Anxious disclaimer: this video is longer than it probably ought to be. Future installments will be shorter.

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 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.

[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 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.

“I’ll never go on antidepressants. Once you start, how do you stop?” —a friend

A couple of weeks ago I paid my biannual visit to the Manhattan office of the woman who prescribes me my medication. For many years I have been on two classes of medication: a selective serotonin re-uptake inhibitor (first Effexor, now Lexapro), and a benzodiazepine, typically Ativan, which I take only at times of acute distress. The woman who prescribes my medication is a psychiatric nurse. She does not provide therapeutic services and she does not have a medical degree. From what I have gathered, she spent much of her career working on an impatient psychiatric ward. She charges $140 an hour, which, given the relief she provides, is a very reasonable expense. For years she was a heavy smoker; the habit has done lovely things to her voice.

Like a lot of anxious people, particularly, I suspect, those of the bookish, cerebral type, I have an actively conflicted relationship with my medications (or, I should probably say, with the fact of my being medicated). On the one hand, as I say, the pills provide relief — although in this claim, I see, already lies the seed of the conflict, for I can not be certain that the pills provide relief. The Ativan is exempt from the dilemma: it has a quick and discernible sedative effect. A benzodiazepine, the best known brands of which are Ativan and Xanax, acts like a martini, but without the inebriation. The problem pill is the SSRI, the efficacy of which can be very hard to gauge. How can you be sure it’s working? Anxiety, like all psychiatric complaints, is subjective. Despite the best efforts of the clinical establishment, the only extant measures of anxiety are purely linguistic: answers to the old eye-roller, “How are you feeling?” There is no blood test, no objective factor like blood sugar or cancer markers. There is only the blooming, buzzing, oceanic flux of experience: description.

At first, if my experience is any guide, the matter of medication efficacy isn’t terribly fraught. When an anxious person first goes on an SSRI, she typically does so because she is in crisis, and the medication either works or it doesn’t. Let six weeks pass. Is there still a crisis? Then the medication isn’t working. Has the crisis abated? Then the medication is working. There remains some doubt clouding the picture, because usually the patient is simultaneously in talk therapy, which could conceivably be the dominant clinical factor. But we are talking here of crises — pronounced and atrocious spikes in mood. Therapy works more slowly than pills. A person can simply tell.

As time goes on, however, and the spike does not recur, and one keeps ingesting the pills and, with a dutiful self-preservation, keeps talking to one’s shrink and making responsible adjustments in one’s habits — in diet, in exercise, in romance, in work —a more serious and insidious confusion creeps in. Changes have been made, real changes. The anxiety is there — it will always be there; you admit this to yourself — but it is now, as the clinicians say, “manageable.” To what do you one owe this protracted, if incomplete, relief: medication or will? Once you needed the pills — urgently you needed the pills. But do you still need the pills? How can you be sure they’re even still working? If the pills were discontinued would the panic come raging and roaring back? Or would life continue along as it is now? Doesn’t it make sense — wouldn’t it make perfect sense — to wean yourself from the medication, to see if it is no longer essential to your continued contented existence?

It does make sense. This is how the medication was sold to you, after all — as a temporary measure, something to get you over the hump. It is troubling, then when you resolve to thank this natural step and you are assailed, quickly, by two vexing and countervailing questions. The first question regards timing. Wisely, you want to be sure that you are not going off your medication during a period of transition or flux in your life. You do not want to be reckless. And yet you know well (because like many anxious people you have looked into Buddhism and absorbed its precepts) that life is nothing but transition and flux — transition and flux to which, you also know well, you are prone by virtue of your anxious temperament to respond with painfully exquisite sensitivity. Now is not the right time. This is the boldness-killing thought. Just now I have an assignment to finish. Just now my child is entering school. Just not my wife and I are quarreling. Just now we are about to move. Just now. Just now I want to be sure of my sanity.

The second question to enter your mind is: Why bother? For me, at least, SSRIs have never caused a significant side effect. I don’t experience constipation, diarrhea, dizziness, drowsiness, dry mouth, headaches, light-headedness, loss of appetite, or nausea. I can still easily summon an erection and I can still reach orgasm. The only annoyance is the very mild one of being handcuffed to the pills themselves: it’s one more thing to before bed, along with brushing my teeth and removing my contact lenses; it’s one more item to remember to pack in my carry-on luggage. There is still, it’s true, the nagging stigma of being among the medicated — but at a time when twenty percent of Americans are on some kind of psychiatric drug, whatever shame one feels is very arguably self-imposed and anachronistic. You’re on a pill. So what? What’s the big deal? May as well continue along as before…..

And so it is that every six months or so I take the subway to the West Side, ascend to the seventh floor of a tall, beige-stone building, and sit thumbing through a Vanity Fair with a check in my pocket, waiting for a fresh prescription. It has been — I don’t know exactly how long it has been. Six years? Eight? Ten? A long time. Periodically I ask the woman who prescribes me my pills how I might go about getting off them. I defer to her expertise — nervously, I defer. Is it a good idea? Is now a good time? She is a person who prescribes medication for a living. She is, in other words, a true believer. But she is ethical and understanding as well, and she tells me that “we” can try. Here is how we might go about it. Here is a schedule, a method, whereby we can lower the dosage — slowly, slowly, until the pills are no more.

I carefully write these instructions down. I always write these instructions down. But I have yet to use them, or even to start the process.

Starting is, of course, the vital step.