Panaceas for a Panic Attack!

Your heart is racing,  your hands are tingling, you can’t breathe and you wonder:  “Is this a heart attack?  Why does it feel like the world is crashing down on me?”

In this episode learn: 
* What a panic attack is and is not
* Evidence-based strategies for overcoming panic
* The role of medication when treating panic disorder 
*  The treatment approach for Tourette’s syndrome, a disorder related to motor and vocal tics, another expertise held by the episode guest.  
 
Expert guest for this episode is Dr. Rob Zambrano, a psychologist at Stress and Anxiety Services of New Jersey (stressandanxiety.com).  Dr. Zambrano, who specializes in panic, Tourette’s syndrome and the anxiety spectrum disorders, will surprise listeners with what may seem like a paradoxical strategy to overcoming a panic attack.  

This episode is dedicated to Ginnie’s House, a non-profit organization which provides 100% free therapy to abused children and their caregivers.  Learn more at ginnieshouse.org. 

Thank you _geogre.art_ , my son, for the photograph.

Transcript

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SPEAKER_00 0:04

To love learn. To understand.

SPEAKER_01 0:13

To bring to the things that matter most.

SPEAKER_00 0:17

This is Psychology America with Dr. Alexandra. Welcome to my show. For every life stage, we have questions. Let's enhance our lives together as we explore the things that matter most. This episode is dedicated to Ginny's House, which provides a hundred percent free therapy. Truly free. With zero insurance involvement to abuse children and their caregivers. Learn more at jinny's house.org. Earlier this week, Mr. Neil Clark, retired English professor from Asheville, North Carolina, shared with May where the word panic comes from. Think of a half man, half goat. The bottom half is goat. That's a character from Greek mythology who was called the great god Pan and who ruled the forest and the animals in the woodlands. When's the last time you walked alone in a dark forest? While the fear that could suddenly come upon you in that situation was named Panic in the English language. Named after the great god Pan. In modern-day psychology terms, people can experience what's called a panic attack. And panic is what this episode is about. I'd like to introduce my very special guest to you, Dr. Rob Zambrano, of Stress and Anxiety Services of New Jersey, where he specializes in panic and also Tourette's syndrome and anxiety spectrum disorders. Dr. Zambrano, Rob, is the son of two immigrants from Columbia. He is like me. I'm also a first-generation American. He loves to sing and dance with his four-year-old son. And his personal hero is Mr. Rogers. Rob, before we begin about this topic of panic, for our international listeners, can you describe the TV personality of Mr. Rogers and why he's your hero?

SPEAKER_02 2:37

Oh, absolutely. And uh I'm I'm honored to actually start talking about my personal hero, Mr. Rogers. So he is a um a children's television show uh producer. Um and I wouldn't call him a character so much in that he essentially played himself. Um and so he was uh he had an American television program on PBS for for many years. I think it might have been almost 30. Um and Fred Rogers was sort of a really gentle, quiet soul. Um and really so much about his show was completely child focused, but in terms of sort of helping children understand how special they are, how special everybody is in their own unique way. Um and it was something that I watched a lot as a child myself. Um, I grew up in an environment where there weren't a lot of kids around, actually, so I was somewhat isolated. And so having a guy like Fred Rogers every day tell me how special I was, how important I was, and say so in, you know, in a very soft, calm, reassuring voice, um was really important to me. And I think he it's a voice that I've carried along in my head for for much of my life, that sort of soothing, relaxing gentleman that he was. He truly was one of the most beautiful and kind souls. If you've never seen Mr. Rogers Neighborhood, which is the name of his show, um, I'd recommend anybody just take a look on YouTube, see where you can find it. Um just some wonderful stuff, beautiful lessons, and uh just an inspiring guy. And I and I think his desire, you know, he he referred to everybody as his neighbor. Um and he wanted to share kindness um and help them feel special. And I and I think that sort of imprinted itself in my brain in terms of a lifelong desire to, you know, want to help out my neighbors. And um and so I think that's what led me to an interest in psychology, um, wanting to be a helper. Um I think he inspired that in me. So I the uh, you know, i if in some small way I'm carry carrying forward his good work, um, then that's that's a really reassuring and happy thought for me.

SPEAKER_00 4:39

He he sure was very loving and magical in the best way, in in his compassion and in the way he talked to children.

SPEAKER_02 4:51

It was pretty astounding.

SPEAKER_00 4:53

Okay, so panic.

SPEAKER_02 4:55

Yes, I and by the way, I really love your description of where panic came from. I never knew that, and I'm absolutely borrowing that. Well, thank you, Mr. Neil Floyd.

SPEAKER_00 5:07

So, this is how my patients have described panic. It's it goes something like this. Your heart is racing. You wonder, is this a heart attack? You can't breathe. And you feel like the world is crashing on you. You might have tingling in your fingers too. Does this sound like panic to you?

SPEAKER_02 5:31

It absolutely sounds like panic. It's a pretty good description. Um now, of course, you said it um in and I think we both uh maybe invoke Fred Rogers from time to time, and that we both, I guess, have um, or at least try and pull off this sort of calm, soothing psychologist voice. Um, but usually when people describe panic, it's uh you you can hear sort of the pain of the experience in their voice. There's something really intense in the description. Um one of the things I found over the years is if I ask a patient, um, have you ever had a panic attack? If they say they're not sure, my guess is that they probably haven't. Because it's a it's a pretty distinct and powerful experience. It's um it's traumatic um in that very often one of the thoughts happening is either I'm going crazy or I'm gonna die.

SPEAKER_00 6:15

Yeah. Dread, a feeling of dread.

SPEAKER_02 6:19

Absolutely. And a lot of patients, a lot of patients have come to me over the years having gone to the emergency room first, having gone to various doctors thinking there's something wrong with my heart. There's you're you're missing it. Um, and after enough doctors tell them, we think this might be a panic attack. This we think this is psychological in nature. A lot of my patients find their way to me through that avenue.

SPEAKER_00 6:39

So what is it not?

SPEAKER_02 6:42

Um, you know, I I think sometimes people misconstrue or misdescribe what a panic attack is, in that they'll sometimes say, um, you know, I had a burst of anxiety, I felt uncomfortable or worried. And and that's not quite panic. And I was actually um thinking a little bit about my experience of getting to know you. Um we shared an email exchange about doing this podcast. And the funny thing is, I I've done some media over the years, and I know in advance of that I'm always pretty anxious, which is weird because typically when I actually get to just when the green light's on and I get to start talking, everything feels fine. Um, or at least relatively fine. Um but the idea of presenting is always pretty scary to me, especially you know, with a fellow psychologist and potentially a pretty educated audience about psychological issues. So, you know, a lot of those insecurities will start to pop up in in the form of what we call anxiety. Um, thoughts like, I'm not good enough for this, um, you know, and and so as I found myself getting anxious, I listened to some of the other podcasts that you've done. I listened to one with um the executive director of our practice, Dr. Wegg, on OCD. And I I listened to it for a few minutes and it was pretty good, but realizing I when when I've known Dr. Wegg for 14 years, uh, and so I've heard every story under the sun about OCD that he can spin. He's I've read his book. Um, and so I switched from his podcast to uh Dr. Simon Rego, who um we both knew from graduate school. Um Dr. Rego was a couple years ahead of me, um, and always really impressive guy, but uh, you know, he he's really bright, very athletic, smooth voice, uh cultured. On top of that, throw in the throw in the back that he's Canadian, so they have that just little extra politeness to him. Um I listened to the whole podcast, I thought, this is wonderful, but oh man, I can't I can't pull off the Simon voice. And I'm not gonna sound as cool and smooth as Simon. So I got a little anxious, and I remember after listening to Simon's podcast, I sort of pumped myself up and I said, You can do this. You don't have to be as good as Simon, you just have to be as good as you, and that's okay, and that's okay. Uh, you know, uh, I'm sure Mr. Rogers would say I'm okay too. So I emailed you back and he said, Okay, let's let's do the panic presentation. And I didn't hear back from you for a couple days. Um, and I kind of felt like, oh, I'm off the hook. Maybe she looked at my bio and thought, eh, maybe not. So um, so there was a bit of relief. And then one day I checked my email and there it's you, and she's like, and you say, Oh, let's do the panic presentation. And right away I noticed my heart started pounding. I was short of breath. Uh, my stomach turned into knots. But I would not say that was a panic attack because the missing element was that felt normal. It made sense to me, right? Oh, okay, I um all these insecurities are suddenly, unexpectedly out of the blue, hitting me, and I'm having a bodily, a normal bodily reaction to that idea, to that thought. Um, and I I think what's helpful and what might differentiate a panic attack from not a panic attack is, or at least the uh the initial experience, is the idea of, okay, this makes sense. This is normal to have these physiological responses to the situation. Um and so, you know, uh I've done cognitive behavioral therapy for a very long time. I know how to talk people down and teach them how to challenge their thoughts, and so I just remembered you've done tons of presentations. Alexander sounded really nice in her podcasts. She's not gonna do a Mike Wallace 60 minutes gotcha interview on me. Um, so I'm probably gonna be okay. She probably wants me to sound good too, because then her podcast sounds good. So take it down a notch, Rob, you're okay. So I took a deep breath and I just said, don't talk too fast, don't sound too jersey, and you'll be alright. Um and then within a few minutes I kind of went back to I went into the kitchen, started washing some dishes or whatever, and uh the feeling was gone.

SPEAKER_03 10:43

Yes.

SPEAKER_02 10:43

Uh and so so that wasn't a panic attack because I wasn't really frightened or it didn't come out of nowhere. It didn't terrify me. At no point did I think I was in some form of danger. Um but if you'll indulge me, I'll I'd like to share a story with you about um the first time I actually had a panic attack, which is Oh, please do. Sure. I I share with my my uh my clients that you know I I've actually it's ironic that I work at a place called stress and anxiety services and I treat anxiety disorders because I'm generally, as you know, aside from a minor um pre-performance jitters, not a terribly anxious person. I'm pretty laid back overall about most things. Um and so the idea of sort of having a lot of anxiety, I understand how to treat it, um, but it's not something I have a ton of experience with. Um and in and that includes panic attacks. But about, I'd say about 10 years ago, um, I'm a huge baseball fan. It's uh I think I joked with you, it's practically a religion for me. Um and so one of my life quests was to go to every stadium around the country, every uh major league baseball stadium around the country. And so in the process of knocking that off about 10 years ago, I went to Houston to catch a baseball game, and I stayed with a friend who um at the time had a studio apartment uh while he was establishing himself in Houston. So we went and caught a game, it was really hot. I may have had a beer, but I don't drink very often, so the one beer had me feeling really lousy. So I basically came back to his studio, crashed on the couch, and had a not so good night's sleep. The next morning I got up and flew to uh Arlington to catch a game uh to see the Texas Rangers. And I I if I remember correctly, it was an afternoon game. And as soon as the game was over, for some reason, I guess, in an attempt to torture myself and save some money, I drove to the airport and hopped on another flight to Colorado to catch a game the following day. Um a lot going on. So I uh so when I got to Colorado, I was pretty tired, and so I said, Well, let me go uh get a Red Bull or something with caffeine to keep me up for the drive to the hotel room. So, okay. I chugged a Red Bull, I got to the hotel room. Um, and at the time I was uh about to start a new diet. Um, and I uh along with that diet got some of those diet pills that they say speed up your metabolism. So um it was late uh from the flight, so I drove to the hotel room. I took some of those pills um that sped up my metabolism, and I sat down to watch a movie on TNT, if I remember correctly, it was one of those movies with J Low where she played an, I think, an abused wife who left her husband, and the husband was stalking her, and she learned to self-defense. And so I'm watching this movie, and it's you know, it's it's not a great movie, but it's got some tension in it. Um and as it goes, I'm going, wow, this movie's really this is more tense than I expected. This is making me pretty anxious. And you know, that's about the time where I guess the combination of the diet pills and the um the over-the-counter diet pills and the and the red wolf kicked in, and my heart's really racing, and I can't catch my breath. I was like, I gotta turn off this movie, this is too much for me. Um, and then suddenly it kind of dawned on me, oh no. I drank Red Bull, I took these pills, and my brain started to say, you may be having a heart attack right now, which was really scary. Um, and just like you described, my fingers went numb. I couldn't think straight, I couldn't catch my breath, and uh I'm just sitting in my hotel room thinking, this is a really stupid way to die.

SPEAKER_00 14:18

Um So you did think you might you might be having a heart attack, or you you had that fear, just the way panic folks can can feel.

SPEAKER_02 14:28

The thought crossed my mind, and I think also the thought, how embarrassing if I'm just having a panic attack and I call an ambulance. Um so I tried sitting there and breathing, which I don't actually advise my clients to do, and I'll explain that later. That, you know, we're that you just sort of have to ride out the storm. So I left the hotel room, I went for a walk, there was a pool out there, and I sat by the pool and kind of stuck my feet in the pool, and the pool had the added benefit of being by the parking lot, so if I do happen to keel over, maybe somebody will pull up and help me. Um and eventually, after a good 30 minutes, the adrenaline rush had passed, and uh I was somewhat back to normal, and I said, Oh wow, that was a panic attack. That's my first panic attack ever. Um, and in a strange way, I'm glad I experienced it because when you work with a lot of panic, it's uh not that it's necessary, but it's helpful to have a sense of what your patients go through.

SPEAKER_00 15:22

So I agree. Yes. You know, if something's gonna go wrong in my life, I tend to move in the direction of anxiety. But that can be a gift for me to experience that and know what that's like for my patients as well. Yeah.

SPEAKER_03 15:40

Oh, yeah.

SPEAKER_00 15:41

It sounds like you're advising your patients about the concept of surrendering to the panic attack because part of what brings on a panic attack, once people have had a panic attack, is the fear of the next panic attack.

SPEAKER_02 15:57

Exactly. So that's where panic attacks roll into what we call panic disorder. So living in fear of having more panic attacks, avoiding situations that you think will cause you to have panic attacks, um, and over and essentially what I try and explain to my patients the first time I meet them is what really kind of happens is that your body experienced a trauma. Um and it's really very unpleasant. And having gone through it, I know what it's like and not and I know the thought. I don't want to feel this way again. Um but the problem is when you experience a trauma, um, as trauma victims will tell you, um, they become hyper-vigilant of situations and sensations that remind them of the trauma. So sometimes you become aware of sensations that otherwise you might miss. So, for example, right now I'm you and I'm having a back and forth conversation. I'm talking a lot. And um, maybe at times, if I let out a long sentence or a long paragraph without catching my breath, I might, my brain, my subconscious might notice so I'm a little short of breath right now. Um, or might notice, you know, I'm performing right now, and so I'm a little bit more amplified, and so my heart might be beating a little faster than normal. But because I don't have panic disorder, my body's not hypervigilant, it doesn't notice it. It only notices it now because I'm describing it for the purposes of the conversation. But ordinarily I'd have that those two experiences being short of breath, maybe my heart's skipping a beat, and it it just wouldn't register. But when you have a history of having experienced panic attacks, and then you develop panic disorder, your body's on guard all the time. Um and so then it notices those those sensations, and I try and teach my patients that what happens next is your body overreacts to those sensations because it's an alarm goes off. It says, This means I'm gonna have a panic attack. Um, and maybe even it means I could die or go crazy. And that's a pretty terrible thing to have happen.

SPEAKER_00 17:53

I'm surprised that well, before I say that part. Regarding the surrender piece, what I tell my patients is to remember that that the panic attack will have a beginning and a middle and an end. That it won't go on forever.

SPEAKER_02 18:13

All things are temporary, including panic attacks.

SPEAKER_00 18:16

And that's part of the way that you surrender to it is that though it feels dreadful, it it it will come to an end.

SPEAKER_02 18:24

Sure. And you know, and of course, for patients, it's you know, typical either response would be easier said than done. That I'm supposed to accept this really horrendous and terrible experience. Um and uh sort of tongue-in-cheek say, yep, that that that's really the best approach. Um, but we're gonna do some things that are going to teach you to respond differently to these sensations. Um of the stories that I often share with my clients is uh, you know, in our practice at Stress and Anxiety Services, we we do a lot of teaching through metaphor and storytelling. Um so you know, we help them understand that, you know, um to think to conceptualize a panic attack, and for a lot of people, the first panic attack is kind of out of the blue. They can't quite understand why it happened, they just know that it did happen. It was really upsetting. So I so I say to them, you know, when I try and help them understand what's going on, why are they experiencing these repeated panic attacks? Um, I say, imagine what it's like to walk around in your neighborhood. It's a neighborhood you feel safe in. Uh, you know the streets, you know the neighbors, you know what cars belong there, um, and you feel comfortable and you're safe there. And you're walking down the street, and suddenly one day a mugger jumps out from behind a car and hits you in the knee with a lead pipe, bashes you in the head, and you're injured pretty badly. What do you think your experience would be like the next time you're walking down that street? It might feel really different. This street that you walk down always comfortably, um, suddenly, you know, uh you're walking down that street again and feeling kind of nervous. And then because you're feeling nervous, your brain says, well, in the animal world, if you're nervous, it must mean that something is wrong or something bad could be about to happen, so let's be prepared. And then you're walking down that street that you walked down many times, and suddenly a squirrel jumps out from uh from a branch, and your reactions to that squirrel is gonna be radically different than had that mugging not happened a while back. And then you walk a little bit further, and maybe you see a shadow or somebody unfamiliar gets out of the car, you're gonna feel a little bit more nervous, right? Um, and so in this metaphor, you know, all the things that you suddenly start noticing, those are the physiological symptoms that, again, we're overreacting to. And so, really, one of the core pieces of treating panic is something we call symptom cue exposure, or uh in some literature you'll see it referred to as interoceptive exposure. And what that is, is we're trying to have the client desensitize to a number of physical cues that people commonly uh associate with panic. So, you know, if you associate the feeling of lightheadedness with a panic attack, I might have somebody in my office shake their head loosely from side to side with their eyes open, and that produces a sensation of disorientation. Some might say, um, I feel like blood rushing to my head. So I might have them sit with their head between their knees and then for 30 seconds and lift their head up quickly to produce lightheadedness. I might have them run in place or do some jumping jacks to produce heart your heart pounding or shortness of breath. You could have somebody tense all their muscles at once uh to produce muscle fatigue or what muscle weakness if that's something they associate with it. We can have them hold their breath, um spin in place if nausea and dizziness are part of it, hyperventilate on purpose if that's a a symptom that triggers panic. And what we're trying to do is we're trying to teach our clients to have a new relationship with those symptoms, to sort of to accept them, to not catastrophize them, to normalize them to some degree, um, and to understand that really what's happening when you have panic attacks is you're overreacting to some of these sensations. And so if we can desensitize you. To some of these descent uh desensitize you to some of these sensations, you might be less likely to have that catastrophic overreaction to those sensations and therefore less likely to panic. But of course the irony of the therapy is also saying, but you have to be willing to panic anyway.

SPEAKER_00 22:16

I'm surprised though that you advise against them doing something like square breathing because I've I've always learned that our breathing has a big part of this. So folks will be anxious before the panic attack and they'll start shallow breathing. In fact, I remember one supervisor way back when I was a permit holder telling me that if we wanted, he and I could induce a panic attack right in his office. Just just through shallow breathing. So I'd love to hear your thoughts on that.

SPEAKER_02 22:53

Sure. I mean, um we part of the protocol is teaching people relaxation skills and meditation skills. And that's actually something I do early on. But a lot of what I try to explain to clients is if the spirit of the set uh of the therapy is to not resist panic feelings, to not try and make those feelings go away, but sort of sit in acceptance of them, then relaxation skills might be used contrary to what we're trying to do in therapy. And so what we know is that a lot of panic attacks can be induced by heightened anxiety. So people who live in heightened states of anxiety tend to be more hyper-vigilant and therefore more likely to panic. So I do like teaching people relaxation skills for a couple of reasons. One, um, it gives them some sense of control. I have a skill that I can use, and when people feel that they're skilled, that they have coping skills that they can use, they're more likely to take risks, they're more likely to fully engage in exposure and do some of the things that I'm gonna ask them to do that are difficult because at least they say, I know how to manage this. But the way I look at relaxation is this is more about before you panic.

SPEAKER_00 23:54

Yeah, it's a prevention.

SPEAKER_02 23:56

Exactly. So what we're saying is it's perfectly okay to try not to panic, but there's almost a point of no return where you then have to realize, here we are, right? That uh, and and so when I described exposure therapy to people, I often talk about the metaphor of writing a roller coaster, right? Um, and so you know, how does exposure therapy work? Why does desensitization work? It's similar to writing a roller coaster. When if you have a fear of roller coaster, we might have you ride some small ones repeatedly until you desensitize to that and we'll work our way up to big ones, right? Now I wouldn't tell a patient who's in line for the roller coaster not to take a few deep breaths to do some relaxation skills to try and be in the moment, um, to use cognitive therapy skills to remind themselves of certain things. But then we also have to accept that once you get on the roller coaster and that um safety harness clicks in, you're in for a rough ride initially. And that you can try all the square breathing you want, but the point of this exercise is to prove to yourself that you can survive these feelings. And so during the roller coaster ride, I don't want you to do any square breathing. I don't want you to try and ward off anxiety. I want you to prove to yourself I can handle this, I can ride these sensations out. And panic attacks and roller coaster rides are both temporary events, and you know, if they're prolonged, it might be because we're psychologically doing something wrong. We're holding on to the trauma a little bit longer than necessary. Uh, we're repeating it in our head, therefore we're perpetuating the cycle. But panic attacks in and of themselves shouldn't take that long. And so uh a big part of then not prolonging that process is teaching people you can handle this, you've got this.

SPEAKER_00 25:35

Um, once they do the exposure, it sounds like once they face the difficult process of exposing themselves to it so that they can overcome it. Tell me if I'm wrong, but it sounds like you would not be against them using breathing or some other method because they've already faced it and they've already learned how to surrender to it.

SPEAKER_02 25:59

Right. You got through it, now let's uh now let's do some relaxing stuff, right? But never um, you know, um uh a colleague of mine once coined it as um experiential avoidance, but we don't want to engage in any experiential avoidance of the actual panic attack, right? Um that there's value in the patient being able to see, I can get through this, I can survive this, I'll be okay. Um and so we don't want them doing anything that's suppressing the experience, that's avoiding the experience. It's I can handle this experience, I can do things beforehand to maybe make it less likely to occur. But once I get on that roller coaster, if I'm if I'm afraid of roller coasters, all the breathing's going out the door, and I'm just gonna have to be scared, and then I get off, and hopefully I can go, that was scary, but whew, I'm glad I'm okay now. Um, and that's when you can take your your nice deep breaths uh and do a little distraction, what have you. And I also tell my patients before doing any kind of exposure work not to take any sort of fast-acting anxiolytic medication. So that would be things like Xanax, Atavan, Klonopin. These are the kind of medications people take when they're worried about having a panic attack. So very often, let's say if they have a fear of flying, somebody might take uh an Atavan 30 minutes before getting on a plane to try and handle those sensations more effectively. It sort of dulls the experience. Um I certainly don't begrudge someone doing that, but what I always try and explain to people is that if the spirit of symptom cue exposure therapy and exposure therapy in general is to teach yourself, I can handle these sensations, I can handle these feelings. We don't want them taking medication before they come into the office to do that good work because we also don't want them associating the idea, I got through this, but only because I had this stuff in my system versus um no, I was able to tolerate these feelings because I I established a different response and relationship to these sensations.

SPEAKER_00 27:51

Yeah, that doesn't give them a chance to face the fear. But I also want to mention, I and I completely understand why you don't want them to take that medication during this part of the therapy, right? Because they're just they're just escaping. But I want to mention in general, um, my listeners know I'm not against medications, and in fact, um I studied two extra years postdoc of clinical psychopharmacology, so that hopefully one day I can also prescribe. But um I want to mention that the first line of treatment for panic disorder is not medication, it's psychotherapy, just like what you're talking about.

SPEAKER_02 28:32

Thank you so much for saying that. You know, a lot of patients ask me, can I do this without medication? And I if I'm honest with them, I'd say I'd prefer you try actually. Um and then, you know, if we find that we really think that you might need something to help you get over some, you know, to to sort of get you over that hump, then we'll look into it. But uh, but you know, as I like you, you know, um uh I think um people from from the the um graduate schools that we went to practice the scientist practitioner model. And so all the research says that the combination um of medication and um empirically supported treatments are the way to go. But there's also robust research that says going without the medication is also pretty, pretty good.

SPEAKER_00 29:14

Yeah, certainly for panic. I mean, for each disorder it's different on what's what is the first line of treatment, what's the second line of treatment. And in some disorders, you do want to medicate as the first line of treatment, but not the case with not the case with panic.

SPEAKER_02 29:29

I'm really glad I'm really glad you brought that up because that's that's really an important point for the audience.

SPEAKER_00 29:35

Any other coping ideas that you use with your patients on panic, Rob?

SPEAKER_02 29:40

Yeah, I'm I'm I'm a big fan of meditation. It's something that's been a personal part of my life for a long time. Um I'm very attracted to acceptance and commitment therapy concepts and mindfulness. In my free time, I spend a lot of time sort of reading about well, actually, uh if I'm complete full disclosure, uh since I have a four-year-old, I rarely read anything. So it's a lot of um reading articles here and there. Uh so I'll catch a lot of sort of memes about Buddhism and compassion-focused therapy and things like that. So I do like to incorporate that in in terms of sort of the work I do with my patients. Um, but the idea of meditation is also not experiential avoidance. It's being able to sit with thoughts and feelings um with a spirit of complete acceptance. Um, okay, this is happening now, and I'm not gonna judge it, I'm just gonna observe it uh in a somewhat detached way, I guess.

SPEAKER_00 30:32

I also love acceptance and commitment therapy. I I love it how you choose your values and move towards those and remember those.

SPEAKER_02 30:44

Yeah, and and I and I think that's a really important part of panic treatment as well, because so many sufferers of panic disorder they withdraw from really important elements of life. Um, things that they used to be able to do, but that but because of the fear of experiencing those sensations again, they they back away from them. And so, you know, in acceptance and commitment therapy, you emphasize, okay, what are as you said, what are your values? What are you not doing? Um, and you know, you combine some motivational interviewing. What are you not doing? What is what is panic robbing you of? And might it be worth it to experience these sensations, especially now that you've gone through a protocol where you've proven to yourself you can handle them and you're learning how to not overreact to them. Is it worth, however, experiencing some version of these sensations if it means you get back to living the life that you value and doing all the things that you want? Um and that I think becomes a lot easier for clients uh to get to that stage of exposure, you know, um, in vivo exposure, going to the places and doing the things that trigger anxiety that they think will lead to panic. I think it's a lot easier if a client has already done the symptom Q exposure where they've learned how to accept certain physiological sensations.

SPEAKER_03 31:53

Yes.

SPEAKER_02 31:53

I know I keep repeating this point, but it's really I teach my patients all the time, it's all about not overreacting to normal, non-dangerous physical sensations.

SPEAKER_00 32:03

Right. And you're also very interested in Tourette's syndrome.

SPEAKER_02 32:08

Yes. Yes.

SPEAKER_00 32:09

Um I know the episode is not about this, but I wanted to give you a chance to share a bit about that and why you're interested in that.

SPEAKER_02 32:17

Absolutely. Uh, you know, it's one of the things that it's a really amazing, humbling disorder. Um through it I've met some really fantastic kids and adults who have this disorder. So to describe it, essentially Tourette's is um, you know, people who are diagnosed with Tourette's have a combination of motor skills and I'm sorry, motor ticks and vocal ticks. Um so with vocal ticks, essentially it's involuntary noises. Uh so it could be words, phrases, sounds, any kind of uh sound that your vocal cords can make or that your nose can make could be considered a vocal tick. Um and a motor tick would be involuntary movements um that that people sometimes engage in. Um and so think of it almost as a dysregulation of the central nervous system. Your body sends sensation, uh your your brain, I'm sorry, sends um messages to your body to do these things that don't quite make sense, and the gatekeeper in the brain isn't functioning as effectively as possible. So sufferers of Tourette syndrome um therefore are engaging in involuntary or semi-voluntary vocalizations and motor movements. And I I got involved with it because when you work with a lot of OCD cases, you tend to see Tourette's. There's a lot of overlap in that. Um, you know, the way we describe it is most people with OCD don't have Tourette's, but uh a significant number of Tourette's patients do have OCD.

SPEAKER_00 33:41

So they both involve the uh the gatekeeper of the brain not doing its job.

SPEAKER_02 33:48

Absolutely. So uh, you know, and and so and the therapy is essentially very similar. That, you know, with OCD, the name of the game is exposure response prevention. Um with uh motor ticks and vocal ticks, it's what we call habit reversal training. Uh so teaching people to be aware of the urges to engage in the behavior and trying to teach them incompatible responses that would block that behavior in hopes of teaching them either how to manage it more effectively, or if we're really lucky, extinguishing those ticks. Now, because it's a neurological disorder, we don't sell it as a cure. You know, we can extinguish a tick and a different one's gonna pop up in some form at some point, but then you use the same techniques to manage those ticks.

SPEAKER_00 34:28

Can you give an example of incompatible behavior?

SPEAKER_02 34:33

Oh, sure. Um, so with vocal ticks, they're they're typically all kind of the same. So um, and if you want, you can even try uh on your end uh of things. Um so a vocal tick, um, so let's say if you were to s to utter a phrase, right? The uh an incompatible behavior would be inhaling while trying to utter that phrase. So it's it's it's relatively impossible to speak while inhaling, right? So if you want, you can try and say your name um while inhaling, and I'll I'll give you a shot. Go ahead, see how it works.

SPEAKER_00 35:02

Alexandra.

SPEAKER_02 35:03

Right.

SPEAKER_00 35:04

Good to hear that.

SPEAKER_02 35:05

I did a little bit. No, you're an act, you're you're better than most at this. But a lot of times people find that, okay, it kind of blocks a vocalization. So that would be a block of a vocal tick. Um, in terms of a motor tick, um sort of a common example might be if you have eye movements that involve rapid blinking, it would be uh practicing blinking extra slow on purpose when you feel that urge to break to blink extra fast. If it's a motor tick that involves uh having your hand shoot up as if like you know you're calling out class, it might be something like um pushing your shoulder downwards instead of upwards, sort of a competing response. So think of it as sort of almost like a counterbalance. And you know, over the years, uh these are kids who who really struggle, and and they're but they've also been some of the most inspiring, cool, nice kids that I've met over the years. So it's really something that's been really, really rewarding to treat, and uh and I think it's an underserved population because a lot of people um assume that they wouldn't know what to do. Uh but it's it's it's not, you know, I often explain the the therapy itself isn't rocket science. Um it's you know, the way I explained it sounds pretty simple. It's really just sort of getting a lot of reps in there and and getting comfortable doing it. Um but it's it's really is a wonderful population to work with. So thank you for asking me about that.

SPEAKER_00 36:24

Oh, yes. Before we get off, I have to mention something to you. I had asked you to send me a description of yourself, and I couldn't believe it when when you said that Mr. Rogers is your hero. I laughed because my sweetheart is always telling me that I am the female version of Mr. Rogers.

SPEAKER_03 36:45

Oh my god, that's so amazing.

SPEAKER_00 36:47

See? I just thought that was funny. We have something in common there. Yeah. So thank you. Uh before we get off, please tell listeners how they can find you.

SPEAKER_02 36:59

Absolutely. So um the website for our um for our practice is www.stressandanxiety.com, which uh we were really lucky we snatched that one up before it went away. Um stressandanxiety.com, we have two offices, one in East Brunswick, New Jersey, where I work out of, and another one in Flora Park. Um all the doctors in our practice do the same kind of work, as you mentioned at the top, OCD, panic disorder, anxiety spectrum, PTSD. Uh I'm probably the one Tourette's expert in the practice. Um, uh body focused repetitive behaviors. So that that's sort of our niche, and we're proud of the work we do.

SPEAKER_00 37:35

Yeah, I really enjoyed talking to you. Thank you for coming on the show.

SPEAKER_02 37:40

Thank you so very much. I really appreciate it. This was a lot of fun. I don't know why I was so nervous.

SPEAKER_01 37:46

If you enjoyed this episode of Psychology America with Dr. Alexandra, show your support by leaving an awesome rating on iTunes. If you'd like to share your comments or ideas about this podcast, follow us on Facebook under Psychology America. Last week, Dr. Alexandra has written an inspiring children's book entitled There's Always Hope, a story about overcoming, which is beautifully illustrated by Brianna Giasula. There's always hope, a story about overcoming, teaches children about finding joy and gratitude, even when things don't go exactly as planned, and can be found at PsychologyAmerica.com or Amazon.com.