Ask Dr. Casey: Managing Anxiety.
Hi Dr. Casey,
I wonder if you have any tips or tricks for managing anxiety. While I have always run anxious, some additional stressors in my life have really sent it through the roof. I don’t want to start on an anti-anxiety medication as I heard things like benzodiazepines can be addicting. Do you have any other tools you reach for with your patients?
Ann C.
Dear Ann,
This is a question for our times! I am talking about anxiety and/or depression with just about every single one of my patients. It’s a stressful world out there! And while yes, our bodies and minds are built to handle quite a bit of stress, most people seem to be beyond their threshold these days. From my point of view, I see it as an evolutionary mismatch between our current environment and our biology. We no longer live in the world that shaped us, and that change happened a millisecond ago on the human timeline. Our bodies and biology have not quite caught up with the demands of our current society, which is a recipe that can lead to chronic stress, anxiety, depression. Ann, you are very much not alone in this. And I will walk you through some strategies and options I have used with my patients.
If you have read any of my other articles, you may be familiar that I like to orientate first with medicine that comes from our own selves as a foundation. This comes along with it a lesson in neurobiology. We have a part of our nervous system that is termed the autonomic nervous system. I like to explain its function as the things our body does automatically, or on autopilot: our pupils dilate and contract, our mouths water with the thought of good food, our heart beats, lungs breathe and our digestive system moves food along its long tube. We don’t have to consciously think about any of these things - our autonomic nervous system performs its duty to keep us functioning without having to coordinate all of these actions.
Within this umbrella term of the autonomic nervous system, it has two parts: sympathetic and parasympathetic. The sympathetic nervous system is more colloquially known as our “fight, flight, freeze” portion. It kicks into gear when we feel conditions are not safe - in times of stress - to help get us to safety. It prioritizes resources which will help us survive: increase cardiovascular output (such as constrict blood vessels to increase flow), shuts down digestion (we don’t need to assimilate nutrients if our life is in danger), reduces our higher centers of critical thinking in the more evolved parts of our brain (creativity, connection with others is not needed for survival). It can either put us on high alert (“fight/flight”) or deaden us (“freeze”). While our body functions in the sympathetic branch of the autonomic nervous system, things like high blood pressure, cold hands and feet, difficulty sleeping, constipation or diarrhea and feelings of anxiousness can prevail. It is a very useful system to have when we feel in danger, and has helped humankind and other animals alive and safety-oriented. Apart from the physiologic responses, emotions such as anger, irritation, worry, panic, anxiety as well as numbness, dissociation, depression, shame can also prevail in the sympathetic nervous system.
The parasympathetic nervous system is the opposer to sympathetic: the rest, digest, relax half of the autonomic nervous system. It brings on all the systems that operate in times of non-survival: improved digestion and intestinal motility, improved circulation to non-vital organs, ability to relate and connect with others, improve the ability to resist infection, and more. Feelings of groundedness, compassion, calm, curiosity, connection can come out of the parasympathetic. This branch is primarily run by a nerve called the vagus nerve (specifically the ventral vagal nerve). It runs most of our digestive system, including parts of taste at the back of the tongue all the way down through the first ⅔ of the long intestinal tract. It also innervates our heart, vocal chords, portions of the lungs and more.
When you compare those two systems, Ann, what do you feel like your body and mind are predominant in? From the brief bit I have gleaned, I would gamble to say sympathetic. Your system is trying to orient you to safety! Which is pretty amazing. But if you are operating from this branch most of the time, our vagus nerve portion of the parasympathetic can become out of practice and lose its tone. For lack of a better term, our vagus nerve and parasympathetic nervous system can get flabby, just as can happen if we don’t use other muscular portions of anatomy. So, how can we increase the tone of the parasympathetic nervous system if it is out of practice? I teach my patients that functional breathing is the backdoor into this part of our nervous system and helps to bring tone back to the vagus nerve.
Functional breathing can be a key to help increase the amount of time spent in the rest and digest system. I like to break functional breathing down into two parts: 1. Extended exhale: breathe out a little longer out than you breathe in. Most do well with a four count inhale, 6 count exhale. 2. Diaphragmatic breathing: using our often forgotten large muscle below our lungs to aid in generating our breath (‘belly breath”). By spending conscious time daily trying to breathe in this way, “training” the vagus nerve and the parasympathetic nervous system, improvements in its tone and increase in the amount of time spent in this half of the nervous system can be experienced. It also increases resiliency to return to the rest and digest portion more easily when under stress.
Just like training muscle groups for a race or competition, our vagus nerve needs to be taken to the gym for training, too. Consistent practice and toning, alongside a controlled environment, are key. This also means no multitasking - part of this practice is doing less and honing in on the nervous system. Just as some are adamant about not missing a day at the gym, I am adamant about not missing a morning of functional breathing. Research shows that 20-minutes twice daily is optimal for vagal nerve toning; however, if that is not the amount of time available to people I start with a more approachable 5-10 minutes twice daily and increase from there. I suggest doing it first thing in the morning before turning the phone on and also as part of the bedtime winddown routine. It’s a nice way to bookend the day with time spent in the parasympathetic nervous system.
An app that I utilize to help track time and breath rate is called Kardia Deep Breath. On it you can set extended exhale, duration of session and breaths per minute. There are also various audio pacers on YouTube that are good tools, too (start with 6 to 6.5 breaths/minute). In-office, I also do more intensive sessions utilizing biofeedback with heart variability to give live-time feedback and experience of what your physiology is doing in relation to the mind to better understand your own stress response. It’s a powerful tool that I have seen lower blood pressure, decrease panic attacks and anxiety and increase levels of awareness.
While I do keep many other nutraceutical tools on hand as well to help manage acute stress and anxiety, any stressed patient of mine gets this debrief and brief training on how to functionally breathe. It is a tool that you always have with you and one that is powerful to use.
