Your Anxiety Toolkit - Practical Skills for Anxiety, Panic & Depression

Welcome back, everybody. Today, we are going to have a discussion, and yes, I understand that I am here recording on my own in my room by myself, so it's not really a discussion. But I wanted to give you an inside look into a discussion I had, and include you hopefully, on Instagram about a post I made about being busy. Now, let me tell you a little bit of the backstory here. What we're really looking at here is, is being busy a compulsion or an effective behavior? Here's the backstory. I am an anxious person. Nice to meet you. Everybody knows it, I'm an anxious person. That's what my natural default is. I have all the tools and practice using all the tools and continue to work on this as a process in my life. Not an end goal, but just a process that I'm always on, and I do feel like I handle it really, really well. In the grand scheme of things, of course, everyone makes mistakes and recovery is an up-and-down climb. We all know that. But one thing I have found over and over and over and over again is my inclination to rely on busyness to manage my anxiety. The reason I tell you this over and over is it's a default to me. When I'm struggling with anything, I tend to busy myself. Even when I had the beginning of an eating disorder, that quickly became a compulsive exercise activity because trying to manage my eating disorder created a lot of anxiety, and one way I could avoid that anxiety and check the eating disorder box was to exercise, move my body. Even though I fully recovered from that, and even though I consider myself to be doing really well mentally overall, I still catch myself relying on work and busyness as a compulsion, as a safety behavior to reduce or remove or avoid my anxiety. I made a post on this and it had overwhelming positive responses. Meaning, I agree, there was a lot of like, "Oh, I feel called out or hashtag truth." A lot of people were resonating with this idea that being busy can be a very sneaky compulsion that we do to run away from fear or uncertainty or discomfort or sadness and so forth. But then some of my followers, my wonderful followers came in hot—when I say "hot," like really well—with this beautiful perspective on this topic and I really feel like it was valid and important for us to discuss here today. Let's talk about that, because I love a good discussion and I love seeing it from both sides. I love getting into the nitty gritty and determining what is what. Let's talk about me just because it's easy for me to use an example. Let's say I have a thought or a feeling of anxiety. Something is bothering me. I'm having anticipatory anxiety or uncertainty about something. My brain wants to solve it, but because I have all these mindfulness tools and CBT tools, I know there's no point in me trying to solve it. I know there's no point in me ruminating on it. I'm not going to change it or figure it out. I have that awareness, so I go, "Okay, now I'm going to get back to life," which is a really wonderful tool. But what I find that I do is I don't just get back to life. I, with a sense of urgency, will start typing, cleaning, folding laundry, whatever it is, even reading. I will notice this shift in me to do it fast, to do it urgently, to try and get the discomfort to be masked, to be reduced. And then, of course, I want to share with you, what I then do is when I catch that is I go, "Okay." I feel the rev inside me and then I ease up on it. I pump the brakes and I try to return back to that activity without that urgency, without that resistance to the anxiety, or without that hustle mentality. But it is a default that I go to that often I don't catch until later on down the track. It's usually until I start to feel a little dizzy, I feel a little lost, a little bit overwhelmed. And then I'm like, "Oh, okay, I'm overusing busyness to manage my anxiety." The perspective that I loved was people saying, and one in particular said, "I want us to be really careful around that message because I think that some people can hear this idea that being busy is a compulsion and then start to question their own normal busyness throughout the day." I'll use the exact terms because I thought it was so beautifully said. They said, "You have to be pretty careful with how you explain this to some people with OCD because we're told to lean into our values or live a 'value-based' life, and that does require us to be busy," and I wholeheartedly agree. I think that's where I'm coming from. I want to offer to you guys that I want you to just check in and see if you're using busyness, this urgent, rushing movement, or frantic experience in your body to avoid discomfort. And if so, that's good to know. Let's not judge that. Let's not beat you up. Let's not be unkind. Let's just acknowledge that that is a normal response to having anxiety. In fact, it's a big part of what's kept us alive for all these years. That's true. And we can return back. Once we catch that we're doing those behaviors, we can return back to staying effective in our skills. But I don't want you guys to worry that you are overusing busyness. I think that the discussion I had online was to say, isn't this a wonderful opportunity for us to see how anxiety or OCD or any anxiety disorder can make a really healthy behavior into a compulsive behavior? You might flip between the two, it mightn't be all or nothing. An example of that might be prayer. Prayer is a beautiful practice for those who are spiritual. However, we can sometimes overuse prayer in a compulsive manner in this urgent, frantic, trying to get anxiety to go away manner, and then it's being misused. There may be sometimes you use prayer in this beautiful non-compulsive way and there'll be other times when you're absolutely using it as a safety behavior. Same goes for cleaning, same goes for thinking through your problems. There will be times when thinking through problems and solutions is a very effective behavior. However, there will be other times if you're doing it with a sense of urgency to make the discomfort go away or you're doing it to try and figure out something that you know you won't figure out because there's really no solution to it—that's something for us to keep an eye out for. There are so many ways in which this can get blurred. Asking for help and reassurance. It's not a problem to go to your loved ones and say, "I have this really huge presentation at work, would you let me rehearse it to you and you can give me feedback?" That's an effective behavior. However, if we are doing that repetitively and we are doing it coming from this desperate place of urgency to get certainty and removal of discomfort, that's how we may determine whether the behavior is a safety behavior that we want to start to reduce. I want to just offer this to you. If we're being honest, this episode isn't really about just the busyness. It's being able to, again, for yourself, determine are the behaviors you're doing being done because they line up with your values? Are they being done with a degree of willingness to also bring anxiety with you? I think that's a huge piece of the work that I have to catch, which is, okay, I'm rushing, I'm hustling, I'm engaging in busyness just for the sake of trying to get rid of that discomfort. Can I pause and return back to that behavior? Because it might be a behavior or an activity I need to get done. But can I do it with an increased sense of willingness to bring anxiety along for the ride? Can I do it with a sense where I'm not trying to train my brain that anxiety is bad? Can I just say, "Yeah, it's cool. Anxiety is here, let's bring it along"? I want to, again, reinforce to you guys, it's okay that you haven't figured this out because it's probably ever-changing. There will be times when you are engaging in compulsive busyness and there'll be other many times in which you're not. What I would encourage you to do is not to spend too much time trying to figure out which is which, because that can become a compulsion as well. A lot of this is just accepting that nothing is perfect and just moving one step at a time moving forward as you can kindly and compassionately. The only other thing I want to address here is this idea of a good distraction and a bad distraction. I think that this has been an argument or a complex discussion in the anxiety field for a long time. When I first was trained as an anxiety specialist, there were all these articles that talked about bad distraction, that distraction is bad and we shouldn't do it, and we should just have our anxiety and let it be there and then focus on it and so forth. I actually don't agree with that. In fact, I would go as far as to say, a real mindful practice would be taking the judgment out of destruction in general and saying that distraction is neither good nor bad. What distraction is, is up to you to decide whether it's helping you and is helpful behavior that brings you closer to your recovery goals or not. I don't want you to spend too much time trying to figure it out either, again, because I think it gets us caught in this mental loop of, am I doing recovery right? Am I doing my treatment right? Am I using the skills perfectly? I think when we get to that point, we're too far in the weeds and we have to pause and let it be imperfect and let it be uncertain and do our best not to try and solve that one, because often how would we know? There isn't actually an answer to what's bad and what's good. I wouldn't encourage you to place good and bad labels on those kinds of things because that usually will just keep you in a loop of anxiety anyway. That's just a few ideas on this idea of being overly busy being a compulsion. I really want to make sure I say one more time. I think there is absolutely an opportunity for us to consider that busyness is also neither good nor bad. It just is, and that you for yourself can determine whether it's helpful for you to stay busy or not. What I will say—and I will use this as an example, I think I actually did a podcast episode on this—not long ago, my parents were voyaging across the Drake Passage, which is a very dangerous body of water that takes you from South America to Antarctica. It's usually very, very calm or it can be incredibly dangerous to pass the Drake Passage. For the 18 hours that they were passing that, I engaged in a lot of busyness. I would say it wasn't compulsive either. It was, I knew they were doing something scary. I knew that it would be probably fine, but it was still uncertain. I knew that there was nothing I would do to make my anxiety go down during that 18 hours. I knew I probably wouldn't get a good sleep because I love them dearly and I want them to have a safe trip. I just said to myself, "I'm going to mindfully go from one activity to another. Because I don't want to engage in a bunch of mental rumination, I'm just going to gently stay busy." I think that's fine. I think that that is effective. In fact, I was very proud of how I handled that. I was able to resist the urge to text them at two in the morning and be like, "Take a photo of the waves. I want to see that you're okay." You know what I mean? I want to just offer to you that to check in whether your busyness is compulsive, be gentle with yourself either way to discuss with your mental health provider on what is a great way for you to engage in this kind of behaviors and for you to come up with your own protocol on how to determine when you've crossed over from being busy into compulsive busyness. That's it. I think that from there, you can be gentle with yourself and practice being uncertain about what's right and wrong. I hope that was helpful. I'm very much just chatting to you. I didn't do a whole ton of prep for this. I just wanted to include you in the conversation on "Is being overly busy a compulsion?" I wanted to give you some ideas and things to look out for and I hope that it helps you move forward towards the recovery that you're looking for. Have a wonderful, wonderful day. If you guys want additional resources from me, you can head over to CBTSchool.com. We have all kinds of online options there for you. If you're looking for one-on-one therapy, if you live in the state of California or Arizona, you can go to www.kimberleyquinlan-lmft.com and I look forward to chatting with you next week.

Hello and welcome back, everybody. We have an amazing guest today. This is actually somebody I have followed, sort of half known for a long time through a very, very close friend, Shala Nicely, who's been on the show quite a few times, and she connected me with Dr. Ashley Smith. Today, we are talking about happiness and what makes a "good life" regardless of anxiety or of challenges you may be going through. Dr. Ashley Smith is a Licensed Clinical Psychologist. She's the co-founder of Peak Mind, which is The Center for Psychological Strength. She's a speaker, author, and entrepreneur. She has her own TED Talk, which I think really shows how epic and skilled she is. Today, we talk about how to be happy. What is happiness? How do you get there? Is it even attainable? What is the definition of happiness? Do we actually want it or is it the goal or is it not the goal? I think that this is an episode I needed to hear so much. In fact, since hearing this episode as we recorded it, I basically changed quite a few things. I will be honest with you, I didn't actually change things related to me, but I changed things in relation to how I parented my children. I realized midway through this episode that I was pushing them into the hamster wheel of life. Ashley really helped me to acknowledge and understand that it's not about success, it's not about winning things, it's not about achievement so much, while they are very important. She talks about these specific things that science and research have shown to actually improve happiness. I'm going to leave it at that. I'm going to go right over to the show. Thank you, Dr. Ashley Smith, for coming on. For those who want to know more about her, click the links in the show notes, and I cannot wait to listen back to this with you all. Have a great day, everybody. Kimberley: Welcome, Dr. Ashley Smith. I'm so happy to have you here. Dr. Ashley: I am excited to be here today. I've wanted to be on your podcast for years, so thank you for this. Kimberley: Same. Actually, we have joint friends and it's so good when you meet people through people that you trust. I have actually followed you for a very long time. I'm very excited to have you on, particularly talking about what we're talking about. It's a topic we probably should visit more regularly here on the show. We had discussed the idea of happiness and what makes a good life. Can you give me a brief understanding of what that means or what your idea about that is? Dr. Ashley: Yeah. Oh, this is a topic that I love to talk about. When I think about it, I have a little bit of a soapbox, which is that I think our approach to mental health is broken. I say that as someone who is a mental health practitioner, and I really love my job and I love working with people and helping. But what I mean by that is our traditional approach has been, "Let's reduce symptoms. Let's correct the stuff that's 'wrong' with someone." When it comes to anxiety or depression, it's how do we reduce that? And that's great. Those are really important skills, but we've got this whole other side that I think we need to be focusing on. And that is the question of how do we get more of the good stuff. More happiness, more well-being. How do we create lives that are worth living? That's not the same as how do we get rid or reduce anxiety and depression. In the field of psychology, there's this branch of it called Positive Psychology. I stumbled on that 20 years ago as a grad student and thought, "This is amazing. People are actually studying happiness. There's a science to this." I looked at happiness and optimism and social anxiety and depression and how those were all connected. Fast forward, 15 years or so, I really hit a point with my professional life and my personal life where I was recognizing, "Wait a minute, I need more. I need more as an individual. The clients I work with need more. How do we get more of this good stuff?" This is the longest preamble to say, I did a deep dive into the science of happiness and learned a lot over the years, and I want to be really clear about a couple of things. When we talk about happiness, a lot of people think pleasure. "I want good experiences, I want to enjoy this." That's a part of it, this positive emotion that we all call happiness or joy. But that's only a piece of it. There's actually this whole backfiring process that can happen when we chase that. If I'm just chasing the next pleasant event, what that actually does is set me up to not have a happy life. Think about it. I mean, I love chocolate, and if I eat that unchecked because it brings me pleasure, at some point, it's going to take a toll on my health. What does that actually do to my well-being and happiness? What was really interesting getting into this area was, it's not just this transient state of pleasure or enjoyment, but they're the other factors that contribute to a good life. It's things like relationships. It's things like meaning and purpose. It's engagement. It's achievement even. It's these things that are not always pleasant in the moment, but that really contribute to this sense of satisfaction with life or contentment with life. I think it's really important that we need to be looking at what are the ingredients that really make a good life. WHAT IS CONSIDERED A GOOD LIFE? Kimberley: I love this, and I love a good recipe too. I like following recipes and ingredients. It's funny, I'm actually in the process of getting good at cooking and I'm realizing for the first time in my life that following instructions and ingredients is actually a really important thing, because I'm not that person. First of all, what is a good life? When I looked at that, I actually put it in quote marks. What is a good life? What do you think? You explained it; it's not chasing pleasure. We know that doesn't work, otherwise, you just buy a bunch of stuff you don't want and behave in ways that aren't helpful. Not to also villainize pleasure, it's a great thing, but what would you describe as a good life? Dr. Ashley: On the one hand, it's the million-dollar question. Philosophers and scientists and religious leaders and all kinds of people have been trying to answer that question for eons. I don't know that I have it nailed down. I think I'm humble enough to say I have my own ideas about it. To me, what makes a good life, it's really when the way we spend our time lines up with what's important to us, when we're living in accordance with our values to use some psych buzzwords, but when we're doing the things that really matter. I think also part of a good life is having daily rhythms and lifestyle habits that support us as biological creatures. I want to contrast that with the demands of modern life, which are that we should be productive 24/7, that we should be multitasking. People sacrifice sleep and movement and leisure time and stillness. I think all of that compromises us. It impacts us on a neurological level. Our brains are part of our system. If we're not taking care of our system, they're not going to function optimally. That gets in the way of a good life. When we're sacrificing relationships, when I look at all of the research, when I look at my own experience, a huge component of a good life is having quality relationships. Not quantity, quality. Trusting ones that are full of belonging and acceptance that are two-way support streets, those are really important. I think a lot of times, modern life compromises that. We get pulled in all of these other directions. Kimberley: Yeah. Oh my gosh, there's so many things. I also think that anxiety and depression pull us away from those things too. You are anxious or you're depressed and so, therefore, you don't go to the party or the family event or the church service. That's an interesting idea. I love this. Tell us about this idea of meaning. How do we find meaning? I'll just share with you a little bit of my own personal experience. I remember when I was actually going through a very difficult time with my chronic illness and I know I was depressed at the time. It was the first time in my life where I started to have thoughts like, "What's the point?" Not that I was saying I was suicidal, but I was more like, "I just don't understand why am I doing all this." I think that that's common. What are your thoughts on this idea of the meaning behind in life? Dr. Ashley: That's a fantastic question. I have a vision impairment, so I'm legally blind. It's a really rare thing and it's unpredictable. I don't know how much sight I will lose. Ultimately, the doctors can't tell me there's no treatment options. It's just I go along and every so often, there's a shift and I see less. For me, I hit that same point you were talking about back in 2014 when I had to stop driving. I was anxious and I would say depressed and really wallowing in this, "What does this mean for my life? I can't be independent. People aren't going to associate with me personally or professionally when they see this flaw." It was a dark point. For me, that's when I went back to the science of happiness when I finally got tired of being stuck and I realized my anxiety skills and my depression skills. They're helpful and I practice what I preach, but it wasn't enough. And that's really what propelled me back into this science of happiness where I figured, you know what, someone has to have done this. I did come across this theory of well-being called the PERMA factors. These are like the ingredients that we need. I'm getting back to that because the M in this is meaning. With this, the PERMA factors, P is positive emotion. That's the pleasure, the joy, the happiness. Cool. I know some strategies for boosting that. E is engagement. Are you really involved and engaged in what you're doing? Are you present? Are you hitting that state of flow? R is the relationships, A (skipping ahead) is achievement, but M is this meaning, and it's a hard one to figure out. I remember then, this started what I was calling my blind quest for happiness where I started to think about, what do I need to do? How do I experiment? How do I live a happy life despite these cards I've been dealt? We don't get to choose them. You've got a chronic illness, I have a vision impairment, listeners have anxiety and depression, and we get these cards. I think of it like if life is a poker game, we don't get to choose the cards we're dealt, but by golly, we get to choose how to play them, and that's important. I think a lot of times people can turn adversity into meaning. For me, I'm now at a point where it's not that I don't care about my vision, it's just I really accepted it. It is what it is, it's going to do what it's going to do, and I'm focusing on the things I can control. That has given me a sense of meaning. I want to help other people live better lives. I want to help other people crack the code of how our brains work against us and how do we play our cards well. If we go to all of this, "meaning" is really just finding something that's bigger than you are, finding something to pursue or contribute to that's bigger than you. I think when we look at anxiety and depression, the nature of those experiences is that they make us very self-involved. I mean, people with anxiety and depression, in my experience, have giant hearts, tons of empathy, but it locks our thinking into our experience and what's going on in these unhelpful thoughts. When we can connect with something bigger than us, it gets us outside of that. If I go back to grad school, writing my dissertation was decidedly not a fun experience. Would I do it again? Yes. Because it was worth it on this path to my reason for being—helping people live better lives. Sometimes I think when we have this meaning, this purpose, this greater good, it helps us endure the things that I want to say suck. Kimberley: You can say suck. Dr. Ashley: Yeah. That's where it's not just about how do I get rid of anxiety or depression. Sometimes we can't. Chronic health conditions, anxiety is chronic. My vision is chronic. I'm not getting rid of this, but how do I live a good life despite that? I think there are a ton of examples throughout history and currently of people doing amazing things despite some hardship. Kimberley: Yeah. I love this idea. It's funny, you talk about being outside yourself. When I'm having a bad day, I usually go, there's like a 10 minutes' drive from us that looks over Los Angeles. If let's say I'm having a day where I'm in my head only looking at my problems, and then I see LA, I'm like, "Oh honey, there is a whole world out there that you haven't thought about." I'm not saying that in a critical way, just like it gives me perspective. Dr. Ashley: I think that's so important, to realize there's so much more. When it does shrink our problems, all of a sudden, it's manageable. Kimberley: Right. Let's talk about just one more question about meaning. I'm guessing more about people finding what's your why and so forth. What would you encourage for people who are very unhappy, have been chasing this idea of reducing anxiety, reducing depression, chasing pleasure, and feeling very stuck between those? Let's say I really have no idea what my meaning is. What would be your advice to start that process? Dr. Ashley: Experimentation. I think experimenting is a lifestyle that I wish everyone would adopt, because what happens is we want to think. We are thinkers. That's what our minds were designed to do. That's awesome and sometimes it's really helpful, but I don't think we're going to think our way into passion or meaning or a good life. I think we have to start trying things. What will happen, if you notice, is your mind is going to have a lot of commentary. It's going to say, "That's dumb. That's not going to work. Who are you to try that? You can't do that." It's all just noise that if we look at what is it doing, it's keeping you stuck. With the experimentation, I'm just a big fan of go try it. Whether you think it's going to work or not, you don't know. We want to trust our experience, not what our mind tells us. Trust your actual experience. For me, I remember getting my first self-help book. It was actually called Go Find Your Passion and Purpose. Because I was at this crossroads, I had been doing anxiety work for a long time, had plateaued, and was feeling a little bored, and that coincided with the stopping driving. My whole personal world was just in disarray and I was like, "I'm going to go hike part of the Appalachian Trail while I can. While I do that, I'm going to find my purpose in life." I did not find it, but it was an experiment. I go and I get this experience and I can say, "Okay, I'm not going to be someone who does a six-month hike. I made it four days. Awesome." But go and experiment with things. I never thought that I would really want to write and I started a blog, and that has turned out to be such a positive experience. Prior to that, my writing experience had been very academic where it was a chore. Now, this is something I really enjoy, or talking to people. I would say experiment and continue to seek out those new experiences. One, seeking out new experiences helps on the anxiety side because you're continually putting yourself into uncertain and new, so your confidence level is going to grow, your tolerance for not knowing grows, and your tolerance for awkward grows. That's my plug for go try new things, period. Somewhere along the way, you're going to find something that sparks an interest or that sparks this sense of, "Yeah, this is me." Notice that. I know you talk a lot about mindfulness, we need to notice what was my actual experience, not what did my head tell me. What did I actually feel? And keep experimenting until you find something. I think that's really the key. Kimberley: I love that you said your tolerance for awkwardness. I think that is a big piece of the work because it is a big piece. We talk about tolerating discomfort, tolerating uncertainty, but I think that's a very key point, especially when it comes to relationships, which I know is one of the factors. Tolerate the awkwardness is key. Dr. Ashley: Yeah. I think it's huge. I've been seeking out new experiences since 2017. This is going to be my New Year's resolution. It was such a transformational experience over the course of the year that I've just continued it, and I'm trying to get everybody to join me because it's such an expansive practice. I think it's great for anxiety and depression, it's great for humans, it's been great for me on this quest for a good life. But with this, it means I have put myself into some awkward situations on purpose. Sometimes I know going into it, sometimes I don't. I went to this one, it was called Nia. I practice yoga. That's cool. That's very much in my comfort zone. This was yoga adjacent, but it was also an interpretive dance with sound effects. You had to make eye contact with people and dance in these weird ways. I distinctly remember having this conversation with myself when I showed up, "What did you just get yourself into?" And then it was immediately, "Okay, you have two choices here. You can grit your teeth and hate the next hour, or you can embrace the awkward and dance at a three. Because she said, you can dance at a one, itty bitty, at a two or at a three and really go for it." That for me was my, "All right, let's just do this." I embrace the awkward, and that was a turning point. That was amazing. And then now, when I think about good life, I feel like so many doors are opened because I'm not afraid of, "This is going to be awkward." It's going to be and you're going to be okay or it's going to make a hilarious story. I said, "Go for it." Kimberley: You're here to tell the story. I love it. You didn't die from awkwardness. Dr. Ashley: No. Kimberley: Can you tell me about the P? Can you go through them and just give us a little bit more information? Because I think that's really important. Dr. Ashley: Yeah. I love this theory because you can think about it as like, how are my PERMA factors doing? When you're low, raise them. You know that those are the ingredients for a good life. The P is positive emotion. That is, we do need to spend time in positive emotional states. The more time we're in the positive emotional states, the better compared to the negative ones like anxiety or sadness, or anger. Now that said, we know if we try to only pursue pleasure, it's going to backfire. If I'm trying to avoid anxiety, I'm actually going to get more anxiety. But this is where behavioral activation comes in. Do things that are theoretically enjoyable and see if it puts you in a positive state. Again, theoretically enjoyable, because if you're in the throes of depression, nothing feels enjoyable, do it anyways. And then notice, did it bring on a pleasurable emotional state? Cool. We want to do those things. E is engagement. This is when people talk about finding flow or being in the zone. These are the activities that you're fully engaged in it. Self-consciousness goes away. You lose track of time because you're just in it. We know that the more consistently we are able to put ourselves in states of flow, the higher our well-being tends to be. Athletes will talk about this a lot. When they're on the field, they're in the zone. Musicians, artists. But there are other ways to do this. This is a place for me personally, I didn't know. I was like, "Well, okay, great. I need E, I need engagement. What puts me in a state of flow?" It took experimentation and noticing. For me, writing does it. Web design, I'm not techy, but when I start to do design projects, I get in that state of flow. It has to be this perfect apex, this perfect joining of skill and pleasure, like enjoyment. If it's too easy, you will not go into a state of flow. That's just the P. If it's too hard, we go into a state of stress or anxiety, so that's not flow. We have to be right on the cusp of our skillset. It's hard work, but we're into it. That's the E. R is relationships. We need quality relationships where we are being open, where we are being vulnerable, we're really connecting with other people. That is huge. I mean, if we look at what's the best predictor of life satisfaction, it's quality relationships. This also is doing things for other people. Altruism, ugh, I love this side note. The act of kindness thing hits on three different factors. It feels good to do something good for other people. If you want a mood boost, go do an act of kindness. That reliably boosts our mood. It also improves relationships and it can tap into that meaning. I love that as just a practice. The M we talked about, that's meaning. And then the A, that's achievement for achievement's sake. As humans, it feels good to conquer goals. It feels good to accomplish things. And that contributes to our well-being independently of the positive feelings that we get from it, or the meaning in the relationships or the engagement. I'm also a really big fan of set goals and then crush them. It can be silly little things like, I'm going to hold my breath for two minutes. Okay, cool. That's a silly little thing, but then it feels good to do it. Or it could be something huge like crossing those bucket list things off your list. Kimberley: You know what's funny around achievement? I've got a couple of questions, but first I want to tell you your stories. Last year, I was struggling to do a couple of things that were really important to me for my medical health. I found an app called Streaks. Have you heard of Streaks? It's a $5 app. But when you do the action, and for me it was taking my medicine, it does this little spiral and then it's like, "You've done this for three days in a row." And then tomorrow you click it and then it says, "You've done it for four days in a row." You would think that the benefits of taking my medicine would be enough. But for me, it's actually knowing I get that little positive reinforcement of like, "Look at me, I've taken my medicine for 47 days in a row, or now are like 300 days in a row." I don't think I deserve a medal for being able to take my medicine. But for me, that little bit of reward center on the achievement was a huge shift for me. And then it became, how many days did you practice your Spanish in a row? Even like, how many days did you do your Kegels? I've got all of the streaks happening and it's really incredible how that little achievement piece does boost your mood. Dr. Ashley: Yeah. But what I love about this is you're also talking about how to hack the system. We're talking about our brains and this is the stuff that just lights me up, because oftentimes our minds will say, "Well, you should just take your medication. You should just do these things." Well, that's not how it works. There's a million reasons why we don't do the things we know we should do. But can we figure out how to hack the system? Yeah. Our brains love streaks. They love streaks. it taps our reward centers, like you're saying, and so let's use the tools that work. That got you if your goal is to take your medication consistently. Using our brain's glitchy wiring to our own advantage is something that's huge. That did it. And then it does feel good. And then you get some momentum going and then you create a habit around that and it's fantastic. Kimberley: Yeah. What about those who are overachieving to the point that it's bringing their happiness down? What would we do there? Dr. Ashley: Yeah. I think that's a great question and it's something that comes up a lot, especially when we look at anxiety and perfectionism. At least the way I think about it is coming back to what's driving this. Is this being driven by fear? Is this being driven by values? For me, I almost think of it as—I'm going to try to make sense with it—is it the -ing or the -ed? Meaning, the doING (I-N-G) or the -ed as in I did this past tense. What I mean by this is, I notice for me when I'm approaching something, say a big goal, like I want to write a book this year. If I can approach that from a place of, "I am doing this because this is important to me, I feel driven to get this message out into the world," the -ing, the process of doing it, that feels like it's going to boost my wellbeing when I start to get pulled into the thoughts of the outcome. I'm going to write this book and how many people are going to read it and is it going to sell? I'm really looking at all of this, and underneath that is fear. What if it doesn't sell? What if people judge it? What if they think it's stupid? Then I'm focusing on the outcome, kind of when it's done. That I think is actually going to detract from my well-being because it's not coming from a valued place; it's coming from this feared place. A lot of times with overachieving, we're chasing this other people's expectations or we're chasing this promise of happiness. When you do this, then you'll be happy. It's not going to work like that. It may be for a moment and then the bar just changes again. Now you've got another target. We have to come back to this, I think the process or the journey. Are you doing this because it matters to you, or are you doing this because some sort of fear is compelling you? Kimberley: Right. I'm just asking questions based on the questions I would've had when I was struggling the most. I remember hearing something that blew my mind and I actually want your honest opinion about it. I remember I used to chase happiness, like you talked about, even though I was doing all these things. I was doing all these things, but there was that anxious drive behind it. I remember hearing somebody saying life is 50/50. Even though you're doing all these things, you're still going to have 50% great and 50% hard. For me, that was actually very relieving. I think I was caught in and I think a lot of people experienced this like, "Okay, I'm at 50%, how can I get to 55? How can I get to 56?" What are your thoughts on also accepting that you won't be happy all the time, or what are your thoughts on balancing this goal for happiness or this lifelong playfulness around happiness? Dr. Ashley: I agree with you completely. I think we have this cultural myth that we should be happy all the time. If you're not happy, there must be something wrong. You're doing something wrong. It sets up even this idea that being happy all the time is possible. It isn't. If we look at, again, happiness, what people mean by that is a pleasurable or enjoyable state, an emotion that we like. Humans are wired. Two-thirds of our emotions would be under that negative category. Just by the way we're wired, we're more likely to have negative emotions, and they're just messengers. They're just designed to give us information about a situation. Some of them are going to be dangerous, so we're going to feel anxious. Or we're going to lose something we care about, so we're going to be sad. We're going to mess up, so we're going to feel guilty. It's unrealistic to expect to not have those emotions. I think that is a hundred percent something that we need to work on, just accepting happiness all the time is not possible and pursuing it is like playing a rigged game. The other thing, you know how on the anxiety side we talk about facing fears because then you habituate or you get used to them. But that habituation process happens on the pleasurable side too. This is why when we chase happiness, we end up on this hedonic treadmill where it's, "Oh, I'm going to go buy this thing. And then I'm going to feel really happy," and you are. And then you're going to habituate. Your body goes back to baseline so that happiness fades. If you're looking to an external source, you're going to get caught up in this always chasing something bigger and better, not sustainable. I like to look at happiness as the side effect of living a good life. Do the things that we know matter. Take care of your health and wellbeing. Sleep, eat well, move your body, practice mindfulness, the PERMA factors that we talked about, and live in line with your values. If you're doing those things, happiness is the side effect of that. Kimberley: To make that the goal, not happiness the goal. Dr. Ashley: Yeah. Kimberley: I think that's very, very true. Again, for me, it was a massive relief. I remember this weight falling off of like, "Oh," because I think social media makes it so easy to assume that everyone is just happy, happy, happy content, to feel all the things. It was delightful to be like, "Oh no, everyone's got a 50/50." Dr. Ashley: Exactly. When we know that's normal, then all of a sudden, you can accept it. Like, I'm anxious for now, I'm sad for now. To do that, it does keep us from piling on extra. I have this saying that I love, "Just because life gives you a cactus doesn't mean you have to sit on it." A lot of times, we sit on it because we're ruminating or I don't want to feel this way and we're fighting it. And that's just amplifying it and making it a lot harder. When we can say, "Oh, this is where I'm at today. I'm still going to choose to do the things that I know are good for me, that are part of me, living a good life by my standards or my terms," that's going to be the side effect, is I'm going to end up with more happiness down the road, but not chasing it in that moment. Kimberley: I love this. Thank you for coming on and talking about this. I think this has been enlightening and so joyful to have these conversations. I feel a little lighter, even myself, after chatting with you, so thank you. Tell me how people can hear from you, get in touch with you, learn about your work. Dr. Ashley: Yeah, absolutely. I have a blog that I publish every week, so if you're interested in that, you can subscribe at PeakMindPsychology.com/subscribe, o you can just check out all of the blog posts. That's probably the best way to follow me and follow my work. I also have a TEDx Talk that came out pretty recently and you can watch that as well. It's called Is Your Brain Deceiving You, and talk a little bit about learning to play my cards well. Kimberley: I love the TED Talk. Congratulations on that. It was so cool. Dr. Ashley: Thank you. Kimberley: Thank you again for coming on. This has been just delightful. Really it has. Dr. Ashley: I appreciate you having me.

Hello and welcome back, everybody. I'm so happy to be here with you. This is not the normal format in which we do Your Anxiety Toolkit podcast, but I wanted to really address a question that came up in ERP School about how to manage 10 out of 10 anxiety. For those of you who don't know, over at CBTSchool.com, we have a whole array of courses—courses for depression, generalized anxiety, panic, OCD, hair pulling, time management, mindfulness. We have a whole vault of courses. In fact, we have a new one coming out in just a couple of weeks, which is a meditation vault. It will have over 30 different meditations. The whole point of this is, often people say to me that the meditations that they listen to online can become very compulsive. It's things like, "Oh, just let go of your fear or make your fear go. Cleanse away and dissolve," and all the things. That's all good. It's just, it's hard for people with severe anxiety to conceptualize that. That whole vault will be coming out very, very soon. But this is actually a question directly from ERP School. Under each video of all the courses, there is always a place you can ask questions, and I do my best to respond to them as soon as I can. But I did say to this student, I will actually do an entire podcast on your question because I think it's so important. Here is what they said: "Hi Kimberley, I love all the information you give us. I get so much more out of this than I do with a therapy session for one hour once a week. That being said, I'm feeling a little bit overwhelmed. There is just so much information and so many tools." Yes guys, I admit to that. I do tend to heavy-dose all of my courses with all the science. I can bring in as many tools as I can with the point being that I want you to feel like you have a tool belt of tools, in which you can then choose which one you want to use, so I totally get what they're saying here. They said: "When I'm at a 10 out of 10, I'm hardly able to function and it all seems to go out the window. It either seems that noticing works as I run through my list of tools or I can't even think straight enough to check in with myself or even think about the tools I could use. So, where do I even start in those terrible moments?" This is a really good question, and I think every single one of my clients in my history of being a therapist has asked this question. I know I have asked this question to my therapist because even as a therapist who has all the tools in those moments, it can feel overwhelming. What I did here is I pulled all of my followers on Instagram and asked them to give me their tools that they find helpful, and then I'm going to weigh in myself, and then I'm going to encourage you to just practice any of them. Now, often what happens—and this is the case for what obviously someone's bought a course from me—is when you have all of these options, we fall into the trap of thinking there is a "right" tool to use, and I want to reframe that. In addition, there's another myth that that one tool will make all your discomfort go away or that will be the tool of all tools for recovery. I want to really normalize that there is no one tool. The whole reason that I do Your Anxiety Toolkit is to remind you that you're going to have to practice multiple different things, you can't put all your eggs in one basket, and it's okay if it's not a 10 out of 10 win. Meaning, it's okay if it's not perfect. Often I'll say to clients, use the tools, even if it's 50% effective. That's still 50% effective more than what it would be in the past, which might be 0% effective or 1% effective. We take any wins we can take and we use it not as a fact that you're a failure if it didn't work, but more as just data on what to use for the next time. At the end of the day, the goals are: Did it give me a 1 or 2% improvement on how I handled it the last time? 1 or 2%, folks. That's all I'm goaling for here. Was I kind as I practiced it? And, did it move me towards the five-year you, or the three-year you, or the one-month you? The you who's in one month, does it move you towards that person that you're trying to be? I often will think about me through the terms of, what would the five-year me do in this situation? What would the three-year me do? What would the three-month me do? It might be different, and then I just pick one. Knowing it's probably not perfect, but that's okay. I have polled a whole bunch of people on Instagram because I honestly feel like folks who were in the thick of it actually are better at giving tools than even I am as a trained clinician who's been through it. Of all of the different responses we got, I've actually broken it down into two separate sections per se. We've got mindset shifts and tools and actions. Again, these may actually feel again like, "Oh my gosh, now I have even more tools," which is not a bad problem. TAKE ONE MOMENT AT A TIME But I want you in the moment that you're at a 10 out of 10 to just pick one and be curious about it. I'm going to say here that the one I loved the most—I'm going to just actually give you one of the tools and actions first—is somebody (multiple people wrote this, in fact) said, just take one moment at a time. I have to say at a 10 out of 10 anxiety, that has been the most helpful for myself and for my clients. That when you slow down and you make it really simple, that's actually the best way to respond. We have these bigger concepts like ERP and habit reversal training and mindfulness and all these big concepts. What's the saying? The rubber hits the road or something like that. When it gets really hard, simplify things, go back to basics, slow down, and just go, "Okay, all I have to do is get through this minute. What can I do in this one minute?" Slow it down. That's one of the tools and actions. BE AN OBSERVER The second tool and action is somebody says, "I notice my five senses," which is a more tactical skill of being present (be an observer) and in the moment, which is your mindfulness skill. For them it might be: What do you see? What do you smell, what do you taste? Some people play games with this. A lot of my clients have said, "When I'm at a 10 out of 10 and I've just faced my biggest fear, or I've been triggered, I find six different colors." You're not doing that to suppress your thoughts or make the fear go away. You're doing it because that's response prevention. You're not engaging in catastrophization and mental rumination. Instead, you're just being an observer of what's in your present moment. BREATHE A lot of you folks said, "Breathe, that the only thing I do is breathe." Again, I love this because it's simple. Now, does that mean we have to breathe a certain way? A lot of people said three breath-in and four counts out, or box breathing. It doesn't matter. Please don't put pressure on yourself. For me, I just really put attention on my breath in and my breath out. I say to myself, "I'm breathing in knowing that I'm breathing in and I breathe out knowing I'm breathing out." Very, very simple. DO NOTHING! ACCEPT IT IS HERE A next person said, "It feels awful, but I do nothing more than just talk to it, accept that it's here, and breathe." Again. These are really simple things. What I'm going to encourage you guys to do is just pick one of these things and play with it for a day or a couple of days, whatever it feels good. And then check in and be like, "How did that work? Was that successful at helping me stay present and reduce behaviors that actually create more problems?" FEEL YOUR FEET ON THE FLOOR Someone says, "I just feel my feet on the floor." Again, these are so basic, but almost everybody's response wasn't like, "I practice these very complex skills." They're just talking about simple, really basic things. "I put my feet on the floor." USE TEMPERATURE Someone says, "I splash cold water on my face." Again, simple. They're just bringing their attention to sensations in the present. CONNECT WITH YOUR SPIRITUALITY Someone said, "I pray." I love that some of you bring your religion into it or your faith. "I pray and I be quiet." Some of you might call that a form of meditation. FEEL YOUR EMOTIONS & CRY This one I really love. Someone said, "I cry. I embrace crying. It's such a good emotional release." This one's really hard for me, you guys. I'm a crier, but when I'm at a high level of anxiety, I feel like there are no tear ducts in my eyes, like I can't get myself to cry. But really when I do allow myself to cry, it is such a cathartic experience, especially if I do it kindly. EXERCISE Someone says they work out. I think that there's some interesting piece to that. Let me just bring a little nuance to that. When we work out, really what I think we're doing is we're putting our attention on something that is very strategic, like 15 bicep curls. Or you get on the treadmill, you listen to some music, and so forth. I love this tool. SOMETHING TO THINK ABOUT (IF YOU ARE PRONE TO EATING DISORDERS) One thing to think about, and the only reason I'm telling you this is just because I myself used to use working out as a skill and it was very helpful. But if you are someone who's prone to an eating disorder or compulsive exercise, just keep an eye out for that because, for me, my healthy practice of working out ended up becoming a compulsive eating disorder compulsion. Now, for most of you, that's probably not the case, but I think with any of these things, like any time we overdo it or we do it to make the fear go away or to avoid the fear, we can get ourselves a little bit into trouble there. So just keep an eye out for that. For me, when I heard that, I was like, "Oh gosh, no, I couldn't do that." But I think for most of you and many of you, that is a really effective tool. We do have research that exercise is a very, very helpful way of managing anxiety. I do still work out for that exact reason, but we have to be careful of becoming compulsive VALIDATE YOURSELF Now, of the last of the tools, P.S. It's actually mine. I did weigh in on the end. My tool and action that I would weigh in, in addition to all of these great ideas, is validate, validate, validate. One of the things I think we miss is when we're at a 10 out of 10, whether that be anxiety, sadness, depression, stress, panic, whatever it may be, we forget to validate ourself by going, "This is really hard." It makes complete sense that you can't think about what tools. You're at A 10 out of 10. It makes complete sense that this is something that is rocking your world. You could say, "Anybody in this position would struggle to find tools." Validate, validate, validate. That's a self-validation, guys. A self-validation. It might be simply as much as you saying, "It's okay that you're struggling, I got you," which moves me to the mindset shifts. There's only four of them, but I thought they were beautiful. The reason I separated them is sometimes when we are in the 10 out of 10, naturally, our brain will send us to get away from here, fight, flight, freeze, and fawn. How can we make the fear go away and get out of this "dangerous" situation? If you can, often you won't be able to. Again, there is some research that when you're at a 10 out of 10, it's very hard to actually have a mindset shift. But on the lower 6s, 7s, and 8s out of 10s, if you practice it, I think it gets a little easier. Here are some of the things that a lot of the folks did weigh in on and say. MINDSET SHIFTS TO CONSIDER Number one mindset shift is, "I remind myself that I don't have to solve the thoughts I'm having." Great mindset shift because in those moments, we're like, "What is the answer? What is the answer? We need to figure it out," and so forth. I love that. The second one is, "I remind myself that I'm resilient and strong." Total shift, away from, "I can't handle this, what do I do" to "I'm resilient and strong." For me—I'll weigh in here—I often say, "Everything is figureoutable. I'll figure this one out." That sentence has changed my life because it takes away the pressure of having to find solutions right now and says, "I'm in a process now. I'll figure it out. We'll get to the end of it. It might take some bounces and bumps." The third one is of course my all-time favorite, which is, "I can do hard things." Today is a beautiful day to do hard things. So good. It can remind you that this is a moment to lean into. I think this last one here is really important. someone weighed in and said, "I remind myself that being uncomfortable doesn't mean dangerous." This is gold, you guys. There are some ideas of the people who weighed in and the most common responses. Let me also say, to be honest, a lot of people wrote, "I totally can't handle it and I just fall apart." A lot of people were making jokes like, "I throw a tantrum on the floor." They were basically saying, "I haven't figured it out yet." I want to just really emphasize again the importance that it's okay if you don't have the 10 out of 10s figured out. We are not here to win all of the challenges. I have been thinking about this a lot lately and I'll actually use this as the final point. In our society and even in the community that I have built here, I have to also acknowledge that we can sometimes overdo the "Face your fears, use the tools, fix yourself, get better." That message can be very, very helpful but also sometimes a little overachieving, a little condescending, a little pressured. I want to just conclude here, if you are early in your recovery and you're working on the 4s, 5s, and 6s out of 10, you're doing enough. If you're in the middle of your recovery or you're accelerating in your recovery and you're doing the 7s, 8s, and 9s, it's okay that you don't yet have the skills to do the 10s. Don't focus too much on that. Just keep the expectations realistic. I don't want you to leave today thinking, "Okay, now I have to go do those tools and I have to handle 10 out of 10s well." That's a lot to ask. I don't handle the 10 out of 10s perfectly. Nobody does. I know so many anxiety specialists who also don't handle the 10 out of 10s perfectly. Let's not fantasize that or let's not make that a thing so that you are constantly feeling like you have to be doing this perfectly. Again, do what you can. Practice. This is trial and error. If it does work, great. If it doesn't work, well good to know. Let's just try again next time. It mightn't work next time, that's fine. Just good to know. We're not here to always win every battle, but the fact that you asked this question, the fact that your inquiring shows me how much you value your recovery and how much you want to overcome this problem. For that, I applaud you. I applaud everyone listening. I hope that today was helpful for you. Again, for those of you who are interested, go to CBTSchool.com. We have a whole vault of different courses you can take. We do have some new ones coming out here this year, which I'm super excited about. We've got courses for depression, all the things. You can go and listen to those. They are on demand. You have unlimited access. You can watch them as many times as you want. Take notes. Just listen, whatever you want to do, and I hope that you find them helpful. Have a wonderful day, everybody, and I will see you next week.

Welcome back, everyone. I am so happy to do the final episode of our Sexual Health and Anxiety Series. It has been so rewarding. Not only has it been so rewarding, I actually have learned more in these last five weeks than I have learned in a long time. I have found that this series has opened me up to really understanding the depth of the struggles that happen for people with anxiety and how it does impact our sexual health, our reproductive health, our overall well-being. I just have so much gratitude for everyone who came on as guests and for you guys, how amazing you've been at giving me feedback on what was helpful, how it was helpful, what you learn, and so forth. Today, we are talking about PMS and anxiety, and it is so hopeful to know that there are people out there who are specifically researching PMS and anxiety and depression, and really taking into consideration how it's impacting us, how it's affecting treatment, how it's changing treatment, how we need to consider it in regards to how we look at the whole person. Today, we have the amazing Crystal Edler Schiller on. She is a Psychologist, Assistant Professor, and Associate Director of Behavioral Health for the University of North Carolina Center for Women's Mood Disorders. She provides therapy for women who experience mood and anxiety symptoms across the lifespan. She talks about her specific research and expertise in reproductive-related mood disorders. She was literally the perfect person for the show, so I'm so excited. In today's episode, we talked about PMS, PMDD, the treatments for these two struggles. We also just talked about those who tend to have an increase in symptoms of their own anxiety disorder or mood disorder when at different stages of their menstrual cycle. I found this to be so interesting and I didn't realize there were so many treatment options. We talked about how we can implement them and how we may adjust that depending on where you are in terms of your own recovery already. I'm going to leave it there and get straight over to the show. Thank you again to Crystal Schiller for coming on, and I hope you guys enjoy it just as much as I did. Kimberley: Thank you so much for being here, Crystal. This is a delight. Can you just share quickly anything about you that you want to share and what you do? Crystal: Sure. I'm a clinical psychologist at UNC Chapel Hill. I'm an Associate Director of the UNC Center for Women's Mood Disorders, where we provide treatment to people with reproductive hormones across the lifespan—starting in adolescence, going through pregnancy, postpartum, and all the way up through the transition to menopause. We also do research. My research focuses on how hormones trigger depression and anxiety symptoms in women. I do that by administering hormones, so actually giving women hormones and looking at the impact on their brain using brain imaging and then also studying specific symptoms that they have with that treatment. We've given hormones that mimic pregnancy and postpartum, and we also use hormones to treat symptoms as women transition through menopause and look at, like I said, how that impacts how their brain is responding to certain kinds of things in the environment and also how they report that changes their mood. WHAT IS PMS? AND WHAT IS THE DIFFERENCE BETWEEN PMS AND PMDD? Kimberley: Wow. You couldn't be more perfect for this episode. You've just confirmed it right there. Thank you for being here. Before we get started, mostly we're talking about what we call PMS, but I know that's actually maybe not even a very good clinical term and so forth. Can you share with us what is PMS and What is the difference btween PMS and PMDD? Crystal: Yeah. PMS stands for premenstrual syndrome. It actually is a medical diagnosis and it includes a host or a range of physical symptoms as well as some mild psychological symptoms. It can be things like breast tenderness or swelling, bloating, cramps, menstrual pain, as well as some anxiety, low mood, mood fluctuations. But those tend to be mild in a PMS diagnosis. PMS is really common in the general population. Some studies estimate 30, 40, 50% of women experience these symptoms. Very, very common. On the other hand, premenstrual dysphoric disorder is a condition that is associated with more severe depression and anxiety symptoms. The mood symptoms are more at the forefront, although those physiologic symptoms like the breast tenderness, swelling, pain, cramps can certainly be a part of it. HOW CAN WOMEN DISTINGUISH BETWEEN NORMAL PREMENSTRUAL SYMPTOMS AND THOSE ASSOCIATED WITH PMS OR PMDD? Most women with PMDD do have those physical symptoms as well. Pain is a commonly reported symptom in folks with PMDD, but the mood fluctuations are more severe. People spend about half their menstrual cycle usually with pretty severe symptoms. And then once the period starts, those symptoms go away in PMDD. That's actually part of the criteria for the disorder that the symptoms have to what we call clear out or remit soon after menstrual bleeding starts. So, that's for the formal diagnosis of PMDD. But then all sorts of people with anxiety or depression have what we call a premenstrual exacerbation of symptoms, so it's also possible to have, let's say generalized anxiety disorder or panic disorder, OCD, and have those symptoms get worse during certain periods of the menstrual cycle. We wouldn't say that that person has PMDD; they just have a premenstrual worsening of symptoms. For some women, that occurs during that time, the week or two leading up to a period, but others have symptoms that are more around ovulation. Other women have symptoms that persist through the period. That's the interesting thing. But also, the really complicated thing about this space is that there's so many individual differences where some people have symptoms that sometimes, but not others. And then if you look at symptoms across the menstrual cycle and the next person, it may show a totally different pattern. But then over time, that pattern is maintained. It is clearly a pattern and a function of hormone change, but it can look different between different people. PMS SYMPTOMS VS PMDD SYMPTOMS? Kimberley: Why is it so different for different people? Do we understand that yet, or do we not have enough research? Crystal: We don't have enough research. This is a relatively new area that one of my colleagues, Dr. Tory Eisenlohr, has been working on at the University of Illinois at Chicago. What she has been finding is that there are different subgroups or subtypes of people with this premenstrual worsening where, like I said, some people have it right before their period; others more around ovulation. Some people seem to have worsening symptoms when their hormone levels are going up. Other people have worsening symptoms when their hormone levels are going down. Some people have worsening symptoms anytime there's a fluctuation or change. That's what we see in my research as well. When I start administering hormones in some women, they almost immediately start experiencing anxiety and irritability. And then as soon as I take the hormone away, they feel better. Whereas other women feel terrible until their hormones even out again, and I've stopped messing with them so much. It's really individualized and it probably has something to do with genetic predisposition as well as early environment. It's this combination of factors. DOES ANXIETY INCREASE DURING PMS? Kimberley: Right. I could be so off base here, and please just tell me if I am. While we know it's chemical, hormonal, biological, and genetic, is there also a small percentage of people who have these shifts from a cognitive component to where they've maybe had some depressive symptoms in the past, and so that when it comes on, they're anxious about the symptoms coming on? Does anxiety increase during PMS? Is it as cognitive as well, or are you more looking at just the physiological piece? Crystal: Both, for sure. First of all, you're not way off base. That's totally what I see in the clinic, that as folks have had these experiences with hormonal shifts and they had some anxiety or symptoms of depression during those times, it raises concern as they go through those similar hormonal shifts in the future. It becomes, in some ways, a self-fulfilling prophecy. Like, "Oh my gosh, this time is going to be so horrible, I must prepare for it. Oh no, here it comes." And then it is terrible because you're expecting it to be terrible on some level. TREATMENT OPTIONS FOR PMS AND PMDD Crystal: There are great treatment options for PMS and PMDD. That's what we do in cognitive behavioral therapy for these very symptoms, is working through some of those expectations about how things are going to be and what we can actually do to prepare for it so that it doesn't end up being bad just because we think it's going to be bad. But that's not to say that there isn't also a hormonal driver because for some people, there clearly is. Again, that's what makes this work so interesting and complicated, is that it's both for so many people. And that's what makes treatment somewhat complicated. CBT can go a long way toward helping with these symptoms. Not everybody, of course, can afford to access CBT. There are medication options as well, but the combination of these treatments seems to work the best for that reason. Kimberley: Yeah. CBT is good for so many things, isn't it? Crystal: Yeah. Kimberley: This is a perfect segue into questions I commonly get. I'm not a medical professional, everybody knows that. I'm a therapist. But people will often report to me that their doctor said, "There's nothing you can do. It's your hormones, it's your cycle. You have to ride it out and ride the PMDD or ride out your OCD or ride out your anxiety or your panic and just wait." Would you agree with that? If so, or if not, what treatments would you encourage people to consider? Crystal: Okay, I want people to know that that is absolutely not true. If a medical provider tells you that, go see someone else because it's just not true. I actually hear the same thing all the time from my own patients and from our research participants too. They raised this concern with their physician; it wasn't taken seriously. That's why I do this work because I think it's really important. We do have good treatments that work. There are a whole bunch of different things that people can try. MEDICATIONS FOR PMDD + PMS Crystal: Because I mentioned there are different ways in which hormones influence mood symptoms across individuals, the unfortunate news is that we have certainly different medication for pmdd + pms treatments that work for a lot of people, but you have to work with a physician that you like to find the combination or the exact right treatment for you. It's not like a one-and-done where you would go in and say, "Okay, great, you're going to put me on this low-dose antidepressant and I will feel better and it will completely take care of this." The thing that I would really encourage people to do is find a physician who's willing to work with them and see them regularly in the beginning, once every few weeks, or even more often as they try these different treatments to see what's going to work. I already mentioned cognitive behavioral therapy. That's a first-line treatment option for PMDD as well as for this premenstrual exacerbation or cyclic exacerbation of underlying anxiety or depression. The other thing that works well for PMDD is selective serotonin reuptake inhibitors. SSRIs that are used to treat depression and anxiety work well for PMDD but the mechanism is different, which is really interesting. A lot of people I hear from are reluctant to take SSRIs because they've heard that they're difficult to come off of eventually if they wanted to, that you can become dependent on them. The good news for PMDD, for people who are worried about those studies, is actually, you don't have any dependence on it because you only take it during that period of the menstrual cycle that's problematic for you. You can take it just those two weeks leading up to the beginning of your period and then stop taking it once the period starts. That has been shown to fully prevent PMDD symptoms in some women. And then some other people take it all the time, like around the whole menstrual cycle just because it's hard to remember to start it, or because they're not exactly sure when their period is going to start. If you're not super regular, it's hard to know and you might miss that window of opportunity to start it before the mood symptoms. That's another option. But SSRIs are another first-line treatment option. And then some women have really good success with oral contraceptives. Low-dose combined estrogen-progestin contraceptives are what's recommended. Yaz is the only one that's FDA-approved to treat PMDD, but it's not all that dissimilar from any other low-dose combined oral contraceptive. Sometimes it isn't covered by all insurances. If that one is not covered, I tell people to ask their doctor about what are the other alternatives because you shouldn't be paying tons and tons of money for your oral contraceptive. And then the other thing that often helps, for women who have some symptom relief with Yaz or other oral contraceptives, is to take it continuously because, as I mentioned, it is often that hormone change that seems to provoke symptoms in folks. If you don't have a period, then you don't have any hormone change. It's those placebo pills that cause a period, it's the switching from a low-dose hormone to then having that withdrawal of progestin that causes a period. But you don't medically need one. You can ask your doctor to prescribe the hormone continuously and not have a period at all. And that works well for a lot of folks with PMDD as well. And then you can combine all these different treatments. LIFESTYLE CHANGES TO HELP PMS ANXIETY + PMDD And then, in addition, some other non-pharmacologic lifestyle changes to help PMS anxiety and PMDD. Exercise has been shown to help. Regular exercise I think enhances all of our moods. It has the same effect within PMDD. There's some studies showing that taking calcium seems to reduce symptoms as well. For most of our patients, I just have them start taking a multivitamin and try to boost up that calcium a little bit. But like I said, a lot of people need a combination of treatments. Different SSRIs work in slightly different ways and may be more effective for some people than others. Just because the first SSRI doesn't work doesn't mean that you couldn't try another one. Again, it's just a matter of finding a physician that's willing to work with you to find the right combination and dose of these various treatments. Also possible for some people that none of these things work and those cyclic mood symptoms persist. And then there are other more invasive options for folks who don't have good success with any of these. Kimberley: Right. I have a couple of questions about that. You've just given us an amazing treatment plan, or treatment options for someone who is experiencing PMDD or they're having more onset of anxiety not to maybe that degree. I just want to clarify, for those who also have a chronic anxiety disorder, I'm assuming, but please again correct me, that they wouldn't be one of the people who should be coming off of their SSRIs; they should stay on them if you've got an additional psychiatric or a mental illness on the side. Crystal: Correct. I would never advise someone to come off of their SSRI if they're still having some breakthrough cyclicity in their symptom exacerbation. What I would suggest instead is to try adding on some of these other options. If you're already on an SSRI and not doing CBT, that's maybe where I would start, is to first track your mood symptoms relative to your period. This is a step that many people skip. The only way to diagnose PMDD, but also an important indicator for this cyclic exacerbation of symptoms, is to track every day your mood symptoms. You can just do this really easily on a calendar, even in the Notes app on your phone. I just have my patients make a mood rating of 0 to 10. 0 is feeling terrible, awful, worst I've ever felt; 10 is the best I've ever felt. It can be as simple as that. Or you can even use a smiley face symptom like, okay, feeling happy, feeling terrible. It doesn't have to be anything special. There are apps and things you can use as well to do this. But what we're looking for is a regular pattern of mood change relative to the menstrual cycle. Once you've established there is a regular pattern, then a CBT therapist can help you, like I said, prepare for those times and use some coping skills or strategies to manage those mood symptoms. But I think the treatments are largely the same for people with PMDD versus other anxiety and depressive disorders. But if you have more of a chronic picture that just has some change in symptoms around the menstrual cycle, then you wouldn't come off your SSRI. That's just for people with pure PMDD. CBT FOR PMDD and PMS ANXIETY Kimberley: I'm thinking about questions I'm assuming people will ask, and what comes to mind is, as myself as an OCD Specialist and as an anxiety specialist, we use CBT, but there are different types of CBT. We do a lot of exposure and response prevention for OCD and so forth. When we are talking about CBT, I want us to really be clear about what that looks like compared to all these other forms. What would that look like specific to somebody who has these symptoms, particularly around their menstrual cycle? Would it be more focused on the cognitive component or would it be an equal balance between managing cognitive distortions and behavioral activation? If we did behavioral activations, what would that look like? Crystal: I'm just going to lay my bias out on the table that I tend to lean more on the B side of CBT. I tend to be a behaviorist, and I do a lot of behavioral activation because, in my experience, it tends to work well in this space and for this population of folks. We do some behavioral planning. We track behaviors and mood symptoms. What did you do or not do when you were having that feeling of frustration or irritability and how did that work out for you? We get pretty in the weeds of like, what did you say, and then what happened next, and that sort of thing, and then we figure out like, okay, how do we prevent this kind of exchange from happening in the future when you're feeling really frustrated or irritable, if it caused problems, because sometimes it doesn't. Sometimes anger, frustration, or irritability serves as fuel to make a behavior change that needs to be made. It's a signal that something isn't working well. I don't want to pathologize all negative emotions because they're not always bad. Anyways, we look at what happened and where are the points at which we could have intervened and we rewind back in time to say, "Okay, how did you sleep the night before that thing happened that didn't go so well? Were you eating that day? What was that like? Were you already pretty depleted going into this negative interaction with your boss?" How do we prepare for the next cycle to make sure that you are allotting enough time to sleep and protecting that sleep time, not staying up super late, getting emails done or something, but really taking good care of yourself, eating well, drinking enough water, taking care of yourself the way you would take care of a child? And then from there, we talk about, "Okay, let's say this frustrating thing happens again and you're noticing yourself getting anxious or frustrated in that moment. What are some tools or skills we could use to respond?" Here, we might use something like taking a break, like, "All right, I noticed I'm getting really upset. I need to take a break from this interaction so that I don't say something that I might regret." We might practice a skill like, "Thank you for that feedback. I'm feeling myself just getting flustered. I'm going to take five minutes and then I'd like to come back and have this conversation with you later, or an hour," or "Can we come back and have this conversation next week," depending on what it is and how out of sorts the person is feeling. And then using some skills to calm down. These might be mindfulness skills or any kind of self-care, emotion regulation skill that a person could use. We tend to start with skills that folks have already had good success with. I'm not teaching Buddhist meditation on the first day of treatment, but instead, it might be simple things like, "Oh, I feel better when I get some sunshine and take a walk outside," so that might be a good skill we could just use right off the bat. It's pretty skill-based. And then we create a behavioral plan around that time of the month that tends to be more problematic so that we can keep people feeling well and well supported. A lot of times, that's all it takes. It doesn't require much more than that. Kimberley: I love that. I love that you're bringing in the mindfulness piece and a lot of self-care. This is really more of a question of curiosity, but I remember as a young teen, having a lot of PMS, being told you have to drink a lot of water. Is that like an old wives' tale? Because now I'm telling my daughter. I'm curious, is that an old wives' tale or is that actually a treatment or a part of the work? Crystal: I don't know. I mean, I think Americans probably go a little overboard on water consumption, but I think it's a good part of self-care to stay well-hydrated as well as well-fed and well-rested. You do lose some water through menstruation, and so it's probably good practice in general just to keep yourself well hydrated. That doesn't mean drinking a certain amount of water every day, but just noticing when you're thirsty and drinking something when you are. Kimberley: Okay, I'll be better about that because, like I said, as I tell my daughter, I'm always like, "This is probably an old wives' tale." Maybe we could talk this one through together. Let's say I'm treating somebody. They've got severe OCD, severe panic disorder or severe health anxiety, severe social anxiety. They know and they've tracked using an app or, as you said, the notes on their phone or on paper, they've tracked it. They know around approximately that such and such day of the month, they're going to probably have an onset of treatment. How prepared should they be in terms of what would that preparation time look like? Is there a strategy you would give people? I know for us, on the clinical side, I'm amping up homework skills for them to manage the actual disorder, but is there something they could be doing on the PMS side that we should remember to do? Crystal: I think it's in my mind really specific to the individual and the symptoms that they're having that they find tend to get worse as well as the physical symptoms. If they're having a lot of pain around that time, then we want to also work on some pain management. Because when you're feeling a lot of pain, that can make your anxiety worse. That would be something I would think about in addition to the standardized ramping up of homework that you would ordinarily be doing. Pain management can again look more like mindfulness, some meditative practice, or it can mean talking with one's doctor about how to manage pain because there are non-addictive ways of managing pain as well. Kimberley: Right. You mentioned before talking to your doctor. Are you speaking specifically about just a GP or should they be going more to a reproductive doctor, OB-GYN? What kind of medical professional would you encourage people to reach out to? Crystal: I think if you have a doctor that you trust, whether it's a GP, OB-GYN, or even a psychiatrist, all of those are good options. Any of them can help treat these symptoms. Sometimes if the symptoms are really severe, then going to a specialist in reproductive mental health—that person would be a psychiatrist—can be helpful. There aren't that many of us out there though. I have a number of really wonderful colleagues that I work alongside in our clinic and we treat patients together. I provide the psychotherapy and then they provide the pharmacotherapy and then I also have an OB-GYN on the team who provides the hormonal treatment. Not everyone can access this highly skilled team, however, and I do recognize that. I think starting with a GP or your OB-GYN is a good place to start. Again, if they're not as knowledgeable as they need to be and they're telling you, you just have to suck it up and deal with it, that's not the right person. Kimberley: I appreciate you saying that because I do think—I'll be transparent—even to get somebody as skilled as yourself on the show for this was a really difficult thing. I was surprised how few people really understand it and are knowledgeable about the treatment options. It was harder than I thought and I'm so grateful for you to be here and talk about it with us. Crystal: I'm really sorry to hear that. I think there are a growing number of people interested in this, and I have a number of wonderful colleagues. But like you mentioned, there aren't that many of us out there. The bright spot, I would say, is that we have a training program at UNC Chapel Hill with lots and lots of applicants every year. We're training clinical psychologists and social workers and psychiatrists to do this work. Kimberley: Amazing. Thank you. Last question: Any final advice you would give someone who is experiencing symptoms of PMS and PMDD in regards to getting better or seeking treatment and help? LAST PIECE OF ADVICE FROM CRYSTAL Crystal: You're not alone. It's not all in your head. You deserve access to treatments that work. There are lots of treatments that work. Unfortunately, our medical system is really complex and sometimes you have to really advocate for yourself in this space. But if you are persistent and know what you're looking for in a provider, you, I hope, will be able to find one that can be a good advocate and supporter of you to recovery because you don't have to experience these symptoms by yourself or forever. Kimberley: Thank you so much for saying that. I think a lot of people feel like they're crazy or they've been told they're being crazy, which doesn't help. Crystal: Yeah. I mean, the word "hysteria" came from studying or psychiatrists working with women who they felt were hysterical and their uterus was traveling around their bodies. The roots of all of this are in this really misogynistic place where many of us are working really hard to overcome that unfortunate history, but there's often still a lot of stigma and misinformation out there. Kimberley: I remember in my master's degree, that was the first part of the history of Psychology, that women who were just having PMS were being totally hyper-pathologized. Horrible. Crystal: Yeah. Really horrible. I hope that the work that we do makes a difference. I'm so glad that you're tackling this topic on your podcast. I think this will, I hope, reach a lot of people. Kimberley: Thank you. Can you tell us where people can get ahold of you, where they might learn about you and the work that you're doing? Crystal: Yeah. I have a website, it's CrystalSchiller.com. C-R-Y-S-T-A-L S-C-H-I-L-L-E-R.com. I'm actually starting to write a book on this topic, so I really appreciate you reaching out and to know that people have questions about this because that's what I see where I'm at too. And then the UNC Center for Women's Mood Disorders, if you just Google that, you'll find our website and you can read more about the different research studies that we're doing and about our treatment program as well. Kimberley: Thank you so much and congratulations on writing a book. It's a big challenge and a big accomplishment. Crystal: Thanks. Kimberley: Thank you so much for coming on. It's been an absolute pleasure.Crystal: It was wonderful being with you today. Thank you so much. Take care.

In this week's podcast episode, we talked with Dr. Katherine Unverferth on Menopause, anxiety, and mental health. We covered the below topics: How do we define peri-menopause and menopause? What causes menopause? Why do some have more menopausal symptoms than others? Why do some people report rapid rises in anxiety (and even panic disorder) during menopause. Is the increase in anxiety with menopause biological, physiological, or psychological? Why do some people experience mood differences or report the onset of depression during menopause? What treatments are avaialble to help those who are suffering from menopause (or perimenopause) and anxiety and depression? Welcome back, everybody. I am so happy to have you here. We are doing another deep dive into sexual health and anxiety as a part of our Sexual Health and Anxiety Series. We first did an episode on sexual anxiety or sexual performance anxiety. Then we did an episode on arousal and anxiety. That was by me. Then we did an amazing episode on sexual side effects of antidepressants with Dr. Aziz. And then last week, we did another episode by me basically going through all of the sexual intrusive thoughts that often people will have, particularly those who have OCD. This week, we are deep diving into menopause and anxiety. This is an incredibly important episode specifically for those who are going through menopause or want to be trained to understand what it is like to go through menopause and how menopause impacts our mental health in terms of sometimes people will have an increase in anxiety or depression. This week, we have an amazing guest coming on because this is not my specialty. I try not to speak on things that I don't feel confident talking about. This week, we have the amazing Dr. Katherine Unverferth. She is an Assistant Clinical Professor at The David Geffen School of Medicine and she also serves as the Director of the Women's Life Center and Medical Director of the Maternal Mental Health Program. She is an expert in reproductive psychiatry, which is why we got her on the show. She specializes in treating women during periods of hormonal transitions in her private practice in Santa Monica. She lectures and researches and studies areas on postpartum depression, antenatal depression, postpartum psychosis, premenstrual dysphoric disorder—which we will cover next week, I promise; we have an amazing guest talking about that—and perimenopausal mood and anxiety disorders. I am so excited to have Dr. Unverferth on the show to talk about menopause and the collision between menopause and anxiety. You are going to get so much amazing information on this show, so I'm just going to head straight over there. Again, thank you so much to our guest. Let's get over to the show. Kimberley: Welcome. I am so honored to have Dr. Katherine Unverferth with us talking today about menopause and anxiety. Thank you for coming on the show. Dr. Katie: Of course. Thanks for having me. HOW DO WE DEFINE PERI-MENOPAUSE AND MENOPAUSE? Kimberley: Okay. I have a ton of questions for you. A lot of these questions were asked from the community, from our crew of people who are really wanting more information about this. We've titled it Menopause and Anxiety, but I want to get really clear, first of all, in terms of the terms and whether we're using them correctly. Can you first define what is menopause, and then we can go from there? Dr. Katie: Definitely. I think when you're talking about menopause, you also have to think about perimenopause. Menopause is defined as the time after the final menstrual period. Meaning, the last menstrual period somebody has. It can only be defined retrospectively, so you typically only know you're in menopause a year after you've had your final menstrual period. But that's the technical definition—after the final menstrual period, it's usually defined one year after. Perimenopause is the time leading up to that where people have hormonal changes. Sometimes they have vasomotor symptoms, they can have mood changes, and that period typically lasts about four years but varies. I think that people often know that they're getting close to menopause because of the perimenopausal symptoms they might be experiencing. Kimberley: Okay. How might somebody know they're going into perimenopause? I think that's how you would say you go into it. Is that right? Dr. Katie: Yeah. You start experiencing it there. I don't know if there's a specific term. Kimberley: Sure. How would one know they're moving in that direction? Dr. Katie: Typically, we look for a few different things. One of the earliest signs is menstrual cycle changes. As someone enters perimenopause, their menstrual cycle starts to lengthen, whereas before, it might have been a normal 28-day cycle. Once it lengthens to greater than seven days, over 35 days, we would start to think of someone might be in perimenopause because it's lengthened significantly from their baseline before. Other symptoms that are really consistent with perimenopause are vasomotor symptoms. Most women who go through perimenopause will have these. These are hot flashes or hot flushes—those are synonyms for the same experience—and night sweats. Hot flashes, as the name describes what it is, they last about two to four minutes. It's a feeling of warmth that typically begins in the chest or the head and spreads outward, often associated with flushing, with sweating that's followed by a period of chills and sometimes anxiety. The night sweats are hot flashes but in the middle of the night when someone is sleeping, so it can be very disruptive to sleep. That combination of the menstrual cycle changes plus these vasomotor symptoms is typically how we define perimenopause or how we diagnose perimenopause. Once someone is later in perimenopause, when they're getting closer to their final menstrual period, often they'll skip menstrual cycles altogether, so it might be 60 days in between having bleeding. Whereas before, it was a more regular period of time. I think one of the defining features too is hormonal fluctuations during those times. But interestingly, there's not much clinical utility to getting the blood test to check hormone levels because they can vary wildly from cycle to cycle. Overall, what we do see is that certain hormones increase, others decrease, and that probably contributes to some of the symptoms that we see around that time as well. Kimberley: Right, which is so interesting because I think that's why a lot of people come to me and I try to only answer questions I'm skilled to answer. Those symptoms can very much mimic anxiety. I know we'll get into that very soon, but that's really interesting—this idea of hot flashes. I always remember coming home to my mom from school and she was actually in the freezer, except for her feet. It was one of those door freezers. So, I understand the heat that they're feeling, this hot flash, it's a full body hot flash stimulant like someone may have if they're having a panic attack maybe. Dr. Katie: Exactly. There are lots of interesting studies really looking at the overlap of menopausal panic attacks and hot flashes too. There's a lot of this research that's really trying to suss out what comes first in perimenopause because we know that anxiety predisposes someone to hot flashes and it can predispose someone to panic attacks, which is interesting. It seems like there's this common denominator there. But I think that that's a really interesting thing that hopefully we'll get into this overlap between the two. WHAT AGE DOES SOMEONE GET PERIMENOPAUSE AND MENOPAUSE? Kimberley: I'm guessing this is something I'm moving towards as well. What age groups, what ages does this usually start? What's the demographics for someone going into perimenopause and menopause? Dr. Katie: The average age of menopause is 51, and then people spend about four years in perimenopause. Late 40s would be a typical time to start perimenopause. Basically, any age after 40, when someone's having these symptoms, they're likely in perimenopause. If it happens before the age of 40 where someone's having menstrual cycle abnormalities and they're having these vasomotor symptoms, that might be a sign of primary ovarian insufficiency. It used to be called premature ovarian failure, but that would be a sign that they should probably go see a doctor and get checked out. If it's after 40, it's very likely that they're having perimenopausal symptoms. Kimberley: Okay. What causes this to happen? What are the shifts that happen in people's bodies that lead someone into this period of their life? Dr. Katie: I think there are a lot of things that are going on. I think it's really important to emphasize that menopause is a natural part of aging. That this isn't some abnormal process. Nothing is wrong. It's a natural part of aging. It can still be very uncomfortable, I think. But basically, over time, a woman's eggs decline and the follicles that help these eggs develop also develop less. There's this decline in the functioning of the ovaries. There are a few reasons this might be. There are some studies that show that blood flow to the ovaries is reduced as a result of aging, so maybe that makes them function a little bit less. The follicles that remain in the ovaries are probably aging, and then the follicles, which are still there, also might not be the healthiest of follicles, which is why they weren't used earlier. There's this combination of things that leads to these very significant hormonal changes that start around perimenopause. The first of these is an increase in follicle-stimulating hormone. Follicle-stimulating hormone is released by the pituitary and encourages the ovaries to develop follicles. That increases over time because the follicles aren't developing in the same way. It's like the pituitary is trying harder and harder to get them to work. At the same time as these, as the follicles and ovaries are aging, what we see is that the ovaries produce less estrogen and progesterone overall. But there's still these wild fluctuations that are happening. FSH is going up, but it's fluctuating up; estrogen and progesterone are going down, but they're fluctuating down. It's these really big shifts that seem to cause a lot of the symptoms that we associate with this time. WHY DO SOME HAVE MORE MENOPAUSAL SYMPTOMS THAN OTHERS? Kimberley: Is there a reason why some people have more symptoms than others? Is it your genetic component or is there a hormonal component? What's your experience? Dr. Katie: I think there are lots of different reasons and we probably need more research in this area. There are definitely genetic components that influence it. For example, we know that women who have family members who went through menopause earlier are likely to go through menopause themselves earlier. There's some genetic thing that's influencing the interplay of factors. I think we know that there are certain lifestyles. There are certain behaviors, like certain behaviors in someone's life that can influence, I think, their symptoms. We know that smoking, obesity, having a more sedentary lifestyle can impact vasomotor symptoms. I think some really interesting research looks at the psychological influences here. We know that women who have higher levels of neuroticism, when they go through perimenopause, have more anxiety and mood changes associated with it. People who have higher levels of somatic anxiety, coming into this perimenopausal transition, can also have a tougher time. I think that makes sense when we think about someone with somatic anxiety. They're going to be very, very attuned to these small changes in their body. During perimenopause, there are these huge changes that are happening in your body. That can trigger, I think, a lot of anxiety and a focus on the symptoms. I think with vasomotor symptoms specifically, like hot flashes and hot flashes specifically, night sweats, not quite as much, we know that there are these psychological characteristics that probably perpetuate and worsen hot flashes. When someone has a hot flash, it's certainly uncomfortable for most people. But the level of distress can be very different. They've looked at the cognitions that occur when people have hot flashes and at some point, people believe like, "Oh, this is very embarrassing, this is very shameful." That doesn't help them process it. They might believe, "This is never going to go away. I can't cope with it." That's also not going to help. I think that's really a target for cognitive behavioral therapy to help people during this time. Kimberley: It just makes me think too, as somebody who has friends going through this, and you can please correct me, what I've noticed is there's also a grief process that goes along with it too, like it's another flag in terms of being flown, in terms of I'm aging. I've also heard, but maybe you have more to say about people feeling like it makes them less feminine. Is that your experience too, or is that just my experience of what I've heard? Dr. Katie: No, I agree. I think in my clinical experience, people go through it in a lot of different ways. I think that there is this grief. I think it can bring out a lot of existential anxiety. It is a sign that you are getting older. This can bring up a lot of these questions like, who am I? What's my purpose? Where am I going? But I think it's really important to remind women that we're not defined by our reproductive functioning. I think that that's something that people forget. Were you less of a woman when you were 15 or when you were 10 maybe and you hadn't gone through puberty? You're still the same person. But I do think that there's a lot of cultural stress around this, and I think there are a lot of complexities around the way society sees aging women. I think that those are cultural issues that need to be fixed, but not necessarily a problem within the woman themselves. WHAT CAUSES MENOPAUSE AND ANXIETY SYMPTOMS? Kimberley: That's really helpful to know and understand. Okay, let's talk about if I could get a little more understanding of this relationship with anxiety. Maybe you can be clearer with me so that I understand it. Is it more of what we're saying in terms of like, it's the chicken and the egg? Is that what you mean in terms of people who have anxiety tend to have more symptoms, but then those symptoms can create more anxiety and it's like a snowball? Or is that not true for everybody? Can you explain how that works? Dr. Katie: With regard to the perimenopausal period, what I think researchers are trying to figure out is, do vasomotor symptoms, like hot flashes, lead to anxiety and panic, or do anxiety and panic worsen the vasomotor symptoms? We don't have a lot of information there. Part of it is because it's difficult to study. Because when you're doing symptom checklists, there's a lot of overlap between a hot flash and a panic attack. It's just been difficult, I think, to suss out in research. I think what we do know is there was one study that showed that people who have higher levels of anxiety are five times more likely to report hot flashes than women with anxiety in the normal range. Whether or not the anxiety is necessarily causing it, I do think that there's probably some perpetuation of like, I think that the anxiety is perpetuating the hot flashes, which perpetuates the anxiety. We just don't know exactly where it starts. MENOPAUSE & PANIC ATTACKS But I mean, if we just think about it for a second, if we think about what's common between them, I think that both panic attacks and hot flashes have a quick onset. They have a spontaneous onset, a rapid peak, they can be provoked by anxiety, they can include changes in temperature, like feelings of heat and sweating. They can have these palpitations, they can have this shortness of breath, nausea. And then it's very common that panic is reported during hot flashes, and hot flashes can be reported during panic. I think there's this interplay that we're trying to figure out. I think what's interesting too is that common antidepressants can treat both panic and hot flashes, which is not something that probably everybody knows. There are probably different reasons that they're treating each of them, but it is still just this other place where there is this overlap. Kimberley: Okay. That's really interesting. One thing that really strikes me is I actually have a medical condition called postural orthostatic tachycardic syndrome (POTS), and you get really dizzy. I'm an Anxiety Specialist, so I can be good at pulling apart what is what, but it is very hard. You have to really be mindful to know the difference in the moment because let's say I have this whoosh of dizziness. My mind immediately first says I'm having a panic attack, which makes you panic. I'm assuming someone with that whoosh of maybe a hot flash has that same thing where your amygdala, I'm guessing, is immediately going to be like, "Yeah, we're having a panic attack. This is where we're going." That makes a lot of sense to me. Now, some people also have reported to me that their anxiety has made them-- and again we have to understand what causes what, and we don't understand it, but how does that spread into their daily life? What I've heard is people say, "I don't feel like I can leave the house because what if I have a hot flash, which creates then a panic attack," or "It's embarrassing to have a hot flash. You sweat and your clothes are all wet and so forth." Do you have a common example of how that also shows up for people? Dr. Katie: Yeah. I think that what you were alluding to is this behavioral avoidance that can happen. We can see that with panic attacks where people sometimes develop agoraphobia, fear of being in certain places. Sometimes they don't want to leave their home. I think with hot flashes, we do also see this behavioral avoidance when people especially tend to find them very distressing. They catastrophize it when they happen. They worry about social shaming. That avoidance, I think, the way that we understand anxiety is that if you have an anxiety and then you change your behaviors as a result of that anxiety, that tends to perpetuate the anxiety. That's one of the targets of cognitive behavioral therapy for hot flashes, is really trying to unwind some of this behavioral avoidance. Also, we know that temperature changes can trigger hot flashes. Unfortunately, it looks like strong positive and strong negative emotion can trigger hot flashes, just feeling any end of the spectrum. There are certain other triggers that can trigger hot flashes. I think that it's just this discomfort and this fear of having a hot flash that I think really generalizes the anxiety during this time. HORMONES, ANXIETY, & MENOPAUSE There's also this interesting hormonal component too that's being studied as well. We've talked a little bit about progesterone. But in reproductive psychiatry, we really focus on this metabolite of progesterone called allopregnanolone. I think this is interesting because allopregnanolone is a metabolite of progesterone. We know that progesterone is going like this, up and up and down during this time. Allopregnanolone works on this receptor that tends to have very calming effects. Other things that work at this receptor are benzodiazepines like Xanax and Ativan or alcohol. It has this calming effect. But when it's going like this, it's calming and then it's not, and then it's calming and then it's not, up and down rollercoaster. There's some thought that that specifically might contribute to anxiety during this time. It can be more generalized. It's not always just related to hot flashes, even though we've been more specific on that. It can be the same as anxiety at any point in anyone else's life, like ruminative thoughts, worry, intrusive thoughts, just this general discomfort. I think this is a really exciting area of research where we're looking at ways to modulate this pathway to help women cope better. There are studies looking at progesterone metabolites to see if they can be helpful with mood changes during this time. Kimberley: Interesting. Let's work through it. As a clinician, if someone presents with anxiety, what I would usually do is do an inventory of the behaviors that they do in effort to reduce or remove that anxiety or uncertainty that they feel. And then we practice purposely returning to those behaviors. Exposure and so forth. From what you understand, would you be doing the same with the hot flashes or is there a balance between, there will be sometimes where you will go in purposely or go out and live your life whether you have a hot flash or not? How do we balance that from a clinical standpoint? Even as a clinician, I'm curious to know. As a clinician, what would I encourage my client to do? Would it be like our normal response of, "Come on, let's just do it, let's face all of our fears," or is there a bit of a balance here that we move towards? Dr. Katie: It's more of a balance. I think one of the important things is that what you want to do-- I think the focus is on the cognition here a little bit. I'm not familiar and I don't think that exposure to hot flashes is intentionally triggering hot flashes repeatedly, like sometimes we do in panic disorders is part of this. What I understand from the protocol is that it's really looking at the unhelpful cognitions that relate to menopause, aging, and vasomotor symptoms. This idea of like, everybody is looking at me when I'm having a hot flash, this is so shameful. Or maybe it goes further, like no one will like me anymore. Who knows exactly where it can go? We know that when people have cognitive distortions, it's not really based on rational thinking. I think other part is you work on monitoring and modifying hot flash triggers, so it feels more in your control like temperature changes and doing those things. I think other things that you do is there's some evidence for diaphragmatic breathing to help with the management of hot flashes. You teach someone those skills. I think your idea is you want to get them back out there and living their life despite the hot flashes, and also just education. This isn't going to last forever. Yes, this is uncomfortable, but everybody goes through this. This is a normal part of aging. Also encouraging them to seek treatment if they need it. In addition to therapy, we know that there are medications that can help with this. If the hot flashes are impacting their life in a significant way or very distressing to them, go see a reproductive psychiatrist or go see an OB-GYN who can talk to you about the different options to really treat what's coming up. Kimberley: Right. That's helpful. I want to quickly just add on to that with your advice. I think what you're saying is when we come from an anxiety treatment model, we are looking at exposure, but when it comes to someone who's going through this real life, like their actual symptoms aren't imagined, they're there, it's okay for them to modify to not be going to hot saunas and so forth that we know that they're going to be triggered, but just to do the things that get them back to their daily functioning, but it is still okay for them. I think what I'm trying to say is it's still okay for them to be doing some accommodation of the symptoms of perimenopause, but not accommodation of the anxiety. Is that where we draw the line? Dr. Katie: I think that's a really good way of explaining it. DEPRESSION AND MENOPAUSE Kimberley: All right. The other piece of this is as important, which is how depression impacted here. Can you share a little bit how mood changes can be impacted by perimenopause? Dr. Katie: Definitely. We know that there's a significant increase in not only the onset of a new depression, but also recurrence of prior depressive episodes during perimenopause. It's probably related to the changing levels of hormones, but also, I think what we've alluded to and what we have to acknowledge is there are big life changes that are happening around this time as well. I think cultural views of aging, I think a lot of times people have changes in their relationships, their partners. Their libido can change. There's so many moving parts that they think that also contributes to it. But specifically with regard to perimenopausal depression, we categorize this in the reproductive subtype of depression. At these different periods of hormonal transition, certain women are prone to have a depressive episode. We know that that's true during normal cycling. For example, premenstrual dysphoric disorder or PMDD is a reproductive subtype of depression. People sometimes get depressed in those two weeks before their period and then feel fine during the week of their period or the week after. During the luteal phase, they experience depression. We know that that group of women also is at increased risk for perinatal depression, so depression during pregnancy and postpartum. And then that same group is also at risk for perimenopausal depression. What we know is that a subset of women is probably sensitive to normal levels of changing hormones, and that for them, it triggers a depressive episode. One of the biggest risk factors for depression during perimenopause is a prior history of depression. Unfortunately, the way depression works is that once you have it, you're more likely to have it in the future. For people who have had depression in their life or have specifically had depression around these times of hormonal transition, it's probably just important to keep an eye on how they're doing, make sure they have appropriate support, whether that's from a therapist or a psychiatrist, and monitor themselves closely. Kimberley: Okay. This is really helpful to know. We know that people with anxiety tend to have depression as well. Have you found those who've had previous depression or previous anxiety also have coexisting in terms of having those panic attacks and depression at the same time? Dr. Katie: That's interesting. I haven't read any research on that. It wouldn't surprise me. But I think at least for research purposes, they're separating it. I think clinically, of course, we can see it being all mixed together. But for research, it's depression or panic and they keep those separate. Kimberley: Right. One thing that just came to me in terms of just clarifying too is, I'm assuming a lot of people who have health anxiety are incredibly triggered during perimenopause as well, these symptoms that are unexplained but explained. But I'm wondering, is that also something that you commonly see in terms of they're having these symptoms and questioning whether it means something serious is happening? Has that been something that you see a lot of? Dr. Katie: Definitely. I think the first time someone has a hot flash, it can be extremely distressing. It's a very uncomfortable sensation. I think there are other changes that happen during perimenopause that, of course, I think, raise concern. We know that in addition to night sweats, people can just have general aches and pains. They can have headaches. Cognitive complaints can be very common during this time. Just this feeling of brain fog, not feeling as sharp as one used to be. They can have sleep disturbances, which can of course worsen the anxiety and the cognitive complaints, and the depression. I think there can be a myriad of symptoms. Other distressing symptoms, I'm not sure if they necessarily-- I think if you know what's going on, it's not quite as distressing, but there can be these urogenital symptoms, like vaginal dryness, vaginal burning. There can be recurrent UTIs, there can be difficulty with urination. There are this constellation of symptoms that I'm sure could trigger health anxiety in people, especially if they have preexisting health anxiety. WHAT TREATMENTS ARE AVAIALBLE TO HELP THOSE WHO ARE SUFFERING FROM MENOPAUSE (OR PERIMENOPAUSE) AND ANXIETY AND DEPRESSION? Kimberley: Yeah, absolutely. Someone's listened to this episode so they're at least informed, which is wonderful. They start to see enough evidence that this may be what is going on for them. What would be the steps following that? Is it something that you just go through and like a fever, you just ride it out kind of thing? Or are there medications or treatments? What would you suggest someone do in the order as they go through it? Dr. Katie: I think it depends on what's going on and how they're experiencing it. If this is distressing, life interfering, if they're having trouble functioning, they should absolutely seek treatment. I think there are a few different things they can do depending on what's going on. For depression and anxiety, medications are the first line. Antidepressants would still be the first-line therapy there. There's some evidence for menopausal hormone therapy, but there's not really enough. There is evidence for menopausal hormone therapy, but it's not currently first line for depression or anxiety. If someone had treatment-resistant depression that came up in the perimenopausal transition, I think it's reasonable to consider menopausal hormone therapy. But currently, menopausal hormone therapy isn't really recommended for that. If someone is having distressing vasomotor symptoms with night sweats and recurrent hot flashes or hot flushes during the day, menopausal hormone therapy is a very good option. That is something to consider. They could go talk to their OB-GYN about it. Certain people will be candidates for it and other people might not. If you think it might be something you're interested in, I recommend going and speaking to your OB-GYN sooner rather than later. Antidepressants themselves can also help with vasomotor symptoms as well. They can specifically help with hot flashes and night sweats. If someone has depression and anxiety and hot flashes and night sweats, antidepressant can be a really good choice because it can help with both of those. There was a really interesting study that compared Lexapro to menopausal hormone therapy for hot flashes, for quality of life, for sleep, and for depression. Essentially, both of them helped sleep quality of life in vasomotor symptoms, but only the Lexapro helped the depression. It really just depends on what's going on. I think another thing that we've also talked about is therapy. This can be a big life transition. I think really no woman going through menopause is the same. Some people have toddlers. Some people have grown children who have just left their home. Some people are just starting their career. Some people are about to retire. Relationships can change. I think that it's really important to take what's going on in the context of a woman's life. I think therapy can be really helpful to help them process and understand what they're going through. Kimberley: Right. You had mentioned before, and I just wanted to touch on this, vaginal drying and stuff like that, which I'm sure, again, a reason for this series is just how much sexual intimacy and so forth can impact somebody's satisfaction in life or functioning or in relationships. Is that something that is also treatable with these different treatment models or is there a different treatment for that? Dr. Katie: With menopausal hormone therapy, when someone has hot flashes or these other symptoms that we were talking about, not the urogenital ones, they need to take systemic menopausal hormone therapy. They basically need estrogen and progesterone to go throughout their body. When someone is just having these urogenital symptoms, they can often use topical vaginal estrogen. It's applied vaginally. That can be really helpful for those symptoms as well. I think if that's something that someone is struggling with that they want treatment for, it's very reasonable to go talk to their OB-GYN about it because there are therapies that can be-- Kimberley: Right, that's like a cream or lotion kind of thing. Dr. Katie: Exactly. Kimberley: Interesting. Oh wow. All right. That is so helpful. We've talked about the medical piece, the medication piece. A lot of people also I see on social media mostly talk about these more-- I don't want to use the word "natural" because I don't like that word "natural." I don't even know what word I would use, but non-medical-- Dr. Katie: Like supplements or-- Kimberley: Yeah. I know it's different for everyone and everyone listening should please seek a doctor for medical advice, but is that something that you talk about with patients or do you stick more just to the things that have been researched? What are your thoughts? Dr. Katie: I think that supplements can be helpful for some people. I don't always find that they're as effective as medications. If someone is really struggling on a day-to-day basis, I do think that using treatments that have more evidence behind them is better. I think that there are some supplements that have a little bit of evidence, but I do think that they come with their own risks. Because supplements aren't regulated by the FDA and things like that, I don't typically recommend them. I think if someone is interested in finding a more naturopathic doctor who might be able to talk to them about those things is reasonable. Kimberley: Super helpful. Is there anything that you feel like we haven't covered or that would be important for us to really drill home and make sure we point out here at the end before we finish up? Dr. Katie: I think we've covered a lot. I think that the most important thing that I really want to stress is this is a normal part of aging. This is not a disease; this is not a disease state. Also, there are treatments that can be so effective. You don't have to struggle in silence. It is not something shameful. There are clinicians who are trained, who are able to help if these symptoms are coming up. Just not being afraid to go and talk about it and go reach out for help. I think that that can be so helpful and really life-changing for some people when they get the right treatment. Kimberley: Right. Thank you. Where can we hear about you, get in touch with you, maybe seek out your services? Dr. Katie: You can find me online. I have a website. It's just www.drkatiemd.com. It's D-R-K-A-T-I-E-M-D.com. You can follow me on Instagram on the same. If you're interested to see more of my talks and lectures, I often post those on my LinkedIn page. You can follow me on LinkedIn. I think if you are personally interested in learning more about menopause, there's a really great book by an OB-GYN, her name is Dr. Jen Gunter, and it's called The Menopause Manifesto. For anybody who really wants to educate themselves about menopause and understand more about what's going on in their body and their treatments, I really recommend that book. Kimberley: Amazing. That's so good to have that resource as well. Thank you. I'm really, really honored. I know you're doing so many amazing things and running so many amazing programs. I'm so grateful for your time and your expertise on this. Dr. Katie: Of course. I'm so glad that you're doing a podcast on this. I think this is a topic that we really need more information and education out there. Kimberley: Yeah. Thank you.

Welcome. This is Week 4 of the Sexual Health and Anxiety Series. I have loved your feedback about this so far. I have loved hearing what is right for you, what is not right for you, getting your perspective on what can be so helpful. A lot of people are saying that they really are grateful that we are covering sexual health and anxiety because it's a topic that we really don't talk enough about. I think there's so much shame in it, and I think that that's something we hopefully can break through today by bringing it into the sunlight and bringing it out into the open and just talking about it as it is, which is just all good and all neutral, and we don't need to judge. Let's go through the series so far. In Episode 1 of the series, we did sexual anxiety or sexual performance anxiety with Lauren Fogel Mersy. Number two, we did understanding arousal and anxiety. A lot of you loved that episode, talking a lot about understanding arousal and anxiety. Then last week, we talked about the sexual side effects of anxiety and depression medication or antidepressants with Dr. Sepehr Aziz. That was such a great episode. This week, we're talking about sexual intrusive thoughts. The way that I structured this is I wanted to first address the common concerns people have about sexual health and intimacy and so forth. Now I want to talk about some of the medical pieces and the human pieces that can really complicate things. In this case, it's your thoughts. The thoughts we have can make a huge impact on how we see ourselves, how we judge ourselves, the meaning we make of it, the identity we give it, and it can be incredibly distressing. My hope today is just to go through and normalize all of these experiences and thoughts and presentations and give you some direction on where you can go from there. Because we do know that your thoughts, as we discussed in the second episode, can impact arousal and your thoughts can impact your sexual anxiety. SEXUAL OCD OBSESSIONS Let's talk a little bit today about specific sexual intrusive thoughts. Now, sexual intrusive thoughts is also known as sexual obsessions. A sexual obsession is like any other obsession, which is, it is a repetitive, UNWANTED—and let's emphasize the unwanted piece—sexual thought. There are all different kinds of sexual intrusive thoughts that you can have. For many of you listening, you may have sexual intrusive thoughts and OCD that get together and make a really big mess in your mind and confuse you and bring on doubt and uncertainty, and like I said before, make you question your identity and all of those things. In addition to these intrusive thoughts, they often can feel very real. Often when people have these sexual intrusive thoughts, again, we all have intrusive thoughts, but if they're sexual in nature, when they're accompanied by anxiety, they can sometimes feel incredibly real, so much so that you start to question everything. SEXUAL SENSATIONS Now, in addition to having sexual intrusive thoughts, some of you have sexual sensations, and we talked a little bit about this in previous episodes. But what I'm really speaking about there is sensations that you would often feel upon arousal. The most common is what we call in the OCD field a groinal response. Some people call it the groinal in and of itself, which is, we know again from previous episodes that when we have sexual thoughts or thoughts that are sexual in nature, we often will feel certain sensations of arousal, whether that be lubrication, swelling, tingling, throbbing. You might simply call it arousal or being turned on. And that is where a lot of people, again, get really confused because they're having these thoughts that they hate, they're unwanted, they're repetitive, they're impacting their life, they're associated with a lot of anxiety and uncertainty, and doubt. And then, now you're having this reaction in your body too, and that groinal response can create a heightened need to engage in compulsions. As we know—we talk about this in ERP School, our online course for OCD; we go through this extensively—when someone has an obsession, a thought, an intrusive thought, it creates uncertainty and anxiety. And then naturally what we do is we engage in a compulsion to reduce or remove that discomfort to give them a short-term sense of relief. But then what ends up happening is that short-term relief ends up reinforcing the original obsession, which means you have it more, and then you go back through the cycle. You cycle on that cycle over and over again. It gets so big. It ends up impacting your life so, so much. INTRUSIVE SEXUAL URGES Now, let's also address while we're here that a lot of you may have intrusive sexual urges. These are also obsessions that we have when you have OCD or OCD-related disorders where you feel like your body is pulling you towards an action to harm someone, to do a sexual act, to some fantasy. You're having this urge that feels like your body is pulling you like a magnet towards that behavior. Even if you don't want to do that behavior, or even if that behavior disgusts you and it doesn't line up with your values, you may still experience these sexual OCD urges that really make you feel like you're on the cusp of losing control, that you may snap and do that behavior. This is how impactful these sexual intrusive thoughts can be. This is how powerful they can be in that they can create these layers upon layers. You have the thoughts, then you have the feelings, then you have the sensations, you also have the urges. Often there's a lot of sexual intrusive images as well, like you see in front of you, like a projector, the image happening or the movie scene playing out that really scares you, concerns you, and so forth. And then all of those layers together make you feel absolutely horrible, terrified, so afraid, so unsure of what's happening in and of yourself. TYPES OF SEXUAL OCD OBSESSIONS Let's talk about some specific OCD obsessions and ways in which this plays out. Now, in the OCD field, we call them subtypes. Subtypes are different categories we have of obsessions. They don't collect all of them. There are people who have a lot of obsessions that don't fall under these categories, but these subtypes usually include groups of people who experience these subtypes. The reason we do that is, number one, it can be very validating to know that other people are in that subgroup. Number two, it can also really help inform treatment when we have a specific subtype that we know what's happening, and that can be very helpful and reduce the shame of the person experiencing them. 1. SEXUAL ORIENTATION OBSESSIONS OR SEXUAL ORIENTATION OCD It used to be called homosexual OCD. That was because predominantly people who were heterosexual were reporting having thoughts or sexual intrusive thoughts about their sexual orientation—am I gay, am I straight—and really struggling with having certainty about this. Again, now that we're more inclusive and that I think a lot more people are talking about sexuality, that we have a lot less shame, a lot more education, we scrapped the homosexual OCD or homosexual obsessions or subtype category. Now we have a more inclusive category, which is called sexual orientation OCD. That can include any body of any sexual orientation who has doubt and uncertainty about that. Now remember when we started, we talked about the fact that sexual intrusive thoughts are usually unwanted, they're repetitive and they don't line up with our values. What we are not talking about here is someone who is actually questioning their sexual orientation. I know a lot of people are. They're really exploring and being curious about different orientations that appeal to them. That's way different to the people who have sexual orientation OCD or sexual orientation obsessions. People with OCD are absolutely terrified of this unknown answer, and they feel an incredible sense of urgency to solve it. If you experience this, you may actually want to listen back. We've got a couple of episodes on this in the past. But it's really important to understand and we have to understand the nuance here that as you're doing treatment, we are very careful not to just sweep people under the rug and say, "This is your OCD," because we want to be informed in knowing that, okay, you also do get to question your sexual orientation. But if it is a presentation of sexual orientation OCD, we will treat it like that and we will be very specific in reducing the compulsions that you're engaging in so that you can get some relief. That is the first one. 2. SEXUAL INTRUSIVE THOUGHTS ABOUT FAMILY OR SEXUAL INTRUSIVE THOUGHTS ABOUT INCEST Incest sexual OCD or that type of subtype is another very common one. But often, again, one that is not talked about enough in fear of being judged, in fear of having too much shame, in fear of being reported. When people have these types of obsessions, they often will have a thought like, "What if I'm attracted to my dad?" Or maybe they're with their sibling and they experience some arousal for reasons they don't know. Again, we talked about this in the arousal and anxiety episode, so go back and listen to that if you didn't. They may experience that, and that is where they will often say, "My brain broke. I feel like I had to solve that answer. I had to figure it out. I need to get complete certainty that that is not the case, and I need to know for sure." The important thing to remember here is a lot of my patients, I will see and they may have some of these sexual intrusive thoughts, but their partners will say, "Yeah, I've had the same thoughts." It's just that for the person without OCD, they don't experience that same degree of distress. They blow it off. It doesn't really land in their brain. It's just like a fleeting thought. Whereas people with OCD, it's like the record got stuck and it's just repeating, repeating, repeating. The distress gets higher. The doubt and uncertainty get higher. Therefore, because of all of this bubbling kettle happening, there's this really strong urgency to relieve it with compulsions. 3. SEXUAL INTRUSIVE THOUGHTS ABOUT GOD OR ABOUT A RELIGIOUS LEADER This is one that's less common, or should I say less commonly reported. We actually don't have evidence of how common it is. I think a lot of people have so much shame and are so afraid of sinning and what that means that they may even not report it. But again, this is no different to having thoughts of incest, but this one is particularly focused on having sexual thoughts about God and needing to know what that means and trying to cleanse themselves of their perceived sin, of having that intrusive thought. It can make them question their religion. It can make them feel like they have to stop going to church. They may do a ton of compulsive prayer. They may do a ton of reassurance with certain religious leaders to make sure that they're not sinning or to relieve them of that uncertainty and that distaste and distress. These are all very common symptoms of people who have sexual intrusive thoughts about God. 4. BESTIALITY OBSESSIONS These are thoughts about pets and animals, and it's very common. It's funny, as we speak, I am recording this with a three-pound puppy sitting on my lap. We just got a three-pound puppy. It is a Malti-Poo puppy dog, and he's the cutest thing you've ever seen. But it's true that when you have a dog, you're having to take care of its genitals and wipe it up and its feces and its urine and clean and all the things, and it's common to have sexual intrusive thoughts about your pet or about your dog or your cat. Some people, again, with bestiality obsessions or bestiality OCD, have a tremendous repetitive degree of these thoughts. They're very distressing because they love their dog. They would never do anything to hurt their dog, but they can't stop having these thoughts or these feelings or these sensations, or even these urges. Again, all these presentations are the same, it's just that the content is different. We treat them the same when we're discussing it, but we're very careful with addressing the high level of shame and embarrassment, humiliation, guilt that they have for these thoughts. Guilt is a huge one with these sexual obsessions. People often feel incredibly guilty as if they've done something wrong for having these obsessions. These are a few. 5. PEDOPHILIA OBSESSIONS Now, for someone who has intrusive sexual thoughts and feelings and sensations and urges about children (POCD), they tend to be, in my experience, the most distressed. They tend to be, when I see them, the ones who come in absolutely completely taken over with guilt and shame. A lot of the time, they will have completely removed themselves from their child. They feel they're not responsible. They won't go near the parks. They won't go to family's birthday parties. They're so insistent on trying to never have these thoughts. Again, I understand. I don't blame them. But as we know, the more you try not to have a thought, what happens? The more you have it. The more you try and suppress a thought, the more you have it. That can get people in a very stuck cycle. SEXUAL OCD COMPULSIONS Let's move on now to really address different sexual OCD compulsions. Now, for all sexual obsessions, or what I should say is, for all obsessions in general, there are specific categories of compulsions and these are things again that we do to reduce or remove the discomfort and certainty, dread, doubt, and so forth. 1. Trigger Avoidance This is where you avoid the thing that may trigger your obsession or thought. Avoiding your dog, avoiding your child, avoiding your family member, avoiding people of the sexual orientation that you're having uncertainty about. 2. Actual Sex Avoidance We talked about that in the first episode. We talked a lot about how people avoid sex because of the anxiety that being intimate and sexual causes. 3. Mental Rumination This is a really common one for sexual intrusive thoughts because you just want to solve like why am I having it? What does it mean? You might be ruminating, what could that mean? And going over and over and over that a many, many time. 4. Mental Checking What you can also be doing here is checking for arousal. Next time you're around, let's say, a dog and you have bestiality obsessions, you might check to see if you're aroused. But just checking to see if you're aroused means that you get aroused. Now that you're aroused, you're now checking to see what that means and trying to figure that out and you're very distressed. We can see how often the compulsion that the person does actually triggers more and more and more distress. It may provide you a moment or a fleeting moment of relief, but then you actually have more distress. It usually brings on more uncertainty. We know that the more we try and control life, the more out of control we feel. That's a general rule. That's very much the case for these types of obsessive thoughts. 5. Pornography Use A lot of people who have sexual orientation OCD in particular, but any of these, they may actually use pornography as a way to get reassurance that they are of a certain sexual orientation, that they are not attracted to the orientation that they're having uncertainty about, or they're not attracted to animals or God or a family member because they were aroused watching pornography. That becomes a form of self-reassurance. There's two types of reassurance. One is reassurance where we go to somebody else and say, "Are you sure I wouldn't do that thing? Are you sure that thing isn't true? Are you sure I don't have that? I'm not that bad a person?" The other one is really giving reassurance to yourself, and that's a very common one with pornography use. SEXUAL INTRUSIVE THOUGHTS PTSD There are some sexual intrusive thought examples, including specific obsessions and subtypes, and also compulsions. But one sexual intrusive thought example I also wanted to address is not OCD-related; it's actually related to a different diagnosis, which is called PTSD (post-traumatic stress disorder). Often for people who have been sexually assaulted or molested, they too may experience sexual intrusive thoughts in the form of memories or images of what happened to them or what could have happened to them. Maybe it's often some version of what happened to them, and that is a common presentation for PTSD. If you are experiencing PTSD, usually, there is a traumatic event that is related to the obsession or the thoughts. They usually are in association or accompanied by flashbacks. There are many other symptoms. I'm not a PTSD specialist, but there's a high level of distress, many nightmares. You may have flashbacks, as I've said. Panic is a huge part of PTSD as well. That is common. If you have had a traumatic event, I would go and see a specialist and help them to make sure that they've diagnosed you correctly so that you can get the correct care. SEXUAL INTRUSIVE THOUGHTS TREATMENT If you have OCD and you're having some of these sexual intrusive thoughts, the best treatment for you to go and get immediately is Exposure and Response Prevention. This is a particular type of cognitive behavioral therapy where you can learn to change your reaction, break yourself out of that cycle of obsessions, anxiety, compulsions, and then feed yourself back into the loop around and around. You can break that cycle and return back to doing the things you want and have a different reaction to the thoughts that you have. PEOPLE ASK HOW TO STOP SEXUAL INTRUSIVE THOUGHTS? Often people will come to me and say, "How do I stop these sexual intrusive thoughts?" I will quickly say to them, "You don't. The more you try and stop them, the more you're going to have. But what we can do is we can act very skillfully in intervening, not by preventing the thoughts, but by changing how we relate and respond to those thoughts." For those of you who don't know, I have a whole course on this called ERP School. ERP is for Exposure and Response Prevention. I'll show you how you can do this on your own, or you can reach out to me and we can talk about whether if you're in the states where we're licensed, one of my associates can help you one-on-one. If you're not in a state where I belong, reach out to the IOCDF and see if you can find someone who treats OCD using ERP in your area. Because the truth is, you don't have to suffer having these thoughts. There is a treatment to help you manage these thoughts and help you be much more comfortable in response to those thoughts. Of course, the truth here is you're never going to like them. Nobody likes these thoughts. The goal isn't to like them. The goal isn't to make them go away. The goal isn't to prove them wrong even; it's just to change your reaction to one that doesn't keep that cycle going. That is the key component when it comes to sexual intrusive thoughts treatment or OCD treatment. That's true for any subtype of OCD because there are many other subtypes as well. That's it, guys. I could go on and on and on and on about this, but I want to be respectful of your time. The main goal again is just to normalize that these thoughts happen. For some people, it happens more than others. The goal, if you can take one thing away from today, it would be, try not to assign meaning to the duration and frequency of which you have these thoughts. Often people will say, "I have them all day. That has to mean something." I'm here to say, "Let's not assign meaning to these thoughts at all. Thoughts are thoughts. They come and they go. They don't have meaning and we want to practice not assigning meaning to them so we don't strengthen that cycle." I hope that was helpful for you guys. I know it was a ton of information. I hope it was super, super helpful. I am so excited to continue with this. Next week, we are talking about menopause and anxiety, which we have an amazing doctor again. I want to talk about things with people who are really skilled in this area. We have a medical doctor coming on talking about menopause and the impact of anxiety. And then we're going to talk about PMS and anxiety, and that will hopefully conclude our sexual health and anxiety series. Thank you so much for being here. I love you guys so much. Thank you from me and from Theo, our beautiful little baby puppy. I will see you next week.

Hello and welcome back everybody. We are on Week 3 of the Sexual Health and Anxiety Series. At first, we talked with the amazing Lauren Fogel Mersy about sexual anxiety or sexual performance anxiety. And then last week, I went into depth about really understanding arousal and anxiety, how certain things will increase arousal, certain things will decrease it, and teaching you how to get to know what is what so that you can have a rich, intimate, fulfilling life. We are now on Week 3. I have to admit, this is an episode that I so have wanted to do for quite a while, mainly because I get asked these questions so often and I actually don't know the answers. It's actually out of my scope. In clinical terms, we call it "out of my scope of practice," meaning the topic we're talking about today is out of my skill set. It's out of my pay grade. It's out of my level of training. What we're talking about this week is the sexual side effects of antidepressants or anxiety medications, the common ones that people have when they are anxious or depressed. Now, as I said to you, this is a medical topic, one in which I am not trained to talk about, so I invited Dr. Sepehr Aziz onto the episode, and he does such a beautiful job, a respectful, kind, compassionate approach to addressing sexual side effects of anxiety medication, sexual side effects of depression medication. It's just beautiful. It's just so beautiful. I feel like I want to almost hand this episode off to every patient when I first start treating them, because I think so often when we're either on medication or we're considering medication, this is a really common concern, one in which people often aren't game to discuss. So, here we are. I'm actually going to leave it right to the doctor, leave it to the pro to talk all about sexual side effects and what you can do, and how you may discuss this with your medical provider. Let's do it. Kimberley: Welcome. I have been wanting to do this interview for so long. I am so excited to have with us Dr. Sepehr Aziz. Thank you so much for being here with us today. Dr. Aziz: Thanks for having me. Kimberley: Okay. I have so many questions we're going to get through as much as we can. Before we get started, just tell us a little about you and your background, and tell us what you want to tell us. Dr. Aziz: Sure. Again, I'm Dr. Sepehr Aziz. I go by "Shepherd," so you can go ahead and call me Shep if you'd like. I'm a psychiatrist. I'm board certified in general adult psychiatry as well as child and adolescent psychiatry by the American Board of Psychiatry and Neurology. I completed medical school and did my residency in UMass where they originally developed mindfulness-based CBT and MBSR. And then I completed my Child and Adolescent training at UCSF. I've been working since then at USC as a Clinical Assistant Professor of Psychiatry there. I see a lot of OCD patients. I do specialize in anxiety disorders and ADHD as well. Kimberley: Which is why you're the perfect person for this job today. Dr. Aziz: Thank you. WHAT ARE THE BEST MEDICATIONS FOR PEOPLE WITH ANXIETY & OCD (IN GENERAL)? Kimberley: I thank you so much for being here. I want to get straight into the big questions that I get asked so regularly and I don't feel qualified to answer myself. What are the best medications for people with anxiety and OCD? Is there a general go-to? Can you give me some explanation on that? Dr. Aziz: As part of my practice, I first and foremost always try to let patients know that the best treatment is always a combination of therapy as well as medications. It's really important to pursue therapy because medications can treat things and they can make it easier to tolerate your anxiety, but ultimately, in order to have sustained change, you really want to have therapy as well. Now, the first-line medications for anxiety and OCD are the same, and that's SSRIs or selective serotonin reuptake inhibitors. SNRIs, which are selective norepinephrine reuptake inhibitors, also work generally, but the best research that we have in the literature is on SSRIs, and that's why they're usually preferred first. There are other medications that also might work, but these are usually first-line, as we call it. There are no specific SSRIs that might work better. We've tried some head-to-head trials sometimes, but there's no one medication that works better than others. It's just tailored depending on the patient and the different side effects of the medication. SSRI'S VS ANTIDEPRESSANTS DEFINITION Kimberley: Right. Just so people are clear in SSRI, a lot of people, and I notice, use the term antidepressant. Are they synonymous or are they different? Dr. Aziz: Originally, they were called antidepressants when they first were released because that was the indication. There was an epidemic of depression and we were really badly looking for medications that would work. Started out with tricyclic antidepressants and then we had MAOIs, and then eventually, we developed SSRIs. These all fall under antidepressant treatments. However, later on, we realized that they work very well for anxiety in addition to depression. Actually, in my opinion, they work better for anxiety than they do for depression. I generally shy away from referring to them as antidepressants just to reduce the stigma around them a little bit and also to be more accurate in the way that I talk about them. But yes, they're synonymous, you could say. BEST MEDICATION FOR DEPRESSION Kimberley: Sure. Thank you for clearing that up because that's a question I often get. I know I led you in a direction away but you answered. What is the best medication for people with depression then? Is it those SSRIs or would you go-- Dr. Aziz: Again, these are first-line medications, which means it's the first medication we would try if we're starting medication, which is SSRIs. Other medications might also work like SNRIs again. For depression specifically, there are medications called serotonin modulators that are also effective such as vortioxetine or nefazodone, or vilazodone. But SSRIs are generally what people reach for first just because they've been around for a long time, they're available generic, they work, and there's no evidence that the newer medications or modulators work better. They're usually first line. Kimberley: Fantastic. Now you brought up the term "generic" and I think that that's an important topic because the cost of therapy is high. A lot of people may be wondering, is the generic as good as the non-generic options? Dr. Aziz: It really depends on the medication and it also depends on which country you're in. In the US, we have pretty strict laws as to how closely a generic has to be to a regular medication, a brand name medication, and there's a margin of error that they allow. The margin of error for generics is, I believe, a little bit higher than for the brand name. However, most of the time, it's pretty close. For something like Lexapro, I usually don't have any pressure on myself to prescribe the brand name over the generic. For something like other medications we use in psychiatry that might have a specific way that the brand name is released, a non-anxiety example is Concerta, which is for ADHD. This medication uses an osmotic release mechanism and that's proprietary. They license it out to one generic company, but that license is expiring. All those patients who are on that generic in the next month or two are going to notice a difference in the way that the medication is released. Unless you're a physician privy to that information, you might not even know that that's going to happen. That's where you see a big change. Otherwise, for most of the antidepressants, I haven't noticed a big difference between generic and brand names. Kimberley: Right. Super helpful. Now you mentioned it depends on the person. How might one decide or who does decide what medication they would go on? Dr. Aziz: It's really something that needs to be discussed between the person and their psychiatrist. There are a number of variables that go into that, such as what's worked in a family member in the past, because there are genetic factors in hepatic metabolism and things like that that give us some clue as to what might work. Or sometimes if I have a patient with co-occurring ADHD and I know they're going to be missing their medications a lot, I'm more likely to prescribe them Prozac because it has a longer half-life, so it'll last longer. If they miss a dose or two, it's not as big of a deal. If I have a patient who's very nervous about getting off of the medication when they get pregnant, I would avoid Prozac because it has a long half-life and it would take longer to come off of the medication. Some medications like Prozac and Zoloft are more likely to cause insomnia or agitation in younger people, so I'll take that into consideration. Some medications have a higher likelihood of causing weight loss versus weight gain. These are all things that would take into consideration in order to tailor it to the specific patient. Kimberley: Right. I think that's been my experience too. They will usually ask, do you have a sibling or a parent that tried a certain medication, and was that helpful? I love that question. I think it informs a lot of decisions. We're here really. The main goal of today is really to talk about one particular set of side effects, which is the sexual side effects of medication. In fact, I think most commonly with clients of mine, that tends to be the first thing they're afraid of having to happen. How common are sexual side effects? Is it in fact all hype or is it something that is actually a concern? How would you explain the prevalence of the side effects? Dr. Aziz: This is a really important topic, I just want to say, because it is something that I feel is neglected when patients are talking to physicians, and that's just because it can be uncomfortable to talk about these things sometimes, both for physicians and for patients. Oftentimes, it's avoided almost. But because of that, we don't know for sure exactly what the incidence rate is. The literature on this and the research on this is not very accurate for a number of reasons. There are limitations. The range is somewhere between 15 to 80% and the best estimate is about 50%. But I don't even like saying that because it really depends on age, gender, what other co-occurring disorders they have such as depression. Unipolar depression can also cause sexual dysfunction. They don't always take that into account in these studies. A lot of the studies don't ask baseline sexual function before asking if there's dysfunction after starting a medication, so it's hard to tell. What I can say for sure, and this is what I tell my patients, is that this sexual dysfunction is the number one reason why people stop taking the medication, because of adverse effects. WHAT MEDICATIONS ARE MORE PRONE TO SEXUAL SIDE EFFECTS? Kimberley: Right. It's interesting you say that we actually don't know, and it is true. I've had clients say having anxiety has sexual side effects too, having depression has sexual side effects too, and they're weighing the pros and cons of going on medication comparative to when you're depressed, you may not have any sexual drive as well. Are some medications more prone to these sexual side effects? Does that help inform your decision on what you prescribe because of certain meds? Dr. Aziz: Yeah. I mean, the SSRIs specifically are the ones that are most likely to cause sexual side effects. Technically, it's the tricyclics, but no one really prescribes those in high doses anymore. It's very rare. They're the number one. But in terms of the more commonly prescribed antidepressants and anti-anxiety medications among the SSRIs and the SNRIs and the things like bupropion and the serotonin modulators we talked about, the SSRIs are most likely to cause sexual dysfunction. Kimberley: Right. Forgive me for my lack of knowledge here, I just want to make sure I'm understanding this. What about the medications like Xanax and the more panic-related medications? Is that underneath this category? Can you just explain that to me? Dr. Aziz: I don't usually include those in this category. Those medications work for anxiety technically, but in current standard practice, we don't start them as an initial medication for anxiety disorders because there's a physical dependency that can occur and then it becomes hard to come off of the medication. They're used more for panic as an episodic abortive medication when someone is in the middle of a panic attack, or in certain cases of anxiety that's not responding well to more conventional treatment, we'll start it. We'll start it on top of or instead of those medications. They can cause sexual side effects, but it's not the same and it's much less likely. SEXUAL SIDE EFFECTS OF MEDICATION FOR MEN VS WOMEN Kimberley: Okay. Very helpful. Is it the same? I know you said we don't have a lot of data, and I think that's true because of the stigma around reporting sexual side effects, or even just talking about sex in general. Do we have any data on whether it impacts men more than women? Dr. Aziz: The data shows that women report more sexual side effects, but we believe that's because women are more likely to be treated with SSRIs. When we're looking at the per capita, we don't have good numbers in terms of that. In my own practice, I'd say it's pretty equal. I feel like men might complain about it more, but again, I'm a man and so it might just be a comfort thing of reporting it to me versus not reporting. Although I try to be good about asking before and after I start medication, which is very important to do. But again, it doesn't happen all the time. Kimberley: Yeah, it's interesting, isn't it? Because from my experience as a clinician, not a psychiatrist, and this is very anecdotal, I've heard men because of not the stigma, but the pressure to have a full erection and to be very hard, that there's a certain masculinity that's very much vulnerable when they have sexual side effects—I've heard that to be very distressing. In my experience. I've had women be really disappointed in the sexual side effects, but I didn't feel that... I mean, that's not really entirely true because I think there's shame on both ends. Do you notice that the expectations on gender impacts how much people report or the distress that they have about the sexual side effects? Dr. Aziz: Definitely. I think, like you said, men feel more shame when it comes to sexual side effects. For women, it's more annoyance. We haven't really talked about what the sexual side effects are, but that also differs between the sexes. Something that's the same between sexes, it takes longer to achieve orgasm or climax. In some cases, you can't. For men, it can cause erectile dysfunction or low libido. For women, it can also cause low libido or lack of lubrication, which can also lead to pain on penetration or pain when you're having sex. These are differences between the sexes that can cause different reporting and different feelings, really. Kimberley: Right. That's interesting that it's showing up in that. It really sounds like it impacts all the areas of sexual playfulness and sexual activity, the arousal, the lubrication. That's true for men too, by the sounds of it. Is that correct? Dr. Aziz: Yeah. Kimberley: We've already done one episode about the sexual performance anxiety, and I'm sure it probably adds to performance anxiety when that's not going well as well, correct? Dr. Aziz: It's interesting because in my practice, when I identify that someone is having sexual performance anxiety or I feel like somebody, especially people with anxiety disorders, if I feel like they have vulvodynia, which means pain on penetration—if I see they have vulvodynia and I feel that this is because of the anxiety, oftentimes the SSRI might improve that and cause greater satisfaction from sex. It's a double-edged sword here. COMMON SEXUAL SIDE EFFECTS OF ANTIDEPRESSANTS Kimberley: Yeah. Can you tell me a little more about What symptoms are they having? The pain? What was it called again? Dr. Aziz: Vulvodynia. Kimberley: Is that for men and women? Just for women, I'm assuming. Dr. Aziz: Just from vulva, it is referring to the outside of the female genitalia. Especially when you have a lack of lubrication or sometimes the muscles, everyone with anxiety knows sometimes you have muscle tension and there are a lot of complex muscles in the pelvic floor. Sometimes this can cause pain when you're having sex. There are different ways to address that, but SSRIs sometimes can improve that. Kimberley: Wow. It can improve it, and sometimes it can create a side effect as well, and it's just a matter of trial and error, would you say? Dr. Aziz: It's a delicate balance because these side effects are also dose-dependent. It's not like black or white. I start someone on 5 milligrams, which is a child's dose of Lexapro. Either they have sexual side effects or don't. They might not have it on 5, and then they might have it a little bit on 10, and then they get to 20 and they're like, "Doctor, I can't have orgasms anymore." We try to find the balance between improving the anxiety and avoiding side effects. SEXUAL SIDE EFFECTS TREATMENT Kimberley: You're going right into the big question, which is, when someone does have side effects, is it the first line of response to look at the dose? Or how would you handle a case if someone came to you first and said, "I'm having sexual side effects, what can we do?" Dr. Aziz: Again, I'm really thorough personally. Before I even seem to start a medication, I'll ask about libido and erectile dysfunction and ability to climax and things like that, so I have a baseline. That's important when you are thinking about making a change to someone's medications. The other thing that's important is, is the medication working for them? If they haven't seen a big difference since they started the medication, I might change the medication. If they've seen an improvement, now there's a pressure on me to keep the medication on because it's working and helping. I might augment it with a second medication that'll help reverse the sexual side effects or I might think about reducing the dose a little bit while maintaining somewhere in the therapeutic zone of doses or I might recommend, and I always recommend non-pharmacological ways of addressing sexual side effects. You always do that at baseline. Kimberley: What would that be? Dr. Aziz: There's watchful waiting. Sometimes if you just wait and give it some time, these symptoms can get better. I'm a little more active than that. I'll say it's not just waiting, but it's waiting and practicing, whether that's solo practice or with your partner. Sometimes planning sex helps, especially if you have low libido. There's something about the anticipation that can make someone more excited. The use of different aids for sex such as toys, vibrators, or pornography, whether that's pornographic novels or imagery, can sometimes help with the libido issues and also improve satisfaction for both partners. The other thing which doesn't have great research, but there is a small research study on this, and not a lot of people know about this, but if you exercise about an hour before sex, you're more likely to achieve climax. This was specifically studied in people with SSRI-related anorgasmia. Kimberley: Interesting. I'm assuming too, like lubricants, oils, and things like that as well, or? Dr. Aziz: For lubrication issues, yes. Lubricants, oils, and again, you really have to give people psychoeducation on which ones they have to use, which ones they have to avoid, which ones interact with condoms, and which ones don't. But you would recommend those as well. Kimberley: Is it a normal practice to also refer for sex therapy? If the medication is helping their symptoms, depression, anxiety, OCD, would you ever refer to sex therapy to help with that? Is that a standard practice or is that for specific diagnoses, like you said, with the pain around the vulva and so forth? Dr. Aziz: Absolutely. A lot of the things I just talked about are part of sex therapy and they're part of the sexual education that you would receive when you go to a sex therapist. I happen to be comfortable talking about these things, and I've experienced talking about it. When I write my notes, that would fall under me doing therapy. But a lot of psychiatrists would refer to a sex therapist. Hopefully, there are some in the town nearby where someone is. It's sometimes hard to find someone that specializes in that. Kimberley: Is there some pushback with that? I mean, I know when I've had patients and they're having some sexual dysfunction and they do have some pushback that they feel a lot of shame around using vibrators or toys. Do you notice a more willingness to try that because they want to stay on the meds? Or is it still very difficult for them to consider trying these additional things? Are they more likely to just say, "No, the meds are the problem, I want to go off the medication"? Dr. Aziz: It really depends on the patient. In my population that I see, I work at USC on campus, so I only see university students in my USC practice. My age group is like 18 to 40. Generally, people are pretty receptive. Obviously, it's very delicate to speak to some people who have undergone sexual trauma in the past. Again, since I'm a man, sometimes speaking to a woman who's had sexual trauma can be triggering. It's a very delicate way that you have to speak and sometimes there's some pushback or resistance. It can really be bad for the patient because they're having a problem and they're uncomfortable talking about it. There might be a shortage of female psychiatrists for me to refer to. We see that. There's also a portion of the population that's just generally uncomfortable with this, especially people who are more religious might be uncomfortable talking about this and you have to approach that from a certain angle. I happen to also be specialized in cultural psychiatry, so I deal with these things a lot, approaching things from a very specific cultural approach, culturally informative approach. Definitely, you see resistance in many populations. Kimberley: I think that that's so true. One thing I want to ask you, which I probably should have asked you before, is what would you say to the person who wants to try meds but is afraid of the potential of side effects? Is there a certain spiel or way in which you educate them to help them understand the risks or the benefits? How do you go about that for those who there's no sexual side effects, they're just afraid of the possibility? Dr. Aziz: As part of my practice, I give as much informed consent to my patients as I can. I let them know what might happen and how that's going to look afterwards. Once it happens, what would we do about it if it happened? A lot of times, especially patients with anxiety, you catastrophize and you feel this fear of some potential bad thing happening, and you never go past that. You never ask yourself, okay, well now let's imagine that happens. What happens next? I tell my patients, "Yeah, you might have sexual dysfunction, but if that happens, we can reduce the medications or stop them and they'll go away." I also have to tell my patients that if they search the internet, there are many people who have sexual side effects, which didn't go away, and who are very upset about it. This is something that is talked about on Reddit, on Twitter. When my patients go to Dr. Google and do their research, they often get really scared. "Doctor, what if this happens and it doesn't go away?" I always try to explain to them, I have hundreds of patients that I've treated with these medications. In my practice, that's never happened. As far as I know from the literature, there are no studies that show that there are permanent dysfunctions sexually because of SSRIs. Now, like I said, the research is not complete, but everything that I've read has been anecdotal. My feeling is that if you address these things in the beginning and you're diligent in asking about the side effects of baseline sexual function beforehand and you are comfortable talking with your patients about it, you can avoid this completely. That's been my experience. When I explain that to my patients, they feel like I have their back, like they're protected, like I'm not just going to let them fall through the cracks. That has worked for me very well. Kimberley: Right. It sounds like you give them some hope too, that this can be a positive experience, that this could be a great next step. Dr. Aziz: Yeah, absolutely. Kimberley: Thank you for bringing up Dr. Google, because referring to Reddit for anything psychologically related is not a great idea, I will say. Definitely, when it comes to medications, I think another thing that I see a lot that's interesting on social media is I often will get dozens of questions saying, "I heard such and such works. Have your clients taken this medication? I heard this medication doesn't work. What's your experience?" Or if I've told them about my own personal experience, they want to know all about it because that will help inform their decision. Would you agree, do not get your information from social media or online at all? Dr. Aziz: I have patients who come to me and they're like, "My friend took Lexapro and said it was the worst thing in the world, and it may or not feel any emotions." I'm explaining to them, I literally have hundreds of patients, hundreds that I prescribe this to, and I go up and down on the dose. I talk to them about their intimate lives all day. But for some reason, and it makes sense, the word of their friend or someone close to them, really, carries a lot of weight. Also, I don't want to discount Reddit either, because I feel like it's as a support system and as a support group. I find other people who have gone through what you've gone through. It's very strong. Even pages like-- I don't want to say the page, but there's a page that's against psychiatry, and I peruse this page a lot because I have my own qualms about psychiatry sometimes. I know the pharmaceutical companies have a certain pressure on themselves financially, and I know hospitals have a certain pressure on themselves. I get it. I go on the page and there's a lot of people who have been hurt in the past, and it's useful for patients to see other people who share that feeling and to get support. But at the same time, it's important to find providers that you can trust and to have strong critical thinking skills, and be able to advocate for yourself while still listening to somebody who might have more information than you. Kimberley: I'm so grateful you mentioned that. I do think that that is true. I think it's also what I try to remember when I am online. The people who haven't had a bad experience aren't posting on Reddit. They're out having a great time because it helped, the medication helped them, and they just want to move on. I really respect those who have a bad experience. They feel the need to educate. But I don't think it's that 50% who gave a great experience are on Reddit either. Would you agree? Dr. Aziz: Right. Yeah. The people who are having great outcomes are not creating a Reddit page to go talk about it, right? Kimberley: Yeah. Thank you so much for answering all my questions. Is there a general message that you want to give? Maybe it's even saying it once over on something you've said before. What would be your final message for people who are listening? WHEN SSRIs IMPACTS YOUR SEX LIFE: ADVICE FROM DR AZIZ Dr. Aziz: I just want to say that when SSRI's impact your sex life, it's really important for psychiatry, and especially in therapy, that you feel comfortable sharing your experiences in that room. It should be a safe space where you feel comfortable talking about your feelings at home and what's going on in your intimate life and how things are affecting you. Your feelings, positive or negative towards your therapist or your psychiatrist, whether things they said made you uncomfortable, whether you feel they're avoiding something, that room should be a safe space for you to be as open as possible. When you are as open as possible, that's when you're going to get the best care because your provider, especially in mental health, needs to know the whole picture of what's going on in your life. Oftentimes, we are just as uncomfortable as you. And so, again, a lot of providers might avoid it because they're afraid of offending you by asking about your orgasms. As a patient, you take the initiative and you bring it up. It's going to improve your care. Try not to be afraid of bringing these things up. If you do feel uncomfortable for any reason, always let your provider know. I always tell my patients, I have a therapist. I pay a lot of money to see my therapist, and sometimes I tell him things I hate about him. He's a great therapist. He's psychoanalytic. Every time I bring something up, he brings it back to something about my dad. He's way older than me. But he's a great therapist. Every time I've brought something like that up, it's been a breakthrough for me because that feeling means something. That would be my main message to everyone listening. Kimberley: Thank you. I'm so grateful for your time and your expertise. Really, thank you. Can you tell us where people can get in touch with you, seek out your services, read more about you? Dr. Aziz: Sure. I work for OCD SoCal. I'm on the executive board, and that's the main way I like to communicate with people who see me on programs like this. You can always email me at S, like my first name, Aziz, that's A-Z-I-Z, @OCDSoCal.org. If you're a USC student, you can call Student Health and request to see me at the PBHS clinic. That's the Psychiatry and Behavioral Health Services clinic on campus at USC. Kimberley: They're lucky to have you. Dr. Aziz: Thank you. Kimberley: Yes. I love that you're there. Thank you so much for all of your expertise. I am so grateful. This has been so helpful.

Welcome back, everybody. We are on Episode 2 of the Sexual Health and Anxiety Series. Today, I will be the main host and main speaker for the episode, talking about arousal and anxiety. This is a topic that goes widely misunderstood, particularly in the OCD and anxiety field where people are having arousal that they can't make sense of. It's also very true of people with PTSD. They're having arousal that makes no sense to them, that confuses them, that increases anxiety, increases shame, increases guilt, and from there, it all becomes like a huge mess to them. It becomes incredibly painful, and it's just so messy they can't make sense of it. My hope with this episode is to help you understand the science behind arousal and the science behind arousal and anxiety so that you can move forward and manage your anxiety around arousal and manage your shame and guilt and sadness and grief around arousal, and have a better relationship with your body and with yourself and your soul. Now, these are more difficult conversations. I have talked about them in the past, and so I want you just to go into this really, really gentle, really open with con compassion and kindness, and curiosity. Your curiosity is going to help you immensely as you move through this series, as you move through some of the difficult conversations we're going to have, maybe a little bit embarrassing, humiliating, and so forth. Even me telling my kids that I'm so excited, I'm doing a series on sexual health, they're like, "Mom, you can't talk about that to other people." I'm like, "Yes, I can. We're going to talk about it. Hopefully, when you're old enough, you'll be able to listen to this and you'll be so glad that we're having conversations around this and taking the shame and stigma, and misinformation out of it." I'm going to go straight into the episode. This is our episode on understanding arousal and anxiety. We are going to come on next week talking about an entirely different subject about sexual health and intimacy, sex and anxiety, and arousal and anxiety. I am so excited. Stick around. Enjoy every bit of it. Take as many notes as you can, but please, please be kind to yourself. Let's get to the show. ANXIETY AND AROUSAL Let's get into the episode. Let me preface the episode by, we're talking about anxiety and arousal. If I could have one person on the podcast, it would be Emily Nagoski. I have been trying to get her on the podcast for a while. We will get her on eventually. However, she's off doing amazing things—Netflix specials, podcasts, vet documentaries. She's doing amazing things. Hopefully one day. But until then, I want to really highlight her as the genius behind a lot of these concepts. Emily Nagoski is a doctor, a psychology doctor. She is a sex educator. She's written two amazing books. Well, actually three or four, but the ones I'm referring to today is Come As You Are. It's an amazing book, but I'm actually in my hand holding The Come As You Are Workbook. I strongly encourage you after you listen to this podcast episode to go and order that book. It is amazing. It's got tons of activities. It might feel weird to have the book. You can get it on Kindle if you want to have it be hidden, but it's so filled with amazing information and I'm going to try and give you the pieces that I really want you to take away. If you want more, by all means, go and get the workbook. The workbook is called The Come As You Are Workbook: A Practical Guide to The Science of Sex. The reason I love it is because it's so helpful for those who have anxiety. It's like she's speaking directly to us. She's like, "It's so helpful to have this context." Here's the thing I want you to consider starting off. A lot of people who have anxiety report struggles with arousal. We're going to talk about two different struggles that are the highlight of today. Either you have no arousal because of your anxiety, or you're having arousal at particular times that concern you and confuse you, and alarm you. You could be one or both of those camps. Let's first talk about those who are struggling with arousal in terms of getting aroused. The thing I want you to think about is, commonly, this is true for any mental health issue too. It's true for depression, anxiety disorders, eating disorders, dissociative disorders—all of them really. But the thing I want you to remember, no matter who you are and what your experience is, even if you have a really healthy experience of your own sexual arousal and you're feeling fine about it, we all have what's called inhibitors and exciters. Here is an example: An inhibitor is something that inhibits your arousal. An exciter is something that excites your arousal. Now, you're probably already feeling a ton of judgment here like, "I shouldn't be aroused by this, and I should be aroused by this. What if I'm aroused by this and I shouldn't be," and so forth. I want us to take all the judgment out of this and just look at the content of what inhibits our arousal or excites our arousal. Because sometimes, and I'll talk about this more, it's for reasons that don't make a lot of sense, and that's okay. SEXUAL INHIBITORS AND SEXUAL EXCITERS Let's talk about a sexual inhibitor—something that pumps the brakes on arousal or pleasure. It could be either. There's exciters, which are the things that are really like the gas pedal. They just really bring on arousal, bring on pleasure, and so forth. We have the content. The content may be, first, mental or physical, and this includes your health, your physical health. For me, I know when I am struggling with POTS, arousal is just barely a thing. You're just so wiped out and you're so exhausted and your brain is foggy, and it's just like nothing. That would be, in my case, an inhibitor. I'm not going to talk about myself a lot here, but I was just using that as an example. You might say your anxiety or your obsession is an inhibitor. It pumps the brakes on arousal. It makes it go away. Worry is one. It could also be other physical health like headaches or tummy aches or, as we said before, depression. It could be hormone imbalances, things like that. It's all as important. Go and speak with your doctor. That's super important. Make sure medically everything checks out if you're noticing a dip or change in arousal, that's concerning you. The next one in terms of content that may either excite you or inhibit you is your relationship. If your relationship is going well, you may or may not have an increase in arousal depending on what turns you on. If your partner smells of a certain smell or stench that you don't like, that may pump the brakes. But if they smell a certain way that you do really like, and really is arousing to you, that may excite your arousal. It could also be the vibe of the relationship. A lot of people said, at the beginning of COVID, there was a lot of fear. That was really, really strong on the brakes. But then all of a sudden, no one had anything to do, and there was all this spare time. All of a sudden, the vibe is like, that's what's happening. Now, this could be true for people who are in any partnership, or it could be just you on your own too. There are things that will excite you and inhibit your arousal if you're not in a relationship as well, and that's totally fine. This is for all relationships. There's no specific kind. Setting is another thing that may pump the brakes or hit the gas for arousal, meaning certain places, certain rooms, certain events. Did your partner do something that turned you on? Going back to physical, it could also depend on your menstrual cycle. People have different levels of arousal depending on different stages of their menstrual cycle. I think the same is true for men, but I don't actually have a lot of research on that. But I'm sure there are some hormonal impacts for men as well. There's also ludic factors, which are like fantasy, whether you have a really strong imagination that either pumps the brakes or puts the gas pedal in terms of arousal. It could be like where you're being touched. Sometimes there's certain areas of your body that will set off either the gas pedal or the brakes. It could be a certain foreplay. Again, really what I'm trying to get at here isn't breaking it down according to the workbook, but there's so many factors that may influence your arousal. SHAME AND SEXUAL AROUSAL Another one is environmental and cultural and shame. If arousal and the whole concept of sex was shamed or booked down on, or people have a certain opinion about your sexual orientation, that too can impact your gas pedal and your brakes pedal. I want you to explore this not from a place of pulling it apart really aggressively and critically, but really curiously, and check in for yourself. What arouses me? What presses my brakes? What presses my gas? And just start to get to know that. Again, in the workbook, there's tons of worksheets for this, but you could also just consider this on your own. Write it down on your own. Be aware over the next several days or weeks, just jot down in a journal what you're noticing. Now, before we move on, we've talked about a lot of people who are struggling with arousal and they've got a lot of inhibitors and brake pushing. There are the other camps who have a lot of gas pedal pushing. I speak here directly to the folks who have sexual obsessions, because often if you have sexual obsessions, the fact that your sexual obsession is sexual in nature may be what sets the gas pedal off, and all of a sudden, you have arousal for reasons that you don't understand, that don't make sense to you or maybe go against your values. I've got a quote that I took from the book and from the workbook of Emily Nagoski. Again, none of this is my personal stuff. I'm quoting her and citing her throughout this whole podcast. She says: "Bodies do not say yes or no; they say sex-related or not sex-related." Let me say it again. "Bodies do not say yes or no; they say sex-related or not sex-related." This is where I want you to consider, and I've experienced this myself. Just because something arouses you doesn't mean it brings you pleasure—main point. We've got to pull them apart. SEXUAL OBSESSIONS & AROUSAL Culture has led us to believe that if you feel some groinal response to something, you must love it and want more of it. An example of this is, for people with sexual obsessions, maybe they have OCD or some other anxiety disorder and they have an intrusive thought about a baby or an animal. Bestiality is another very common obsession with OCD, or could be just about a person. It could be just about a person that you see in the grocery store. When you have a thought that is sex-related, sometimes, because the context of it is that it's sex-related, your body may get aroused. Our job, particularly if you have OCD, is not to try and figure out what that means, is not to try and resolve like, does that mean I like it? Does that mean I'm a terrible person? What does that mean? I want you to understand the science here to help you understand your arousal, to help you understand how you can now shift your perspective towards your body and your mind and the pleasure that you experience in the area of sexuality. THE GROINAL RESPONSE Let's talk about the groial resopsne. Again, the body doesn't say yes or no; they say either sex-related or not sex-related. Here's the funny thing, and I've done this experiment with my patients before, if you look at a lamp post or it could be anything. You could look at the pencil you're holding, and you think about, and then you bring to mind a sexual experience, you may notice arousal (or the groinal response). Again, it doesn't mean that you're now aroused by pencils or pens; it's that it was labeled as sex-related. Often your brain will naturally press the accelerator. That's often how I educate people, particularly those who are having arousal that concern it. It's the same for a lot of people who have sexual trauma. They maybe are really concerned about the fact that they do have arousal around a memory or something, and then that concerns them, what does that mean about me? The thing to remember too is it's not your body saying yes or no; it's your body saying sex-related or not sex-related. It's important to just help remind yourself of that so that you're not responding to the content so much and getting caught up in compulsive behaviors. A lot of my patients in the past have reported, particularly during times when they're stressed, their anxiety is really high, life is difficult, any of this content we went through, they may actually have a hard time being aroused at all. Some people have reported not getting an erection and then it completely going for reasons they don't understand. I think here, we want to practice, again, non-judgment. Instead, move to curiosity. There's probably some content that impacted that, which is, again, very, very normal. BETTER SEX THROUGH MINDFULNESS I'm talking with patients. I've done episodes on this in the past and we've in fact had sex therapists on the podcast in the past. They've said, if you've lost arousal, it doesn't mean you give up. It doesn't mean you say, "Oh, well, that's that." What you do is you move your attention to the content that pumps the gas. When I mean content, it's like touch, smell, the relationship, the vibe, being in touch with your body, bringing your attention to the dance that you're doing, whether it's with a partner or by yourself or whatever means that works for you. You can bring that back. Another amazing book is called Better Sex Through Mindfulness. It talks a lot about bringing your attention to one or two sensations. Touch and smell being two really, really great ones. Again, if your goal is to be aroused, you might find it's very hard to be aroused because the context of that is pressure. I don't know about you, but I don't really find pressure arousing. Some may, and again, this is where I want this to be completely judgment free. There is literally no right and wrong. But pressure is usually not that arousing. Pressure is not that pleasurable in many cases, particularly when it's forceful and it feels like you have to perform a certain way. Again, some people are at their best in performance mode, but I want to just remind you, the more pressure you put on yourself on this idea of ending it well, it's probably going to make some anxiety. Same with test anxiety. The more pressure you put on yourself to get an A, the more you're likely to spin out with anxiety. It's really no different. Here is where I want you to catch and ask yourself, is the pressure I put on myself or is the agenda I put on myself actually pumping the brakes for me when it comes to arousal? Is me trying not to have a thought, actually in the context of that, does that actually pump the brakes? Because I know you're trying not to have the thought so that you can be intimate in that moment and engaged in pleasure. But the act of trying not to have the thought can actually pump the brakes. I hope that makes sense. I want you to get really close to understanding what's going on for you. Everyone is different. Some things will pump the brakes, some things will pump the accelerator. A lot of the times, thought suppression pumps the brakes. A lot of the times, beating yourself up pumps the brakes. A lot of the time, they're more like goal, like I have to do it this way. That often pumps the brakes. Keep an eye out for that. Engage in the exciters and get really mindful and present. A couple of things here. We've talked about erections. That's for people who struggle with that. It's also true for women and men with lubrication. Some people get really upset about the fact that there may or may not be a ton of lubrication. Again, we've been misled to believe that if you're not lubricated, you mustn't be aroused or that you mustn't want this thing, or that there must be something wrong with you, and that is entirely not true. A lot of women, when we study them, may be really engaged and their gas pedal is going for it, but there may be no lubrication. It doesn't mean something is wrong in those cases. Often a sex therapist or a sex educator will encourage you to use lubrication, a lubricant. I've talked to clients and they're so ashamed of that. But I think it's important to recognize that that's just because somebody taught us that, and sadly, it's a lot to do with patriarchy and that it was pushed on women in particular, that that meant they're like a good woman if they're really lubricated. That's not true. That's just fake, false, no science, has no basis in reality. Now we've talked about lubrication, we've talked about erection. Same for orgasm. Some people get really frustrated and disheartened that they can't reach orgasm. If for any reason you're struggling with this, please, I urge you, go and see a sex therapist. They are like the most highly trained therapists. They are so sensitive and compassionate. They can talk with you about this and you can target the specific things you want to work on. But orgasm is another one. If you put pressure on yourself to get there, that pumps the brakes often. What I want you to do, and this is your homework, is don't focus on arousal; focus on pleasure. Again, it's really about being in connection with your partner or yourself. As soon as you put a list of to-dos with it is often when things go wrong. Just focus on being present as much as you can and in the moment being aware of, ooh. Move towards the exciters, the gas pedal things. Move away from the inhibitors. Be careful there. Again, for those of you who have anxiety, that doesn't mean thought suppress, that doesn't mean judge your thoughts because that in and of itself is an inhibitor often. I want to leave you with that. I'm going to, in the future, do a whole nother episode about talking more about this idea of arousal non-concordance, which is that quote I used: "The bodies don't say yes or no; they say sex-related or not sex-related." I'll do more of that in the future, but for right now, I want it to be around you exploring your relationship with arousal, understanding it, but then putting your attention on pleasure. Being aware of both, being mindful of both. I'm not a sex therapist. Again, I'm getting all of this directly from the workbook, but most of the clients I've talked to about this, and we've used some worksheets and so forth, they've said, "When I put all the expectations away and I just focus on this touch and this body part and this smell and this kiss or this fantasy, or being really in touch with your own body, when I just make it as simple as that and I bring it down to just engaging in what feels good, use it as a north star. You just keep following, that feels good. Okay, that feels good. That doesn't feel so great. I'll move towards what feels good"—moving in that direction non-judgmentally and curiously, they've had the time of their lives. I really just want to give you that gift. Focus on pleasure. Focus non-judgmentally and curiously, being aware of what's current and present in your senses. That's all I got for you for today. I think it's enough. Do we agree? I think it's enough. I could talk about this all day. To be honest, and I've said this so many times, if I had enough time, I would go back and I would become a sex therapist. It is a huge training. Sex therapists have the most intensive, extensive training and requirements. I would love to do it. But one day, I'll probably do it when I'm like 70. That will be awesome. I'll be down for that for sure. I just love this content. Again, I want to be really clear, I'm not a sex therapist and so I still have tons to learn. I still have. Even with what we've covered today, there's probably nuanced things that I could probably explain better, which is why I'm going to stress to you, go and check out the book. I was thinking about this. Remember I just recently did the episode on the three-day silent retreat and I was sitting in meditation. I remember this so clearly. I'm just going to tell you this quick story. For some reason, my mind was a little scattered this day and something came over with me where I was like, "Wouldn't it be wonderful if I didn't just treat anxiety disorders but I treated the person and the many problems that are associated with the anxiety disorder? Isn't that a beautiful goal? Isn't that so? Because it's not just the anxiety; it's the little tiny areas in our lives that it impacts." As soon as I finished the meditation, I went on to my organization board that I use online and it was like, "Arousal. Let's talk about pee and poop," which is one episode we recently did. "Let's talk about all the things because anxiety affects it all." We can make little changes in all these areas, and slowly, you get your life back. So, I hope this gives you a little bit of your sexual expression back, if I could put it into words. Maybe not expression, but just your relationship with your body and pleasure. I love you. Thank you for staying with me for this. This was brave work you're doing. You probably had cringey moments. Hopefully not. Again, none of this is weird, wrong, bad. This is all human stuff. So, finish up. Again, go check out the book. Her name is Emily Nagoski. I'll leave a link in the show notes. One day we'll get her on. But in the meantime, I'll hopefully just give you the science that she's so beautifully given us.

You guys, I am literally giggling with excitement over what we are about to do together. Last year, we did a series, the first series on Your Anxiety Toolkit where we talked about mental compulsions. It was a six-part series. We had some of the best therapists and best doctors in the world talking about mental compulsions. It was such a hit. So many people got so much benefit out of it. I loved it so much, and I thought that was fun, let's get back to regular programming. But for the entire of last year after that series, it kept bugging me that I needed to do a series on sexual health and anxiety. It seems like we're not talking about it enough. It seems like everyone has questions, even people on social media. The algorithm actually works against those who are trying to educate people around sex and sexual side effects and arousal and how anxiety impacts it. And so here I am. No one can stop us. Let's do it. This is going to be a six-part sexual health and anxiety series, and today we have a return guest, the amazing Lauren Fogel Mersy. She is the best. She is a sex therapist. She talks all about amazing stuff around sexual desire, sexual arousal, sexual anxiety. She's going to share with you, she has a book coming out, but she is going to kick this series off talking about sexual anxiety, or we actually also compare and contrast sexual performance anxiety because that tends to better explain what some of the people's symptoms are. Once we go through this episode, we're then going to meet me next week where I'm going to go back over. I've done an episode on it before, but we're going to go back over understanding arousal and anxiety. And then we're going to have some amazing doctors talking about medications and sexual side effects. We have an episode on sexual intrusive thoughts. We have an episode on premenstrual anxiety. We also have an episode on menopause and anxiety. My hope is that we can drop down into the topics that aren't being covered enough so that you feel like you've got one series, a place to go that will help you with the many ways in which anxiety can impact us when it comes to our sexual health, our sexual arousal, our sexual intimacy. I am so, so, so excited. Let's get straight to it. This is Episode 1 of the Sexual Health and Anxiety Series with Dr. Lauren Fogel Mersy. Lauren is a licensed psychologist. She's a certified sex therapist, she's an author, and she is going to share with us and we're going to talk in-depth about sexual anxiety. I hope you enjoy the show. I hope you enjoy all of the episodes in this series. I cannot wait to listen to these amazing speakers—Lauren, being the first one. Thank you, Lauren. What Is Sexual Anxiety Or Sexual Performance Anxiety? Are They The Same Thing? Kimberley: Welcome. I am so happy to have you back, Dr. Lauren Fogel Mersy. Welcome. Dr. Lauren: Thank you so much for having me back. I'm glad to be here. Kimberley: I really wanted to deep dive with you. We've already done an episode together. I'm such a joy to have you on. For those of you who want to go back, it's Episode 140 and we really talked there about how anxiety impacts sex. I think that that is really the big conversation. Today, I wanted to deep dive a little deeper into talking specifically about sexual anxiety, or as I did a little bit of research, what some people call sexual performance anxiety. My first question for you is, what is sexual anxiety or what is sexual performance anxiety? Are they the same thing or are they a little different? Dr. Lauren: I think people will use those words interchangeably. It's funny, as you say that, I think that performance anxiety, that word 'performance' in particular, I hear that more among men than I do among women. I think that that might be attributed to so many people's definition of sex is penetration. In order for penetration to be possible, if there's a partner who has a penis involved that that requires an erection. I often hear that word 'performance' attributed to essentially erection anxiety or something to do with, will the erection stay? Will it last? Basically, will penetration be possible and work out? I think I often hear it attributed to that. And then sexual anxiety is a maybe broader term for a whole host of things, I would say, beyond just erection anxiety, which can involve anxiety about being penetrated. It could be anxiety about certain sexual acts like oral sex giving, receiving. It could be about whether your body will respond in the way that you want and hope it to. I think that word, sexual anxiety, that phrasing can encompass a lot of different things. WHAT ARE SOME SEXUAL ANXIETY SYMPTOMS? Kimberley: Yeah. I always think of it as, for me, when I talk with my patients about the anticipatory anxiety of sex as well. Like you said, what's going to happen? Will I orgasm? Will I not? Will they like my body? Will they not? I think that it can be so broad. I love how you define that, how they can be different. That performance piece I think is really important. You spoke to it just a little, but I'd like to go a little deeper. What are some symptoms of sexual anxiety that a man or a woman may experience? Dr. Lauren: I think this can be many different things. For some people, it's the inability to get aroused, which sifting through the many things that can contribute to that, knowing maybe that I'm getting into my head and that's what's maybe tripping me up and making it difficult to get aroused. It could be a racing heartbeat as you're starting to get close to your partner, knowing that sex may be on the table. I've had some people describe it can get as severe as getting nauseated, feeling like you might be sick because you're so worked up over the experience. Some of that maybe comes from trauma or negative experiences from the past, or some of it could be around a first experience with a partner really hoping and wanting it to go well. Sometimes we can get really nervous and those nerves can come out in our bodies, and then they can also manifest in all of the thoughts that we have in the moment, really getting distracted and not being able to focus and just be present. It can look like a lot of different things. SEXUAL AVOIDANCE Kimberley: That's so interesting to hear in terms of how it impacts and shows up. What about people who avoid sex entirely because of that? I'm guessing for me, I'm often hearing about people who are avoiding. I'm guessing for you, people are coming for the same reason. You're a sex therapist. How does that show up in your practice? Dr. Lauren: One of the things that can cause avoidance-- there's actually an avoidance cycle that people can experience either on their own or within a partnership, and that avoidance is a way of managing anxiety or managing the distress that can come with challenging sexual experiences and trying to either protect ourselves or protect our relationships from having those outcomes as a possibility. There used to be a diagnosis called sexual aversion. It was called a sexual aversion disorder. We don't have that in our language anymore. We don't use that disorder because I think it's a really protective, sensible thing that we might do at times when we get overwhelmed or when we're outside of what we call a window of tolerance. It can show up as complete avoidance of sexual activity. It could show up as recoiling from physical touch as a way to not indicate a desire for that to progress any further. It could be avoidance of dating because you don't want the inevitable conversation about sexuality or the eventuality that maybe will come up. Depending on whether you're partnered or single and how that manifests in the relationship, it can come out in different ways through the avoidance of maybe different parts of the sexual experience, everything from dampening desire to avoiding touch altogether. Kimberley: That's really interesting. They used to have it be a diagnosis and then now, did they give it a different name or did they just wipe it off of the DSM completely? What would you do diagnostically now? Dr. Lauren: It's a great question. I think it was wiped out completely. I haven't looked at a DSM in a long time. I think it was swiped out completely. Just personally as a sex therapist and the clinician I am today, I don't use many of the sexual health diagnoses from the DSM because I think that they are pathologizing to the variation in the human sexual experience. I'm not so fond of them myself. What I usually do is I would frame that as an anxiety-related concern or just more of a sexual therapy or sex counseling concern. Because I think as we have a growing understanding of our nervous system and the ways in which our system steps in to protect us when something feels overwhelming or frightening or uncertain, I think it starts to make a lot of sense as to why we might avoid something or respond in the ways that we do. Once we have some understanding of maybe there's some good sense behind this move that you're making, whether that's to avoid or protect or to hesitate or to get in your head, then we can have some power over adjusting how we're experiencing the event once we understand that there's usually a good reason why something's there. Kimberley: That is so beautiful. I love that you frame it that way. It's actually a good lesson for me because I am always in the mindset of like, we've got to get rid of avoidance. That's the anxiety work that I do. I think that you bring up a beautiful point that I hadn't even considered, which is, we always look at avoidance as something we have to fix as soon as possible. I think what you're saying is you don't conceptualize it that way at all and we can talk more about what you could do to help if someone is having avoidance and they want to fix that. But what I think you're saying is we're not here to pathologize that as a problem here. Dr. Lauren: Yeah. I see it, I'm trained less in the specifics. I think that makes a lot of sense when you're working with specific anxiety disorders and OCD and the like. I've, as of late, been training in more and more emotionally focused therapy. I'm coming at it from an attachment perspective, and I'm coming at it from somewhat of a systemic perspective and saying, what is the avoidance doing? What is it trying to tell us? There's usually some good reason somewhere along the way that we got where we are. Can I validate that that makes sense? That when something is scary or uncertain or you were never given good information or you really want something to go well and you're not sure about it, and it means a lot to you, there's all kinds of good reasons why that might hit as overwhelming. When we're talking about performance anxiety or sexual anxiety, really the number one strategy I'm looking for is, how can we work with what we call your window of tolerance? If your current comfort zone encompasses a certain amount of things, whatever that might be, certain sexual acts with maybe a certain person, maybe by yourself, I want to help you break down where you want to get to and break that into the smallest, manageable, tolerable steps so that what we're doing is we've got one foot in your current window of what you can tolerate and maybe just a toe at a time out, and breaking that up into manageable pieces so that we don't keep overwhelming your system. That is essentially what my job is with a lot of folks, is helping them take those steps and often what our nervous system needs to register, that it's okay, that it's safe, that we can move towards our goals. Cognitively, we think it's too slow or it's too small. It's not. We have to really break that down. If there's something about the sexual experience that you're avoiding, that is overwhelming, that you're afraid of, what I do is validate that, makes sense that that maybe is just too much and too big all at once. And then let's figure out a way to work ourselves up to that goal over time. Usually, slower is faster. WHY DO PEOPLE HAVE SEXUAL ANXIETY? Kimberley: I love that. I really do. Why do people have sexual anxiety? Is that even an important question? Do you explore that with your patients? I think a lot of people, when I see them in my office or online, we know there's a concern that they want to fix, but they're really quite distressed by the feeling that something is wrong with them and they want to figure out what's wrong with them. Do you have some feedback on why people have sexual anxiety? Dr. Lauren: I do. I think it can stem from a number of experiences or lack thereof in our lives. There are some trends and themes that come up again and again that I've seen over the years in sex therapy. Even though we're taping here in the US, we're in a culture that has a lot of sexuality embedded within the media, there is still a lot of taboo and a lot of misinformation about sex or a lack of information that people are given. I mean, we still have to fight for comprehensive sex education. Some people have gotten explicitly negative messages about sex growing up. Some people have been given very little to know information about sex growing up. Both of those environments can create anxiety about sex. We also live in a world where we're talking openly about sex with friends, parents teaching their children more than just abstinence, and going into a little bit more depth about what healthy sexuality looks like between adults. A lot of that is still not happening. What you get is a very little frame of reference for what's 'normal' and what's considered concerning versus what is par for the course with a lifetime of being a sexual person. So, a lot of people are just left in the dark, and that can create anxiety for a good portion of those folks, whether it's having misinformation or just no information about what to expect. And then the best thing that most of us have to draw on is the Hollywood version of a very brief sex scene. Kimberley: Yes. I was just thinking about that. Dr. Lauren: And it's just so wildly different than your actual reality. Kimberley: Yeah. That's exactly what I was thinking about, is the expectation is getting higher and higher, especially as we're more accessible to pornography online, for the young folks as well, just what they expect themselves to do. Dr. Lauren: That's right. We have young people being exposed to that on the internet. We've got adults viewing that. With proper porn literacy and ethical porn consumption, that can be a really healthy way to enjoy erotic content and to engage in sexuality. The troubling thing is when we're not media literate, when we don't have some of the critical thinking to really remember and retain the idea that this entertainment, this is for arousal purposes, that it's really not giving an accurate or even close depiction of what really goes on between partners. I think it's easier for us to maintain that level of awareness when we're consuming general movies and television. But there's something about that sexuality when you see it depicted in the media that so many people are still grappling with trying to mimic what they see. I think that's because there's such an absence of a frame of reference other than those media depictions. SEXUAL ANXIETY IN MALES VS SEXUAL ANXIETY IN FEMALES Kimberley: Right. So good. Is there a difference between sexual anxiety in males and sexual anxiety in females? Dr. Lauren: I think it can show up differently, certainly depending on what role you play in the sexual dynamic, what positions you're looking to or what sexual acts you're looking to explore. There's a different level or a different flavor of anxiety, managing erection anxiety, managing anxiety around premature ejaculation. They're all similar, but there's some unique pieces to each one. All of the types of anxiety that I've seen related to sex have some common threads, which is getting up into our heads and dampening the experience of pleasure not being as present in the moment, not being as embodied in the moment, because we get too focused on what will or won't happen just moments from now. While that makes so much sense, you're trying to foretell whether it's going to be a positive experience, there is a-- I hate to say like a self-fulfilling prophecy, but there's a reaction in our bodies to some of those anxious thoughts. If I get into my head and I start thinking to myself, "This may not go well. This might hurt. I might lose my arousal. I might not be able to orgasm. My partner may not think I'm good in bed," whatever those anxious thoughts are, the thoughts themselves can become a trigger for a physical reaction. That physical reaction is that it can turn on our sympathetic nervous system, and that is the part of our body that says, "Hey, something in the environment might be dangerous here, and it's time to mobilize and get ready to run." What happens in those moments once our sympathetic system is online, a lot of that blood flow goes out of our genital region, out of our chest and into our extremities, to your arms, to your legs. Your body is acting as if there was a bear right there in front of you and your heart rate goes up and all of these things. Now, some of those can also be signs of arousal. That's where it can get really tricky because panting or increased heart rate or sweating can also be arousal. It's really confusing for some people because there can be a parallel process in your physiology. Is this arousal or is this anxiety? CAN ANXIETY IMPACT AROUSAL? CAN ANXIETY IMPACT SEX DRIVE? Kimberley: It's funny that you mentioned that because as I was researching and doing a little bit of Googling about these topics, one of the questions which I don't get asked very often is, can anxiety cause arousal? Because I know last time, we talked about how anxiety can reduce arousal. Is that something that people will often report to you that having anxiety causes them to have sexual arousal, not fight and flight arousal? Dr. Lauren: Yeah. I mean, what I see more than anything is that it links to desire, and here's how that tends to work for some people because then the desire links to the arousal and it becomes a chain. For many people out in the world, they engage in sexual activity to impart self-soothe and manage stress. It becomes a strategy or an activity that you might lean on when you're feeling increased stress or distress. That could be several different emotions that include anxiety. If over my lifetime or throughout the years as I've grown, maybe I turn to masturbation, maybe I turn to partnered sex when I'm feeling anxious, stressed, or distressed, over time, that's going to create a wiring of some of that emotion, and then my go-to strategy for decreasing that emotion or working through that emotion. That pairing over time can definitely work out so that as soon as I start feeling anxious, I might quickly come to feelings of arousal or a desire to be sexual. Kimberley: Very interesting. Thank you. That was not a question I had, but it was interesting that it came up when I was researching. Very, very cool. This is like a wild card question. Again, when I was researching here, one of the things that I got went down a little rabbit hole, a Google rabbit hole, how you go down those... Dr. Lauren: That's never happened to me. WHAT IS POST-SEX ANXIETY? Kimberley: ...is, what about post-sex anxiety? A lot of what we are talking about today, what I would assume is anticipatory anxiety or during-sex anxiety. What about post-sex anxiety? What is post-sex anxiety? Dr. Lauren: I've come across more-- I don't know if it's research or articles that have been written about something called postcoital dysphoria, which is like after-sex blues. Some people get tearful, some get sad, some feel like they want to pull away from their partner and they need a little bit of space. That's certainly a thing that people report. I think either coexisting with that or sometimes in its place can be maybe feelings of anxiety that ramp up. I think that can be for a variety of things. Some of it could be, again, getting into your head and then doing a replay like, was that good? Are they satisfied? We get into this thinking that it's like a good or bad experience and which one was it. Also, there's many people who look to sex, especially when we have more anxiety, and particularly if we have a more predominantly anxious attachment where we look to sex as a way to validate the relationship, to feel comforted, to feel secure, to feel steady. There's a process that happens where it's like seeking out sex for comfort and steadiness, having sex in the moment, feeling more grounded. And then some of that anxiety may just return right on the other end once sex is over, and then you're back to maybe feeling some insecurity or unsteadiness again. When that happens, that's usually a sign that it's not just about sex. It's not just a sexual thing. It's actually more of an attachment and an insecurity element that needs and warrants may be a greater conversation. The other thing is your hormones and chemicals change throughout the experience. You get this increase of bonding maybe with a partner, oxytocin, and feel-good chemicals, and then they can sometimes drop off after an orgasm, after the experience. For some people, they might just experience that as depressed mood anxiety, or just a feeling of being unsettled. Kimberley: That's so interesting. It makes total sense about the attachment piece and the relational piece, and that rumination, that more self-criticism that people may do once they've reviewed their performance per se. That's really helpful to hear. Actually, several people have mentioned to me when I do lives on Instagram the postcoital dysphoria. Maybe you could help me with the way to word it, but is that because of a hormone shift, or is that, again, because of a psychological shift that happens after orgasm? Dr. Lauren: My understanding is that we're still learning about it, that we've noticed that it's a phenomenon. We're aware of it, we have a name for it, but I don't know that we have enough research to fully understand it just yet. Right now, if I'm not misquoting the research, I believe our understanding is more anecdotal at this point. I would say, many different things could be possible, anything from chemical changes to attachment insecurities, and there's probably things that are beyond that I'm also missing in that equation. I think it's something we're still studying. HOW TO OVERCOME SEX ANXIETY, AND HOW CAN WE COPE WITH SEX ANXIETY? Kimberley: Very interesting. Let's talk now about solutions. When should someone reach out to either a medical professional, a mental health professional? What would you advise them to do if they're experiencing sexual anxiety or performance anxiety when it comes to sex? Dr. Lauren: That makes a lot of sense. That's a great question. What I like to tell people is I want you to think of your sexual experiences like a bell curve. For those who were not very science or math-minded like myself, just a quick refresher, a bell curve basically says that the majority of your experiences in sex are going to be good, or that's what we're hoping for and aiming for. And then there's going to be a few on one tail, there's going to be some of those, not the majority, that are amazing, that are excellent, that really stand out. Yes, mind-blowing, fabulous. And then there's the other side of that curve, that pole. The other end is going to be, something didn't work out, disappointing, frustrating. There is no 100% sexual function across a lifetime with zero hiccups. That's not going to be a realistic goal or expectation for us. I always like to start off by reminding people that you're going to have some variation and experience. What we'd like is for at least a good chunk of them to be what Barry McCarthy calls good enough sex. It doesn't have to be mind-blowing every time, but we want it to be satisfying, of good quality. If you find that once or twice you can't get aroused, you don't orgasm, you're not as into it, one of the liabilities for us anxious folks, and I consider myself one of them having generalized anxiety disorder my whole life—one of the things that we can do sometimes is get catastrophic with one or two events where it doesn't go well and start to jump to the conclusion that this is a really bad thing that's happening and it's going to happen again, and it's life-altering sort of thing. One thing is just keeping this in mind that sometimes that's going to happen, and that doesn't necessarily mean that the next time you go to be sexual that it'll happen again. But if you start to notice a pattern, a trend over several encounters, then you might consider reaching out to someone like a general therapist, a sex therapist to help you figure out what's going on. Sometimes there's a medical component to some of these concerns, like a pattern of difficulty with arousal. That's not a bad idea to get that checked out by a medical provider because sometimes there could be blood flow concerns or hormone concerns. Again, I think we're looking for patterns. If there's a pattern, if it's something that's happening more than a handful of times, and certainly if it's distressing to you, that might be a reason to reach out and see a professional. Kimberley: I think you're right. I love the bell curve idea and actually, that sounds very true because often I'll have clients who have never mentioned sex to me. We're working on their anxiety disorder, and then they have one time where they were unable to become aroused or have an erection or have an orgasm. And then like you said, that catastrophic thought of like, "What happens if this happens again? What if it keeps happening?" And then as you said, they start to ruminate and then they start to avoid and they seek reassurance and all those things. And then we're in that kind of, as you said, self-fulfilling, now we're in that pattern. That rings very, very true. What about, is there any piece of this? I know I'm disclosing and maybe from my listeners, you're probably thinking it's TMI, but I remember after having children that everything was different and it did require me to go and speak to a doctor and check that out. So, my concerns were valid in that point. Would it be go to the therapist first, go to the doctor first? What would you recommend? Dr. Lauren: Yeah. I mean, you're not alone in that. The concerns are always valid, whether they're medical, whether they're psychological, wherever it's stemming from. If after once or twice you get freaked out and you want to just go get checked out, I don't want to discourage anybody from doing that either. We're more than happy to see you, even if it's happened once or twice, just to help walk you through that so you're not alone. But the patterns are what we're looking for overall. I think it depends. Here's some of the signs that I look for. If sex is painful, particularly for people with vaginas, if it's painful and it's consistently painful, that's something that I would recommend seeing a sexual medicine specialist for. There are some websites you can go to to look up a sexual medicine specialist, someone in particular who has received specialized training to treat painful sex and pelvic pain. That would be an indicator. If your body is doing a lot of bracing and tensing with sex so your pelvic floor muscles are getting really tight, your thighs are clenching up, those might be some moments where maybe you want to see a medical provider because from there, they may or may not recommend, depending on whether it's a fit for you, something called pelvic floor therapy. That's something that people can do at various stages of life for various reasons but is doing some work specifically with the body. Other things would be for folks with penises. If you're waking up consistently over time where you're having difficulty getting erections for sexual activity and you're not waking up with erections anymore, that morning wood—if that's consistent over time, that could be an indicator to go get something checked out, maybe get some blood work, talk to your primary care just to make sure that there's nothing in addition to maybe if we think anxiety is a part of it, make sure there's nothing else that could be going on as well. HOW TO COPE WITH SEX ANXIETY Kimberley: Right. I love this. This is so good. Thank you again. Let's quickly just round it out with, how may we overcome this sex anxiety, or how could we cope with sex anxiety? Dr. Lauren: It's the million-dollar question, and I've got a pretty, I'll say, simple but not easy answer. It's a very basic answer. Kimberley: The good answers are always simple but hard to apply. Dr. Lauren: Simple, it's a simple theory or idea. It's very hard in practice. One of, I'd say, the main things I do as a sex therapist is help people really diversify what sex is. The more rigid of a definition we have for sex and the more rigidly we adhere to a very particular set of things that have to happen in a particular order, in a very specific way, the more trouble we're going to have throughout our lifetime making that specific thing happen. The work is really in broadening and expanding our definition of sex and having maybe a handful of different pathways to be sexual or to be intimate with a partner so that, hey, if today I have a little bit more anxiety and I'm not so sure that I get aroused that we can do path A or B. If penetration is not possible today because of whatever reason that we can take path C. When we have more energy or less energy, more time, less time, that the more flexibility we have and expansiveness we have to being intimate and sexual, the more sexual you'll be. Kimberley: Just because I want to make sure I can get what you're saying, when you say this inflexible idea of what this narrow you're talking about, I'm assuming, I'm putting words in your mouth and maybe what you're thinking because I'm sure everybody's different, but would I be right in assuming that the general population think that sex is just intercourse and what you're saying is that it's broader in terms of oral sex and other? Is that the A, B, and C you're talking about? Dr. Lauren: Yeah. There's this standard sexual script that most people follow. It's the one that we see in Hollywood, in erotic videos. It centers mostly heterosexual vaginal penetration, so penis and vagina sex. It centers sex as culminating in orgasm mainly for the man, and then nice if it happens for the woman as well in these heterosexual scenarios. It follows a very linear progression from start to finish. It looks something like—tell me if this doesn't sound familiar—a little bit of kissing and some light touching and then some heavier touching, groping, caressing, and then maybe oral sex and then penetration as the main event, orgasm as the finish line. That would be an example of when I say path A or B or C. I'm thinking like that in particular what I just described. Let's call that path A for not that it's the gold standard, but it's the one we draw on. Let's say that's one option for having a sexual encounter. But I also want people to think about there's going to be times where that is not on the table for a variety of reasons, because if you think about it, that requires a certain energy, time. There might be certain conditions that you feel need to be present in order for that to be possible. For some people, it automatically goes to the wayside the moment something happens like, "Well, I don't feel like I have enough time," or "I'm tired," or "I'm menstruating," or whatever it is. Something comes up as a barrier and then that goes out the door. That can include things like anxiety and feeling like we have to adhere to this progression in this particular way. Let's call that path A. Path B might be, we select a couple of things from that that we like. Let's say we do a little kissing and we do oral sex and we say goodnight. Let's say path C is we take a shower together and we kiss and we soap each other's backs and we hug. That's path C. Path D is massaging each other, full body. You've got all these different pathways to being erotic or sensual or intimate or sexual. The more that you have different pathways to being intimate, the more intimate you'll be. Kimberley: That is so relieving is the word I feel. I feel a sense of relief in terms of like, you're right. I think that that is a huge answer, as you said. Actually, I think it's a good answer. I don't think that's a hard answer. I like that. For me, it feels like this wonderful relief of pressure or change of story and narrative. I love that. I know in the last episode you did, you talked a lot about mindfulness and stuff like that, which I will have in this series. People can go and listen to it as well. I'm sure that's a piece of the pie. I want to be respectful of your time. Where can people hear more about you and the work that you're doing? I know that you have an exciting book coming out, so tell us a little bit about all that. Dr. Lauren: Thank you. I do. I co-authored a book called Desire. It's an inclusive guide to managing libido differences in relationships. I co-authored that with my colleague Dr. Jennifer Vencill. That comes out August 22nd, 2023 of this year. We'll be talking in that book mainly about desire. There are some chapters or some sections in the book that do intersect with things like anxiety. There's some particular instructions and exercises that help walk people through some things that they can do with a partner or on their own to work through anxiety. We've got an anxiety hierarchy in there where whatever your goal might be, how to break that up into smaller pieces. We're really excited about that. I think that might be helpful for some people in your audience. And then in general, I am most active on Instagram. My handle is my full name. It's @drlaurenfogelmersy. I'm also on Facebook and TikTok. My website is drlaurenfogel.com. Kimberley: Thank you. Once again, so much pleasure having you on the show. Thank you for your beautiful expertise. You bring a gentle, respectful warmth to these more difficult conversations, so thank you. Dr. Lauren: Oh, I appreciate it. Thanks for having me back.

Welcome back, everybody. I had a whole other topic planned to talk with you about today and I've had to basically bench it because I feel so compelled to talk to you about this topic, which is the topic of having fun. Now, you might be having a strong reaction to this and maybe there's a bunch of people who didn't listen because the idea of having fun feels so silly when you are anxious and depressed. It feels like a stupid idea, a ridiculous idea. But the last few weeks have taught me such valuable lessons about mental health. I talk about mental health all the time. That's what I live and breathe pretty much. Sometimes when you have an experience—I keep saying it changes your DNA—I feel to a degree my DNA has been changed these last few weeks and let me share with you why. For those of you who follow me on social media, you will know that in the last couple of weeks, I made a very last-minute trip to the United Kingdom. What happened was pre-COVID, I had booked tickets to visit London for a work event, and COVID happened. I had a certain amount of time to use these tickets, and I actually had thought that those tickets had expired on December 30th of last year. And then one Friday morning, I woke up and checked my email and it said, "You have 18 days until you depart." I'm thinking, 18 days to depart, where? I haven't booked any tickets. Only to find out that my tickets were put on what's called an "open hold," which meant they had just put a date to a trip knowing that I would log in and reschedule it when I was ready. It turned out to be three years later. And then I logged on and saw I have 19 days to use my ticket. I went upstairs, I talked to my husband, and I said, "I have this ticket to the United Kingdom I've never been to. I would really love to go." He said, "You should go. I think it would be really good for you. I'll stay home with the kids. You go." That was the plan. I was going to go, I was going to keep working, I was going to see my clients, but when I wasn't working, I would go out and have British food and maybe go walk around London and maybe visit a castle or two. That was the plan. I was so excited. I happened to mention it to my sister-in-law who I love, and I said, "Ha-ha, you should come." She said, "Oh! No, there's no way I could come and I didn't think anything of it." And then the next morning I woke up, she had messaged me and said, "I've changed my mind. I'm coming." Now, there is a point to this story, which is, my first thought was, "Oh my gosh, that's so exciting." My second thought was, "Oh my gosh, that is scary," because my sister-in-law is the most wonderful human being and she loves to have fun. What was shocking to me is I started to notice I was going to pump the brakes on fun. No, no, no, no, no, no. Oh my gosh. Now quickly, of course, I said, "Come, I'm so excited." We went, but that response was so interesting to me. What it was, was my anxiety did not like the idea that we were going to go and let loose. My anxiety did not like that inhibitory piece, that amygdala deep in my brain was like, "Whoa, whoa, whoa, whoa, pump the brakes. This is going way too fast for me." The reason I'm doing today's episode is I bet you that's what your brain does too. It wants to pump the brakes on fun and pleasure because it creates uncertainty and it creates vulnerability and it creates where things aren't in control anymore. Letting go and having fun is hard when you have anxiety. Letting go and having fun is hard when you have depression. "Yes" Week We went and we called the week "YES week." Actually, I called it "YES week" because I knew this was an exposure I needed to do. We made an agreement that if one person wanted to do something, both of us had to say yes. If someone wanted to try a food, and my sister-in-law loves to try all the different foods, we both had to say yes. It was such a deep exposure experience for me. A deep, oh my gosh, pleasurable. I don't want you to think it was all hard because the truth is, it was all pleasurable and I was so surprised at how my brain kept making problems out of having fun. I'll give you another example. We're sitting at this Indian restaurant. We kept saying to the maitre d' or the people at the front desk, "Tell us the best Indian restaurant. Tell us the best high tea. Tell us the best place to go and have drinks. Tell us the best place to get scotch eggs. Tell us the best place to have Scottish pie. Tell us the best." We kept saying that. We were sitting at this Indian restaurant and my sister-in-law was like, "We'll have one of those and one of those and one of those and one of those." She's a foodie. I could even feel my body going like, "No, no, no, no, that's too much fun." It's so interesting to me how my brain was pumping the breaks on fun and how when you have fun, again, after doing this for one week, I felt like my DNA was changed. I realized how-- I don't want to use the word controlling because I don't consider myself a controlling person, but how much my brain wants to monitor the amount of fun that happens and how much my brain's anxiety wants to raise alerts about the simplest things. We went to a million abbeys and I realized that I have this deep love for visiting churches and abbeys. Oh my gosh, I feel like my whole heart just shines bright. I'm not particularly a religious person at all, but just visiting these abbeys in these gorgeous places. And then she'll come up and she'll pull on my sleeve and she'll say, "Let's go do this extra tour." My mind wants to be like, "No, no, no, no. We've done enough fun for one day." She's like, "Let's go." I'd be like, "Yes," because we have to say yes. There's this place called Duck & Waffle, which is a '70s nightclub restaurant. It was fabulous. She's like, "We should try that." My brain kept going, "No, no. We just had some food before." It was all these things and it was just keep saying yes to fun. Keep saying yes, keep saying yes. Yes week, that's what it was. I realized after a week of doing this how little power my anxiety had. I'm thinking about it. I'm just dropping down into it. You can see I'm slowing down. Now, number one, I want to acknowledge, you can't live like that forever. That was a vacation. I would never do that on a day-to-day basis because it's not realistic, it's not reasonable. We have to live a reasonable life. But I made a deal with myself as I was going back over Greenland. I was flying over Greenland looking at this huge snowy country and I was thinking, wow, I wish I lived in a country this beautiful. And then I was like, "Wait, I do." You could start to practice being in the beauty of your country more. And then I started thinking, what would happen if I went home and I deeply enjoyed the food? Like I slowed down to actually take in the pleasure of the food. I mean, I think I do an okay job at this, but on vacation, like I said, we were practicing going, "Ooh, I love the flavor of this. Ooh, that's so soft and that's so sweet and that's so tender," and all the things. What if I actually really allowed pleasure and fun to tickle my senses here in my daily life? What if instead of making dinner like a serious mom, which I often do because I don't want to embarrass my children—what if instead I let myself dance more? What if I goofed off more? What if I enjoyed laughing more? What if I practiced and made a habit of implementing fun into my life on the daily? This is what I was thinking about, what's the ratio of work to fun in your life? I mean, I'm guessing you have either school or work or family or a mental health issue that you're managing or a medical health issue that you're managing. That's work. What's the ratio of work to fun? It made me really think like I have a wonderful life and I'm so grateful for my wonderful life, but the ratio of work to fun is not ideal. It's not where I want it to be. Once I had spent a week of just saying yes, yes, yes, and not letting fear ever say no, it was so cool because I had this accountability buddy right next to me. I realized like once I'd done that for a week, I wanted to keep it going. I didn't want to go back to pumping the brakes anymore. It's been such a beautiful gift that I had. The Fun Habit Now, I'm going to encourage you to create a yes week or a yes day, or a yes hour. I just finished a book called The Fun Habit: How the Pursuit of Joy and Wonder Can Change Your Life. It's by Mike Rucker. A friend of mine encouraged me to read it after I had told her like I literally just had this date with fun. I had this exposure of fun. I had a yes week where we said yes to. If we wanted to sleep in, we slept in. If we wanted to read, we read. It was really beautiful. Again, I understand the privilege of having that experience, but I worked my butt off too. I needed that. I really, really needed that. My mental health really needed it and so forth. But the book is talking about how we have talked about and trained ourselves to be afraid of fun. We've demonized fun as if it's irresponsible or unnecessary or ridiculous or lazy. I want to leave you today with the idea to plant a seed where you go and have more fun. I was thinking about it. For those of you who have anxiety disorders or depressive disorder, this is the biggest FU to anxiety. It's the biggest FU to depression. It's the biggest "Don't tell me what to do" when it comes to recovering from anxiety and depression. Is it going to fix it completely? No. I don't want to oversell it here. But is it a major game changer? Does it change the way we see the world? Does it increase the dopamine that gets released into your body? Does it make the hard work worth it? Yes. I was thinking like, I was so excited to go back to work because I had a week of fun. If I had have done my original plan, which is where I worked while I was in London, and I just visited a little on the side, I wouldn't have been that excited to come back to work. But I was so excited to come back to work and I was so excited to sit down and talk to you on this podcast. I don't think that would've been the case if I had have pumped the brakes like I was planning to for that week. Have More Fun! There you have it. I'm going to ask you, please give you permission. Go and have more fun. Increase the percentage a few percent or 100% or 50% or 10%, whatever you can do. But do your best to implement pieces of fun into your daily life. It will literally change your DNA. Not literally, that's scientifically not true. Don't take that as literal. But for me, I felt like my DNA had been changed. I kept saying it. I'm like, "I feel like my DNA has something shifted in me." It's because I realized even though I have so much joy in my life, I do still pump the brakes on fun and I want there to be more and I'm dedicating more time to fun and savoring pleasure. So that's all I want to say. Go and have some fun, please. I'd love to hear about the fun that you're having. When fear shows up, try to confuse it by saying, "You know what, fear? You can be here and I'm going to go choose fun anyway." Fun can be whatever it is for you. There's no right way of having fun and it doesn't have to be expensive here either. Like I said, a lot of the things that my sister-in-law and I did cost no money. It's just that we were saying yes to silly things. Some of it was even like cartwheeling in the underground train station or giggling at stupid things that are so silly and so immature, but having fun with it. Just have some fun. I love you. I hope you're having a wonderful day. It is a beautiful day to have fun is all I'm going to say to you today. I will see you next week. We have a very cool series coming up, which you are going to love, so stick around. I'll see you next week.