The Hidden Causes Of Anxiety And How To Manage It

Introduction to Dr. Ellen Vora 0:00

Well. Hello again everyone. Welcome back to the Depression and Anxiety Solutions Summit. And here we go with just one of our favorites in the mental health space a good friend, a colleague for I think all of our careers. Doctor Ellen Vora, you just heard about all of her training and expertise. I love her book, The Anatomy of Anxiety, helping us really think about, you know, the most common mental health disorder, but also one of the most common challenges in the modern world, which is struggling with excess worry and anxiety.

Doctor Ellen Vora, welcome. It's so great to see you, my friend. Thank you. Drew, it's good to see you. Let's get right into it. What is going on with anxiety today? Why are we in the midst of an anxiety epidemic? Is it as bad as I'm worried it is because I feel, boy, it's a really. There's just so much to worry about. And psychiatrist the anxiety epidemic is making us anxious. Yeah, so I think it is as bad. I do think it's bad and it's getting worse. And I think that there's two main contributing factors and one is the one we're thinking about that we are intuitively connecting to, which is that things are heavy in the world, and a lot of us are viscerally connected to that suffering around the world, which is not something to pathologize that's not what's wrong with us.

I think in many ways, when we really feel the suffering in the world, that's evidence of an open heart. It's what's right with us in many ways. But, but it's a difficult burden to carry, and that's what we think of.

Why Anxiety Is Rising 1:35

That's our intuition about why is everyone so anxious. And I think it's valid, but I don't think it's the whole story. And I think there's this whole other piece of what's happening in modern life that's contributing to our anxiety, which is not some deep truth or something about our essential concerns. I think it's what I would call false anxiety. It's avoidable anxiety and it's based in the physical body. It doesn't have to be happening, it's just unnecessary suffering. Well, that sounds like a wonderful problem.

I think everybody listening, we like we like hearing that. So let's get rid of this unnecessary and say well what is false anxiety. So an example would be something is happening in our physiology. Maybe we're in a blood sugar crash. Maybe we stayed up all night doomscrolling and we didn't get enough sleep. Maybe we had an extra cold brew coffee, or we're hungover and our body is tipped into a stress response, and then we subjectively experience that stress response as states like anxiety or even panic or feeling easily overwhelmed.

And our mind the consummate meaning maker that it is. If you give our mind a picture of two dots and a line and our brain says, I know what that is, that's a face. And if you give our brain a blood sugar crash induced stress response that feels identical to anxiety, our mind says, I know what that is. I'm anxious about this thing happening at work, this interpersonal dynamic from the seventh grade that still irks me to this day. So our brain tells us a story to make sense of what is first and foremost, a physical sensation.

It's a retrofitted justification. Point is, what we really want to do is identify what is putting us in these false stress responses and address it. Eliminate all of that unnecessary suffering. How do we go about doing that, particularly for everybody listening? I'm really wanting you to listen to Doctor Vora around. Some of the things that we can do in and really, you know, the coming days, weeks and months, the summit is really about us thinking about solutions. And so when you when you meet someone like, you mean to someone like me, I've got a little excessive anxiety.

And how do I, kind of, as a person, sort through what's false, what's true? How do I start? Especially getting rid of some of the, like, low hanging fruit of false anxiety? Yeah. I think that there is an algorithm to this, and we all carry a burden of true anxiety,

False Anxiety and Physical Triggers 4:00

but I actually don't even want to start digging into that until we've already addressed the false anxiety, because it kind of muddied the waters, and it can make it really difficult to discern what is our truth. We want to address that low hanging fruit first, because when our physiology is pinballing around and we're in and out of false anxiety, it's easy to misinterpret it as some deep, essential truth. And so when I'm working with a patient or in my book, I have what I call an avoidable anxiety inventory.

And it's basically a list and you kind of go through it and think to yourself, well, that actually does remind myself of me, or that's resonance. Whether it's that you know that you're someone who gets hangry or you get angry when you're hungry, you might also be experiencing anxiety, which is anxiety when our blood sugar swings. And we come by that honestly in the modern world, because our diet is built on a foundation of coffee drinks that are secretly milkshakes and rosé all day. So we're on a blood sugar roller coaster.

And then there's sometimes things that we wouldn't ordinarily think about. Like when I have patients who I can tell our mouth breathing, then they're breathing through their mouths while they sleep at night, which means that their brain is not getting sufficiently oxygenated while they're sleeping. The sleep is not as restorative or restful. They're less clear during the day. That's a contributor to false moods. One that comes up a lot in my practice is that for any patients who, let's say someone takes their antidepressant first thing in the morning upon waking up, sometimes those folks wake up already in a panic.

Their thoughts are racing. They're already feeling that cloud of doom and gloom. And I've come to observe that that's often enter dose withdrawal. That is somebody in a state where their physiology is anticipating its dose of medication. They're at their pharmacologic nadir or lowest point of that medicine in their bloodstream. And just seeing that a lot of the, medications, you know, have a half life of about, let's say, 22, 30 hours. And so after you haven't had a dose, you know, the blood level starts to drop a little bit.

Right? Exactly. And it varies person to person. We're all slightly different in terms of how we metabolize these medications. And so if you are waking up in a panic and you're due for your dose, it's not like we're looking to solve that. We're not going to say, now you're going to set an alarm for 4:30 a.m. and take your medication. It's more that it can be powerful to recognize that you're seeing the world through that lens. So you're just going to take your medication. We're not going to change anything.

But the difference between getting swept away on that magic carpet ride of, oh God, everything is terrible. It's going to be a bad day, versus, oh, I'm in introduced withdrawal right now. It's a false mood. It's clouding my outlook and I'm going to take my medication. My mood is going to simmer back down within an hour or two, and it just can take us away from that normal until you're in New York City. Right now that I've been in my ten years of life is definitely there's some. I think it's appropriate to have the alarms going off because it sort of tells you something.

There's a way that New York is full of noise and alarms and danger, but people wander through the streets, head in the cell phone, completely ignoring it. Yeah. Well, you acclimate, and I think it's in some ways a bit, you know, a model of one of the techniques that, which is really around kind of enduring or having some tolerance of anxiety and noise and all the parts of the modern world, but also how we have to be careful because we can really become, unaware of, you know, the, the effect of it.

I don't usually live in New York. And so I was on a corner when one of these ambulances went by. And, afterwards, I felt the power of how dissociative I've been. I had both my hands and my ears. I was on the corner. I hit back, my head tucked down, and I was in a freeze response. I just waiting for it to go by. And you know, I was fine at first, but it really it kind of completely took me out of where we were. I don't I don't know what kind of went off into, you know, some dissociated spot just for a couple little like five seconds.

But, you know, it's kind of thing that you experience every day here and over time that that certainly feels like it's taking a toll. Let's get into it. You know, a lot of people watching have been struggling with some symptoms and have had some of the basics checked already, for sure. Folks who've looked at their B12 level, for example, I would say that's one of those, hey, if your B12 is low, I just had this. I had a patient with panic disorder come in. Everything's great. No one we don't know is, it seems probably caused by some steroid.

Also happened. B12 was a little low and. Oh, is that all of it? Probably not all of it, but is it contributing a bit? It really is contributing in some way. So, let's just run the list here of things that you look for as physicians. You want to make sure everybody's got a good, normal B12 level and kind of a little, higher. We don't want you just, like, dragging down in the low end, because we know I think it's about 25% of people who have a normal B12 level but are on the low end of the spectrum, still have neuropsychiatric symptoms from the B12.

And so a little more B12. What what are some other kind of lab tests or things that you make sure that we look for. So micronutrient deficiencies are a big one, something like

Medical and Lifestyle Causes of Anxiety 9:20

low B12, low folate or where you're not properly methylated, folate, something like insufficient amounts of magnesium in the body. Magnesium is involved in some 600 biochemical reactions in the body. We need it. We're deficient in it because our food is because our soil is because a mono crop farming. So unless you're listening to this in the shadow of an active volcano in Sicily, you're probably deficient in magnesium, and it's helpful to take an Epsom salt bath or supplement with magnesium. Glycine. A diet is big, and we're in a complicated tribal conversation, always about diet, and I think it sometimes distracts us from the fundamentals of eating real food generally when possible, avoiding fake food which is ultra processed food, and then focusing on nutrient density and eating a diverse array of different types of foods.

Different colors of the rainbow. That's a big category. Inflammation and gut health is an enormous category of contributors to false anxiety. This has to do with the fact that when our gut is unwell, whether that's dysbiosis or an imbalance in the gut flora, or maybe Our brain experiences that inflammation. Inflammation. It's it's inflammatory cytokines circulating in our bloodstream. The amygdala, the sort of fear center of our brain perceives that almost as though our body's under a state of threat and it can contribute to our anxiety levels.

That's gotten inflammation. It's a longer conversation. Compromised gut health also compromises our ability to manufacture critical neurotransmitters like serotonin, like Gaba, which impact our mood directly. And then there's a unfun conversation around false anxiety that involves things like alcohol, caffeine, and with caffeine. I'm not really here to take away anyone's coffee. I don't think caffeine is an inherently bad substance in many ways. It's an inherently good substance, but we want to be strategic about it, recognizing it has a long half life.

So a cup of coffee in the morning is one thing. A cup of coffee in the afternoon is more likely to impact our sleep and in turn, our anxiety levels. And then alcohol, by contrast, is an inherently bad substance. Which is not to say we all need to forgo it altogether, necessarily, but we just deserve to have informed consent around alcohol. And I think part of why we like it is that it rushes our brain with Gaba, this neurotransmitter that makes us feel calm and like everything's going to be okay, but our brain doesn't really care whether or not we feel calm.

It is tasked with preserving our survival. So it sees all that Gaba and it thinks to itself, what if a leopard were to come around the corner right now? I could be too buzzed to care and I'd potentially be in danger. So it furiously attempts to restore homeostasis. And part of how it does that when we drink is that it converts that Gaba to the neurotransmitter glutamate, which is a different vibe. That's not a calming, inhibitory neurotransmitter, that's excitatory. And I think this accounts for why, if we've had a couple of glasses of wine at dinner, we might wake up at 2 or 3 in the morning, heart racing, thoughts racing, and then we proceed to toss and turn for the remainder of the night.

And so we just want this to inform our choices around alcohol. And the last one I'll touch upon right now is sleep, which most of us are not walking around with some inherent genetic neurologic sleep disorder. We have what I think of as modern insomnia, which is that we're not sleeping as a result of aspects of the modern environment. That's kind of good news and bad news, bad news because we're swimming in these waters. It's good news because we can identify these aspects of the modern world and do something about it.

And more than anything else, I focus on light with my patients. I want to make sure that they are getting the correct light cues, because that's what programs our internal clock, the super quiet magic nucleus. It's not that it's connected to a cell phone tower, and that that's how it knows what time of day it is. It's connected to our eyeballs and the way it has to know whether we should feel awake or sleepy is based on the light coming in through our eyes. That system was foolproof on the proverbial savanna of human evolution.

You couldn't get it wrong. These days. It's hard to get it right. I don't blame evolution for not anticipating this plot twist, which is that we were going to invent the light bulb and harness electricity and eventually invent the iPhone, and then no one was going to sleep anymore. But that's what we're up against right now. So something as simple as a circadian walk early in the morning, where you're just somehow getting sunshine into your eyeballs as pretty energy is like, wake up and do just like first thing in the morning, just like pop outside for a little bit, if that's possible.

The way I make it work in my life is I dropped my daughter at school. I walk back home, I find whatever patch of cement in New York City has managed to get some rays of sunshine poking through, and I take off my glasses that have the blue blocking filter on them. Because this can't be through sunglasses or a windshield or a window. It has to be the real thing. You just take in that signal of morning light for a couple of minutes, and then what happens after sunset is really where it gets spicy. And, whereas we we evolved seeing fire and moonlight, and these days we're surrounded by overhead lighting.

And, the laptops open. We bring the phone into the bed with us. So the solution is simple. We actually just have to move off the grid and homestead raised chickens make our own sauerkraut. I did. That's exactly what I did for my choices. Thank you. Here I am living in New York City. But, if we're not ready to do what drew did, then we need a harm reduction strategy. And I think the best we've got are the blue blocking glasses, something that's going to block out blue spectrum lights so that we can still go about our modern lives.

But we are not having blue light suppressing our melatonin so we can still get sleepy at night. The I like my screen, my, laptop, my phone. I'm getting blue light at night, so my brain is getting the signal that the sun is up exactly. And then I'm not making melatonin. And so the sort of is the spiciness at night, I think is around. There's all that stimulation. And we really need to do we dim the lights in our house. Do you put your devices in a box, like how do you deal with this on a personal level and for your patients?

Yeah. And so that's exactly right. We always hear this buzzword blue spectrum light. Why does that matter? But if you picture the daytime sky, it's blue. And here's our sweet little brains thinking it's 10 p.m. I'm so tired. It feels like it's been a long day. But then we hold our phone screen up to our face and it thinks, I can't argue with that. That's clearly the daytime sky. The sun has risen and so it's suppresses our melatonin and we don't get sleepy at the appropriate time. And so what I do is I dim the lights in my home at sunset, I put on a pair of blue blocking glasses that look kind of normal.

I wear those for a few hours, and then as it gets closer to bedtime, I put on these puppies. And that's how I protect my brain's ability to secrete melatonin at night. Even better, would be it's all candles and it's a boys to men video.

Sleep, Light, and Circadian Rhythm 16:20

And it's, you know, no artificial light. It's not realistic for most of us. So blue blocking glasses go a long way. Okay, let's, so the sleep hygiene piece is certainly something everyone knows about. But, you know, again, as you've heard from some of the guests in the summit, you know, we're at a really, phenomenal moment in the history of mental health. We just have more tools. And we were thinking about blue blocking glasses. Now we do is over thinking about, you know, the vibrations. We, talked to diva and even Raven in this, idea that that certain frequencies really kind of sue their nervous system in a way.

And, it's just such a, you know, he mentioned, you know, we're living in this time, there's more opportunity to work on your mental health and heal than ever before. And that's what we're all here to do. Eleanor, I want to, after going over some of the strategies and some ideas of, of, you know, false anxiety, I want to get to the kind of true anxiety in the sense, you know, how do you understand what that is? And your model of thinking around anxiety. What, what when we've got you know, we've gotten these things taken care of.

We're eating when we're sleeping. We still are kind of panicky or anxious or socially anxious. What are some of your solutions for us? Yeah, false anxiety is avoidable. True anxiety is purposeful. It's not something that we want to suppress. We're not going to decaf coffee our way out of true anxiety, nor would we want to try. It's something that we actually want to get better at listening to. And so this involves slowing down and getting still, having some practice of listening and being in dialog with what is our body trying to tell us?

What is source trying to tell us? Just having some spirit of listening and valuing the message baked into it. There's usually some call to action involved, and it can pertain to anything that's out of alignment. And that might be our personal lives, our personal choices or behaviors. It might be in our community, it might be in the world at large. And we can only really know for ourselves what are we being asked to respond to. And I think that's where, you know, you're talking about that freeze response on the corner in New York City.

And I think sometimes we actually just need clearing practices, like we need a way of shaking off everything that we carry, everything we accumulate. So shaking is a great practice. Crying is underrated and free and it's medicine. And then I think practices for tapping into what messages want to come through. And that can be anything from meditation and journaling to working with psychedelics and everything in between. And I think that just having some way of not just moving through our lives constantly distracted, constantly myopically, focused on work and taxes and mortgages, and we want to step back and seek and ask the bigger questions and listen for what might be trying to come through.

Are there ways in your daily life being a super busy doctor and, a partner and, mom, an author? I've got another book, that you're working on. We're just talking, turning in and here in a few months, what are some daily rituals or weekly rituals that you make sure to get into your life? To ensure that you don't get caught up in all of the busyness and the taxes and the anxiety is constant for me. I mean, I'm a sensitive person living in New York City surrounded by sirens. And I think especially as I've developed my craft, I feel like I'm opening my antenna even more, which is a wonderful gift and also a liability, you know, now, in a noisy world.

So I do shamanic shaking. At the end of the day with patients, I burn various things and have rituals around that. I start the day with a couple of minutes of meditation that I've reframed for myself as my listening time. Basically, instead of thinking I'm trying to clear my mind, or like explore some non-dual state, what I'm really focused on right now is listening and hearing what's coming through. And I think for me, actually, grief has been a really big factor. So because I've lost both of my parents at this point and I choose to stay connected to them and in ongoing dialog with them, that's almost like an all day long prayer.

It's being in conversation with spirit. In many ways, psychedelics play a role for me, and that's work that I'm not doing every day. That's more of a once a quarter or sometimes once a month kind of work where it's, if everything else are these micro, consistent practices, that's more of a macro practice of, shaking up the snow globe and seeing if the fall, if the snow wants to fall a little bit differently.

True Anxiety and Listening Practices 21:00

So many people have questions around that. People range from professionals who are curious and getting trained to people who want to get treatment. And it seems like it's, a bit of the Wild West in terms of a lot of different modalities, a lot of different substances, some legal, like ketamine, some not. How do you recommend people go about, sorting out what's right for them in the psychedelic space? Yeah. Everyone's different. And I think that, ketamine is a really wonderful place to start. Because it's legal.

Because you can do it in this clinical supervised setting. And there's a lot to be said for that. Sometimes if someone has the resources and the willingness traveling to a place in the world where substances like psilocybin or ayahuasca are illegal can be a good place to go deeper in this work. It's to me a shame in many ways that we don't have, like, this is such a complicated conversation because there are risks, of course. And I don't just say that as a sort of checking the box of medical legal considerations, but I don't think psychedelics are for every brain.

I think some brains are already chaotic, and you don't want to introduce new chaos to that system. And yet some people are stuck and entrenched in patterns around PTSD or depression or end of life angst. And that's where shaking things up can be so critical and so helpful. So I just I'm hopeful that we continue to do research and continue to push forward and find ways to make this accessible while being judicious and responsible with it. And so I think that, you know, there are underground practitioners who do incredible work and are making this work available to people, even though it's not legal.

And that's where we have to be so discerning about, you know, it's a very vulnerable state that we're handing over to someone, and you want to go about that with the utmost meticulous needs to be someone meticulous in their integrity with this work. It's really great advice. And it's something important. I think a lot of the concerns are like, is a harms really? And not particularly. Well, into is documented or thought about. I have seen a lot of them, because it's based on self-report a lot, you know.

How do you feel? How are you feeling? What happened? And, you know, in the weeks and months after these compounds, there's, there's a lot going on upstairs for people. And so the idea of really working with, highly qualified practitioners, that's a little harder to find people who, you know, have morals, ethics, values and that, you know, oftentimes through a personal network or, you know, starting aboveground. But thank you for your thoughts on that and for letting us know that it's part of how you've, evolved some of your practice, as I think a lot of people are thinking of and exploring right now, maybe just add one more caveat to it all.

I think that we can be tempted to chase the big experience, but I find that one ceremony can be a lifetime of of material to be processing. So the critical piece of this is actually integration. It's being in some kind of integration therapy where you're working with what came for in a ceremony. It seems like good integration is kind of hard to find in the sense of a lot of the individuals I've evaluated or seen over the years. When they report engage with the psychedelic medicine, there is sometimes a little prep and a little integration, but it's oftentimes a little, challenging to find consistency or cohesion.

Can you share a little bit of your experience of like what works great for integration? Yeah, I mean, I don't actually think it's hard to find.

Psychedelics, Integration, and Spirituality 24:35

I think it's hard to commit to. And so it's usually not one in the same person that's facilitating the ceremony. There are different skills in certain ways. And so, maybe you're working with one person who's facilitating the ceremony and somebody else who you're then meeting with on a weekly basis to unpack it. And there's groups like Fluence that are training therapists in ketamine associated therapy. And then there's also, if you can find any open minded therapist, whether they're familiar with these substances or not, you can come forth with the material and they can do their thing as therapists.

And so I think that there's a lot of good ways to be supported through integration, but I think it's more on the person working with psychedelics. Like we actually have to commit to that. And that's it's not a big fun, sexy experience. It's the unsexy week after week unpacking and being held accountable to the insights that came through. And so I think it's it's out there. But we have to we have to take advantage of it. That's a really great point that that is really quite available. It can even be with a non psychedelic trained person in terms of an open mind therapist trying to explore and unpack and experience, but it really requires a commitment and that if we go into these substances with the idea that we're going to have the big life transforming journey, meet our spirit creature and like, that's it, no more anxiety.

I'm at my I've met a couple spirit creatures. They do help with anxiety, but that that that isn't really doing, tribute to the amount of work that often needs to be done to understand what's happened to our minds in the in the suffix when weeks and months, that is, very helpful. Ellen, I'm wondering what you're excited about right now. We've talked about a lot of different tools. We've talked about false anxiety and true anxiety and some of the tools for understanding the differences between those.

But I'm wondering what's exciting you about mental health, right now in terms of what you're seeing, especially in regards to depression and anxiety? Yeah. So I'm thinking the writing process of my second book right now, it's called season of the witch, and what I'm excited or even obsessed with at the moment is I think that we might be culturally poised and ready to tiptoe back toward openness to this world being something vastly beyond our comprehension. And that was certainly something that I held at arm's length most of my life, certainly most of my training.

We are living in a world that values the rational, the objective, the evidence based, and, and anything else quickly erodes your credibility. And, I sort of have learned myself to disavow that more intuitive side of myself to perform, being more evidence based. And I'm at a point now where I have given myself permission to be fully witchy. And, I've found it gives me comfort, it gives me guidance. It helps me be a better support to my patients. It keeps me connected to my parents. There's a lot that I find as beneficial with it.

And what I'm excited about is more people exploring this edge, giving themselves permission to come out as witches. Well, that is a wonderful and unexpected place to end on, but I think this is what I until is. It leads to the question around or answers the question around, you know, incorporating a little bit more spirituality into one's mental health, a mental fitness plan. And I really love your example of that, which is so often we think what that means. It's, you know, going to church or volunteering at the soup kitchen or, you know, getting a spiritual teacher, learning Buddhism.

But the idea that no, you know, it might be your season to be a little witchy and a little bit more mystical or magical. I think we're all on slightly different swing spots of that pendulum. You know, I grew up really quite atheist without spirituality, so I, I'm on a swing that's coming to this on my own. Some folks have been traumatized, have been harmed by, religion, by spirituality in their lives. So they're in a different place with it. But I think all of us benefit from giving ourselves permission to seek and to identify what feels resonant, what feels true to us.

But I think shutting it down entirely for some of us, that is our truth. And for some of us, that's something we've learned to do through cultural conditioning and that's worth reexamining. Well everyone, thank you so much for spending some time with, Doctor Ellen Vora as part of the Depression and Anxiety Solutions Summit. I'm Doctor Drew Ramsey your co-host. And as always, I ask that you take something with this. Whether it's sitting down with your journal and thinking about some of your anxiety and where it's coming from, or realizing, lo and behold, for all of your interest in mental health, we've even ever had your B12 level checked.

Or maybe something about the psychedelics or shamanic shaking, or some of your or as inspiration of some nontraditional ways to think about this really resonated with you. Whatever it is, please take these lessons and some of the great energy from Doctor Vora and use it as part of your solution for depression and anxiety symptoms. I'll see you in the next talk. Thanks so much.