How We Should Be Thinking About Anxiety And Holistic Treatments That Work

Episode Transcript

Dr. Nicole Beurkens 

Hi, everyone, welcome to the show. I’m Dr. Nicole, and today we are going to talk about anxiety, which is something that every child and every adult experiences sometimes. That’s especially true right now with everything we have been dealing with over the past couple of years. And while anxiety and even anxiety disorders are becoming more common, it’s also something that is often misunderstood. People typically think of anxiety as being a mental problem in their head, but the reality is that anxiety is a whole-body situation. And when we ignore the physiology, we are missing out on an important piece that we really need to understand and address. There are so many ways to support anxiety reduction and treatment that go beyond the traditional recommendations of just counseling or medication. I have become convinced over the years based on research and what I see in my practice, that a holistic approach to anxiety is the most appropriate and effective for the majority of people. And we are in luck because the amazing Dr. Ellen Vora is on the show today to help us understand how we should be thinking about anxiety and holistic ways to approach it for ourselves, as well as for our children. So let me tell you a bit about her.

She received her BA from Yale University and attended Columbia University Medical School. She’s a board-certified psychiatrist, medical acupuncturist, and yoga teacher. Dr. Vora takes a functional medicine approach to mental health, considering the whole person and addressing imbalance at the root rather than reflexively prescribing medication. In addition to her private practice and speaking engagements, Dr. Vora consults for healthcare startups, and has a book called The Anatomy of Anxiety coming out in March, which we are going to get to talk with her about today. Ellen, welcome to the show. Thank you for being here.

Dr. Ellen Vora 

Nicole, thank you so much. I’m so happy to be here.

Dr. Nicole Beurkens 

So I want to start with sort of going back in time, because I’m always interested to understand people’s stories in terms of how it brought them to do the work that they do today. So I’m curious for you to share with us; what got you on the path of psychiatry, and then more recently, what got you on the path of the holistic psychiatry and sort of out of the box psychiatry that you practice today?

Dr. Ellen Vora 

There are two separate pathways. Psychiatry — I was really tortured by the decision of which specialty to choose and someone could have saved me a lot of trouble if they just told me early on that if you were a humanities major as an undergraduate, there was a decent chance you were going to like psychiatry. And I mean, it’s interesting how I was an English major, and I lived for the gray areas and the complexities of the human condition. And someone who’s into that is not always going to be all that jazzed about, say nephrology or dermatology. So it should have been obvious to me. It wasn’t. It took me years to figure out. The holistic approach among so many of us, who take the holistic approach, really the way we came about it is through our own health journey. And every once in a while, you run into a person that says, “You’re only doing this because it’s trendy, or to make money, or something.” And it’s like “No, no, no, no. Nobody gets here without a really personal connection to it and a pretty heartfelt passion about that this is a better way to approach health. That was certainly true for me. And when I was a med student, my health could not have been — I think that was truly the least healthy time in my life, even though I was ostensibly learning how to keep other people well and learning about the workings of the human body. And I thought I’m doing everything “right”. I’m eating my skinless chicken breast and my low-fat dairy, and I’m running. That felt like I’m a model of health, but I had polycystic ovary syndrome, I was getting migraines, I had all these different autoimmune factors showing up in my blood work, and joint pain, and acne. And perhaps what caused the most suffering of all was that my mood wasn’t good. I couldn’t have clear thoughts. I couldn’t really focus. I didn’t feel all that calm or optimistic about life. And I felt like a machine where the screws were popping out. So after many unsatisfying encounters with conventional Doc’s where it was like, “Oh, you’re just stressed, oh, you’re just depressed, oh, it’s just this, oh, you know what? Let’s just put you on the pill and then you’ll get your period back.” And I didn’t have the vocabulary for it yet, I didn’t understand the concept of functional medicine. But I at least had this little inkling that maybe the pill was going to give me my period back. But wasn’t that not going to fix the underlying problem? And should I ever decide to go off the pill, the problem is still there, no further progress towards solving it?

And so, I had a little suspicion that this wasn’t really the path but it took me probably about 10 inefficient years of figuring out how do I get my body well, and that happened in tandem with figuring out how do I help my patients thrive. And it was somewhat disenchanting what I was learning and then applying and feeling like, okay, I’ve become incredibly skilled at putting people in a cocktail of medication. But I’m not convinced that I’m seeing my patients thrive or lead fulfilling lives. And so these really were parallel processes where I figured out how do I get and keep myself well, and how do I help my patients truly achieve their goals.

Dr. Nicole Beurkens 

Beautifully said, and I think you’re right that so many of us in this field can relate to that. Conventionally trained and then realized at some point because of either personal, or our children, or a family member, or somebody that “Whoa, there’s a lot I don’t know and understand and haven’t been taught here”, which takes us on this other path, and then it all ends up coming back together, right? Because I know that you feel the same way I do that there’s a role for all of this. There’s no throwing the baby out with the bathwater and saying there’s no role for conventional psychiatry, conventional psychology, conventional medicine, of course there is. And also at the same time, there’s a big role for all these other pieces, too.

Dr. Ellen Vora 

Yeah, I mean, I think this is a little bit of a meta concept. But there’s a role for all the different people in this conversation. Some people are more dogmatic about it, like it has to be holistic, you can never do meds. I think there’s a role for that. We are all sort of on this Hegelian dialectic figuring out the truth together. I’m somewhere a little bit more moderate, where I do prescribe medication. I’ve seen it help my patients. To me, it just is not the only tool. And if somebody doesn’t want to be on medication, or if they have been on it in the past, and it wasn’t helpful, or if for some reason they are having side effects or a contraindication or they need to taper off, then I step in and say, “There’s still reason for hope. There are other tools, there’s other things we can do to get you well”, and there’s this other subtle aspect of medication, which is that so often I think of mental health as from a very functional medicine perspective of, it is a symptom. It’s not the diagnosis, it’s not the end of the inquiry. The mental health issues are a symptom of something else, some underlying state of imbalance. So I’m always just curious for the sake of it’s like a compulsive need to do this elegantly. I want to know: What is the underlying state of imbalance? And I want to identify that and address that. And then often, once someone’s back into a state of balance, it puts on the debate like, are they still somebody with anxiety or with depression or with bipolar even? And so then the medication is no longer necessary.

Dr. Nicole Beurkens 

Yeah, absolutely. I feel the same way about it and I’ve seen the same. So let’s start this conversation specifically about anxiety, around just having you maybe give your take on what anxiety is, maybe the actual definitions that we have for that, but also how you have grown to conceptualize and understand what anxiety is, because I think those things are different, right? We have our diagnostic manual that tells us here’s what anxiety is. Okay. But then we also have our understanding now after years and years of practice and delving into all of this, okay, but what is it really? So let’s start there.

Dr. Ellen Vora 

So I mean, the DSM or Diagnostic Statistical Manual definition to me — my copy of the DSM is quite dusty at this point. It is not something I’m finding useful in my day-to-day practice, and I think that the most generous read of why it formulates anxiety with all these different categories: We have generalized anxiety disorder and OCD and panic disorder, with or without agoraphobia, PTSD, so on and so forth. The idea is always to guide management. And with the idea that perhaps if it’s panic disorder, we might steer somebody towards cognitive behavioral therapy. Or if it’s generalized anxiety disorder, only if you meet criteria, then do you warrant the diagnosis and then warrant the treatment. And I think you do want to be careful about gatekeeping a diagnosis with criteria if there is any potential harm to the treatment. And so, understandably, if the DSM is saying you have generalized anxiety disorder, and therefore the indicated treatment would be an SSRI, an antidepressant, that is something to gatekeep.

I approach anxiety completely differently. And I think part of the reason I don’t need any lists of criteria or any gatekeeping is that nothing that I’m recommending has potential for harm. And we can kind of go a little deeper into that, there’s a conversation to be had around issues like orthorexia, but I think that for the most part, what I’m dealing in are interventions that are safe, they are noninvasive, they are affordable. So I don’t really need somebody to check 6 out of 10 boxes to suggest, like “Let’s start prioritizing an earlier bedtime.” So for me, it’s a subjective diagnosis. If somebody identifies with anxiety and comes to me and says, “I’m feeling anxious”, to me, it’s like hook, line and sinker. Let’s address this as though it were anxiety. And sometimes I’ll identify something that somebody didn’t have a subjective connection to, it’s like they are coming in and they are saying, “I’m just feeling blah.” And then maybe I’ll say something like, “Well, actually, that seems like anxiety.” But I’m not necessarily interested in putting words in people’s mouths, because we are all very suggestible, we can take on these diagnoses like an identity. And that can really impact our narrative about ourselves and our potential for arriving at a state of wellness.

Dr. Nicole Beurkens 

Yeah, and for kids, too, I find that I work with children of all ages, but especially, I tend to do a lot of work with older teens and young adults, and it’s amazing how that identity develops from being told at a really young age, given these labels, told, “These are the things that are wrong with you, this is what you are”, and how that really impacts the trajectory of their development of sense of self and all of those things. So I agree, it’s something to keep in mind for all of us, kids and adults, for sure.

Dr. Ellen Vora 

One small anecdote on that: I have a six-year-old daughter, and early on, long before we thought that she had any ability to really understand what we were saying, my husband and I were muttering, she was playing in a corner by herself with her toys. We were like “She’s kind of an indoor cat.” Something we said, and she has fully owned that and incorporated into her sense of self. So now it’s like, let’s go outside. She’s like, “No, I’m an indoor cat”. Okay. And we have run with it. We do, we take on these labels.

 

And to answer the second part of your question, I think that’s helpful. The way I do formulate anxiety, to me, I break it down into something called false anxiety, and something called true anxiety. And false anxiety I have learned can be somewhat of a triggering term because it feels so invalidating, it’s like, “What do you mean my anxiety is false?” It doesn’t make the suffering any less real, but it speaks to the underlying cause. And I really think of false anxiety as preventable or avoidable anxiety. It’s the anxiety that’s a result of some physical state of imbalance. And usually, that’s caused by seemingly pretty innocuous aspects of our daily lives, even something as subtle as a little blood sugar swing or exposure to blue spectrum light after sunset, and that has an impact on circadian rhythm. Even just drinking a little bit more coffee one day. These are the causes of false anxiety. And I like to start there first, that’s the low hanging fruit. So we can just get them out of the way. These are not true to the core of our being; these are just aspects of modern life that can put our body in a stress response. And that can feel synonymous with anxiety. So I like to help people just eradicate the false anxieties from their life. And then I see the remaining anxiety as something I call true anxiety, or purposeful anxiety. And that’s where we have this feeling of uneasiness deep within us that is really speaking to the fact that we have to pay attention to something, something’s not right in our lives, in the world around us, in our communities. And it’s like our deep inner knowing is asking us to slow down and take steps to rectify what isn’t right. And that’s not something we would want to medicate away. It’s not something that’s going to improve if we go gluten-free. It’s just something that is true to us, but it’s a call to action.

Dr. Nicole Beurkens 

I love that idea of a call to action that our brain and our body send us signals of things that we need to pay attention to. And I can just speak for myself and say that my experience over the course of my life has been that my brain and body send louder and louder signals, the longer I try to ignore them or not deal with them, until you get to a point where it’s like, “Okay, I can’t ignore this, and I need to address this now.” And I think that’s such a more helpful way of looking at it than this idea of, “Oh, I have XYZ condition and I’m broken, and this is who I am.” To understand it as “No, this is sending me a message of what do I need to be paying attention to that I’m not? What do I need to be understanding more about myself or my environment?” Because the big piece of this is, as you were talking about, things going on around us in our community, in our world, it’s like, “Yeah, there’s a lot that’s wrong with what is around us, especially in this point in time”, and we can have a really strong response to that, anxiety being one of them. And a lot of times I say to people, “You’re a normal human being operating in a very abnormal situation. It would be really weird if you weren’t feeling anxious at this point in time.”

Dr. Ellen Vora 

So well said, and I agree 1000%, I think that symptoms are really communications. And that is such an important paradigm shift because we think symptoms are a nuisance, and let’s figure out what’s the right pill that’s going to suppress it so I don’t feel that symptom anymore. But then some people describe it as the check engine light goes on, and we just put a little piece of duct tape over it, like “No more check engine, problem solved.” It’s like, well, not only is the problem not solved, but you’re not addressing something that needs addressing.

Dr. Nicole Beurkens 

I love what you said about the check engine light, I think that’s so true, especially as adults. I think that’s harder with kids. Kids often let us know pretty quickly what’s going on through their behavior, through changes in how they are managing themselves, even changes in eating and sleep and whatever. And that can cause a lot of anxiety to parents because it’s like, “Something’s going on with my kid, I need to stop that”, sort of our equivalent of “I need to find the duct tape to put over that check engine light”. And yet kids don’t operate in that way. Right? They call us to really look at what is going on here, and what needs to happen, often for kids, as uncomfortable as this can be for us as parents and adults to lean into, often for kids, they are responding to a lot of things with us in the environment, and helping them with anxiety, or dealing with their anxious behaviors or whatever’s going on there requires us to take a look at ourselves, how we are operating, and how we have set up life around them. And that can be a hard thing for parents to really be willing to look at and face. It’s easier to think about it as “Well, my kid’s got this problem. Just give me the pill or tell me the thing to do to make that go away.” And almost never is it just isolated to something going on with the child.

Dr. Ellen Vora 

So true. And you know, we have this concept of the designated patient, when really it’s always part of a system, an interconnected web. And I think kids, like bodies, are very true clear communicators. There’s not a lot of subterfuge or manipulation. It’s like when my daughter was younger, and I’d be like, “Here, have a bite of this.” And she turns her head to the other side, that is a very clear bodily way of saying no. Adults are like, “Maybe I should”, we do all this false representation of our inner truth because we are conditioned to throughout our lives. But kids have actually been so informative for how I think about false anxiety, actually. I remember when my daughter was a newborn or an infant, we would have almost like a list on the fridge. It’s like “Why is she fussy right now?” Because it’s just a few too many things to keep in your mind at any given moment. So we would refer back to that list of, oh, is she overtired? Is she hungry? Does she need a burp? Does she have a wet diaper? Is she teething? And we just kind of had to be able to refer back to that list to be like, “Ah, we didn’t think to burp her.” Or maybe she is teething. And I think that with adults, we kind of have our own inventory. And actually, in the book, I put a little list, just almost like as if someone’s going to take scissors to their book and cut it out and put it on the refrigerator, and it’s basically like when we are in our meltdown or when we are feeling anxious, is it that we are hungry? Are we tired? Are we dehydrated? Are we coming out of a rabbit hole from the phone and are dysregulated from technology? Are we over caffeinated or under caffeinated? Are we due for our medication? Are we sort of in that pharmacologic nadir, where our body is really waiting for its medicine, and there are several others. And so basically, just to be able to refer back to that and think “That’s why I’m anxious.” And it’s not to invalidate whatever content comes up in your thoughts when you’re anxious, that’s meaningful, but it can take the power and the charge out of the situation to realize that it feels more urgent because the body is in a stress response. And the body is in a stress response because we are hungry or tired, and not because the world is crumbling, necessarily, at that moment.

Dr. Nicole Beurkens 

Yeah, the stories that we tell ourselves in our heads in those moments are certainly exacerbated by whatever’s going on in our body. I mean, I know that just for myself on a very practical level, I am sensitive to blood sugar shifts, and if I go too long without eating or without having some protein, I will start to notice that the stories in my head start to shift, and everything seems like a bigger deal and everything feels more stressful. And you’re right to stop and go, “Oh, I need to eat something. I need to have some protein”, and then it’s amazing. Pretty quickly after that, it’s like oh, the stories in my head just sort of settle down to a more rational and manageable level again.

Dr. Ellen Vora 

Yeah, every time. In my household, I have two — my partner and my daughter are both very blood sugar fragile, and it’s not nothing for me, but my problems are different. But they are very blood sugar fragile, and sometimes if we just were out and didn’t get a chance to eat, it’ll be World War Three in my household, I’ll be looking at this like “Oh man”, and then it’s like a couple spoonfuls of something and then go back to loving each other, just every single time. But I think it’s so important, and things I’ve learned from other episodes of your podcast is when someone’s in that blood sugar crash, it’s really hard to have the presence of mind. I’ve learned this firsthand with my partner. Certainly, it’s like he’s sort of coming at me and I realize, it’s his adult version of lizard brain. He can’t think clearly in that moment that “Oh, this is just a blood sugar crash.” And I’m not here to invalidate the very meaningful content that he brings up in those moments. Yes, there are things to address, but we always address them more fruitfully when we are talking in a place of calm. And it’s interesting how you somehow have to be a little sneaky with yourself, with others of like, how do you replete your blood sugar without it feeling like an attack on that very real sense of “Things are not right, right now”. So you know to not invalidate the validity of the content while still addressing the underlying stress response that’s exacerbating the feeling.

Dr. Nicole Beurkens 

I think so many parents find themselves in that sort of conundrum with their kids, right? Okay, I’m sorting through what maybe is really going on here at the same time as trying to empathize and help you feel seen and heard, while recognizing that we just need to make some scrambled eggs and sit here and get you fed. And it can be a tough balancing act.

Dr. Ellen Vora 

It’s like one hand is doing the back rub, eye contact on the validation, the right hand is scrambling the eggs secretly in the background. Yep.

Dr. Nicole Beurkens 

I think this is such an important conversation for parents to be hearing because so often parents go to this place in their mind when their kid is having those very normal, very real moments of “Oh my gosh, there’s something so wrong with my kid.” And so much of the work that I do, especially on this podcast, is helping to normalize a lot of this, even if your child does have a clinical diagnosis, normalizing this process that happens for all of us, and if we can keep our stories in check in that moment, like when I’m interacting with my 15 year old daughter, and she is anxious and melting down about something, and trying to keep the story straight in my head of “Okay, she’s a 15 year old girl, there’s a lot going on, I wouldn’t be 15 again, for anything, if someone asked me to go back in time”, and just trying to put it in context, as opposed to letting those stories in those moments sort of spiral into “Oh my gosh, there’s something really wrong with her. She can’t handle things. She’s anxious”, whatever, to try to keep ourselves in that place. And so it is this balancing act of “Okay, I need to manage myself first and my stories and what’s going on with me so that I can support my kid”, and that’s part of what makes parenting so tough.

Dr. Ellen Vora 

Absolutely. And I think there is something kind of almost escapist about wanting to jump to the conclusion of “You have a problem, you need help”, it ends up being this escape hatch, like “So then I don’t need to address how I’m showing up here”, that the idea that this is a dance and that there’s two of us tangoing. Just say, “Okay, well, the problem is yours. And now we need to escalate up to professional help.” And we are not saying that that’s not helpful. I mean, we are therapists, and I’m fully in support of professional help. But I also think that in that moment, it’s a way of avoiding looking at what role we are playing and how we can show up differently. And the fact that sometimes this is a very healthy response to a set of circumstances that are too much for our little bodies and minds to go through.

Dr. Nicole Beurkens 

So true.

Dr. Ellen Vora 

That’s an aspect in the in the book actually, where I talk about there’s this well-trodden metaphor of the canary in the coal mine, and I do think that people who struggle with anxiety are in many ways the canaries in our modern coal mine, that there is some subtle, poisonous gas about modern life that’s affecting us all, but anxious folks most prominently and in a way that’s most pronounced. And I think that with children, many times when they are struggling, it’s giving us a little hint about what are these aspects of modern life that are in certain ways incompatible with thriving? And so I think children kind of reveal that to us.

Dr. Nicole Beurkens 

I think that’s so true. And we are seeing that more and more with a number of kids who are struggling right now, particularly with anxiety and they are saying to us that nothing about what’s gone on in the last couple of years is normal or healthy or good for any of us, and they are letting us know that with the number of kids who are struggling. And I want to just touch on — because I think as adults, we have sort of an experience or an understanding of what anxiety is for us. Maybe it’s heart palpitations, feeling kind of warm, it’s maybe difficulty shutting off our thoughts or ruminating or having just a lot of feelings of stress or overwhelm or those kinds of things. And I want to just touch on for all of you as parents: That can absolutely be the case for kids as well. And sometimes in kids, anxiety shows up in ways that seem counterintuitive to us as adults: Hyperactivity and impulsivity and sort of behavioral explosions being one of them. Most adults don’t think about anxiety being at the root of explosive behavior or impulsivity. But for kids, that is absolutely the case. And we see a lot of overlap, even. I see kids sometimes misdiagnosed with ADHD, really, the issue is anxiety, but it’s presenting like this impulsive, sort of always needing to be moving and doing something, not able to settle down, sort of hyperactive stuff. And so I think that’s just something I wanted to put out there for parents, and I’m wondering what your thoughts or experiences are around that?

Dr. Ellen Vora 

Yeah, absolutely. And also things like stomach aches and migraines or headaches. This makes me think of a book that I’m probably going to get the title wrong, it’s either called “Scattered” or “Distracted” by Gabor Maté. Which is the right title?

Dr. Nicole Beurkens 

I think it’s Distracted.

Dr. Ellen Vora 

I think I’ve always thought I wish it was called Scattered. So basically, if I’m remembering correctly, sort of the thesis of that book, it pertains to the fact that in certain ways, that more ADHD presentation of anxiety, the common ancestor of both is actually trauma, and that in certain ways, trauma creates a pattern of behavior where it’s harder to sit still and be in stillness, where difficult memories come up. It’s almost like a way of avoiding the present moment, avoiding reality, to just be always distracted. And so I think that that’s just another interesting view on that, in a way like, yes, hyperactivity can be a manifestation of anxiety. But also, hyperactivity and anxiety can be a manifestation of a different underlying cause, which might even just be poor oxygenation of the brain overnight during sleep. I see this a lot in the adult population, I see it, and usually when I talk to them about their childhood, that kind of mouth breathing and poor sleep quality and hyperactivity during the day often starts very young. And there, we will say this is a diagnosis of ADHD. But in many ways, the inability to focus or sit still is a body’s attempt at staying alert and awake when there wasn’t adequate restful sleep. And that can happen very commonly these days from mouth breathing and poor oxygenation. And that itself has as a root, any number of things, including multigenerational soft foods and processed foods, which means that we are not developing healthy jaws, and then we don’t have properly formed airways, so we are not able to nose breathe at night.

Dr. Nicole Beurkens 

That sleep piece is so important for kids and adults, for sure. Let’s get into a bit of what strategies and recommendations from now, having this sort of new, more helpful, holistic understanding of what’s actually going on with anxiety. Talk to us about some of the things that you think are really important for us to be thinking about or addressing for ourselves, as well as you know, for our kids to support anxiety reduction, or just managing anxiety better.

Dr. Ellen Vora 

Yeah. And it’s nice that anything we do for ourselves impacts our kids beneficially, and then also can be applied to our kids directly. Sleep is a wonderful place to start. There’s a lot we can do, and a lot of us think of sleep as this black box and sort of inscrutable, hard to crack nut of difficulty, but I actually think it’s eminently treatable, and it’s really just about being a little strategic, I apply a very ancestral perspective to sleep with the idea being your body knows how to sleep, it wants to sleep, but there are the subtle aspects of modern life that are really getting in the way of our ability to sleep. The central issue is the circadian rhythm, and the key here is to recognize that our circadian rhythm or our sleep wake cycle is cued primarily by light. And that’s the part that our modern environment has deviated most of all from how we evolved. On the proverbial Savanna of evolution, if it was nighttime, it was by definition dark out. And light, by definition. meant daytime. And so it’s a brilliant design, to be honest, that if it’s dark out, we suppress cortisol, our stress hormone, we release melatonin, it helps us feel sleepy, and we sleep deeply. And then the sun rises and we suppress melatonin in response to the light cue. And we release cortisol, and we feel awake and alert. Bravo to the boardroom of evolution that came up with this design, and it is just unfortunate they didn’t anticipate we were eventually going to invent the light bulb and Netflix and then Tiger King and then nobody sleeps anymore.

We can get strategic, and it doesn’t mean you have to live off the grid or away from all light pollution, it can be as straightforward as just getting a pair of blue blocking glasses and putting them on around sunset and wearing them until bedtime. There are ones that are fully orange. And that’s pretty hardcore. It really is effective. But not everybody wants to see the world as orange for the last few hours of their day. So you can get these new ones now that look almost like normal glasses, they just have a filter that blocks blue spectrum light. And that will really help our modern environment approximate our evolutionary environment in the evening. And then earlier, bedtime is an interesting one. That’s certainly when I found out, I’ve sort of learned the hard way after having a kid, where it was like if you talk to someone who’s not a parent, it’s like, “Yeah, you get tired, and then you get more tired.” And I had to learn the hard way with my daughter that she gets tired, and she’s rubbing her eyes, and she’s yawning, and it’s adorable. And what I didn’t realize is that is an emergency, and you need to stop whatever you’re doing, change the diapers, swaddle and put that pile of dynamite sticks into the crib and get out of there before it’s too late. And so routinely, we were letting her get overtired. And then she was struggling to fall asleep, and she wasn’t sleeping well through the night. And we were like, “God, why is this so hard?” Until we realized how to really honor those sleep signs and to swoop her into bed right when she’s tired. And I think it also dawned on me that adults, we are really just gigantic toddlers in many ways, and we also have over tiredness as a concern. And that’s where our body is just trying to help, it says, “Okay, you were tired one minute, you were falling asleep on the couch, but you didn’t go to bed for the night at that moment. So you must have some good reason for staying up. Maybe tonight, you’re on night watch duty, or maybe it’s the great migration.” So it thinks “Let me help and suppress your melatonin and give you some cortisol so you can do a great job on the night watch”. And then the next thing we know we are tossing and turning, and we are scrolling TikTok until midnight because our physiology really supported wakefulness once we got overtired. And so even just pushing bedtime a little bit earlier, maybe around three hours after sunset and really noticing our own tired signs and sweeping ourselves into our crib at that point is helpful.

 Dr. Nicole Beurkens 

So true what you’re saying. And I want to point out that even for elementary-aged kids and overnight, even just our tiny ones, often parents will come in with a concern about “My kid gets so wound up, can’t settle down for sleep, it’s 11 o’clock before they are in bed and sleeping.” And to your point exactly, when does that progression first start? Because if it’s 8:30 and your kid is wound up and bouncing off the walls, you missed something earlier that said they were already — now they are way overtired. And yeah, exactly what you’re describing. Now, they are so overtired that now, they have gone into this overdrive mode, and it’s almost impossible to get them to settle down. And so looking at the progression of what’s happening from that after school time through dinner, through the evening, and watching for the timing of that of what’s going to make more sense, in terms of how is their body indicating that they are needing to settle down and maybe sleep earlier? Watching for those things. Because, yeah, nothing’s more frustrating with an eight-year-old than having them totally bouncing off the walls, beside themselves, chaotic at nine o’clock, and you’re trying to get them to bed. And so to look at those pieces, I think you’re so right.

Dr. Ellen Vora 

I don’t make many friends with this one, but it’s like you kind of do need to create a little bit of that Little House on the Prairie vibe in your household toward bedtime, and you pay most attention to light. If the lights are on full blast overhead. If the TV is on in the background, if someone’s looking at a screen, on a phone, on a tablet, especially these kinds of light that are associated with lots of things that are kind of hard hitting on our dopaminergic signaling, very rewarding, flashy, quick changing, cuts, all of that is going to be so stimulating. And is it any wonder that so many of us and our kids struggle with sleep? Our modern environment is really destructive to our ability to kind of feel bored and sleepy in the evening. So you do kind of want to — I remember, I was on an early parenting board, and people were like, “How do I get my kid to sleep?” What does it look like in the environment? And it’s like, “Well, maybe you want to switch to a salt lamp and turn off the TV, and maybe it’s just candlelight during bedtime”, and I was laughed out of that chatroom. I realize now I have to first earn credibility before I bring up salt lamps, but I think that it is valid and our precious little situation, not that we have perfectly hacked sleep. But my daughter’s nightlight was a salt lamp, and to get that more orangey hue light and something dimmer is protective of healthy melatonin release at night.

Dr. Nicole Beurkens 

And the impact of sleep on anxiety cannot be overstated when we are not sleeping well, when our kids aren’t getting enough good quality restorative sleep, it just opens the floodgates for anxiety and lots of other things, but anxiety in particular, to be a much bigger problem the next day, and so recognizing how strong that connection is and how good the research is around.

Dr. Ellen Vora 

Yes. And there’s kind of a misunderstanding that I see around a lot, where people say,” Well, I’m not sleeping well, but it’s the depression or it’s the anxiety causing the poor sleep.” And that’s fair, we can definitely have that conversation. They are such closely related concepts that it’s true that if you’re struggling with anxiety, maybe your thoughts are racing, you’re kind of in that tossing and turning mindset as you’re trying to fall asleep. And in certain ways we can identify it as the anxiety causing the disruption in sleep. But more importantly, we have to just establish in a public conversation, all mental health issues are exacerbated by lack of sleep. And so even if the anxiety can cause sleep deprivation, sleep deprivation can cause the anxiety, and in many ways the sleep is the easier entry point to addressing the whole vicious cycle. And I think that we sometimes need that why, like, “Why does sleep matter so much?” And in certain ways, I struggle to answer that because I have an answer for it, but I don’t think it’s the whole story. I don’t think we fully understand the whole story just yet. But one correlate to think about is the glymphatic system, which is our body’s ability to detoxify in our brain. We kind of understand maybe from high school biology, we have our lymphatic system, that series of vessels that gather waste from ourselves and help us excrete it, whether it’s through sweat or urine. But we also have this system in our brain, it’s called the glymphatic system, because it’s related to the glial cells in the brain. And that’s when we basically — the analogy I use in my book is that our brain is like this little city, and all the little shops and stores create trash during the day. And then the garbage bags are kind of piled up in the alleyways. And it’s only at night while we are asleep that the glymphatic system revs up. And the garbage trucks basically go around these alleyways of the brain and clear away the garbage bags. And so if we don’t get adequate sleep, that process is not complete by the time we wake up, and we are going through our days with alleyways full of garbage bags, we feel kind of there’s gunk in our brain, we can’t think as clearly, we can’t stabilize our mood. We can’t operate from that most fragile resource, which is executive function and being in a place of our prefrontal cortex where we can operate with integrity and restraints and calm ability to see things from both perspectives. And you sort of see the evidence of that today in our kids and adults as well, it’s like we are really not meeting each other from a prefrontal cortex place. We are very reactive and very amygdalar. We are kind of operating from a brain that hasn’t been fully cleaned out at night.

Dr. Nicole Beurkens 

Imagine how different the world would be right now if everybody’s brain effectively was able to take out the trash every night.

Dr. Ellen Vora 

Yeah. We could be on our way towards world peace.

Dr. Nicole Beurkens 

That’s right. It’s a great example. I love the visual of that, even kids can understand that like, what a great way to describe that to kids as to why sleep is so important with the garbage and the trucks. That’s great. So sleep is a big one. Talk to us quickly about what are some other things that we should be paying attention to for ourselves and our kids with anxiety?

Dr. Ellen Vora 

So blood sugar is another big one. And the definitive solution is to eat a blood sugar stabilizing diet, which looks kind of like well-sourced protein and carbohydrates from starchy vegetables, and plenty of vegetables, and then healthy fats liberally distributed throughout. And that can feel like a 180-degree departure from how people are currently eating or it’s like a scone at Starbucks and nachos. So if it feels too difficult, there is a little temporary hack that you can use in the meantime, which is to do something like a spoonful of almond butter, some people use ghee or coconut oil, but something to give you a safety net of blood sugar, to just kind of catch you and buffer any crashes and blood sugar, and that can prevent the stress response. Caffeine is not a popular conversation, but there’s nothing inherently wrong with caffeine. Coffee has magnesium and antioxidants and its associated with decreased risk of Parkinson’s and type two diabetes and even suicide. There’s merit to coffee, there are benefits. Green tea has antioxidants and polyphenols. It’s all good stuff, but with our bio-individuality, some of us are really sensitive to caffeine. And so if you know you’re the person who can have an espresso after dinner and still fall asleep, no problem, great, more power to you. But if you know that if you have one coffee, you are going to effectively be on cocaine for the rest of the day and you can’t sleep for a week like me, then it’s just worth getting honest with yourself about where’s the right place to land with caffeine. And a lot of my patients with anxiety, their anxiety improves precipitously when they consume less caffeine. But PSA, you don’t do that overnight, you build gradually, actually precipitously is totally the wrong word. Nothing should be precipitous with caffeine. Want to go gradually, you want to wean over the course of many weeks. Yeah, and then just try it out, see where you land. I think that alcohol is such an unpopular conversation. But we do need to also talk about that. I use science to sort of justify this argument, but alcohol is not doing us any favors when it comes to anxiety. And there’s two main reasons: One is that it actually causes its own blood sugar crash, often overnight, which then interrupts our sleep, which then in its own right impacts our anxiety. But then it rushes the brain with a neurotransmitter called GABA, which is a really important neurotransmitter when it comes to anxiety. So it helps us feel calm. It’s the primary inhibitory neurotransmitter of our central nervous system. But our brain sees all that GABA from alcohol, and it doesn’t think, “Gosh, it’s so nice to be relaxed.” It thinks this is a risk to our survival, because we are too buzzed to worry about a potential threat. And so it corrects that, it reclaims homeostasis by converting that GABA into a different neurotransmitter called glutamate, which is an excitatory neurotransmitter. And that’s why we toss and turn in the second half of the night after we have been drinking, we wake up with that kind of uneasy headache you are feeling. That’s the glutamate conversion. So we really want to be careful with our GABA. GABA is really central to anxiety, and we want to protect that resource. And alcohol has the opposite effect.

Dr. Nicole Beurkens 

I’m really glad you brought it up. Because yes, it’s unpopular. And I’ve commented on it several times. And it’s unpopular, especially on social media. But I think we have a lot of moms listening, and this whole mommy wine culture has become a whole thing now of day drinking or evening drinking to take the edge off, to manage, to settle your anxiety. And I totally understand where that’s coming from. And yet, what you’re describing is exactly what I see in so many of the parents that I work with, where you have a very short-term benefit for a long-term problem then, because they get trapped in this cycle of thinking that they need the alcohol to settle themselves down. But it’s only causing this revving up process where they are actually more anxious and destabilized and moody the next day, and you just ended up chasing that. And so I think what started out as sort of this mommy wine thing, it’s humorous, whatever. I mean, there really are some important things to think about here for each of us to decide as individuals what role we want that to play in our lives, and what are the bigger picture things that we need to be thinking about.

Dr. Ellen Vora 

Mommy wine culture is such an important topic. And I feel like so often I’ll see these sorts of corporate interests, taking us almost through a lot of really big truths, but then the solution is actually something that makes the problem worse. So the truths here are, the culture, the marketing is telling us, “What you’re doing is really hard. Being a parent is really difficult, and you’re exhausted, and you’re not getting your cup filled, and you’re not getting your needs met.” And so we are in the background as parents nodding along. “Yes, yes, yes, this is all true. Yes, you see me, I feel so seen.” And then they are like, “The solution is chardonnay”. And you’re like, “Okay, that sounds good. Especially because I’m already withdrawing from chardonnay.” So we will go ahead and replete. It will be the antidote to its own withdrawal. And the problem is that these solutions that corporate interest tell us, are usually something addictive. And they are something that actually exacerbates the original problem. So I’m all for everything up until that suggestion of chardonnay is so true, and something we have to slow down and pay attention to. It’s very difficult to be a parent always, but I think it’s especially difficult in this modern world. And a lot of parents are just at their wit’s end, not getting their needs met. This was true before we entered the pandemic with unpredictable childcare interruptions and masking and our own anxiety and so on and so forth. And so what we need to recognize is that we have fundamental human needs that are not being met, and can we address those. And the chardonnay was never a true solution to that problem. And in many ways, it made the problem worse.

Dr. Nicole Beurkens 

Yeah. So glad that we are touching on that. So we talked about sleep, we have talked about some food and drink kinds of things. What else? Movement, I’m assuming. Movement is a piece I talk about that all the time for kids, like getting off the couch and having physical activity.

Dr. Ellen Vora 

Exercise is such a big one. And I was recently in Joshua Tree, California. And it was so beautiful. And it was just so funny, I woke up one morning, and I was meditating at the sunrise, and my friend put on a laptop, he streams some kind of exercise workout, and he’s like doing this workout. And he felt so much better afterward. And I was thinking to myself, this guy was evolutionarily hardwired to be someone who’s like, “I need to go hunt, like I need to go acquire the food to provide for my tribe.” And that’s how he feels right. And since modern world, we just use Instacart and order our groceries, he’s not out on the hunt. And so he needs to sort of stream this guy who yells at him to his knees up high while he marches. And so it’s just interesting how I think exercise is basically trying to replace something that we are hardwired to need, which is movement. We are just hardwired to feel well when we are doing what kept us alive and well in the proverbial circumstances of evolution. So I think that we need to move because we had no choice but to move to keep ourselves fed. And now that’s in our hardwiring. And I think it’s so important to me to lower people’s standards. Yes, it’s great if you want to train for an ultra-marathon, I won’t stand in the way of that. But if you’re in more of that all or nothing relationship to exercise, and it’s kind of more of a nothing, then you just lower your standards, you figure out what is something that you can do for a couple of minutes. Can you put on Whitney Houston and dance in your living room? Take a 20-minute walk after dinner, just hold one plank pose for 30 seconds, anything that creates inertia in the direction of more movement.

I think the last big category to touch upon briefly is just all things technology. And that’s a toughy. What is even the solution here? I think it starts with awareness of how addictive it is. It starts with a little bit of mindfulness around how do we feel before and during and after we have engaged with something, and to just be as intentional and conscious and eyes wide open as we can be in how we develop relationships with our products, our technological products. And I think as parents, we are present for setting the ground rules for our children. This is setting the paradigm for their lives of how they interact with technology. And many of us in our sort of a parent generation, that wasn’t really part of our childhood. It just wasn’t, we didn’t have to establish etiquette around it. And we just have to recognize that we do. I always think technology is sort of similar to, I heard this analogy to cars without seatbelts. Yeah, okay, we have invented cars, but we haven’t yet invented seatbelts. So we are just using and we are using sort of dangerously all these technological devices. And in a way, we have to figure out for ourselves, what are the seatbelts? And certainly for our children, what are the seatbelts? Where are their limits? Where can we maybe have this be something that is intentional, and not just the default setting all the time? Which I think is impacting how we are wiring our children’s brains, and it certainly creates quite a bit of, at least for my daughter, dysregulation, which then causes a lot of suffering for me and my husband, certainly, but also for my daughter herself. And I feel like it’s always on us when she gets into one of those post-technological, dysregulated meltdowns, that’s suffering in her that we, in certain ways, have caused. And so to just be so conscious about choices with it. It’s tough, though.

Dr. Nicole Beurkens 

It is tough. And as you’re talking about that, I’m thinking that screen time and device use for kids has sort of become the equivalent of mommy wine culture for adults, where we use in the short term, we think, especially if the kid is anxious or worked up, or whatever, it’s like, “Okay, this soothes them, they feel better.” It’s sort of that short term, but then over the longer term, what we get is sleep disruption, increased irritability, decreased movement, all of these bigger picture problems that then just exacerbate the anxiety that we are trying to soothe by giving them a device and their app or their video game. And so it just strikes me how really the pattern is the same. It’s just a different substance.

Dr. Ellen Vora 

That’s a great connection. I think that’s absolutely true. It is kids’ mommy wine culture. That’s right. And I think that in both issues, it’s really just humans who have some fundamental needs, and I think a big thing that we can do a very actionable strategy is to arrive at this place for ourselves and model it for our kids, which is just being able to move through our emotions. So often the reason we reach for wine or we reach for a screen is to numb out, is to change our state. And a lot of it pertains to this kind of emotion-phobic lockdown we have with our feelings. And I’m biased, I’m a psychiatrist, but I say feel our feelings. And it can feel very scary in anticipation, but just start to dabble in that, what if you had that sensation to cry, and instead of holding it back or sucking it back in, you kind of just let yourself fully cry and have a big cry? And we tend to think, “Oh, if I’m crying, I’m in a bad place, and I’m a mess.” I really think crying needs a rebrand, and crying is very quintessentially human and healthy. And it’s the wisdom of our body saying “We need a release right now.” And so rather than numbing out in that moment, dive into our emotions and feel them deeply. And usually, that’s actually what properly scratches the edge rather than just sort of numbing out to avoid feeling what we are feeling, which just kind of pushes our feelings under the rug where they are transmuted into things like, abdominal migraines, and for adults, chronic low back pain and chronic headaches and digestive issues.

Dr. Nicole Beurkens 

I always say to people: It comes out one way or another. We can try to stuff it down and ignore it right now in the moment, but it’s going to show up, probably in a bigger way later on, for kids and for us. So yeah.

Dr. Ellen Vora 

Well, it relates back to what you’re saying earlier about your body starting at a whisper, and then it builds. And it’s like, our body is always trying to say “You need this release, I’m going to start gently, but if you ignore me systematically, it’s going to get louder.”

Dr. Nicole Beurkens 

Yeah, so true. This is so great. Ellen, you and I could talk about this for days. I know that we need to wrap up here. But I want to make sure that people know about your new book, which we have given sort of a preview of today in our conversation, but tell us about the book and where people can get it.

Dr. Ellen Vora 

Yeah, thank you. The book is called The Anatomy of Anxiety, and people can buy it wherever they like to buy books. And if you ever need a clearinghouse, my website ellenvora.com can point you towards lots of different resources. And on Instagram, I’m at @EllenVoraMD.

Dr. Nicole Beurkens 

Yeah. And you have so many great resources on your website, and have such a great Instagram as well. I follow you on there, and just great information. And so I really encourage all of you listening, go follow Ellen on Instagram, go to her website, and definitely get the book. Ellen, when you said what the name of the book was, however many weeks ago, I was like that is a brilliant name for a book. I love it. I love everything that you’re doing with this. So glad you wrote a book about it. And so everybody should go out and get that book, and I’m going to recommend it widely at the clinic too. So thank you for everything that you’re doing in this realm. It’s just so important, and the world needs it more now than ever. So thank you.

Dr. Ellen Vora 

Well, thank you so much.

Dr. Nicole Beurkens 

And thanks to all of you as always for being here and for listening. we will catch you back here next time.