Michigan Answers: Questions About Anxiety

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Anxiety disorders are the most common mental health condition in the U.S. today. Even so, there’s still a stigma around anxiety and panic attacks.

Emily Bilek, Ph.D., a clinical psychologist at University of Michigan Health, joins us to answer some of the most searched questions on the internet about anxiety, including:

  • What’s the difference between an anxiety attack and a panic attack?
  • Why do anxiety attacks cause chest pain?
  • What can you do to help someone who is having an anxiety attack?
  • What could exposure therapy mean for people who live with anxiety?

Anxiety disorders are real, and they are common. But there’s a lot to be hopeful about, and Dr. Bilek helps walk us through the facts.

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Dr. Preeti Malani:
Your heart is pounding, you may feel a rush of heat, or waves of chills, shortness of breath, shaking, or trembling. These symptoms aren't the same for everyone, but the experience is one that is hard to forget. We're talking about anxiety and panic attacks. Although anxiety disorders are the most common mental health condition in the United States today, there is still some stigma around these conditions. Anxiety is real. Anxiety disorders are common, and they are treatable.Joining us today is Dr. Emily Bilek, a clinical psychologist at the University of Michigan Health, and an expert on this important topic. Let's get started. 

I'm Dr. Preeti Malani. Thank you for joining us on the Michigan Answers podcast. Hi, Dr. Bilek. Thanks for joining us today.

Dr.  Emily Bilek:
Hey, good to be here.

Dr. Preeti Malani:
All right, you're familiar with how this works. We take a topic, one that you have considerable expertise in, and we'll talk about some of the most searched questions on this topic. How does that sound?

Dr.  Emily Bilek:
Sounds good.

Dr. Preeti Malani:
We hear a lot about anxiety and panic attacks. What is the difference between an anxiety attack and a panic attack?

Dr.  Emily Bilek:
This is a good question. I'll be honest, I don't think we need to worry too much about differentiating between anxiety and panic attacks. From a pure diagnostic perspective, a panic attack refers to a short period of intense or overwhelming fear, and is characterized by a number of physical symptoms, such as sweating, heart racing, feeling unreal, shortness of breath, muscle tension, et cetera. Panic attacks can be triggered by something, or might not be.

Anxiety attacks aren't a clinical term, but I see the term used pretty much interchangeably with panic attacks, and I think that's fine. Anxiety disorders are distinct from panic attacks, and include a number of diagnoses, such as social anxiety, generalized anxiety, panic disorder, or specific phobias, which refer to things like fear of flying, or getting shots, et cetera. There are also some diagnoses that are more common in childhood, like separation anxiety.

Dr. Preeti Malani:
Keeping the terminology in mind, why do panic attacks cause chest pain?

Dr.  Emily Bilek:
This is a great question, because our bodies have evolved to respond to threat in really effective ways to keep us out of danger. And one of those, of many, is muscle contraction. If we are in a threatening situation, we need to respond quickly and effectively to both feel uncomfortable so that we act quickly - if we're uncomfortable, we're going to want to respond now. And if I'm uncomfortable, I want to get out of that discomfort. But another reason is that I want that those responses in my body to be acting in such a way to help me get away from the danger.

And so one of the things our body does is it responds with muscle contraction. Blood flows to muscles, and our body tightens and contracts. And that happens all over our body, including around the chest, and the muscles near our chest tighten and contract, which helps us if we need to run away from say, a tiger. That doesn't help us as much, if for instance, there's no tiger nearby. And if we're just left, let's say, giving a presentation in a room full of people, then we might be just noticing the feelings and sensations in our body, and suddenly, be focusing inward and noticing that tightening sensation, and be really focused on what feels like a chest pain.

And unfortunately, we can really perseverate or become hyperfocused on this chest pain, which is not dangerous to us at all. It's just really a side effect of our body heightening and getting ready to help us, and if there were real danger.

Dr. Preeti Malani:
What do we know about the causes of anxiety disorders? And why do some people struggle with anxiety?

Dr.  Emily Bilek:
Isn't that the million-dollar question? Yes, of course, there's lots of reasons why people struggle with anxiety. Just like with any mental health concern, there are lots of reasons why people struggle. And certainly, there are causes that are both environmental and genetic, so you can have risk factors related to genetics. If your family members in the past have struggled with mental health concerns, like anxiety, you may be more at risk, or if there are environmental risk factors, such as stressors in your environment, or parental, or other factors, trauma in your experience, those could add to your risk factors.

But at this time, we do not have any perfect predictive model. I cannot look at your history and say perfectly with any prediction you will go on to have anxiety, or someone else will not. And in fact, we can't even say someone who has a very high risk factor profile will have anxiety. And there's lots of people who have very low risk factor profiles who don't, or who do go on to have anxiety. It is a very rich area of research right now.

The other thing I will say is, you know, why do some people have anxiety and other people don't? From a broader perspective, one thing that I keep in mind is, how can some people... How can you as an individual consider going out in the world and benefiting? How can you as an individual think about, "How can I lower my personal risk for anxiety? What can I do?" Because anxiety, in and of itself, is not bad. Anxiety is a human experience. It's a human emotional experience. It's good for us. It's a good, healthy, emotional experience.

We can't control anxiety. We can't stop ourself from experience anxiety. What we can do is control how we respond to it. And what I would say is that if you respond to the experience of anxiety, especially if you respond to the experience of anxiety in the context of when there's no physical danger present, like if you are... As I was saying before, if you are giving a presentation and you experience anxiety as if there's a tiger present, which is totally normal, and you respond by withdrawing over and over again, over time, your life is going to get smaller. That's avoidance. If we, over time, respond to anxiety by withdrawing and avoiding, our life is going to get smaller.

And so to your question about what are the causes of anxiety, one of the things that maintains anxiety over time, and causes anxiety to impair our lives and make it worse over time, I think a big factor, and that is avoidance. The flip side to that, if we instead can hold our ground with anxiety, and potentially in situations that are not dangerous, hold our ground, lean in, our lives are going to blossom instead.

Dr. Preeti Malani:
A related question is, how can you treat anxiety?

Dr.  Emily Bilek:
Yeah, I think this is why I like to work with anxiety, is because luckily, anxiety is one of the more treatable conditions. We have great treatments for it that for many, if not most individuals, are quite effective.

I am a psychologist, which means that I provide psychotherapy, or colloquially, therapy for anxiety disorders. And we have gold standard treatments, psychotherapies for anxiety disorders, and that is known as cognitive behavioral therapy. And for adults and children, which is the population that I primarily work with, cognitive behavioral therapy has been very well researched as being the first-line treatment.

Within cognitive behavioral therapy, there are several different components that have been shown to be effective, but exposure therapy is coming... As more research is being done, it's coming out as being the ingredient with potentially the most efficacy. And that really is a fancy word, exposure therapy, or exposure and response prevention. It's a fancy word for facing your fears, because it really is what I was just talking about. It refers to being able to see your fear, stand your ground, and say, "You know, I can do this anyway. I can feel my fear and do it anyway."

Dr. Preeti Malani:
Okay, this is very important. How can you help someone who is having a panic attack?

Dr.  Emily Bilek:
Yeah, I think it's really hard. It's really hard to see someone you love or care about who's in distress. And I know that oftentimes what we want to do is try and fix it for them. We want to take away their pain. And I would caution you that most of the time, that's probably not the best thing to do in that situation. Oftentimes, there may not be a way to end the panic attack for someone. And even if you could, that might have some consequences in the long run, or they may not want you to intervene in that situation in that way.

Typically, what I might recommend in that situation, if you are able to get through to them in that moment beyond just sitting with them, it's to ask them, "Would you like me to distract you, or would you like me to just sit with you right now?" And again, I think maybe the best thing to do with most people is to just sit with them, be there for them until it's over. But if they want something more than that, often, the best thing to offer someone is to offer a grounding exercise, or... It offers a distraction component, but really, the benefit here is to bring their attention back to the present moment.

What do I mean when I say a grounding exercise? Really, what I would be saying to someone in that moment is, "What is one thing you can see right now? What is one thing you can hear right now? What is one texture you are feeling right now?" And trying to bring their senses back to the present moment, rather than having all of their attention focused on the unpleasant sensations within their body, the unpleasant thoughts in their head, and potentially, whatever else they are experiencing, which is likely focused more on the past or the future.

And so hopefully, that could help them get out of the panic attack a little bit more quickly. But again, the goal typically in treating panic attacks is to let people know that there's nothing wrong with experiencing anxiety. Anxiety is okay. It is safe. There's no danger in the panic attack itself. And sometimes, as a bystander, whether it is a bystander of someone you don't know or a loved one, it's actually really important for you to know that too. They are not in danger. They are just experiencing something very unpleasant. They will experience the full wave of their emotions, and they will come out okay on the other side.

If you can know that and remain calm, you will be a calming presence. Remain supportive and non-judgmental, and help them through that, and then they will be, I'm sure, very appreciative of that as well.

Dr. Preeti Malani:
Okay, this is the part where I sometimes squeeze in an extra question. And I would love to hear what you are hopeful about in terms of research related to anxiety.

Dr.  Emily Bilek:
Is this the part where I plug my research?

Dr. Preeti Malani:
Yeah, go ahead.

Dr.  Emily Bilek:
Okay. Yeah, maybe I have hinted at it this whole time that what I feel most excited about or passionate about when it comes to anxiety is this piece about anxiety, is that anxiety is not the problem. And in fact, it's the resistance to anxiety that tends to be the problem, because anxiety is natural, anxiety is normal, and anxiety is not dangerous. But when we fight anxiety, that's when we get ourselves into trouble.

And instead, oftentimes, the crucial piece of treatment here is to face our fears. And so exposure therapy, that's the type of treatment that I often provide, and it's really effective. But understandably, it can be a challenging treatment for some people to wholly engage in, because again, facing your fears, oof, that can be exciting, and I love to do it, but sometimes it can be overwhelming.

There are some promising augmentations to exposure therapy that I am investigating with some researchers here at the University of Michigan, like Ethan Kross at LS&A. He has researched for a couple decades now something called self-distancing, which is just a cognitive intervention that holds a lot of promise because it shows a lot of research in increasing perseverance and self-regulation.

And I have been wondering, if when combined with exposure therapy, if it could really help therapists become more willing to do exposure. What we need in the field of anxiety treatment is more therapists willing to treat and willing to learn how to treat things like OCD and more complicated anxiety disorders. We just need more therapists in the field. We also just need ways to get... Again, I treat youth, so we need more parents willing to get their children into this kind of treatment. And we need treatments that are even more effective.

Right now, it's just a theory, but I'm hopeful that this small augmentation could make the treatment more effective, it could make parents more engaged, and it could potentially get more therapists invested in learning this treatment. And it's just a theory, but I think all big discoveries start that way.

Dr. Preeti Malani:
Dr. Bilek, thanks for sharing your time and expertise with us today.

Dr.  Emily Bilek:
Yeah, no, that was my pleasure. I'm so happy to be here.

Dr. Preeti Malani:
Thank you for listening to this week's episode of Michigan Answers. If you enjoyed today's episode, please subscribe wherever you get your podcast.

This season, we'll be unpacking some of the most searched for health topics on the internet. And if you're interested in learning more about how Michigan Medicine is improving lives and advancing health, please visit us at michigananswers.com. See you next week.

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