mentalhealth

Anxiety Sucks, but Trump Could Use Some.

I don’t normally wish a psychiatric disorder on anyone, but I wish Trump had Generalized Anxiety Disorder (GAD). See then he’d overthink everything instead of being so brazen. Then he’d get stuck on thinking and thinking and thinking about how other people viewed him. His anxious brain would force him to attend to other people’s feelings before his own. I’m convinced that a Trump with GAD would be a toned down more empathetic human being.

But, for most people afflicted with any of the anxiety disorders, especially kids and teens, life is extra challenging.

A major component of anxiety disorders is overthinking. So when presented with a situation, a youth with anxiety disorder will automatically and effortlessly come up with every possible cause and effect of said situation. If the situation is dangerous, than this overthinking is a good thing. A biologic, rewired brain, protective thing (Anxiety disorders like PTSD can develop after or during exposure to adverse experiences such as abuse). But when the situation is no longer dangerous and it’s just plain old life, the overthinking is detrimental. It prevents the youth from being in the moment, developing their complete identity & positive self-worth, and making good decisions. They end up trapped in an endless loop of negative automatic thoughts, feelings, and behaviors based on what they perceive will keep others happy even if they harm themselves or someone else. Here’s a common example of overthinking that teen girls tell me about in the office: “I was at a party, the parents were out of town. And the guy I was kind of dating wasn’t there. This popular boy started talking to me. I used to like him so I was all giddy inside. Anyway, he gave me a beer and I didn’t really want to drink it but I did. He started touching me and it was cool at first. But then I wasn’t sure. I tried to move his hand away, but he was like, ‘Come on, I’ll be gentle. Don’t give me blue balls.’ I told him I had a boyfriend but he said ‘he doesn’t have to know.’ I knew that was wrong but he kept trying to convince me. I’d never had sex before and I didn’t want to but I couldn’t say no. If I said no he would get mad. He’d tell everyone I was a loser. He’d hate me and then everyone would hate me. So I let him. Hey, I’d rather deal with it than risk having him mad at me.”

Woah, right? But that is how powerful anxiety is. It makes youth do things their rational selves wouldn’t do.

In addition to overthinking, anxiety disorders can also make youth hold the opinions of others as definitively true. They have difficulty creating thought and feeling boundaries and are often unable to cling to rational thoughts of themselves. And this can have tragic effects. A common example of poor thought and feeling boundaries that teens tell me about: “The kids at school teased me about being fat ever since I was in second grade. It was so bad. I didn’t tell anyone. No one helped me. I even started making fun of myself. I hated what they said but I hated myself more. I started skipping meals. Exercising in my room at night. By the time I got to high school, I was binging and throwing up everyday. I still got teased. Nothing I did made me lose weight. I couldn’t stop thinking about what a worthless piece of shit I was. Am. I wanted to die. I tried to kill myself a couple of times…”

In med school and residency, I’ve gotten top notch training on how to help kids and teens with anxiety disorders. But more than that, I have an anxiety disorder and I’ve come to understand how it almost destroyed my life—this has made me passionate about helping anxious youth find their way through the quagmire of overthinking. And I practice what I preach. I practice being mindful and in the moment. I practice doing cognitive behavioral therapy on my automatic negative thoughts. I get enough sleep. I eat regularly. I exercise regularly. I don’t partake in social media. I try to work on expressing my true thoughts and feelings in the moment even though it takes everything inside of me to do so sometimes.

My latest battle is not internalizing the harsh negative online reviews people have posted about me as a psychiatrist. Things like, "I didn't like her at all" or I'm "unprofessional." My personal favorite, I'm "the worst psychiatrist." Luckily, these days I can fight off the anxious overthinking that tries to make me ignore all the evidence that points to the opposite of their disapproving opinions—that there are more positive reviews online than negative, that reviews shouldn’t really matter at all because I know in my heart that I give my all to my patients in every session (even if that means pointing out things that they don’t want to hear since I know this will give them a better chance of truly healing), that I don’t just do fifteen minute medication checks, that I will not prescribe medication unless it is medically necessary, that I insist on family therapy if indicated because youth don’t exist in a vacuum, that I do intensive talk therapy with youth with the goal of making them assertive, self-confident, and able to utilize a myriad of coping strategies to recover from—and/or live with at a manageable level—whatever psychiatric disorder(s) that plague them. All that and I’m not Trump.

SUICIDE THOUGHTS ARE NOT LITERAL EDICTS BUT THE MIND’S RED FLAG

In 2016, suicide was a leading cause of death in the United States—tenth overall, second for ages 10-34, and fourth for ages 35-54—and there were twice as many suicides as homicides (1). The rate of suicide increased 28% from 1999 to 2016 (2).

My patients, many of whom suffer from anxiety, depression, bipolar disorder, or substance abuse issues, are often plagued with suicide ideation and suicide attempts. No demographic is spared. Suicide intentions are a common discussion point in my office. Just yesterday, a 12-year-old and a 19-year-old were in the throws of intense suicide ideation and we spent the sessions (along with a parent for the 12-year-old) figuring out ways for the young people to distance themselves from those life-ending considerations.

Given the tragic and heartbreaking suicides of Kate Spade and Anthony Bourdain this week, I wanted to offer one of my psychiatric perspectives on suicidal thoughts, perhaps it can contribute a little to the conversation. When patients with anxiety and/or depression reveal active suicide ideas or plans, or a history of, I teach them that suicidal thoughts are their mind’s red flag, a warning that they’re completely overwhelmed and need to ask for help, not a literal edict to kill themselves. I will start the discussion with something like this, “I’m so sorry you’re having these scary suicidal thoughts. I know they seem unavoidable but let’s take a step back for a bit, ok? What if I told you the suicidal thoughts are your mind’s red flag and it’s waving it, shouting, ‘Hey! Stop! You haven’t asked for help with all the spiraling negative thoughts and feelings and now you’re completely overwhelmed! I need some relief, I need to feel in control. Please get some help, ASAP!’ What if I told you that not only are your suicidal thoughts a red flag but also your mind’s secret code, and that you and I can decipher the code and get to the real issues, which are NOT anything that involve killing yourself. Imagine if you had asthma and you were around smoke or allergens, you’d probably cough or wheeze, right? The coughing and wheezing are symptoms of the asthma when you are around an irritant. Similarly, the suicidal thoughts are a symptom of your anxiety and depression when you are overwhelmed and haven’t expressed your true thoughts and feelings to others, which we’ve been working on in therapy but takes awhile to master. It’s important that you don’t act on the suicidal thoughts, but accept that they are your mind’s tricky signal that you need to figure out what’s really going on. Let’s do that now. Tell me about…”

Depending on the age of the patient, I will make the above discussion more or less sophisticated. It is wonderful when patients have their aha moment with suicidal thoughts being a red flag, and not a word for word command.

Suicide prevention is multifaceted. Here are some basics that I hope everyone becomes familiar with:

  1. Know the sign and symptoms of someone thinking about suicide. Examples include: talking about wanting to die or kill themselves, talking about feeling hopeless or having nothing to live for, making plans or researching ways to kill themselves, talking about feeling shame, unbearable pain, or being a burden to others, using drugs or alcohol more often, acting different (more anxious, agitated, or withdrawn), more intense mood swings, giving away possessions, or saying goodbye.

  2. Know the risk factors. Common ones include: depression, other mental disorders or substance abuse disorders, some medical conditions, chronic pain, a prior suicide attempt, family history of a mental disorder, substance abuse, or suicide, family violence and/or abuse, having guns in the home, or being exposed to others’ suicidal behavior (like a family member, friend, or celebrity).

  3. Have an action plan.

    • Ask them if they are thinking about killing themselves. Don’t worry, asking directly “Are you thinking about killing yourself?” doesn’t make them do it.

    • If the suicidal person has a plan, try to get them away from lethal items or places.

    • Listen and talk to the person. This will not increase suicidal thoughts, but rather the opposite.

    • Connect them.

      1. National Suicide Prevention Lifeline 1-800-273-TALK (8255)

      2. Family member or friend

      3. Mental health professional

    • Keep in touch with them if possible.



1 Centers for Disease Control and Prevention WISQARS Leading Causes of Death Reports

2 Centers for Disease Control and Prevention Fatal Injury Data Visualization