Most Fridays, when I’m not too overwhelmed by work and life, I publish an exchange with my mother, Marilyn Smith — psychotherapist, anxiety expert, and genetic wellspring of my neuroses — about anxiety and anxiety disorders. Sometimes I forgo these exchanges and publish questions from readers, and my mom’s responses. If you have a question about anxiety you’d like me to share with my mother, please email me at dansmonkeymind@gmail.com. (Note: I reserve the right to edit submissions [delicately, lovingly] for grammar, length, etc.) 

Dear Dan’s Mom: I have been thinking about having my first child within the next year or so, but I’m anxious about weaning myself off of Klonopin (which is the only medication that truly helps me, after a decade of experimentation) and Neurontin (which was prescribed to me years ago for racing thoughts). Of course I will be doing this under medical supervision, but I was wondering if there was any general advice you could offer about going through the process. I worry that being off my meds will put me “over the edge” and prevent me from functioning in both my personal and professional life. Also, I’m assuming that there aren’t any “safe” anxiety meds that can be taken while pregnant. Thank you so much for your help! —Wannabe Mommy

Dear Wannabe Mommy: I’m glad to hear that you’ll be doing the wise thing and weaning yourself off of your medication under the supervision of a psychiatrist. I’m not an M.D. — I can’t and don’t prescribe medication — but in my experience many young women face the challenge you’re now facing and most of them, you’ll be happy to know, do quite well. In fact, I find that many women feel not worse but better when they’re pregnant. They have less anxiety, fewer worrying or obsessive thoughts, and an improved mood. Many express surprise by how well they doing off of their meds. (Hormones: they can be a wonderful thing!) With any luck, this will be your experience, too. In the meantime, there are things you can do now to manage the stress and anxiety that can continue during pregnancy. These will be familiar suggestions if you’ve been reading my advice to others (and to my stubborn son): meditation, breathing exercises, cardiovascular exercise, eating healthy, and eliminating caffeine. Also, if you haven’t already done so, get a referral to a therapist who specializes in the treatment of anxiety disorders. You’re going to be a mom: trust me, you’ll want all the help you can get. —Dan’s Mom

Dear Dan’s Mom: I’m a 29-year-old Italian architect and I’ve had anxiety for some time now. During my university years, I recall being confident and articulate in front of my teachers and fellow students, but when I started working things started to go wrong. Meetings with superiors and colleagues became moments of terror. I’d evade responsibility and make up stories not to be there. And when I did have to be somewhere, I’d end up soaked in sweat and completely out of it. Since then the feeling has branched out into all sorts of situations. It’s like a fear of making a fool of myself. I fear looking sweaty, red, uncomfortable, and inarticulate. Then everything piles up: fear of failure, of getting stuck, of not doing enough with my potential, of time passing. I feel the urge to do so much. I have so many ideas. But I always run away so as not to face anxiety-triggering situations. Now I’m starting a new job and I feel the stakes rising. I don’t know where all this comes from. I know it is something about seeing myself fail, others seeing me fail, being in the spotlight, figures of authority questioning me. It is very weird, as I know that in reality everything is and will be fine. But inside it doesn’t add up, and the fear and insecurities are powerful. How can I single out the elements that trigger my anxiety and start working on them? —In the Spotlight

Dear In the Spotlight: It is difficult from your letter to pinpoint exactly what the “elements” are that trigger your anxiety in social situations. It sounds like you were doing just fine until the stakes got bigger and you were given more responsibilities. The fear of being judged negatively by authority figures is often what triggers panic attacks with people who suffer from anxiety in these types of situations. But then the extremely unpleasant physical symptoms you felt during the attack — feeling shaky and sweaty, your face getting flushed and your heart racing — became the target of your avoidance. After all, why would you want to go into a situation where you’re going to have these sensations? Where you worry others might notice your anxiety? But wait, signore, has anyone really noticed? I suspect not many, if any at all. And if they have, so what? I would suggest you take a calming breath before going into the next situation — but do go into it. Avoidance only brings down the fear temporarily. In the long run it increases the anxiety. Good luck with your new job! You’re going to be great! —Dan’s Mom

Dear Dan’s Mom: I don’t like to step on manhole covers or bulkhead doors or metal grates. I don’t like to stand too close to the edge on train platforms or be trapped inside elevators for more than fifteen seconds. I worry that the cab driver is going to lock me inside like in that movie The Bone Collector and murder me before we get to my destination. What do you suggest? —Storyteller

Dear Storyteller: You have a marvelous imagination and have created some great newspaper headlines in that head of yours. I can just visualize your terror as you’re falling through a manhole cover. Then there’s a scene change and you’re in a cab screaming, struggling to stay alive. Aaaaaaaaaa! But images and thoughts such as these are unproductive (unless you’re writing a horror movie) and can certainly trigger feelings of anxiety and/or worry. Sounds like you may need to rewrite these awful scenarios and replace them with more realistic images. Or you can try extinguishing these images by spending some time every day repeatedly visualizing the scary scenes. You can even write down the scenarios, record them on a loop tape and listen for 30 minutes a day. After a short while, I suspect you’ll be laughing at the absurdity of your irrational fears, which will take the power out of them, which in turn will help kill off the anxiety. Can you be 100% certain that nothing bad like this will happen? Of course not. No one can give you that guarantee. What you do have are the odds. And the odds are greatly in your favor. —Dan’s Mom

[Mother-Protecting Legal Disclaimer: The contents of this site are for informational purposes only. The content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. If you think you may have a medical emergency, call your doctor or 911 immediately. This site does not recommend or endorse any specific tests, physicians, products, procedures, opinions, or other information that may be mentioned on the site. Reliance on any information provided by this site or others appearing on the site is solely at your own risk.]

Most Fridays, when I’m not too overwhelmed by work and life, I publish an exchange with my mother, Marilyn Smith — psychotherapist, anxiety expert, and genetic wellspring of my neuroses — about anxiety and anxiety disorders. Sometimes I forgo these exchanges and publish questions from readers, and my mom’s responses. If you have a question about anxiety you’d like me to share with my mother, please email me at dansmonkeymind@gmail.com.

Dear Mom: It’s been a couple of weeks at least since we’ve corresponded about my anxiety. You’ve been fielding other people’s questions, and haranguing them to breathe. Frankly, it’s been nice to have someone else be the target for a while. But I thought I’d chime back in here because I’ve been pretty anxious again and could use your advice. You see, I’ve decided to go back into therapy. Cognitive therapy, to be specific. And it’s freaking me out. I don’t mean the anxiety is freaking me out. I mean being in therapy is freaking me out. I’ve only been to two sessions so far, and already I’m spooked by … by what? By getting help, I think. Now why on earth would that be? Is it normal for anxious people to get more anxious because of the prospect of feeling better? Is this a common thing? If so, why? Also: hi. How are you? I know I owe you a call. Sorry. I’ve been slammed with work. Which is only making me more anxious. I think I might be getting an ulcer. Do you think I’m getting an ulcer? Do ulcers run in our family? Love, Dan

Dear Dan: Oy! No, ulcers don’t run in the family. Only cancer and heart disease! But if you’re having abdominal symptoms check it out. You could be the first! Lol! Hopefully it’s nothing but tension. Meanwhile, I’m delighted you started therapy and am not surprised it’s freaking you out. A fair number of people feel increased anxiety when they begin treatment. It’s quite normal and nothing to worry about. Worry is probably the reason you’re going in the first place — is that right? So my telling  you not to worry is probably not helpful. Or maybe it is for the moment. You mention your anxiety has to do with the prospect of feeling better. Could you explain that? My experience is that anxious people coming into therapy worry that they’ll always feel the way they do when they start treatment — that they’re a hopeless, intractable case. They yearn to feel better although it may mean giving up the worry thoughts and behaviors that are so ingrained in their being. It may mean having to face situations they’ve avoided for years or the elimination of thoughts that seemingly protected them from some imagined catastrophe. I have no idea what’s in your head and frankly, I’m not sure I want to know.  My advice is to discuss your concerns with your shrink! Love, Mom

You  say you’re not sure you want to know what’s in my head. That makes two of us. As for discussing my concerns with my shrink, I will, but I don’t want to take up precious therapy time on my wormy, niggling meta-worries. This guy is super-expensive! He’s so expensive that I’m not even paying for the therapy myself: a dear friend has agreed to pay. Which makes me even more anxious, because now I worry that the therapy will take too long and this friend will have to pay oodles and oodles of money and come to resent me and regret that he ever offered to pay in the first place, even though I never asked him to pay — I never even hinted at it — and even though he has the money and insists that he doesn’t care about the cost and that I shouldn’t worry at all…. Whew! In any event, that’s why I’m bothering/exploiting you. You’re kind of like my supplementary therapist! And you’re free! Congratulations!… You said something very interesting in your response. You said that many patients yearn to feel better even though that might mean the elimination of thoughts that “seemingly protected them from some imagined catastrophe.” That’s what I’m wondering about. I’ve always thought of my anxiety as this shitty, jerky, patently destructive thing. But now I’m thinking that maybe, subconsciously, I’ve also always considered it a somewhat useful thing. I’ve been reading a book by this fancy-schmancy therapist of mine about worry, and like you, he says that a lot of chronic worriers have ambivalent feelings about giving up their worrying. The reason? Because (here he is addressing the reader) “your worry is a strategy that you think helps you.” By worrying, he writes, you are demonstrating a belief (again, not totally conscious) that “you will catch things before they get out of hand, get rid of any unpleasant emotion immediately, and solve all your problems. You think that following [your worrying habits] will make you feel secure.” But you learn over time that the worrying isn’t actually accomplishing any of these goals. So you go into therapy. But you’re still ambivalent! Does this ring true to you? Is this a way of thinking with which you’re familiar?

Wow… How lucky for you! This friend must really think you’re worth the investment. (I agree.) I bet he’s not worrying about the outcome. Maybe his generosity can serve as a great motivator for you to work hard in therapy — unless you screw it up by worrying too much about not getting better! Here’s the thing: Worry thoughts can be either useful or harmful depending on what you’re ruminating about and much time you spend on the thoughts. If you’re worrying about material you need for teaching your college class, that’s fine as it spurs you to do adequate preparation. But when you worry excessively about not performing well enough, anxiety can escalate and interfere with having the outcome you’re hoping for. But I don’t think I’ve answered your question. Your shrink writes that “your worry is a strategy that you think helps you.” I agree with that statement. For example, when you started driving, I worried constantly when you took the family car out. I pictured you crashing and splattered on the LIE, bleeding profusely. I felt powerless. The worry drove me nuts, but I was more afraid not to worry as the worry thoughts in a weird way seemed to protect you from danger. If I stopped worrying, then the imagined catastrophic fear might actually occur. In essence, worrying gave me some sense of control, however false. Does that make any sense to you? And by the way, who said my services are free. I expect periodic rewards, like sleepovers with my beautiful granddaughter!

That makes perfect sense. And doesn’t this make my run-of-the-mill anxiety kind of like obsessive-compulsive disorder? I mean, don’t people who suffer from OCD believe that by checking things, or counting in a certain sequence, or washing their hands a gazillion times, they will be able to prevent bad things from happening to themselves or people they love? And don’t they at the same time know that this is crazy? Just like you knew it was crazy to believe that by picturing my violent death (!) you would somehow be preventing my violent death. What nuttiness, to believe two things at once like that! What horror, to be trapped in such a conflict!

No, Dan, it’s not nutty and it’s not horrific. It’s kind of expected. Wait until your daughter starts to drive. See how you feel the first time she takes the car on a highway! It’s not as if I was consciously telling myself that if I worried about something bad happening to you then you’d be safe. There’s a difference between having normal worry thoughts during periods of high stress and having an anxiety disorder. I think you’re a little confused and it’s understandable since it’s difficult at times to distinguish between what’s normal and what’s not. I don’t think you have OCD. I think your worrying that you have OCD (if that’s in fact what you’re doing) is part and parcel of having generalized anxiety, even if you have some of the same symptoms as people with Obsessive Compulsive Disorder.

After a short hiatus in which my mom went to Portland to visit my brother and I forgot to get her material in time, “Ask Dan’s Mom” returns with answers to four questions from anxious readers.

If you have a question about anxiety you’d like me to share with my mother, please email me at dansmonkeymind@gmail.com. (All questions will be posted anonymously.)

Part 1 of “Ask Dan’s Mom” here. Part 2 here. Part 3 here. Part 4 here. Part 5 here. Part 6 here.

Dear Dan’s Mom: I’ve been anxious most of my life, but didn’t have my first full blown panic attack until the age of nineteen, at which point I was put on Paxil and given Klonopin as needed. I continued to live life to the fullest until last year when a medical misdiagnosis sent me over the edge. My anxiety turned into an anxiety disorder. Even though I do CBT on a regular basis, I have developed a full-blown phobia/fear/belief that I’m going to develop schizophrenia. I’ve tried thought replacement, distraction … everything. And yet this is still something I fear on a regular basis. (I should mention that I don’t hear voices, I don’t think the world is plotting against me, I don’t see Jesus, etc.) How on earth can I start to work on breaking this fear down and getting rid of it —Over the Edge

Dear Over the Edge: I  once led a group of “normal” folks with anxiety disorders who were mostly diagnosed with panic disorder and obsessive-compulsive disorder. This was in the outpatient section of a major psychiatric hospital. From the window of the room where we gathered on a weekly basis you were able to see the inpatients walking around the grounds of the inpatient units. Every week without fail someone would look across the yard and say, “Oh my god! That’s going to be me! I’m going to become one of them!” It never happened — not once in the more than ten years I worked there. As the group made progress, mostly through CBT practice, the fear of going insane subsided and for many was extinguished altogether. It takes time, patience, and hard work to be able to break down the fearful, irrational thoughts and change them. But you will get there. Some helpful questions to ask yourself along the way: How long have I had this fear? Has what I feared ever happened? What is the likelihood of what I fear actually occurring? And as I often tell Dan (to no avail), “Don’t forget to breathe.” This will help slow down your scary thoughts and bring you back to the moment. —Dan’s Mom

Dear Dan’s Mom: Flying makes me very nervous. Also standing in lines, being late, and potentially forgetting to pack the right pair of shoes. Do you have any suggestions on how to minimize my travel anxiety? —Anxious Traveler

Dear Anxious Traveler: You are in good company,  which is the reason why most airports of full of crowded bars. Some folks are anxious about their airplane crashing, others are worried about turbulence, and the balance are generally frightened of being enclosed in a small space. Given the anxiety you feel when you wait on lines it sounds like you may fall into that last category — but that’s just an educated guess. Whatever the case, it’s difficult to practice overcoming this specific fear as most of us don’t fly on a daily or even weekly basis. For that reason, distraction tools are very useful. Some suggestions: If you like to read, start a good novel at home to be continued on the plane. Or if you enjoy knitting or crocheting you may be able to complete a small project on your flights. And don’t forget the breathing. Try making yourself comfortable. Put one hand on both arms of the seat, close your eyes, feel yourself sinking into the seat and breathe. In addition, it’s great to use imagery. If you’re flying to a vacation spot, focus on the scene you’ll be part of when you reach your destination. Or on that reunion with a loved one. Anything that puts a smile on your face. And so what if you don’t pack the right pair of shoes. What’s the worst that will happen? When you get where you’re going, you get to shop! —Dan’s Mom

Dear Dan’s Mom: For my job, I need to have business lunches several times a week. I am a picky eater to begin with, and I worry about people secretly disparaging me because I don’t eat sushi, or ordering certain kinds of food that might be messy, or if I just really want the appetizer Caprese salad but I don’t want my lunch date to think I am being cheap or that they can’t go nuts on the hangar steak. It gets very difficult to concentrate on the business at hand. Why am I such a freak? —Picky Eater

Dear Picky Eater: I’m  wondering if others even take notice of what you’re eating. Unless you’re ordering something weird, like a chocolate ganache tart for your appetizer, I don’t think so! Generally, people are so in their own heads, with their own thoughts, feelings, and worries, that they aren’t going to notice what you fear they’re going to notice. If you’re concerned that they think you’re being cheap can you just say something? Let them know you’re fine with whatever they order — and hopefully, it’s not coming directly out of your pocket! —Dan’s Mom

Dear Dan’s Mom: How can I judge how much rumination about to-do lists and goals is healthy and normal — and how much is counterproductive — making my body curl up into a hardened shell which will soon crack into a million pieces the next time someone shoves me on the subway? How do I stop the unproductive ruminations? —Subway Shell

Dear Subway Shell: Great question. If the ruminations do not interfere with your having fun and being productive, I wouldn’t worry if it’s normal or not. Probably it is but a stress management program might help reduce some of your tension and concerns. That might include cardiovascular exercise (clear this with a doctor if you’re not normally active), breathing exercises (of course), a healthy diet with little or no caffeine, and perhaps some yoga or pilates added into the mix. Being shoved on a subway just sounds like the last straw, so bringing your general level of stress down should do the trick. —Dan’s Mom

[Mother-Protecting Legal Disclaimer: The contents of this site are for informational purposes only. The content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. If you think you may have a medical emergency, call your doctor or 911 immediately. This site does not recommend or endorse any specific tests, physicians, products, procedures, opinions, or other information that may be mentioned on the site. Reliance on any information provided by this site or others appearing on the site is solely at your own risk.]

Every Friday I publish a new exchange with my mother, Marilyn Smith — psychotherapist, anxiety expert, and genetic wellspring of my neuroses — about anxiety, anxiety disorders, and anxiety treatments.

The series “Ask Dan’s Mom” has now been opened to questions from readers. If you have a question about anxiety you’d like me to share with my mother, please email me at dansmonkeymind@gmail.com.

Part 1 of “Ask Dan’s Mom” here. Part 2 here. Part 3 here. Part 4 here. Part 5 here.

Hi Mom.  I hope you’ve had a good week. I still have a lot I want to talk to you about regarding my own anxiety, but I’ve been getting a lot of questions for you from the outside. People want your sage advice! Are you willing to give it? Can I start sharing your wisdom with the world?

Hi Dan. It was actually a pretty awful week. There was a fire in my office! Can you believe it? My whole side of the building got burned down! All of my files, thank goodness, survived. But still, very stressful. I had to take lots of slow deep breaths to keep myself calm. I know — I’m still trying to pitch the benefits of the breathing. But that’s only because it works so well. To answer your question: yes! I’m ready and willing to help out your fellow anxiety sufferers. So let’s get started.

*****

Dear Dan’s Mom: I keep waking up at 4:00 in the morning. Not always from anxiety (sometimes I just need to use the bathroom), but then my mind starts racing and I can’t fall back asleep. Next thing you know, my alarm is ringing. I’m constantly exhausted. Sometimes I’ll take half a Xanax or Ambien before I go to sleep but then I’m just groggy the next day. How do I turn my brain off? —Sleep Deprived

Dear Sleep Deprived: It sounds as if your body and mind are conditioned to wake up at the same time every night. It becomes a bad habit that needs to be broken and it can be. Here’s what to do: Rather than lie in bed allowing the mind to become a playground for runaway thoughts, if you wake in the middle of the night and don’t fall back asleep within fifteen minutes, get up and go into another room. Relax, have something warm to drink, like herbal tea, and when you start to feel sleepy again go back to bed. It sounds simple, I know, but often the simplest solutions are the most effective. (It’s also a good idea to limit your liquid intake before you go to bed. If you don’t have to pee at 4:00 am you might not wake up at all!) —Dan’s Mom

Dear Dan’s Mom: I am paralyzed with fear about insects, and bed bugs in particular. I have ceased going to movies because I’m convinced the theaters are all infested. I freak out when I have to stay in hotels. I dry clean all new clothing I purchase and inspect the backseats of taxis and couches in bars, which is revolting. Believe it or not, I’m way better about this now than I was last year. How do I put this out of my mind once and for all? Thanks! —Bugged Out

Dear Bugged Out: Don’t let the bed bugs bite! No one thought seriously about this cutesy expression until the media exploded with bed bug horror stories. But how many people do you know who’ve got bitten by those little ugly critters in a hotel or in a movie theatre? Not many, I’d guess. Probably not even one person. Every day there are thousands upon thousands of people who stay in hotels and go to the movies — and are just fine. You’ve probably heard some terrible tales in the newspapers. But don’t universalize based on individual stories. (Newspapers love to sensationalize: it sells newspapers.) I think it’s great that you’ve made so much progress this past year. That’s probably because you’re not avoiding hotels, cabs, and wherever else you see a risk. Keep doing what you’re doing. Facing your fear will conquer your fear. Whatever it takes is fine at this point, even if it means covering the seat in the movie theater. Over time, if you keep exposing yourself to fearful situations, the scary thoughts will subside and die of boredom as it takes the worry to keep them alive. And eventually you will no longer be bugged out. —Dan’s Mom

[Mother-Protecting Legal Disclaimer: The contents of this site are for informational purposes only. The content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. If you think you may have a medical emergency, call your doctor or 911 immediately. This site does not recommend or endorse any specific tests, physicians, products, procedures, opinions, or other information that may be mentioned on the site. Reliance on any information provided by this site or others appearing on the site is solely at your own risk.]

Every Friday I publish a new exchange with my mother, Marilyn Smith — psychotherapist, anxiety expert, and genetic wellspring of my neuroses — about anxiety, anxiety disorders, and anxiety treatments.

The series “Ask Dan’s Mom” will soon be opened to questions from readers. If you have a question about anxiety you’d like me to share with my mother, please email me at dansmonkeymind@gmail.com.

Part 1 of “Ask Dan’s Mom” here. Part 2 here. Part 3 here. Part 4 here.

Hey Mom.  I was planning to continue our conversation about therapeutic breathing techniques — I was supposed to practice Step Two before we moved on to Step Three — but to be honest I’m not prepared. It’s been a lousy week. A lot of anxiety. A lot of tension and thoughts of things falling apart and anxiety-induced fatigue. I hate when this happens, and probably I should have been especially dedicated to the breathing this week. But it never seems to work that way. The more anxious I get, the more despairing I get, and the more despairing I get the less motivated I am to work on my anxiety. Probably this is something you hear a lot from your patients.

Dan, my gut Jewish mother reaction is to make a big pot of chicken soup and drive it over to your place. (Nurturing the mind and body are not bad ways to handle a lousy week.) Know that it’s not unusual to experience difficulty doing the breathing exercises when you’re first starting to learn the techniques and feeling especially anxious. Until the deep breathing becomes automatic it takes a lot of energy to bring your conscious attention to the breath — which is why it’s best to practice when you’re feeling most relaxed, in the early morning or late evening. Don’t give up on it! It’s so worth the effort and the few minutes of your time. Try making it part of your daily routine, like brushing your teeth. In the meantime, do you want some chicken soup?

Thanks, Mom. I would actually love some chicken soup. But if you made some and drove all the way to Brooklyn I suspect it’d just make me feel worse: there’s something about being a grown man being comforted by his mommy that feels … weak, I guess. Like I’d be indulging the self-doubt and sense of powerlessness that the anxiety creates. Like I’d be giving in. Silly? Anyway, I just can’t get myself to do the breathing! You know what I can get myself to do when I’m really anxious? It’s a short and pretty pathetic list: eat crappy food, surf the internet, stare at the wall, and quietly beat myself up… I’m sorry. I shouldn’t be laying this on you. But I figure, you’re an expert, right? You have a better idea than most people about how a person can jolt himself out of these kinds of nervous patterns.

Silly? No, it makes total sense that my bringing over chicken soup would make you feel worse. (But it would have made me feel better!) Having severe anxiety often creates a feeling of helplessness, of not having any control. Which is why the diaphragmatic breathing is so important. It’s something that is concrete, beneficial, and in your control. Like many people you want immediate relief—thus the junk food and web-surfing. And then you beat yourself up for being self-defeating … So I guess your shtick doesn’t work for you. Then why not give the breathing a chance? Maybe you don’t believe it’s worth the effort. Is that it?

You know,  maybe I don’t truly believe it’s worth the effort. I mean, I believe it when I stop and think logically. Scott [my oldest brother] says it works. You say it work. I’ve read books that say it works. But when I’m anxious I’m not sure I believe that anything will work, except maybe a lobotomy or a brain transplant. It’s not just the fight-or-flight desperation, though that’s certainly there. It’s also the … the despair, I guess. It’s like a coin that keeps flipping: the anxiety makes me exhausted and depressed, which makes me more anxious, which makes me exhausted and depressed, and so on and so on. When the pattern is in effect, it can be very hard to stop and do something useful.

So you do believe the breathing works when you’re thinking logically? And are there times during the day when your anxiety settles down: windows of opportunity, brief moments to take that breath and slow down your thoughts? It doesn’t have to be at a prescribed time of day, you know. Do it when you’re reading, when you’re walking to the subway, when you’re playing with my granddaughter. At this point it doesn’t really matter when. Just find what works for you and to try to do it. Try to catch that moment and breathe. Dan, you can stop the vicious spinning-out-of-control anxiety by breaking into it and changing its path. (Incidentally, and to make clear to your readers that I’m a responsible therapist, if you were a real patient I probably would’ve referred you to be evaluated for meds by now — if you weren’t already taking them.)

I know, I know.  You’re right, of course. It’s just the anxiety talking, saying “Dan, it’s not worth it. Things are already RUINED! You’ve ruined everything!” Do I believe the breathing works when I’m thinking logically? Theoretically, I do. But for me there have only been two things in this world that have been so obviously and unignorably helpful that I know in my bones they work, and that’s pretty strict cognitive therapy and Zen meditation. Everything else that you’ve preached over the years, particularly vigorous exercise and diaphragmatic breathing, haven’t helped as dramatically. So I suppose I do remain a bit skeptical. I’ve got my things — in sixteen years of chronic anxiety I’ve found what works for me — and I find myself sort of reluctant to strike out toward something new.

OK, so don’t try something new. Let’s assume therapeutic breathing doesn’t work for Mr. Monkey Mind, but Zen meditation and cognitive therapy do. That’s fine. But are you meditating and working on the cognitions? There’s nothing wrong with doing what has worked in the past … if you do it. What’s important is that you break into the vortex of anxiety and stop the action dead in its tracks. If you have techniques that work for you, then what’s the problem? Just do it! I hope I’m not being too tough on you, Dan. It’s just that I never said diaphragmatic breathing is the only way to get better. It’s a tool, a great one for many people, but obviously not for everyone. “Whatever works” happens to be a pretty good rule of thumb here.

Every Friday I ask my mother, Marilyn Smith — psychotherapist, anxiety expert, and genetic wellspring of my neuroses — some questions about anxiety, anxiety disorders, and anxiety treatments.

The series “Ask Dan’s Mom” will soon be opened to questions from readers. If you have a question about anxiety you’d like me to share with my mother, please email me at dansmonkeymind@gmail.com.

Part 1 of “Ask Dan’s Mom” here. Part 2 here. Part 3 here.

Hi, Mom. How was your week? How’s Bennie [her dog; see Pt. 3]? Has he stopped throwing up?

Good morning! Thanks for checking up on Bennie. He’s been fine, although for some reason he still gets carsick. Luckily this doesn’t make him throw up, just drool … a lot. I gave him some Dramamine but it didn’t help. The vet said I could try Xanax next. Maybe I should teach him the breathing techniques we’ve been talking about, because now I think he has anticipatory anxiety about feeling nauseated!

Wow, yet another child on Xanax, huh? If you’re not careful you’re going to get a reputation. I suspect you won’t have much luck getting Bennie to stop panting uncontrollable, but maybe we can continue to work on me. I took your advice and spent the past week working on Step One of the breathing technique. I admit that I didn’t do it religiously, but I did it as often as I could — and I think I got the hang of it. So I’m ready for Step Two. Educate me!

OK! This is fun. You’re finally following my advice!  So Step Two is not that different from Step One. Again, no distractions, and you should still pick a time to practice when you’re relatively relaxed: usually at bedtime or early in the morning before my granddaughter wakes up and starts demanding your attention. Now that you’ve practiced getting the breath lower into your lungs we can add in a meditational component. Start counting your inhales and exhales to help you focus on the breath (and not, for example, on what work you have to accomplish that day). As I said last week, I like to breathe in through my nose for a count of four and exhale through pursed lips to a count of six — but do whatever combination works best for you. What’s important is that the exhale is longer than the inhale. When your thoughts start to wander (and trust me, they will), accept them but gently return yourself to your breath. I know how hard this is, especially for someone like you whose mind jumps around like a meshugana monkey! (Mea culpa. I know my genes are to blame.) Work on this for another week and then we’ll move on to Step 3.

OK, Mom. I’ll try. In the meantime, I want to pick up a thread that we let drop last week. You mentioned that you tend to favor cognitive-behavior therapy for people who are very anxious. I know this is true of a lot of clinicians these days. Could you explain why this is?

I thought I already answered this question. But since you obviously don’t remember, I’ll try again. (Sometimes we have to hear the same thing repeatedly before it resonates and makes sense.) Interestingly, to get the full benefit from CBT you have to practice continuously, just like you do with the breathing (and in fact better breathing techniques can be an integral part of CBT). Or like going to the gym to build up muscles and stamina. It takes time and patience. Essentially, with CBT treatment bad habits of mind get replaced over time by new and healthier habits of mind. By this I mean that what CBT practitioners call “automatic thoughts” gradually get chipped away at by a conscious, careful questioning of those thoughts and the premises behind them.

You totally did not answer this question last week.  We only touched on the subject and said we’d get back to it. In fact I’d still like more information. Let’s try a hypothetical, if you’re game. Say a person comes in with a relationship anxiety: she’s concerned that her husband may not love her anymore. How would a CBT practitioner handle the situation?

OK, I’ll try to give you a very quick (I’ve got to run out to talk to your grandmother’s nurse) run-down of how this hypothetical might be addressed using CBT. I’m actually visiting your brother right now, and he’s lying on the couch like a slug, so I’ll use him as inspiration.

Wife: I don’t think my husband loves me anymore. 

Therapist: Why do you think that?

W: He comes home from work, sits right down on the couch, and zones out.

T: What do mean he “zones out”?

W: He turns on the TV and doesn’t talk to me except for the occasional muttering.

T: Does he do this on weekends also?

W: No. He’s entirely different on weekends and holidays.

T: What is he like on those days?

W: He’s funny. He’s engaged.

T: So what’s another possible explanation for why he’s so out of it during the week?

W: Maybe he’s tired?

T: Yes. What else?

W: He’s stressed and needs to unwind?

T: OK. Right. So maybe his behavior has little or nothing to do with his feelings for you …

This example is pretty rudimentary, but you get the idea. You can apply the questioning process — call it the “reasoning-about-your-assumptions-and-beliefs” process — to almost any other hypothetical. The basic premise is that the thoughts about a situation precede the feelings about a situation — so you want to focus on the “automatic” and scary thoughts and examine them to determine if they’re in fact rational.

And does the breathing help this process along, in your experience?

Absolutely it does. For most people the breathing helps to calm down the mind, which makes it all that much easier to scrutinize the negative and often irrational thoughts.

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Every Friday I ask my mother, Marilyn Smith — psychotherapist, anxiety expert, and genetic wellspring of my neuroses — some questions about anxiety, anxiety disorders, and anxiety treatments.

The series “Ask Dan’s Mom” will continue as a one-on-one correspondence for a little while — until my mother and I exhaust the conversation or she gets pissed at me, whichever comes first. At that point, I’ll open the floor to questions from readers, thus turning the series into a new breed of advice column: Dear Abby for Neurotics. If you have a question about anxiety you’d like me to share with my mother, please email me at dansmonkeymind@gmail.com.

Part 1 of “Ask Dan’s Mom” here. Part 2 here.

Hi, Mom. I hope you’ve had a good week, and that Bennie [her dog, short for “Benzodiazepine”] has stopped throwing up. I’d like to continue along in the same vein as our last round. We talked about the many anxiety treatment options that are out there but we didn’t talk specifically about psychotherapy. I think a lot of people who feel anxious or panicky seek out therapy but don’t know what kind of therapy is best. Do you have an opinion on this?

Funny you should mention Bennie. He just threw up again (this time yellow bile!) and I’m getting worried that he may be sick. Also, Grandma may have to go back into the hospital if she doesn’t do her deep breathing exercises to clear out her lungs. It’s interesting: whether you’re very old and sick like your 95-year-old grandmother or young and anxious like you, breathing helps. I mean the diaphragmatic, deep breathing that can relieve symptoms of anxiety. When you slow down your breath, you slow down your mind … which usually helps you feel calmer. Which brings me to your question about psychotherapy, of which, yes, there are many kinds. Like most therapists these days, I have a practice that draws on many different therapeutic traditions (“eclectic” is what people call this informed mixing and matching), but with anxiety I incline toward cognitive-behavior therapy. CBT often focuses on the breath, as well as teaching techniques to change your negative thoughts. The emphasis is on the here and now. I believe that people who are too anxious to delve beyond the surface should work with a CBT therapist to relieve their symptoms.

Sorry to hear about Bennie, Mom. And I’ll call Grandma as soon as I can and urge her to do her exercises … There are two points here: the importance of breathing and the usefulness of CBT. Let’s take them one by one. Regarding the breathing, this is something you’ve always told me to do and I’ve pretty much always ignored the advice, probably to my detriment. Is the only importance of breathing the one you enumerate — that slowing down the breath slows down the mind? Or are there physiological benefits, too? And what exactly is the right way to breathe for someone who is anxious?

Wow, I love this question because I’ve been trying to convince you for years to breathe. I find it interesting that so many people like yourself resist the one technique that can turn things around. If you can control your breath you will calm the mind and slow down the body — and prevent the symptoms that come from shallow chest breathing. You know what I’m talking about: the sweating, the chest pressure, the shortness of breath, the lightheadedness, etc. OK, so now you want to know the right way to breathe! Here it is. Step One of the breathing lesson is to shut off your cell phone, the television, the lights, take off your glasses, loosen your clothes … no distractions. Then, lie down in a bed or on a recliner (if you’ve got one) and place one hand on your chest and one hand on your belly just below your belly button. Breathe in through your nose, gently … don’t force it. Then exhale through pursed lips, slowly. Don’t worry about anything at this point but trying to get the air into your abdomen. If you’re doing it correctly then the hand resting on your belly will rise and the hand resting on your chest will stay still. It takes time to learn the right technique, so be patient. Do this for a week or so and then I’ll give you Step Two. The idea is to do it every day for at least five to ten minutes. And don’t expect immediate results. Be patient.

I’m interested that you call breathing “the one technique that can turn things around.” That’s a pretty big claim, especially coming from a therapist — that is, from someone who is dedicated to communication as a means toward recovery. Did you mean to be so definitive?

Perhaps it is a big claim, Mr. Monkey Mind, but I stand by it. If you don’t slow down your breathing and thus your mind and body, it is much more difficult to change your scary and usually irrational thoughts into thoughts that are more realistic and less negative. Those who practice deep breathing religiously (and I don’t mean only on Sundays) find that it becomes automatic and they’re better able to ward off panic attacks and control the anxiety. There is absolutely nothing to lose and a lot to gain. So just do it!

All right, all right! I’ll do it! Stop hounding me! Jeez. And next week you can tell me Step Two. Also, we can move on to talking about therapy and CBT. Have a good weekend, Mom!

Every Friday I ask my mother, Marilyn Smith — psychotherapist, anxiety expert, and genetic wellspring of my neuroses — some questions about anxiety, anxiety disorders, and anxiety treatments.

The series “Ask Dan’s Mom” will continue as a one-on-one correspondence for a little while — until my mother and I exhaust the conversation or she gets pissed at me, whichever comes first. At that point, I’ll open the floor to questions from readers, thus turning the series into a new breed of advice column: Dear Abby for Neurotics. If you have a question about anxiety you’d like me to share with my mother, please email me at dansmonkeymind@gmail.com.

Part 1 of “Ask Dan’s Mom” here.

Good morning, Mom. In last week’s exchange, you mentioned that a tendency toward anxiety may be caused by “the way you were brought up by your parents.” I know that you’ve had a hard week, what with Grandma being sick, so I’m going to let that one pass. For now, let’s talk about treatment. One thing that’s always confused me about anxiety is what exactly to do about it. There are so many treatment options, from medication to psychotherapy to meditation to acupuncture to I don’t know what else: sweat lodges? religious conversion? coffee enemas? What would you say to someone who perplexed by all these offerings?

Thanks for going easy on me this week, sweetheart — though now you’ve got me nervous about future installments!… To begin with, I know how scary it is to feel anxious and to have no clue about where to turn for help. Generally, I think the best idea is to first go to your doctor and let him or her check you out — this to make sure you don’t have any medical problem that may be making you feel jittery. If you’re OK (which you probably are) then I think the next step is to make an appointment with a therapist who specializes in anxiety. Most doctors can give you a referral. Or go to the Anxiety Disorder Association of America’s website; they maintain a list of well-trained clinicians. If you think you need medication then you can ask the therapist for the name of a psychiatrist. Meanwhile, I would definitely try exercise: brisk walking or jogging is just great. Meditation, yoga, or tai chi might help also. Whatever you do, though, it’s very important to be patient. It may take time to feel better, but you won’t always feel the way you do right now.

I’d like to quibble with you on that last part, Mom. You say, “You won’t always feel the way you do right now.” This is something you’ve always told me, and it’s a comforting sentiment. But I first started experiencing anxiety eighteen years ago and I still feel anxious. It’s not as bad, but it’s certainly still there. I still have to fight against it every day. Do you think it’s true of most people who have been diagnosed with an anxiety disorder that it won’t ever totally go away? Or am I just exceptionally jittery?

You may be exceptionally jittery; I’m not sure. But probably you’re just a little lazy…. Listen: I think it’s really important to offer hope and optimism here, as well as encouragement. The key is to “follow the program.” By that I mean exercising, eating less sugar, seeing the right shrink, engaging in some sort of meditational activity (which could be anything from dancing to boxing to knitting to formal meditation), and taking medication if warranted. If you do this then yes, you will probably have to continue working at it every day — but you don’t have to have this warlike attitude. You don’t have to think of your life as this great battle against anxiety. You can just think of yourself as leading a healthier lifestyle than the one you were leading before.

And this worked for you? Has “following the program” made your anxiety manageable or even functionally nonexistent?

Yes, for the most part it really has. You know that I’m something of a maniac when it comes to exercising. I take frequent brisk walks and do pilates and (sometimes) yoga. I hardly have caffeine anymore and I eat right. My anxiety still pops up when I’m faced with certain stressors and when I’m trying new things that scare me. But even that I now think of in a positive way. Eleanor Roosevelt said, “Do one thing that scares you every day.” I agree. I believe that it’s very important to constantly face your fears in order to get stronger and build confidence. It’s worked for me and it works for the patients I see who are constantly faced with fearful situations. As confidence increases, anxiety decreases! So yes, following a program of a healthier lifestyle, therapy and meds when needed, plus doing something “scary” everyday (like revealing yourself in your son’s blog!) has definitely helped me manage my anxiety, which is fairly well contained at this point in my life.

And what point is that? How old are you, exactly, Mom?

Shut up, you little punk.

The lovely woman shown here is my mother, Marilyn Smith. Marilyn/Mom is a psychotherapist who specializes in anxiety disorders. Which means that she was first a human being who suffered from anxiety. That, after all, is usually why people become therapists: because first they were patients. You like the smell of paint, you become a painter. You’re scared that the fumes from an open can of paint are going to give you leukemia, you become a shrink.

My mom and I have an interesting relationship. It’s a very Jewish relationship, I think, in that we are capable of loudly denouncing each other and then hugging and laughing as if nothing ever happened. (Every meeting is like the dinner scene in Annie Hall.) I attribute a great deal of my anxiety to my mother, simply on genetic grounds. There are other grounds, too, which I cover in Monkey Mind under the heading “Hurricane Marilyn.” But here the most important thing to note about my mother is her remarkable and invaluable expertise. I have never in my life met someone who knows more about anxiety, both clinically and personally, than she. Her understanding is encyclopedic, and her advice invariably right on the money.

In other words, she’s a great resource. I call her all the time for advice on anxiety: how to treat it, what it means, whether she’ll lend me some Xanax. And it has occurred to me, as I’ve completed Monkey Mind, that it isn’t quite fair to keep my mother to myself. Her knowledge and wisdom should be shared with the world.

Toward that end, I recently initiated an email correspondence with my mom on the subject of anxiety. She’s gamely agreed to make this a regular thing. Once a week I’ll send her some questions, and every Friday I’ll publish them here on this site, for public consumption, under the title “Ask Dan’s Mom.”

I’ve started basic, with some FAQ-type things about anxiety, and as we progress I suspect we’ll get more detailed, and perhaps more personal. If you have your own questions you’d like to ask her, please feel free to email them in to dansmonkeymind@gmail.com, and I’ll pass them along — that is, so long as she doesn’t have to worry about liability issues. I don’t want the dear woman being sued.

Let’s start with a simple one. What is anxiety? 

Anxiety is fear, worry, or nervous uncertainty about something, and that something is usually an event that has not taken place yet. Everyone has some degree of normal anxiety. In its lesser forms, anxiety is often a good thing. It serves as a motivator. It helps us to study for a test, or to get out of bed in the morning so we’re not late for work or school. This type of brief anxiety is very justified and is like feeling the heat when your hand gets too close to a hot stove. It signals us to do something. But when anxiety is longer lasting and more intense there’s a great risk of developing what we call an anxiety disorder. When this occurs, unpleasant and uncomfortable sensations such as sweating, shaking, palpitations, lightheadedness, stomach distress, etc. may accompany the anxiety and in fact, become the primary problem. For some, anxiety reaches a panic level and becomes very difficult to manage.

What causes everyday, useful anxiety to become “longer lasting and more intense”?

This is a difficult question to answer as there are so many factors that can alter the course of anxiety. Normal anxiety doesn’t just become intense and persistent for no reason, although it may feel like that at times. It usually takes a trigger to cause normal anxiety to go haywire and feel out of control. Most of the time, the triggers are significant life experiences. They can be both positive stressors, such as going off to college, getting married, having a baby, finding a new job; or negative stressors, such as dealing with an illness, a loss of a loved one or losing one’s job.

Are there any other factors behind anxiety besides stressful life events?

There is a lot we can discuss about why some people react to significant stressors with severe anxiety or panic attacks while others may get a bad cold or a fever, or just feel nervous and fatigued. The explanation may lie in genetic make-up and vulnerability to developing an anxiety condition and/or in the way you were brought up by your parents. If a child predisposed to anxiety has an anxious or an ill parent, they may be led to believe that the world is unsafe and frightening. If the parent is overly critical or abusive the child may become increasingly anxious over time. Or if a parent is overbearing and a child does not learn that he/she is competent to care for themselves. Children raised in these environments may not be able to tolerate a significant life event or stressor when it inevitably occurs. The anxiety has already reached a point high enough to spill over when faced with one more frightful trigger, whether it be something mundane or something serious.