutely no relationship with their parents, for example, or is being mistreated or beaten at home, then the approach will be different. It really depends on the individual case. The point is that parents should often be able to recognise when something is going on with their children, because anxiety in a child — not necessarily a teenager, but even much younger children — is often a sign that there is conflict within the family, that there may be a genetic predisposition within the family, or simply that things at home aren’t going particularly well.

Volunteer: If you recognise yourself in the experiences we’ve talked about in this discussion, you can find a list of mental health clinics across the country on the mentalhealthforromania.org website, offering services that are fully or partially covered by the National Health Insurance House. What’s more, if you find yourself in a crisis situation, don’t forget that you can call the Romanian Alliance for Suicide Prevention helpline or depreHUB. You can also access the Yellow Canary platform, which is designed to assess your level of wellbeing and gives you the opportunity to connect with psychotherapists. And you can follow us on Facebook and Instagram under the name Mental Health for Romania.