Ways to Handle Anxiety without (or along side of) Medication

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Welcome September! This month encourages new beginnings with the change of seasons and
the start of the school year. Nervousness, apprehension, stress and anxiety frequently
accompany excitement, opportunities and life changes.

Stress and anxiety were among the most common complaints I would encounter while in
Residency, Urgent Care and Family Medicine. During residency, I encountered an article in
JAMA which stated, 60-80% of office visits can be related to stress (JAMA Intern Med 2013). I made ‘Stress’ my residency research project. I felt frustrated that I had no perfect pill for managing stress. After seeing thousands of patients with anxiety, I fully appreciated the complexities of the issues. I became curious for understanding the causes and became more empathetic towards others.

Can Stress be Harmful or Make you Sick?

Stress is physical and mental response related to an external source. Simply, stress can be
anything that is overwhelming. The exact definition of stress is debatable. Stress can be
beneficial or harmful. It is typically temporary. One definition provided by the American
Institute of Stress website, “stress is a condition or feeling experienced when a person
perceives that demands exceed the personal and social resources the individual is able to
mobilize.” Everyone experiences stress at some point in the life.

Stress can make you sick. Stress can produce physical symptoms including: headaches,
inattention, insomnia, high blood sugar, high blood pressure, weight changes, stomach pain,
rapid breathing, chest pain, muscle tension, erectile dysfunction and low sex drive (source Prolonged periods of stress increase your risk of chronic disease including heart disease and cancer.

I had a patient who came to my office over multiple visits to discuss his chest pain. He had no significant health conditions despite a thorough workup. He did have a very stressful IT job. I mentioned to him that I thought his job was actually killing him based on his description of his work-life. I was concerned he would have a heart attack one day. During his third office visit, he excitedly shared with me that he made a job change and his chest pain had resolved. He was a new person during that last encounter.

The Global Organization for Stress Statistics reported, “Stress is the number one health concern of high school students.” In practice, I have found young people to be the most stressed patient population while in practice. I found that adolescents and young adults often experienced more feelings of uncertainty, fear and discomfort but did not have the skills to manage those emotions.

My top 10 recommendations for managing stress:

  1. Deep exhalation and nasal breathing. Practice all day long. Often the mistake is telling ourselves, “I will do this for 5 minutes once per day”. In actuality, our bodies need to breath all day long and we can practice all day long. Practice while in-line at the grocery story, stopped at the stop light, while waiting to sign into the computer, while cooking or performing household chores. The more you practice the more routine it becomes.
  2. Movement. Move your body. Exercise. This helps reduce the nervous energy. Find an activity you love. Walking is the simplest yet underrated form of activity. Sometimes we need activities where we can release our aggression such as kick boxing, tennis or pickleball for examples.
  3. Meditation. I have heard so many patients claim they tried and cannot do it. Their minds cannot focus. Actually, it is normal for the wind to wander and completely okay. There is no right or wrong way to meditate. Mindfulness-based meditation appreciates the truth that the brain will drift, to acknowledge those thoughts and release them. Guided meditation can be beneficial especially if starting a meditation practice. Here is one of the best free guided meditations I have come across is by Vishen Lakhiani: A 15 Minute Mind-Hack to Massively Enhance Your Brain Power and Emotional state found on Youtube:
  4. Spend time in nature. Breath the fresh air, hear the birds, see the fall color changes.
  5. Music. Listening, singing, playing. All of these activities help with anxiety. Contrary to what we like to believe, our brain can only focus one task at a time. Sometimes fast paced and loud music is counterproductive. A nurse whom I knew struggled with anxiety. I recommended she start listening to meditation music and she found it was helpful.
  6. Stress relieving activities. Find something you love and makes you happy. Examples puzzles, coloring, games, reading, soaking in a warm bath.
  7. Acknowledge the feelings of anxiety. 50 percent of our thoughts are negative. Fear is ok.
  8. Conversation, Socialization and Community. Talk to friends, family members, find a lifecoach or a counselor if needed. Sometimes speaking out-loud to ourselves or our pets is helpful. We all want to be heard.
  9. Introspection and Journaling. My favorite question to ask patients, “if something in your life could be different, what would it be?”.
  10. Plan ahead. Plan your routines, meals, activities at home and work. If nothing else helps, see your doctor.

Medications exist. I have prescribed them in practice. I found medications to be equally both successful and unhelpful. What was I missing in order to help my patients?

I realized one thing I could offer patients was perspective. Not all patients needed counseling or medications. Most of us could use a sound board to help us appreciate the thoughts playing in our mind. I found Life Coaching and decided to become one.

My Life Coach Program (I trained through the Life Coach School) reminded me that anxiety is a normal part of life. Anxiety is a feeling. It is a general sense of worry, fear, nervousness and apprehension. Physical symptoms can be present. The real issue with anxiety is our reaction to and resistance to it. Anxiety is a person’s reaction to stress. One of my favorite patient quotes, “It’s not stress, it’s anxiety”. This patient was unsuccessfully managing their stress and felt it was beyond their control leading to anxiety. Anxiety was becoming my most common complaint to see during the day.

The first step to managing anxiety is to recognize anxiety for the feeling that it is and the physical sensations it causes. Through coaching, I have come to appreciate that anxiety is not a problem until we make it a problem by resisting it, reacting to it or avoiding it.

  1. Resistance: we push it away
  2. Reaction: we do counterproductive things
  3. Avoidance: pretending it does not exist
  4. Acceptance: acknowledging the anxiety feeling or vibration to be present and feel its intensity subside (more to come on processing feelings).

The first three methods of managing anxiety are not helpful. Medicating anxiety is only partially helpful. Here is a universal truth: Our thoughts create our Feelings. Anxiety is a feeling. Our thoughts create Anxiety. In order to accept anxiety, we have to remind ourselves anxiety is a feeling created by our thoughts.

The Steps to Accepting Anxiety (LCS resource):

  1. Write it down. Describe the feeling, physical sensation and the thoughts associated with anxiety.
  2. Play with it. Allow yourself time to worry and be anxious. Set a timer if you need to. Plan anxiety on purpose. Figure out the worst case scenario. Allow anxiety to be present and experience the feeling. Find the thoughts that make the anxious feeling better and worse.
  3. Breathe. Panic attacks are created by resisting anxiety and not breathing. I cannot begin to count the number of patients I have managed who experienced panic attacks. Many times people believe they are having a heart attack. The correct answer is always ‘go to the Emergency Department’ if you are experiencing persistent chest pain. During medical school, I met a psychiatrist who mentioned “Deep breathing can be as effective as a short-acting anxiety medication.” His words have always played through my mind when seeing patients with anxiety.

We underestimate the power of breathing. In practice, I found many patients knew and practiced deep breathing but the answer was often, “It doesn’t work.” Little did they know, I practice deep breathing all day and sometimes in their presence. I had a patient demonstrate to me how he practiced deep breathing because he believed it did not work. He sat on the exam table, took a full deep inhalation breath over 3 seconds, then let out a huge sigh during a one second exhalation. Timeout. Of course it didn’t work for him. He was missing the prolonged exhalation part of the breathing cycle. He taught me a lot during that encounter. I came to realize how the concept of ‘deep breathing’ frequently implies deep inhalation. This alone does not help. It maintains the pressure in your chest and may contribute to hyperventilation symptoms of tingling at the tips of your toes, fingers and nose. The key to deep breathing is deep exhalation or belly breathing. The exhalation phase of breathing dispels the air within our lungs, reduces the pressure in our chest and calms down the nervous system.

I am a fan of biofeed back devices such as Heartmath and apps such as Headspace. I appreciate the Mindfulness-Based Stress Reduction programs created by Dr. Jon Kabat-Zinn. There are free courses online, once such course is offered at created by Dave Potter who is a retired psychotherapist specializing in anxiety, stress and trauma.

I recently came across a book called. “Breath” by James Nestor. In this book, he summarized the benefits of proper breathing after hours of researching, interviewing and performing self- experiments. The information in this book was enlightening. “90 percent of us are breathing incorrectly (page xix)”. Breathing can influence our weight, nervous system, immune response and help us live longer and is the missing pillar in our health (xix).

In addition to exhalation which I have found to be true in practice, this book discussed the importance of Breathing through the nose and offered different breathing techniques. This was the piece that I was missing.

The author interviewed Dr. Mark Burhenne, who had been studying the links between mouth breathing and sleep, “mouth breathing contributed to periodontal disease, bad breath, and was the number one cause of cavities.” (page 49). “mouth breathing was both a cause and a contributor to snoring and sleep apnea” (page 50). In his experience, Dr. Burhenne found mouth taping helped a 5 year old overcome ADHD (page 50).

Alternate nostril, Box Breathing, 4-7-8 Breathing, Yogic Breathing, Breathhold Walking, Tummo, Coherent Breathing. I had no idea so many forms of breathing existed. The perfect breath, ‘Inhale for 5.5 seconds, exhale for 5.5 seconds.’ (page 212)

Breath through the nose. Exhale. Chew. These might be the overlooked secrets to health. I wished learning how to breath was introduced in schools every fall. It helps with so many things including focus, performance, stress & anxiety and emotional regulation.

Free Online Mindfulness Based Stress Reduction Program:
JAMA Intern Med. “When Physicians Counsel About Stress: Results of a National Study”. 2013
Jan 14; 173(1):76-77. PMCID: PMC4286362

Book: “Breath” by James Nestor
Castillo, Brooke. “Chapter 2: Anxiety”. How to Have a better life. Pages 27-27. (LCS resource)
Vishen Lakhiani: A 15 Minute Mind-Hack to Massively Enhance Your Brain Power and Emotional
state found on Youtube:

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Meet Leah

It’s one thing to be sympathetic, it’s another thing to be compassionate. Dr. Novak’s compassion stems from experiencing her own health struggles. Her experiences have given her a unique ability to relate and empathize with patients who are struggling to find healing and just wanting their life back.

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