THANKSGIVING IN BORA BORA

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!

LET'S TALK ABOUT PERFORMANCE ANXIETY!

As Leonard Bernstein, the pianist, conductor and composer of the musical West Side Story has done in the 1980s, making classical music more easily accessible for the public through lectures and seminars explaining classical music in plain English, inviting many people to enjoying this music, I intend to do the same with psychiatry and mental health.

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.



PERFORMANCE ANXIETY


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:

• irritability;
• insomnia;
• 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.







Psychotherapy:

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.




Life coaching:

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.



Medication Management:





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."

BEING TOO GOOD OF A SALESMAN CAN BE A PROBLEM TOO

"It's final. They are letting me go." Kyle came in, very distressed, voicing the realization of his worst fears.

He has mild attention deficit, which we brought under control with small dose of Adderall. But lately, he has been dealing with a great deal of anxiety. Kyle is a young businessman. His job requires to be very careful with numbers and details. Landing this job was a subject of much pride for him. He had the oportunity to do important an interesting work, right after graduating from his MBA. But that has been a blessing and a course.

Kyle is a very ambitious, diligent person, willing to put in any amount of work needed to get the job done. But because his job was asking of him skills and experience that only in time one could accumulate, he was never able to catch up. His work looked sloppy, although he was extremely careful and put a lot of time into it. His boss was not happy with him, although he could recognize Kyle's drive and desire to do good work and succeed. Feeling under constant pressure, he started making easy mistakes. He even was so anxious, he nearly had a panic attack in the middle of an important meeting, being very aware of the high level of that meeting and beginning to feel extremely inadequate. His confidence was waning. His self-esteem was going down rapidly for weeks. We tried to trouble shoot for that during our meetings, creating strategies to best deal with these problems. I gave him a small dose of Propranolol, a medication used extensively for public speaking and performance anxiety because it takes the edge off of anxiety but doesn't make you sleepy while doing an important presentation. In other words, he worked really hard to keep his job.

With all this effort, he continued for months to keep having problem. I was beginning to feel that letting him go, would be a merciful thing for his boss to do. He was exhausting himself, without being able to make any progress. Why? Because there are things that determination alone will not be enough to cover, and that is the day to day experience performing the same job. Just pure volition will not teach you how to solve all the problems. It takes time and enough exposure to that task to figure out how to approach it from more than one angle, to bang your head several times before you fond the right solutions--in other words, to "give it time to learn it well." And this was a big problem for my patient. He was young, capable, brilliantly intelligent and very, very impatient. He wanted things done yesterday. All the time.

Another problem was that he was too good of a salesman. When I asked him, months ago, how did he landed this prestigious job, he answered with "I wanted it badly and I presented myself well." In other words, he did an excellent sale job, convincing his future boss that he is the best man they could find for it. His hope was, of course, that he will be able to catch up.

"What do you think about loosing this job?" I asked, curious to see how he would handle situations that don't go his way, and ready to intervene if he would take it too hard.

But my patient surprised me again. He said: "To tell you the truth, I feel relieved. It was too much for me, it was eating me alive."

"A very reasonable conclusion," I said, "since we both know how true that is."

He smiled for the first time that day. "Yeah," he said, "but now, I have no idea what else to do. I thought if I want something badly enough, I should psych myself up and go for it with all I've got. And that's what I did. And you can see how badly it turned out. Where did I go wrong? How can I do things differently?"

"First of all, there is nothing wrong with intensely wanting something and going for it. I think the problem is that you are too good of a salesman."

"I am too good of what?" he asked me uncertain that he heard me right.

"Yes, a too good of a salesman. You managed to sell the idea that you could do that job even to yourself. You were like a mechanic that has all the parts to make a very good car but doesn't have the patience to take the time and put them all together to make it, or like a woman who just wants to have a child but doesn't want to wait nine months to have it, or like a..."

"OK, I get it," he interrupted me. "But what can I do differently?"

"What you could do is to give yourself a reality check. Don't be afraid, you are capable of doing big things. But you also need to understand the level that you really are at in that process. I believe you could, in a few years, be extremely good at this job you underperformed right now. But not now. It may take you a few years. Which is a short period of time compared to most people, who need ten or twenty years to get to the same level. Do not sell ideas to yourself. Never do that. You need to know exactly what is possible in real time and what isn't. What you tell others, that is your salesmanship. You can have free rain to get what you want. But take care that you never, ever, behave as a salesman to yourself."

He left my office feeling better. He was disappointed but he had a game plan: a piece of paper folded in a half, on one side was written "Expectations" and on the other "Reality Check." Following this simple plan, I know he will not fail again. The courage to accept reality was the missing link in his case. Once he does that, he will indeed be capable of making good use of his impressive qualities, in a more measured, more realistic and more successful way.

"Totally not my type but so right for me."

"He is nothing I have ever thought HE would be," said Kara from the doorway, while stepping into my office today. I could tell she was excited. She was bouncy. She was walking on clouds.

"Can you believe?" she continued, with her sparkling eyes fixed on me, "I found him! And he is nothing like I've ever imagined. He is blond, and I thought I don't like blonds. He is rather stout, and I always thought I like long legged, feline like bodies. But he is good looking and, oh... What a gentleman!"

I was indeed very happy for her. 11 months ago, as she likes to keep track of her progress, she came to see me as a young, fragile looking and utterly terrified young girl, plagued by excessive use of cocaine and severe anxiety. She had severe insomnia, as you might expect. She had daily panic attacks to the point that she couldn't leave her apartment. She also had horrific migraine headaches because of the drugs.

She wanted me to help her but I was seriously wondering if I could. With intensive treatment for five years, only 45% of cocaine addicts are able to maintain sobriety. I had no idea how determined she was to change her life. And she was not yet "addicted" to cocaine in the strict sense of the word. But she was abusing it and suffering all the unintended consequences from it.

At that time, she was struggling to break up with an abusive boyfriend who was bringing cocaine in her apartment everyday. She was just let go from her job as a graphic designer because she couldn't keep the deadlines for the clients, yet, because she was well liked despite her flaws, she wasn't fired but laid off so she could get unemployment. She was in a sorry state.

With very little hope that she will stick around long enough to get well, I laid down the rules we will both follow if we are to work together: I was to be there for her giving her support and counsel her on helpful medications, and she was to stop using cocaine and take the medications, once we agree on that, exactly as prescribed. She agreed and we started. I gave her a list with the cocaine anonymous support groups in her neighborhood and stressed the fact that she needs to go there regularly. I gave her an anti-anxiety medication, Lexapro, and to take as needed for panic attacks and insomnia, Clonazepam. The problem with the "as needed medications" is that most of them have a potential for addiction. But she had such a severe insomnia and panic attacks, I felt it was cruel not to give her anything for that, especially as I knew she will go into, hopefully mild, withdrawal from stopping the cocaine. She promised she will not take more Clonazepam than prescribed and agreed to come back the next week. I gave her only one week supply of the medication, thinking that if she abuses it, it would be a small dose to abuse. I did worn her that if she takes more than she should, and she runs out before the week is up, I will not give her another prescription.

Despite her promise, she did run out of the medication she had for a week in only two days, believing, like all addicts do, that more is always better. When she called for more, I told her, as promised, that she will not get any until the week was up. She kept calling, she got upset, she cried and in the end, she threatened, but to no avail. I was holding her to her promise. We had few other struggles in the next months. But she did stop the drugs and the panic attacks slowly backed away. She was getting stronger and stronger. She was going to the support groups and to the gym. She was doing increadibly well, by the most stringent standards.

Six months later, she was looking for a job again.

Eight month later, we were discussing dating.

"I don't even know what to say to a guy anymore. I haven't been dating sober in ten years," she told me at that time. "I don't know how to make small talk, as the matter of fact, I don't know what to say at all. What do people talk about these days on dates?"

"Well, things have not changed all that much in the past five years. They talk about what they like and what excites them, about music, movies...things like that."

"You make it sound so easy talking about these things but I haven't a clue about any of this. I haven't been to a movie in years."

So, I started coaching her on the science of "small talk," on being social and assertive, sweet but not a goose, and many other useful dating tips.

"OK, Dr. Forest, I got it," she finally said. "I will keep it as you said, nice and smooth. When I don't know what to say, I smile and ask them what they think about it. Right?" She was, by this time, eight months sober and would have liked to find a boyfriend.

After a few bad dates with men who wanted to sleep with her at the end of the first date, or with guys who were heavily drinking while dating or with "prejudiced" guys who didn't hesitate to talk about their skewed views in public, she came in one day saying: "I thought I was screwed up because of the drugs but these guys are completely nuts!" Disappointed, she put the date on hold for a while.

She was now sober for over nine months, contrary to my pessimistic predictions. She was incredibly determined to put her life together and to show me that I have grossly underestimated her. She said at some point, that she worked so hard to be clean and go about her life "the good way," that she is not going to let "all kinds of losers back into her life." And again, she was true to her word.

Two months ago, she found a new job, which gave her even more confidence.

"How have you met your new boyfriend?" I asked her comming back into the present.

"At work!" she said, "Can you believe? I go there in the morning as I usually do, and here he was, walking around with my boss, coming to do some consulting for our company and," she added with a broad smile, "trust me on this, consulting he did."

CREATIVE AND FEARLESS

One of the believes that has always guided me, in my own life and in my work with patients, is that hard work pays off. This believe has often been challenged by the circumstances. It has also been challenged by many, as being too idealistic, too simplistic in the face of "how complicated things usually are," and too trusting.

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.

The selection process was brutal. There were eight rounds of interviews. Thirty two people were selected. Then twelve. She was in the final selection. Then one day, on a Friday afternoon, when I was driving to the airport to pick up my parents coming to visit from Romania, my phone rings. It was her. She was crying. At first, I thought she had an emergency. Not this time. She was crying because she made it. She was one of the eight.

IRRESISTIBLY, AN ARTIST or TALES OF EXTRAORDINARY CREATIVITY

Although there is an artist in each one of us, there are some of us for whom being creative is not a choice, but an irresistible calling. Being creative is part of their identity. Asking them to give it up is the same as asking them to stop breathing. They think, plan, create non stop, 24 hours a day. They are like a well tuned violin, resonating equally deep to the sighs of the world and to happenings in their day to day life. They vibrate at high emotional intensity all the time. And they don't have a choice. They are blessed with special talents, but also they need to know how to harness the emotional charge attached to that, in order to function well. This is what the modern researchers in creativity, like Dr. Nancy Andreasen from the University of Iowa, calls extraordinary creativity.

In a broader sense, people with extraordinary creativity are not just well known artists. They are also the people who have highly creative professions and careers. This category includes less known artists like museum curators who use skill and imagination to restore and maintain works of art, editors and publicists who devote their lives to nurturing books and the art of the written word, professors who teach subjects they are deeply immersed in and have the talent and the power to transport their students into a different world even if only for the duration of a one hour class, archaeologists who dig for fragments of history and reconstruct an entire civilization from the knowledge contained in a ceramic shard, computer programmers who envision revolutionary ways to use technology, business people who use their creativity to find ingenious business solutions--all these anonymous people have responded to the irresistible call of their creativity and embraced careers that satisfy this call.

Recent research in the neurobiology of creativity is beginning to show that even the brain of the exceptionally creative people is wired differently than that of people possessing only a day-to-day type of creativity. In highly creative people, the inspiration for a new idea arises suddenly, connecting in a non sequentially with many areas of the brain, accessing the unconscious mind in a free, uncensored way. The rapid fire of information, with seeds in both, conscious and unconscious mind, and the capacity of the creative people's brain to "go with it", is just one way the scientists believe the exceptionally creative brain works differently than an average one.

But for all the benefits of the exceptionally creativity, there is often a price to pay. These people tend to be much more sensitive to the world's impact on their lives, and therefore, much more vulnerable. They tend not to have the practical skills most people have. They are often so immersed in their creative process that often they forget to return the phone call that would get them the job, doing it for money. They are easily crushed if something goes wrong and they have a hard time tolerating criticisms of their work. In other words, it's not easy to be talented. Many creative people have notoriously suffered from emotional disorders, the classic example being Vincent Van Gogh and his struggle with bipolar disorder, but I believe it is very common for talented people to struggle with different degrees of anxiety, at the very least.

Zeke, one of my "exceptionally creative" patients, is a good example. He came in not long ago for his monthly follow up appointment.

"Even though I no longer have panic attacks," he began, "I realized recently that I am not like my friends. I am painfully aware of everything around me. I avoid saying things to people because I am mortally afraid I will disturb them. When we watched the NASA hit the moon with the projectile to raise a dust cloud and analyze it, I was the only one watching it with tears in my eyes. When I work and I am thirsty, I postpone for hours getting up and having a glass of water because I don't want to disturb the flow in my ideas. I realized I am constantly on the look to make sure I don't disturb something or someone or even my own thoughts. I rarely miss anything from what I see and I remember details that my friends swear they never see, or worse, they say that never existed. I wonder why am I so different? Why do I have to live with this fears and worries all the time?"

"Does this anxiety interfere with your work?" I asked, trying to understand the extent of this problem.

"No," he said quickly,"not at all. I am very productive. A magazine I used to work for, renewed my contract and I am working on a new project that is extremely exciting."

Zeke is a photojournalist. He travels the world and tells the stories as he sees them--a very interesting and exciting life you might say, but for his daily struggle with anxiety.

Listening to his litany of complaints, it struck me that the very complaints that were bothering him, were also helping him better at what he was doing. Yes, it was a nuisance to live under heightened pressure and worries. But that was making him more alert and more in tune to the world. It was unpleasant not to get up from his desk and allow himself a brake, but working at that intensity was helping him get "in the zone," in a creative flow that was helping him turn in remarkable journalistic work. In other words, it wasn't all bad. I have heard before these types of complains from my other creative patients.

"I will need to take more medication, I am afraid," he said as an afterthought.

For few months, he was taking Cymbalta 60 mg a day that helped him control the initial mixture of panic attacks and depression. But I was not sure if this low level anxiety he was talking about now, was really a matter of medication management.

"Have you ever considered," I said, " that this low level anxiety you have now has some benefits?"

His startled look indicated he hasn't. I continued with my theory.

"Although unpleasant at times, this low level anxiety helps you being better at your work. Imagine we would increase the medication and you would feel almost nothing, living in a bubble of indifference to the world. Would you like that?"

"I would loose my job, I wouldn't be myself, but other than that..." he said with a smile.

"Exactly. We need to balance the level of anxiety in such a way that it allows you to be the creative artist that you are, but without becoming so intense that dealing with anxiety becomes the focus of your life."

"What do you suggest, then? How can I reach that balance?"

"Understand that this anxiety is part of who you are. You need it, in order to be creative. It is your emotional edge that makes you resonate with the world deeply and creatively. As it isn't too intense, as you said, perhaps we can find ways for you to better cope with it, rather than make it go away with medication, which would numb you out in the end. For example, when you are afraid to do something that might disturb "the flow," use the rule of "just do it." Simply recognize what holds you back and act against it. Do not give into that fear. But if anxiety enhances your emotional reaction to certain events, news, books or other things you come in contact and move you deeply, allow yourself to feel that. Your emotional reaction then, may just be the trigger for a crative thought."

"I am not quite sure I understand this," said Zeke sounding puzzled. "Are you suggesting I can learn how to turn my anxiety off when it's bothering me and on to enhance my perception or to aide my work when I need it?"

"Yes, you could learn how to modulate it, work with it, rather than against it. Denying this anxiety and attempting to squash it doesn't work and it only makes you more frustrated."

After going into many details and examples, he agreed that he will try to approach his low level anxiety in this way.

Few weeks later he called me from Ruwanda, where he was working on an article about "the oil paradox." He said he had been "learning to make friends" with his anxiety and that made him happier and put his mind at ease. He felt more creative and productive than ever before and he was very excited.

THE ARTIST IN EACH ONE OF US or THE DAY TO DAY CREATIVITY

How many times when, being upset, we find refuge in listening to music, journaling, write a letter to a friend or watch an uplifting movie and, after a little while, we feel better? Why are these actions helpful? Because instinctively, when uncomfortable, we turn to our inner sense of beauty, joy and harmony to soothe our momentary emotional edge.

We are all undiscovered artists. But our creativity comes up in many different forms, at unexpected times, often in unexpected ways. Suddenly, it hits us, seemingly out of nowhere. In the morning of the day I visited the Nijo Castle in Kyoto, I woke up without having any idea that, that day, I would fall in love with Japanese brush painting. Yet, I did, by watching a fragile chrysanthemum petal venturing astray from the orderly bloom, on the gold gilded screens decorating the Hall of Chrysanthemums in the castle.

Many of my patients discovered the "artist inside" in desperate, painful situations. One of my patients helped herself survive by writing poetry when her knee replacement surgery went horribly wrong. Another patient discovered water colors while trying to find a way to deal with the death of her husband. Yet another patient, dealing with severe social anxiety, discovered that photography was offering him respite. "When I look at the world through the lens of my camera, I can narrow the entire world down to a small window, and it becomes so much less intimidating." At first, the only times he was not anxious, was when he was taking pictures. Going from there, he reacquainted himself gradually with the world at large, to a point where now he "forgets" to be overwhelmed by it and his panic attacks have melted away.

In broader terms, almost anything can be "art," in the sense that it appeals to our sense of beauty and harmony. Arranging the plants in the garden in a certain pattern that looks good to us, or pruning a shrub, getting dressed in the morning and choosing certain clothes because they "go well together," rearranging and redecorating a room in the house, cooking a new and sophisticated dish--all of these action could qualify as day to day art that requires creativity to make them happen.

There are many art forms we instinctively adopt. For example the street artists who made out of graffiti a new art form, or break dancing that started in the streets and then became a well known dance form. And, yes my dear bloggers, even blogging, if you look at it this way, is a contemporary art form. Many blogs I read are about coping with life through writing--using the creative art of writing to cope with a night of insomnia, living in a foreign culture, recalling treasured memories from the past, coping with change or loneliness or parenthood. Many bloggers also become, for a moment, graphic artists and decorate their blogs in visually unique ways. Many become ad-hoc photographers, trying to convey to others the beauty of a special moment, when the light of a sunsetting sun strikes just so the forested hills they have to cross on their way home. It's all art. I think you all experienced at some point the feeling of "being in the zone" or "going with the flow" when you do something creative. When I sit down and paint, suddenly it's morning. I've been painting all night and I feel still as excited and energized as I felt seven hours ago. It is the magic and the power of our creativity--awoken, alive, stimulated and fertile. It's this power that gives us a welcomed break from our pain, fears and, sometimes, a break from simply a mundane existence from which we desperately try to escape.

Giving ourselves permission to unearth these hidden talents we already posses, buried under layers and layers of day to day rush, chores and responsibilities, will make our lives more meaningful, more beautiful, more pleasant and, overall, easier.

What is your hidden talent and how did it help you get through?

WHAT KEEPS US GOING

"What keeps you grounded in your work with patients?" was the question we were trying to answer. It was few days ago, at a round table discussion with a few colleagues, psychotherapists. It was a sunny Friday morning, an early fall day in Southern California, filled with the scents of autumn but warm and pleasant, without a trace of cold.

Someone said "placing myself in their shoes." Another colleague said "the knowledge that their visit to my office is just a brief stop in their life's journey. I decided long ago that no matter what my patients do, good or bad, I will not take neither the credit nor the blame. It's their journey."

While they were talking, I was thinking of what keeps me going, seeing patient after patient, listening to their problems, trying to come up with solutions that make sense, pouring everything I knew, read, heard or felt, into their care. Memories of my residency training came to my mind out of nowhere. I remembered my rotations in the psychiatric emergency room at the County General Hospital in Los Angeles, one of the busiest hospitals in the country. Most patients where brought in by police, found in the streets of downtown, delirious, extremely manic, psychotic paranoid or overdosed on drugs. Once at the hospital, they were constantly bossed around by the staff, telling them roughly where to go and what they are expected to do.

They were scared and rebellious. The more authority it was used to make them quiet, the angrier they would become. I was never able to display that kind of raw authority with them, no matter how sick they were. Early on in my training, I started thinking that I have, in fact, no right to judge these people. I have no right to be rough with them or use unnecessarily harsh words. I always preferred talking to them calmly and respectfully, answering their spoken and unspoken questions, trying to calm them down with patience and understanding. Even when they didn't speak English, and that was nearely half the time, I kept talking to them, often telling them the same thing over and over, hoping that at least the sound of my voice, if not the words, would help them quiet their fears.

And it worked almost every time. The patients assigned to me were the calmest and the most compliant patients in the ER. They needed, on average, less physical restrains and less emergency medications. They helped me understand that treating people with respect, no matter at what low point of their lives we would meet, is something that transcends language and cultural barriers. It even transcended psychosis and mania and drug intoxication.

Taking care of these patients, the sickest patients in the county, I understood clearly that my job was to help if I can, to offer choices if I can figure them out, but to never substitute my judgement for theirs, never to assume they are powerless and can't understand the choices ahead of them. I promised myself that I will always respect my patients' right to live their lives and make the decisions they want to make. But I would also help them make these decisions in full knowledge of the pros and cons of their actions, providing them with reliable, practical, common sense and medically sound information, guiding them, but never imposing my values on them.

Now that I work with different type of patients--high functioning, more motivated to get well and not even remotely as ill--these principles are becoming more valuable than ever.

When it was my turn to talk, all I said was: "What keeps me going is the trust I have in my patients that, if I provide them with good information and guidance, they will find a way to use it well, heal and confidently pursue their highest dreams of happiness."

I wonder what keeps you going, at work or as a parent or doing some of the most important work of your life?