By MARK BANSCHICKUpdated: DECEMBER 4, 2018 14:20Anxiety(photo credit: PIXABAY)Comedian Sarah Silverman once said there’s no doubt about her being Jewish, in part because she worries a lot. The anxious, neurotic Jew has been a staple of comedy for a long time.Honestly, I can hardly picture the Jewish people without it.The Jewish thinker, Simon Rawidowicz, even wrote that the Jews have only one image of their future –‘‘the end is near, unless and if.” But, it is also this fear coupled with the ‘nevertheless’ attitude, which has allowed us to survive for so many centuries.Living with anxietyWhether it is a people or a singular person, living with anxiety is far from an easy experience. It takes a heavy toll on our health and relationships – and it’s exhausting.Not to get you anxious, but there are many kinds of anxiety: social anxiety, obsessive compulsive anxiety, generalized anxiety, phobias, agoraphobiaת and panic disorder, to name a few. And, to put levity aside, trauma, both physical and psychological, can cause long-lasting anxiety in the form of PTSD and its variants.But, as Rawidowicz reminds us, there is always ‘unless and if’ for those who seek relief. Today, there are effective treatments for most anxiety, usually combining medication and psychotherapy.These protocols work, and I have used them for years, but we can also do better.Medications often work – and have a time and a place – but medication is often not the exclusive or even necessary answer. In medical practice there are illnesses that have a relatively simple medicinal answer, such as a bacteria-infected wound, where taking antibiotics can clear up the problem with limited side effects. Anxiety, however, is usually more complex, and the effects of medication are less fully understood. Plus, there can be habituation to meds that makes the project of anxiety management problematic.In addition, with psychiatric medications, the placebo effect tends to be quite high. In other words, some of the healing power of medication does not come from its chemical composition but from us believing it works. This means that the mechanism of a drug’s action may be more complicated than we think.In fact, it may be because of the way we think.The usual suspectsMany of the more popular medications prescribed for anxiety disorders can be characterized either as antidepressants or benzodiazepines. Benzodiazepines can cause a relatively quick calm and are much appreciated by patients who are feeling panicky. I can think of countless patients who, anticipating panic, are thrilled to have a benzodiazepine in their bag or purse. Side effects are varied. It is easy to use benzodiazepines too liberally because they work quickly and effectively. They can be addictive, but when monitored properly, folks can benefit.The antidepressants work more slowly and maintain a consistent blood level with the advantage of muting some anxiety throughout the day. Yes, they are called antidepressants, but many of these widely used medications have proven anxiety reducing properties. The antidepressants have a wide range of side effects, from rare cardiac issues, to weight gain or loss, to night sweats, and more. Fortunately, most of the side effects of these meds are relatively benign, but who wants to be on medication if they don’t have to be?Helping the body healResearch has shown that medication, especially when combined with treatment by a competent therapist, can help many people recover from different forms of anxiety. But, in the long run, the best way to manage symptoms of anxiety might not be with a drug that could induce dependence or other side effects.Good treatment enables a person to learn the best ways to manage their anxiety themselves, because, after all, each human being is unique. Or as Hillel put it: “If I am not for me, who will be for me?” Medicine should be used as needed, while keeping in mind that our body is a living entity that holds ways to heal itself – sometimes without external aid.Saying “let the body heal itself” brings to mind the image of a snake-oil salesman on television infomercials peddling expensive “natural” products, or maybe a representative of some counterculture who might be just a little out of touch with the real world.In reality, though, many of these treatments have been used for centuries. An integrated approach to anxiety is based on sound scientific principles that essentially encourage people to do the very things that mainstream doctors regularly advise (or ought to advise): namely, paying careful attention to lifestyle decisions and recognizing how the body and the emotions can affect one another.To that end, consider a few non-medicinal ways to manage stress and anxiety with less or no medication.PsychotherapyUnless you are overwhelmed by your anxiety and need relief immediately, give therapy a chance. Psychotherapy has something in common with the ancient Jewish understanding of Teshuvah, which is meant to enable a person to return to their better and more stable self.Consider Proverbs (12:25): “If there is anxiety in a man’s mind let him quash it, and turn it into joy with a good word.” One opinion of this verse can be interpreted as an early endorsement of talk therapy; “he should tell others [yesiḥena] his concerns, which will lower his anxiety.”A trained professional, such as a psychologist, social worker, family therapist or psychiatrist, have a number of proven tools to help with anxiety. And, for those who require an observant therapist, many contemporary rabbis and rebbitzens have pursued training as therapists, as well.Theoretically, at least, there should be a good fit for every patient.Insight-oriented psychotherapy can identify past hurts, and put them in better perspective, enabling a patient to live with less anxiety. Numerous studies support the efficacy of Cognitive Behavioral Therapy (CBT), which can be quite effective in just a few sessions. The purpose of CBT is to teach you to think in a less anxiety-inducing way, and it works!If you have a history of trauma or abuse leading to anxious feelings, you may want to try EMDR, Somatic Experiencing or Progressive Exposure Therapy. The scientific literature supports these methods of reducing intrusive anxiety caused by past or present trauma.Yes, breatheTake good care of your body by exercising and developing consciousness about how you live your life, day to day. Sometimes it can be as simple as being more mindful about the way you breathe. The body participates in many cycles: hunger-satiation, awakening-bedtime, and the most basic – breathing in and out.The proper circulation of oxygen and carbon dioxide is vital to every part of the anatomy’s functioning, especially the brain. In times of stress, people can unconsciously deny themselves the oxygen they need, either by holding their breath or entering a constant, low-level state of hyperventilation without realizing it.Healthy breathing and meditation based on consciousness of one’s breath has been studied extensively by John Kabat-Zinn, formerly of the University of Massachusetts Medical Center; and it can be a helpful adjunctive approach to anxiety. If this piques your interest, see his book, “Wherever You Go, There You Are,” try a meditation app, or find a teacher.Daily meditation can make a huge difference in your life, and it costs very little.SleepSleeping is key to a good life. Sleep is the brain’s one opportunity each day to relax and sort itself out. It’s a good idea for adults to get 7 or even 8 hours of sleep per night. If you’re like most people, it may seem that there’s just not enough time in your schedule to fit in a good night’s sleep. Sometimes it’s unavoidable, but if you find yourself consistently running on too few hours and suspecting that your mental health may be suffering, it might be time to think about cutting down on your workload, or saying “no” to some nonessential responsibilities.This can be a Catch 22, because fatigue can make you more anxious, which in turn makes it more difficult to settle down at night, leading to tossing and turning, and more fatigue and anxiety. Anxiety has a way of showing up when the head hits the pillow. In fact, intrusive, anxious ruminations are common in anxiety disorders.Constructive things that you can do include the use of over-the-counter melatonin, a natural hormone that helps many people settle down. It is the only hormone produced at night, and sometimes you can fool the brain into thinking it’s time to sleep by adding a low dose just before bed.Sometimes, a warm bath can help a lot. Also, consider cutting down on caffeine after lunch; some people are just too sensitive to the stimulation. If you’re a drinker, note that a drink or two may get you to sleep, but you will inevitably wake up at 3 a.m. and be unable to get back to sleep. This is called REM rebound and it will fatigue you terribly. Just give up the booze at night, and you’ll sleep better.Important! Work with your partner and make up before going to bed.It may not be easy, but hurt feelings do not go well with settling down to sleep.ExerciseEverybody knows how important exercise is to physical health, but sometimes people forget that it plays a role in mental health as well. During exercise, you do more than burn calories and improve muscle tone; you release feel-good neurotransmitters and endorphins.If you get triggered, and anxiety is building, reset your brain circuitry through exercise. Ride your bike, hike up that hill, go to the gym, or just run in place. Muscle movement, breathing, circulation, endorphins and simply changing the setting of your anxiety can reduce the surge of feelings. And if not, it is still good for you.I am not knocking medication; it’s useful for many. Just consider that exercise can affect your brain positively, lead to better self-esteem, get you out of your head and into your body, while sharpening cognition and reducing stressful thinking.It may be worth the hassle.DietAs far as dealing with anxiety goes, the general advice is obvious: make healthy choices that supply the nutrients and vitamins that your body needs, without causing dramatic surges of insulin.Good hydration is smart for everyone because it encourages the body to metabolize better and can keep you alert. Many stressed people eat high carbohydrate meals comprising bagels, bread, pasta, and so on, which make you feel good temporarily, but inevitably triggers an insulin surge only to fatigue you a little while later.Fatigue opens the door to anxiety (and more feel-good carbohydrates), so think healthy – it’s good for your head. And, as mentioned before, pay attention to what you drink. For example, caffeinated beverages may make you feel less tired, but they do so by making you more edgy and prone to anxiety. It bears repeating that alcohol can relieve stress in the short term, but can cause mental instability later on with unanticipated effects on your sleep and energy level.Yoga, acupuncture, herbs and massageIn case of mild anxiety or if you’re already in treatment but would like to explore more, consider yoga, acupuncture, herbal remedies or massage therapy.Yoga combines both physical exercise and conscious breathing during a series of poses that range from gentle to strenuous. A growing body of evidence indicates that, when practiced regularly, it can help reduce the physical stress response (heart rate, blood pressure) and lessen symptoms of anxiety and depression.Acupuncture is not mainstream but can help some anxious patients. It’s been an integral part of traditional Chinese medicine since ancient times, and can encourage relaxation. I have seen a number of patients benefit, particularly when pain and anxiety coexist.No one can argue against the calming qualities of some good teas; I personally find a cup of chamomile tea relaxing before bed. For those of you near the Machane Yehuda market, you might want to try a cold glass of the Rambam’s drink. The proprietor’s concoctions all sound intriguing – and I plan to stop by next time in Jerusalem.Herbal remedies do have some supportive research; for instance, kava has done well in clinical trials and may be helpful.And, let’s not forget the value of massage therapy, which both feels good, and may possibly reduce cortisol, a stress hormone. Cortisol is secreted in response to acute stress, but in those suffering from anxiety can be elevated more chronically.It is also nice to be pampered every once and while.Love, purpose and spiritualityIf we’re lucky, we’ve internalized a sense of stability from our parents. We felt held or understood in some deep way. This plays out in adult life in good friendships and family connections. Men, for instance, who get divorced, don’t fare as well medically or psychologically as their married counterparts (and that includes men unhappily married).Connections count. Purpose counts How we conceive of our lives in the face of the bigness of the world and the smallness of our nature can bring strength or supply more anxiety. A personal sense of purpose and value can be invaluable.I would argue that greatness is a misunderstood concept that we apply to athletes, movie stars, important rabbis and Silicon Valley tycoons. Sometimes we are socialized to look at what others are doing, when what is really of value lies within our hearts.Anxiety has its own power, and has its source in one’s unique biology and personal experience, yet when a person has a sense of purpose he or she is not an anxious person, but rather a person dealing with anxiety. If the anxiety has its source in trauma, it’s critical to see oneself not as a traumatized person but rather as a person who has suffered trauma.It is an important distinction. You are not your anxiety.For many, enjoying a sunset or the miracle of a child’s laugh may be sufficient spirituality, and provide a sense of grounding that can settle their anxiety, at least for a moment. Some spiritual souls have a genuine ability to draw goodness and calm from the world around them. It is a gift.For those who believe in God, whatever His or Her presence means to you, prayer can be a wonderful tonic. When anxious or distressed, remember that you are not alone, God is with you. Turn to Him/Her, open your heart and allow yourself to be healed. This can help greatly – you don’t need the research to know it’s true.Take-home messageAnti-anxiety medications, antidepressants and other pharmaceuticals we haven’t discussed for lack of space are important tools, but are not the sole line of defense when dealing with anxiety – one should remember there are less intrusive alternatives. Don’t get me wrong. For many people anxiety can be debilitating and pills can work; just know that there are additional approaches as well.So, consult with your doctor to determine what’s going on with you. Each presentation of anxiety requires an individualized treatment, based on who you are, how severe it is, and what might be at the root of the problem.It is emotionally healthy to pursue treatment and not avoid it. Yes, for some, taking medication is not only a medical good, but an assertive approach to a difficult problem. Yet, even if medication is necessary, consider integrating a well-researched form of psychotherapy and some health-promoting approaches into your care.Each person is different.Take charge of your health.If not now, when?Mark Banschick, MD, is a Child and Adolescent Psychiatrist, with a practice in Katonah, New York. He is the author of ‘The Intelligent Divorce’ book series, offers a free online divorce course and is also a co-founder of Alums for Campus Fairness (ACF), a StandWithUs non-profit that mobilizes alumni to improve campus life for the pro-Israel community.
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