- Christine Forest, M.D.
- Los Angeles, California
- I have initially created the Better Than Cured Guide to Healing and Happiness to help patients in my psychiatric private practice who were suffering from anxiety and depression. My goal was not only to help them get well, but beyond that, to also help them find a viable path to a happier life. They were loosing any hope that they can ever be healthy and happy again. They were amazed when they did it. If hundreds of my patients could do it, so can you, my dear reader. I hope their stories of courage and success will empower you to reinvent yourself and rekindle the hope that your life too can be better and that your pain can be healed. Set your life course on a "better than cured" path that leads to your own profound and personal journey to healing and happiness. For more information about my medical career and my private practice, please visit my web site at drforest.com.
Wednesday, November 25, 2009
Thank you for visiting my blog. I will have fresh posts for you next week. Now I am frantically getting ready to spontaneously go to Bora Bora. I will have a romantic Thanksgivigng--an emerging trend. Great packages for this destination over the Thanksgiving holiday, where most people travel east of LA, to their families, rather than west, to South Pacific French Polynesia. But here I am, packing for the islands. I was told to pack light. So I believe two bathing suits, a shirt and one good, light adventure book carefully downloaded on my Kindle, qualifies.
I wish I could have written few posts in advance, that would have been neatly and precisely released at regular intervals while I am on vacation, but suddenly the time got very short and now my taxi is outside, waiting to carry me away to my exotic destination where I would celebrate Thanksgiving with fresh fruit and fish, cooked deliciously French.
Another emerging trend in LA lately: celebrate Thanksgiving day with one's family (if any available because so many people are not LA natives) and the evening and the rest of the holiday with friends. We'll see how well it works.
One of my patients, who is very creative and very social, came up with an original idea to entertain her guests this holiday. After the proverbial Thanksgiving dinner with all the trimmings, she is to show up dressed in her Halloween costume, carrying a big, colourful box in her arms. Pulling a string, the box's walls would collapse to reveal a giant pumpkin painted and decorated in many different colours and patterns. But inside of this pumpkin, she carved out little tunnels with surprises at the bottom. For kids, small candies and miniature toys. For adults, tiny flash lights and other miniaturized gadgets they will need to be brave and stick their hand in the tunnel to get. A fun idea? Perhaps. How do you plan to entertain your guests while they are digesting your delicious meal?
Wishing you all a wonderful Thanksgiving Holiday, I have to leave right now to catch my next adventure!
Friday, November 20, 2009
I plan to start a series of posts, and this is the first one, in which I will demystify the psychiatric language translating it into plain English, so that every one could understand it and learn the necessary tools to heal. Lack of accessible information is at the root of people's fear of emotional illnesses and psychiatry. Many people prefer to suffer in silence, because they don't know that these conditions have a good prognosis, if managed adequately. There are a great many things people can learn to do themselves to make their emotional problems better. When that is not enough, qualified help is available to assist them.
Healing is possible. Living a better life is possible, even though you may have to learn how to cope with an emotional problem.
Anxiety disorder in general is described in psychiatry as excessive worry, present more days than not for a period of at least six months. It is called "disorder" when it begins to interfere with daily activities, for example, people afraid of wide and open spaces are afraid to go out and spend a great deal of time in the house, unable to live their lives (agoraphobia). But this is an extreme case of anxiety and in general, severe cases are not that frequent, contrary to what the media will have you believe, describing only the most severe mental illnesses, in their perpetual search for shocking examples.
Most people suffering from anxiety disorder (18% or 40 million Americans) have symptoms in the mild or moderate range--annoying, but manageable with some effort.
The problem is when something unexpected happens to someone who is already barely managing his anxiety. It could be a good event (a promotion, marriage) or a negative event (getting fired, failing an exam) that triggers the anxiety level to switch into high gear, making the emotions completely unmanageable.
This is usually the time when people ask for help.
Example of these symptoms:
- problems focusing attention;
- the feeling of being unable to quiet down the mind;
- going over and over all the things that didn't get done that day or over the guilt of saying something to someone that might have been the wrong thing to say
- agonizing over possible worse case scenarios
- imagining that something bad is about to happen and you need to be in constant state of alertness and readiness
All these symptoms are, in general, very unpleasant. Insomnia will trigger even more anxiety. Feeling of guilt that follows after talking to people in anger, can be overwhelming. It seems that every step is a circular way to create even more anxiety.
The performance anxiety is characterized by extreme fear of being unable to perform a task, fear of failing miserably or fear of being harshly judged by others. While all of us could be apprehensive about performing a task in front of someone else, for the most part we can control it and complete the task. For people suffering from performance anxiety disorder, it becomes an agonizing situation that often prevents them from accomplishing the task at hand.
If you search the Internet using the key word "performance anxiety" you will get many links to sexual performance anxiety. But the exaggerated fear of being unable to perform sexually is just one form of performance anxiety. It could manifest, and it actually does quite often, in many other situations through the same mechanism. You could find performance anxiety in public speakers, actors, musicians and comedians. It could also manifest in the classroom when asking the teacher a question or at the office when facing an important meeting or asking your boss for a raise or trying to deal diplomatically with a matter of office politics.
Here are the most common manifestations of performance anxiety:
- sweaty palms
- sensation that the mind going suddenly blank
- dry mouth
- heart palpitations
- sensation of being unable to swallow or breathe
- felling weak in the knees and terrified at the thought of collapsing on the floor in front of everybody
- thoughts of "how come you are so stupid" or "shut up or everyone will see you are a fraud."
If you encounter this type of symptoms but they are mild in intensity and you are able to control them, you have a normal reaction of performance anxiety. But if you feel they are overpowering you to the point that you are extremely uncomfortable and you even have to leave the room to compose yourself, you may suffer from performance anxiety disorder. If that is the case, don't panic. Read on to see how you could conquer it.
What to do if you think you suffer from performance anxiety disorder:
BETTER THAN CURED PROGRAM IN ACTION: There are many good ways to manage performance anxiety. I will talk about those I found useful in my practice, helping my patients best deal with this problem. I will talk about each intervention of Better Than Cured separately for didactic purposes. In real life, all four interventions blend and merge to create the most suitable plan of action for each patient.
Getting familiar with this approach, if it makes sense to you, you could construct your own Better Than Cured Program that will, of course, work best for you. Use mine only as a blue-print.
Cognitive Behavior Therapy will teach you how to talk yourself out of that situation by challenging the anxious thoughts. It is the form of psychotherapy proven to be the most effective in dealing with anxiety. It is based on the principle of identifying the anxiety provoking thought (emotional thought) and contrasting it with reality based thought (rational thought). For example, you could tell yourself realistic and reassuring words like: I am well prepared, people are not gathered here to judge me but to hear what I have to say, all I need to do is to stay calm and say what I have to say, it will only take a minute, and when I am done, I can go home and then I can allow myself to panic...
You get the idea. You can do a silent, reassuring monologue for yourself. If you have to speak in public, try to focus on the fact that you are there to share your expertise and not to tell anyone what to do. There are many books you could read about learning how to put mind over mood and facts over emotions. The book I most commonly use is Feeling Good, by David Burns.
Developing good strategies to deal with performance anxiety will help too. For example, if you realistically determine that there is a legitimate cause for you to feel on edge, then you can figure out ways to remedy the situation. Maybe you are not very well prepared for the talk--next time devote more time to prepare better. It is possible you may feel uncomfortable because you didn't get enough support from your boss or your teacher in doing your presentation--try to engage them more in what you're doing, ask his opinion and try to gain his support. If you feel uncomfortable because there is a toxic work environment, consider a transfer to a different department or, if it gets really bad, you may consider finding another job. Using the practical principles of life coaching, a realistic plan can be devised and that will alleviate you anxiety. You may consider reading some of the work of Thomas Leonard, a famous life coach. For an original take on business management, you may be interested in the work of Charles Handy.
Do not be afraid to admit you need a change. Even if you don't admit it, the change is still needed. If you are afraid to look into it, your anxiety will grow in intensity and you may be headed to a crisis. Then you will consider the change. But fixing it then will be highly unpleasant and, usually, very costly.
This is something you can not do by yourself, but I will mention it because it is good to have information about medications used to treat anxiety, if all else fails. I would like you to put aside everything you heard or thought about psychiatric medications and start anew with the following information:
Psychiatric medication does not make people "zombies." Doctors, in fact, can make people zombies by prescribing it wrongly, usually in too large doses for a given patient.
Psychiatric medications, like any other medications, can be used with extraordinary success or it can have multiple unpleasant side effects. There is an art to use it, but don't be afraid of it. If you feel you can not deal effectively with your anxiety on your own, look for a psychiatrist in your community. And if you feel he is not careful enough with your medications (you have many side effects and he is not adjusting your medication or you are not getting better and he is not trying new medication strategies) then look for a better psychiatrist rather than abandoning the treatment of your anxiety. Psychiatrists are like any other doctors, are some good and some not so good. Find the right one for you.
One of the easiest medications to use for performance anxiety is a small dose of the beta-blocker Propranolol. It is easy to use because it can be taken as needed. It works only for 3-4 hours but it is not addictive and it doesn't put you to sleep in the middle of your performance.
If the anxiety is more intense that what the Propranolol can do for you, then the Benzodiazepines like Xanax or Ativan can be used. They may make you sleepy, so don't drive after you take them, and they do have some potential for addiction. They should never be used with alcohol because the combination will make you very sleepy and groggy. They are best used as needed and your doctor should tell you exactly how and when to take them
Sometimes, the anxiety can't be managed with "as needed" medication alone. Then the next step is using an anti-anxiety medication that is taken everyday and works around the clock. One of the most common, are those from the Prozac's family, the SSRIs or selective serotonin reuptake inhibitors. It is believed that when we have more serotoning in the certain areas of the brain (hippocampus, amigdala, limbic lobe) we tend to feel less anxious and more emotionally balanced. I found Celexa, Zoloft or Lexapro to be the best tolerated SSRIs in my practice. Paxil could be used as well but it has more weight gain and more sedation as side effects.
There are other medications like Effexor, Cymbalta and Pristiq that can be used with good results. They belong to a different category--the SNRIs, meaning they are serotonin-norepinephrine reuptake inhibitors--a dual mechanism of action.
The decision about when and which medication to use depends on the severity of the symptoms, how well the medication agrees with a patient, other medications that he tried and failed in the past. Sometimes, if another member of the family suffers from anxiety and uses a medication that agrees with him, it is likely (but not always the case) it will agree with the patient as well.
Develop your personal creativity: means really think outside the proverbial "box." Because we are in the technological era, we will think of it as "thinking outside the norm and beyond the usual patterns."
Depending on the situation, using your creativity to deal with anxiety will help quite a lot. For example, if it is to give a presentation you are terrified to give, maybe the standard ways of giving that presentation doesn't fit your style. You will then be better off if you allow yourself to present the information your own way. Maybe you are more comfortable engaging the audience more, or leave the lights in the room on and dimmed rather than turned off, so you can see your audience. Or maybe you like to use a lot of gadgets because you are good at it and you do it in a way that your audience will enjoy it. Or you may like to make a joke every once in a while because hearing your audience laugh relaxes you.
In general, if you find ways to increase your level of confidence by using your creativity, you will be less anxious.
One of my patients told me once that in order to decrease her fear of the audience she imagines everyone naked and vulnerable. "That gives me a big laugh in my mind and stops them from intimidating me just because they are there." Laughing is incompatible with anxiety. The more relaxed and the more you enjoy yourself, the less anxious you will be.
Other practical suggestions:
- schedule a reward for yourself ahead of time, something you can look forward after you're done with the anxiety provoking event
- allow yourself not be perfect
- choose your clothes for the event carefully; they have to make you feel empowered and at ease at the same time
- always prepare really really well; do not leave anything to chance
- trust that people you will meet are there because they are interested in what you have to say and not in judging you
- if you make a mistake, smile, apologize and go on with your presentation without skipping a bit; never lose your cool; everyone can make mistakes; it will make you look more human
- talk to your audience as you would with a friend; you can imagine that your most supportive friend is seating in the front row and nods his head in approval every time you make a point, laughs at your jokes and absorbs every word you say with interest--an ideal listener
- remember "performance" in a broader understanding of the word, means many things: a public speaking event, a date, a meeting with your boss, CEO or share holders, a sensitive talk with your parents, a networking party and so on. Be emotionally prepared for all these events; you can apply some of these tools in all these occasions.
I hope you will find this discussion about performance anxiety helpful. I look forward to your feed-back and to your stories, if you would like to share them with us. You could include them in your comments or you can e-mail them directly to me. If you would like me to include any of them in future posts, please rest assured that I will alter your identity and be very careful protecting your privacy. Or you could just sign "anonymous."
Tuesday, November 17, 2009
Thursday, November 12, 2009
I still hold true to its value. The following story, I hope, will make my point.
I had once a patient who came to Hollywood from the Mid-West to become a screen writer. She, of course, like many other young and talented people, started out as a personal assistant. Her boss, a powerful figure, quickly understood her value and liked her a great deal. He started giving her more and more creative assignments in program developing. She liked program developing and it turned out she was good at finding new and talented people to go on the shows. It seems that things were looking up for her. But suddenly, her boss made a logistical mistake. The company lost a lot of money and he was ostracized. They moved his office from the prominent location he used to enjoy, to an obscured part of the building, at the end of a corridor, in a place people working there for years didn't even know it existed. My patient had to follow him there, feeling extremely discouraged. She was so disappointed that she had a mini-depressive episode. Of course she didn't think of it as "mini" until she got out of it, months later.
This was the time when her friends told her she has got to see "someone" so they referred her to me. In our first session, I've got a pretty good idea that she was not only intelligent and talented, but also very reliable and hard working--a rare combination in Hollywood, at least as far as I know.
In our first session, I asked her point blank: "Do you think your hard work will pay off?" She thought for a moment and then, resolutely, said "NO."
"During the coming sessions, I hope to show you the opposite. I believe hard work will pay off, even though it may be in different ways than you expect. Your talent for discovering other talented people and fit them in the right positions in the shows, is uncanny. The fact that you always follow through, even if you have to stay up all night to read a script, must have been noticed by someone other than your chastised boss, at the studios."
Fateful to her depressed mood and the negative unconscious process that usually goes with it, she said: "I don't think so. My professional career is tight up with my boss' and he has just been demoted."
For the following sessions, we worked on rebuilding her self-esteem. It wasn't going very well. I kept pointing out her good qualities and she kept denying she possessed any of them.
One day, she came in saying that there was a special program that has just been announced, in which they will take a small group, 8 creative, talented people, and train them to become executive directors for programing. "Of course," she said, "I will never make the cut, there are already 1800 applicants for the 8 positions, who am I to even think I could get there..."
I gasped. Maybe this was the chance I was looking for to demonstrate my theory. I asked her if she will consider signing up.
"I already did," she said. I immediately thought that all my work with her was finally beginning to pay off. At the very least, even if she did not get the position, I thought, she did not give up trying, she did not give up hope. For that, she was already a winner in my book.