Dr. Stieg talks to psychiatrist Dr. Richard Friedman about the neuroscience of fear: How parents can transmit anxiety to their kids, how some babies seem hard-wired for anxiety, and why a little anxiety is good for you (but too much is like a burglar alarm that sounds all the time).
Dr. Stieg: Today I'm with Dr. Richard Friedman, Professor of Clinical Psychiatry and Director of the Psychopharmacology Clinic at Weill Cornell Medical College. He's also an op-ed contributor to the New York Times. Richard, thank you for being with me today. It's a pleasure. So being a psychiatrist, we're going to have an interesting conversation about some of the more common things that you deal with and as a matter of fact, as a neurosurgeon I have to deal with on a regular basis and I'm happy to start with one where, this week actually, in clinic, I felt like I was more of a psychiatrist because all of my patients were incredibly anxious about their brain surgery and I can't understand why. *laughs* So tell me what's the difference between good and bad anxiety?
Dr. Friedman: If you think of anxiety, like an alarm that's supposed to tell you that there's something that you should pay attention to that might not be good, like a burglar alarm in your house. It's supposed to go off and there's an intruder or there's a danger, that kind of anxiety, which is a signal that there's something either bad in the environment or bad that's about to come around. The corner is a good kind of anxiety because it's adaptive. But what if you feel anxious and there's no danger or to put it in another way, what if you feel anxious and basically the danger is imaginary. There's really no risk. My patients feel anxious for no good reason at all. They come home and they feel anxious, they go out and they feel anxious. They could be in Tahiti and they would feel anxious so they have inappropriate anxiety. Or if you had a house with a burglar alarm, your alarm was being set off by a mosquito. That's a bad alarm. So it's over-sensitive and it's basically telling you there's danger when there isn't any danger. That's the kind of anxiety you don't want to have.
Dr. Stieg: I'm sure a lot of people that have anxiety worry about this. Is it genetic or is it environmental? Is it learned?
Dr. Friedman: So it's both. You know, there are people who when you see them, when they're very young, from the first year of their life, they're reactive. They're more frightened of strangers. They don't like novel situations. You take them away from their parents and they get really upset and anxious. And that's a trait and that seems to be hardwired. And although those kids who have a lot of anxiety and stranger anxiety when they're young, some of them actually grow out of it. A fair percent of them, it's stable. And what you see early on is what you get later as an adult. And on the other hand, you know, the kids learn to be anxious from their parents. You see this on the street, you'd see the parents who's got a kid who's about to cross the street and they grab them by the back of their shirt and yank them back where they're, you know, just looking at their kid, wondering when the next accident's about to happen. They say, no, no, no, no, don't do that because you might fall. So you learn anxiety and it's modeled by your parents, but you have a genetic loading for it to start with.
Dr. Stieg: What do you have to say about pregnancy? There's all this stuff about sitting in putting a little tape of Mozart next to the pregnant woman. Is that, is there any role for anxiety or non anxiety activities during the gestation period?
Dr. Friedman: There's a lot of speculation about this. You know that what happens in your in utero environment to somehow going to set the stage and effect whatever your genetic endowment is, depending upon what your mother listens to and whether you swim or you do ballet or you ride a horse and there's not a shred of evidence for that. The evidence is for all the bad things like being exposed to the flu or you know, having some viral infection during pregnancy does something that's harmful to the fetus. But the idea that you could do something when you're a pregnant mother that will enhance the outcome of your kids. You know, emotional wellbeing or cognitive wellbeing. Well, we just don't know anything about that.
Dr. Stieg: And I'm assuming that the, the extreme of anxiety is a panic attack.
Dr. Friedman: It's one form of really pathological anxiety where it's kind of a, a seizure of anxiety and sometimes they come out of the blue, you know, you could be feeling completely calm and then you go from zero to a hundred miles an hour in five seconds and you feel like you're going to go crazy and die and your heart rate goes up and you can't catch your breath and you go to an emergency room and they say, you know what, there's nothing wrong with you. We've checked your heart out, there's something medically wrong and they discharge you and they got half of it right. And half of it wrong. There is no cardiac problem, but you have a panic attack, which is, you know, a kind of intense paroxysm of anxiety.
Dr. Stieg: The first time this happens for somebody, do they know it?
Dr. Friedman: Almost no, never. They think something, either cardiac is happening, that they're going to die of a heart attack. Or are you going to have a seizure or they're going crazy? It's usually one of those three things.
Dr. Stieg: So they go to the doctor and the doctor tells them that, no, you're having a panic attack. Are they, are they surprised?
Dr. Friedman: They're relieved because usually they don't actually get the diagnosis until they've been seen a few times in an emergency room and sent home reassured that nothing, you know, medically is catastrophic. And eventually they see their family doctor where they see a specialist who says, Oh right, you don't have a heart attack, you haven't had any real cardiac problems and you're not having a seizure and you don't need to see Dr. Stieg. And there's nothing wrong with your brain. You're having a panic attack. It's really common, really common.
Dr. Stieg: Really. How common are panic attacks?
Dr. Friedman: Anxiety is probably the most common complaint in the general population. So you're talking about a lifetime risk of about 18-20%
Dr. Stieg: Is it the, I'm always anxious, that type of person? Or every now and again I'm going to have an an attack of anxiety in my—
Dr. Friedman: Yeah, so it's all forms of anxiety. So it could be panic attacks, could be general anxiety. People who are constantly in the background worried and tense and they worry about one thing and if they don't worry about one thing, they substitute another. And people who are socially anxious and people who have performance anxiety and worry, you know when you stick them in front of group of people, they get really nervous and can't speak. Right. So if you add all that up together, that's about 20%.
Dr. Stieg: So that person, as I see it, they take some Inderal all to get rid of their speaking problems, right? Inderal, being a beta blocker, slows the heart down a little bit. What struck me the other day when I was dealing with this patient was a younger woman. Her mother was there and I was just watching this anxiety-ridden individual. I didn't want to do anything. I was telling her she didn't need to do anything and she just got incredibly anxious about not doing anything. And I was watching the mother kind of play into this. Well, my next question is, does this come on in childhood? Is it come on in adulthood or any time?
Dr. Friedman: there's a peak of anxiety in late sort of adolescents for the kinds of anxiety we're talking about. Social anxiety and let's say panic attacks. The trade anxiety is early. You know, people who are generally nervous and anxious, you can see that in childhood. Okay. Um, and separation anxiety. You see early on when kids have to start going out from the nest and first step to go to kindergarten and first grade and they just get really uncomfortable and anxious and or sick physically. I have a stomach ache. I can't go to school today. And uh, you know, depending upon how their parents respond to them, it totally shapes the nature of their anxiety.
Dr. Stieg: Well, that's where I wanted to go with this is the watching the mother watch her daughter, let's say said as a parent, we all want to think that our children are perfect and we see this anxious trait in this behavior. You look at them, you know, what am I to do as a parent? What's the best thing? Get help right away or should I try to cope with it? With my adolescent child?
Dr. Friedman: Well, the answer actually depends on what kind of person you are. So if you're an anxious parent and you have reasonable people in your family and friends who say, you know, you worry too much, there's nothing wrong with your kid and you're going to make your kid anxious like you, you should back off. So actually it was an interesting study done of the parents of anxious children, the kids who are just generally anxious, and what they found is the mothers who worried about these kids and tried to protect them and shield them from situations that they thought would make them anxious. The outcome in those kids was much worse than the parents who didn't try to protect them. So if you hover over these kids who are anxious, they end up being more anxious. And if you let them get anxious and get exposed to things and get over it, they do much better. And they're less anxious as teenagers.
Dr. Stieg: What is it about the adolescent brain that makes them, you said that, that's the peak. Is there something about their brain that makes them more susceptible? Things like....
Dr. Friedman: Yes.
Dr. Stieg: And that is?
Dr. Friedman: And that is that different regions of the brain develop at different rates. And so one of the regions of the brain that comes online early is the limbic system and the limbic system is the emotional brain in a way that is not conscious. It's primitive and it develops very early in life and is fully functional before your prefrontal cortex, which basically is the part of your brain that allows you to think critically and to suppress impulses and to think, you know, if I do a then B will happen and if I do B then C might happen. And the limbic system is basically your emotional responsiveness and that could be to, you know, anxiety and fear. It could also be to the desire to want to have sex or use drugs.
Dr. Stieg: Based on that, and we know also that boys' executive frontal prefrontal cortex develops more slowly than in girls. It can. I assume then that boys have a higher incidence of anxiety than girls do because their prefrontal cortex is, is more fully developed early on in life.
Dr. Friedman: In some forms of anxiety, they do, actually — they have higher rates of social anxiety as teenagers.
Dr. Stieg: As you said, so if mom and dad are both anxious people probably best that they shouldn't try to cope with their child's anxiety and they should, then you would say get some professional help? Yes. Yes. What about in this day and age where every state seems to want to legalize marijuana? What role does cannabis play in managing anxiety disorders?
Dr. Friedman: That's an interesting question. I mean, we don't know. We worry about kids who are exposed to a lot of cannabis early during, you know, critical brain development and we know that it's associated. That doesn't mean it causes, but it's definitely associated with the risk of certain psychotic disorders like schizophrenia. I doubt it causes it, but it might actually unleash it at an earlier age and people who are genetically prone. As far as anxiety, we don't know. It may be the kids who were more anxious are self-medicating and are more likely to be drawn to use cannabis because it lowers anxiety.
Dr. Stieg: Is therapy or medication the better way to approach dealing with a severe anxiety disorder or person is having such frequent panic attacks that they can't function.
Dr. Friedman: So they both work. But actually it depends on what age they are. So we know younger people like adolescents because of the way their brain is developing and their prefrontal cortex is not yet mature. They actually have a hard time with certain forms of therapy where they're being taught to be unafraid because you need a prefrontal cortex to learn and you know, exposure therapy's not so effective in teenagers
Dr. Stieg: is the basis of all this anxiety. We talked about it being familial in parents and some genetic component, but is the basis of anxiety fear?
Dr. Friedman: The basis of anxiety is a fear circuit that is somewhat out of control and is mismatched. It's got a very strong signal and has got the upper hand and the people with a lot of anxiety have an overactive fear circuit that can't be shut down by their you know, reasoner-in-chief, which is their prefrontal cortex, so there's a mismatch.
Dr. Stieg: And do we have to differentiate between external causes of fear and then there's internal irrational sense of fear?
Dr. Friedman: We do because the people who have anxiety disorders are not confronted by external dangers in order to feel anxious. They feel anxious even when there's no danger.
Dr. Stieg: I read an article that you had written about resilience and it seemed to me to play a little bit of a role in children's response to fearful environments was in Chicago and they were I think exposed to terrifying events and then you found that those individuals are actually more resilient than individuals that grew up in a higher economic class and were never exposed to any kind of fear and anxiety. They weren't as resilient.
Dr. Friedman: So there's two things. One is the idea that you get more resilient by tolerating a certain level of stress and adversity seems to be true up to a certain point obviously. And if the stress and the anxiety is so great that you can't manage or master it, it's probably not helpful and adversive. And that study that was in Chicago was slightly different, which was basically showing a link between how much connectivity there was in the brain between different circuits and being able to control oneself and good health outcomes. So people with more connectivity actually had better health outcomes and better sense of wellbeing than those with less connectivity.
Dr. Stieg: I thought the implication was that a, I'm playing a little bit off the fear, you know, the normal external fear, you know, you're being threatened and so your frontal cortex is somehow regulating the amygdala, the limbic system that you're talking about. And as a result of that, you are more resilient.
Dr. Friedman: No, I think that's exactly right. And the reason you're more resilient is because you probably are making better choices when you're scared. What I'm really trying to get at then is the parenting role in all of this, you know, is a certain amount of fear in a child's life good?
Dr. Friedman: Yes. I mean there's no question that you can't shield people from everyday adversity and it would be bad thing to do it. It's like immunity. You know, the kids these days grow up and their parents are terrified that they should get dirty and they give them bottles of Purell. And what do we see? We see high rates of allergies to things like peanuts, which in my day didn't exist. We played in the dirt, we ate the dirt. You know, we were given levels of immunity because we were exposed to the external world and not told to be afraid of it.
Dr. Friedman: So as a psychiatrist, how are you dealing with these? What I see as these hypervigilant parents when they bring their children in to see me and I'm, I really worry about what we're doing to our children down the road. And then are they going to do this to the next generation?
Dr. Friedman: Yes. I worry about it too. And so I, this is the whole phenomenon of the helicopter parents who, you know, as good as their intent is to be sure their kids grow up happy and healthy and get every advantage in life. It may be that their protective attitude is having the opposite effect because they're less able to deal with adversity. How do we go about getting parents to not be this, as you call it, helicopter parent or as hypervigilant. There's is, is there a movement going on? Like you said, I mean these peanut allergies are everywhere. My kids can't go out to dinner with somebody and we don't have to worry about the peanuts.
Dr. Friedman: Well, I mean there's a role for, you know, professional organizations like you know, the American Medical Association, the American Psychiatric Association and you know, leaders in the field who basically can say, look, we see a sort of change in social attitude and you know, we have data to show us that it's not a great thing. On the other hand, how did this come about? What are the social forces that made helicopter parents in the first place? It's probably related to certain social classes. You know, it's an upper middle class phenomenon of, you know, parents who want to be sure their kids are going to get the competitive advantage. Why? Because there's more competition, right? More kids are applying to colleges and more applications per kid. It's a natural reaction.
Dr. Stieg: Which creates more fear and creates more anxiety, a vicious cycle. As you said, if the parents are anxious, they probably shouldn't try to deal with it. As a professional that deals with this. Is your first choice some kind of verbal therapy or do you immediately go into drugs and if there are drugs, what are the drugs that you use for dealing with anxiety and anxiety that stems from an abnormal fear?
Dr. Friedman: So if it's something that is not so severe in the sense that it looks like it's learned and it's easy to intervene and convinced the kids and the parents to change their behavior. Not saying that's easy. You would intervene with some counseling and therapy and basically, you know, the problem might be that the parents may be responding to an anxious kid by trying to protect them. It could be. The parents are so anxious. The kid is learning it from the parent, and you have to spend some time with them and figure out which it is, and then intervene. But let's say it's the kid who's really got anxiety, so they're, you know, you might use some cognitive behavior therapy, and the best biological treatment for anxiety is a antidepressant in a serotonin reuptake inhibitor family like Prozac and Zoloft and Selectsa and Lexapro, and these are drugs that increase the function of the neurotransmitter serotonin in the brain. That lowers anxiety. It also makes depressed people feel better. So it does both.
Dr. Stieg: We'll be continuing this fascinating conversation in our next episode. Please join us.