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What is clinical anxiety? And how does it differ from everyday anxiety?

We are delighted to welcome back to the show Karen Lowinger, who is a clinical psychologist from Panama. For fourteen years now, Karen has been working with teenagers and adults going through anxiety disorders, mood disorders and borderline personality disorder. She last spoke to us about high functioning mental health problems, which you can find at episode 5.

In today’s episode we will be taking a deep dive into the world of clinical anxiety. We’ll begin by discussing what anxiety is, and what the difference is between everyday and clinical anxiety. We’re going to dig into the detail of how we understand anxiety, with a little ancient philosophy thrown in for good measure. We’ll explore the phenomena of catastrophisation and the ‘panic attack’, and we’ll explore some of the ways to treat anxiety.

Will refers to an article about anxiety he’s written, which you can find here.
The lecture by Martin Rossman that is referred to in the conversation can be found here.

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Please note that this show does not constitute medical advice and is not a replacement for seeking professional help. You can find our more about the show and get signposting to support on our website


W: Hello everyone, my name is Will.


E: My name is Ellie.


W: You are listening to Lively Minds, the podcast about mental health challenges that go beyond the ebb and flow of the everyday.


E: The podcast that is less about how we deal with our mental health and more about how we understand it in the first place.


W: In today’s episode, we will be taking a deep dive into the world of clinical anxiety. We’ll begin by discussing what anxiety is and what the difference is between everyday and clinical anxiety.  We’re going to dig into the detail of how we understand anxiety with a little ancient philosophy thrown in for good measure. We’ll explore the phenomena of catastrophization and the panic attack and we’ll explore some of the ways to treat anxiety as well.


E: To help guide us through this conversation we are delighted to welcome back to the show Karen Lowinger who is a clinical psychologist from Panama. For 14 years now she has been working with teenagers and adults going through anxiety disorders, mood disorders and borderline personality disorder.


W: So welcome, Karen.


K: Hi, thank you for having me today.


W: It is great to have you here. Our first conversation with Karen was about high-functioning mental health problems, and you can find that at episode five in our catalogue.

So, Karen, to start off with, what is anxiety?


K: Anxiety is a primary emotion. It’s a basic emotion, and it manifests itself with a heightened state of worry, of unease, of dread. And it’s actually pretty normal to have anxiety. We’ll talk a little bit later as to when it’s not normal. But it has a function, which is to protect ourselves from any potential threat, any potential danger or challenge.


When we see the process of anxiety, we’re always going to see that there is some sort of stressor, even though at the time we might not identify it per se, but there is always some sort of stressor. And what happens here, what’s mobilising itself in our minds, is to somehow try to have some control over that situation, which we feel we don’t have control. And the situation to which we don’t have control is something that is a threat to us.


W: I was listening to another podcast the other day, they told a story that I thought was really interesting, and kind of quite good at articulating anxiety. Imagine that you’re walking down the street and suddenly you see a guy who’s half naked, no shoes, running up the street the other way, screaming. What would we think of that? Well we probably would think that guy was, you know, a bit unhinged but then you see he’s being chased by a lion and suddenly that completely changes the context of that situation in that actually the, his response then suddenly seems much more rational.


K: Well, what you’re saying is very important, not just for anxiety, but for most difficulties regarding mental health.


E: Yeah.


K: Because they’re invisible. You know, other people are not aware of what’s going on. So they just see that guy running around and they don’t see that bear and they just think, wow, that guy is unhinged.


W: There are people for whom that lion, as you say, is invisible. The anxiety that that person is experiencing may be deemed irrational by other people, but for the person who’s experiencing the anxiety, it’s something which causes very genuine fear.


E: It’s quite a nice metaphor to kind of bear in mind in order to keep our patience, you know, if someone’s really feeling really anxious and panicking about something that we personally don’t see, why that’s anxiety inducing or whatever, just sort of reminding yourself like there’s an invisible lion and chasing them, just remember that and try to help. I think that’s quite nice.


W: When does everyday anxiety become clinical anxiety?


K: There are three factors that we need to take into account. Intensity, duration, and frequency.

Intensity relates to the following. If we explain to others and we put others in certain positions that they have gone through life, we can find that everybody in their lives has, have gone through anxiety. That’s a normal emotion, just like happiness, sadness, anger, fear. The thing is that anxiety is normal, regarding anxiety when it’s proportional to the situation. Okay?


When, when, you know, I have a test, so I’m going to really study and I’m worried about that test and whatever. But if I’m just really, really having a hard time sleeping and a hard time eating and a hard time doing my own stuff or anything, recreation, socialisation, it’s starting to affect so much more than the actual stressor. And that’s a problem regarding intensity.


Another thing is the duration. The duration, usually the anxiety should go away when the stressor is gone. So for example, if I was anxious about a presentation or a test that I had, I had to take, then as soon as it’s done, the anxiety should go away. If it doesn’t, then we should check into it.


And the frequency has to do with how often we are getting into this state of anxiety. If there are, you know, if we find that there are too many things that are constantly triggering our anxiety, then again, we should look into it. So the three things, again, they are intensity, duration and frequency.


W: I want to just pick up on this idea of rational and irrational responses to things that we find anxiety inducing. This is something about how we understand anxiety on a fundamental level. Before we started recording I was waxing lyrical about the Stoics of Ancient Greece. This idea of Stoic philosophy from the time of Ancient Greece is this way of thinking that emphasise is finding inner peace and contentment through self-control, rationality and acceptance of the things we cannot change. And it’s this very nice idea that as human beings, we can control the way that we respond to things. And using that as a frame to understand anxiety, it’s saying, the problem isn’t the thing out there in the world that is causing your anxiety, the problem is your reaction, how you are reacting to that thing. I guess that the stoics would say there’s no such thing as a rational response to anxiety that includes getting panicked about it for example, that they would argue that the rational response is to control your response and respond in a way that you choose, which, as you can probably tell by the way I’m describing this, I feel very sceptical about. I don’t really have much time for that argument because I think that human beings have a lot less control over how they respond to events whether rational or irrational however you want to describe them than this line of thinking suggests.


K: I think here it would be a good idea to make a difference between what is called an irrational

response versus what is really an irrational thought. Because you said, well, that according to these Greek philosopher, that there is no such thing as a rational response to anxiety. And I disagree. I think there’s actually no such thing as an irrational response to anxiety. What we have to control is this distorted thoughts because the thoughts are what takes us to the action. It’s like the example about the bear and the person that you were talking about. The person is not really having an irrational reaction because for them the stressor is real. So what they’re having is an irrational thought and that’s what we’re working on in therapy.


So what are the thoughts that could be irrational? For example, “I need to be in control of everything that happen that could go wrong is going to go wrong”. “ Things are always going to be worse than I expect them to be”.  You know, those are some sort of irrational thoughts that take us to actually have anxiety. So if we have those thoughts, if we believe, “I need to control my children. If I don’t control them, they’re going to die. I need to control what they eat. If I don’t do that, they’re going to die.” We’re not that aware of it, but that’s the root of it.


W: Then what that suggests is that it isn’t necessarily the thing itself out there in the world that we are finding anxiety-inducing. So take the children eating example. If I had children, I might be worried about what I’m going to give them for their dinner. But the actual irrationality is the thought process behind it. So the irrationality is the, the worry, if I give them the wrong thing, they’re going to die. So in a sense, it’s the way that we process events that can be the challenge and the problem rather than the events themselves?


K: Exactly.


W: I’ve written about anxiety a few times and one of the stories I tell in one of the articles I wrote was about when I was a teenager and I went to a local department store and I was taking the escalator and I dropped a 20 pence piece as I was going down the escalator and I couldn’t find it and then I had to get off the escalator. And then I went about my business, went home, and then later on suddenly started this real anxiety that, real anxiety that this 20 pence piece would get stuck in the escalator and would spark a fire and it would burn down the department store. And you know, many people would die and it would all be my fault. So I guess, how would, how would that idea apply to that then? So it would be saying that the issue isn’t the dropping the 20 pence piece on the escalator. That’s not, that’s not the issue here. The issue is my catastrophization, which we’re going to talk about in a moment that idea of catastrophization is my catastrophizing of that scenario. That’s the challenge. That’s the thing that needs to be challenged. Would that be right?


K: Exactly. Somewhere in your mind you had the idea that that 20 pence… I’m sorry, we don’t have that money here. I’m not sure I’m saying it right.


E: Yeah, 20 pence.


W: Pennyfarthing. No, not really a pennyfarthing.


K: What?


E: No, it’s 20 pence.


W: That’s a bicycle, isn’t it?


E: I think it’s an old Victorian bicycle.


K: What are you talking about?


E: Sorry, it’s really confusing.


K: Okay. So, somewhere in your mind you had the idea that a 20 pence piece somehow jammed into the escalator’s mechanism and would cause it to overheat itself, causing a fire. So look at the whole fantasy that’s going on in your mind to cause that anxiety. What really happened is you dropped it down. That’s what happened. If somebody didn’t have that fantasy, they would not get anxiety over it.


K: That takes us on to catastrophization, really, which is such a massive part of clinical anxiety. And I’ve actually got a little extract from an article that I wrote. I say,

“The imagination is an impressive human feature. It is our best friend. It provides the spark that leads to human creativity and achievement, as well as the prescience to anticipate and tackle problems ahead. It can also be our worst enemy. It can spin out of control and consume us with nothing but impending doom. Here’s a tip. Never ask someone with anxiety what’s the worst that could happen. Our ability to tell disaster stories can be sort of impressive.”


I think, yeah, I do wonder whether some people with bad anxiety are often people who are the more imaginative ones [laughter] because that’s what it is, isn’t it? It’s that kind of snowball effect of, I mean, I describe it in the same article as each chapter zipping by faster and faster “like stations glanced at in terror from a runaway train”. So it’s like, you know, this idea of this this, this kind of cycle that just develops and develops and develops, picks up speed, picks up speed.


And I guess going back to the 20 pence piece story and the escalator, it was, at first, I am in that space that you just described as the more rational response, which is I just I dropped 20 pence piece, oh, that’s a that’s a bit annoying. I’m 20 pence short back in those days, 20 pence

was worth a lot more than it’s worth now! But then of course, what happens is your imagination

just starts, there’s a little trickle, it starts to trickle, doesn’t it? And then it becomes a stream

and then a river and then a torrent because you just go the next step of the story becomes,

it gets trapped in the escalator, the next step it overheats the mechanism, the next step it causes a fire, the next step and it just becomes this, this, and it always ends in death. It’s funny how for me the catastrophization always ends in something massive like death and it’s amazing

how there must begnine things that can end up with lots of death and it’s weird.


K: The other day I was talking to a colleague and I was telling her how in my experience with anxious and panicky and hypochondriac patients and even obsessive compulsive patients, it seems that the base always tends to come down to the fear of, of death, whether it’s their own death or their loved ones. You know, so it seems something very important to tackle. We cannot always contribute that reality to absolutely everybody that we encounter, but it seems to be a very prominent denominator that is shared between all of them. What, what it all comes down to, honestly, is the lack of control. You know, you cannot control things, you cannot control when, where, how, who.


E: And also, the idea that death is the worst possible outcome. So it’s always going to end the thought pattern there.


W: And also I think another thing about the idea of irrational and rational responses to things, a stick that I think you can hit yourself with quite a lot is other people can deal with this situation far better than I can. I will spend a lot of time being very harsh on myself because I’m thinking to myself, nobody else would get as anxious about this as you’re getting. And I think that’s can become a real problem because I think that it’s important sometimes, I find it quite helpful sometimes, to actually go, you know what, what’s at play here is your anxiety. However you want to understand that, whether it’s through more of a biomedical approach, whether it’s through a more social approach, however you want to understand that, it is your anxiety that’s actually doing this at this moment. And that’s something that other people don’t have to the same extent as you. And that’s reason why you’re reacting to this in the way that you think other people aren’t and also actually other people possibly are reacting to it in a similar way to you, it’s just you don’t know it because actually they wouldn’t know that you’re reacting to it in this way that you’re reacting to it. But I think we can use that rational irrational idea as a way to both judge ourselves a little too harshly and others too harshly. Going back to the, the guy being chased by the lion analogy again, it’s like, if it’s a real lion, if it’s actually a lion, everyone’s like, oh, right, okay, you’re behaving completely rational in that situation, mate. Run, run for your life! If it’s a imaginary life, if it’s if the lion’s more of a metaphor, as we discussed, then I think there’s a lot more judgement around in terms of whether he’s just off his rocks, sorry to use the blunt language, or whether he’s, you know, actually reacting, reacting in a way that could be considered rational.


K: I think it’s also important then to note the concept of mentalization in psychology. It states in a really, really small nutshell, it states that we are aware of how we feel, but we’re not aware of how we look to others. We are aware how others look to us, but we’re not aware of their internal world.  Okay, so when you’re describing Will, for instance, that you think that everybody’s dealing with it better than you, it has very much to do with the fact that you’re aware of what you’re feeling, but you’re not aware of what you’re showing to others, and you’re only aware of what others are showing to you, but not what they’re feeling.


W: Yes.


K: Because maybe other people would feel the same way towards you. They would never believe that you were having anxiety or panic.


E: Yeah, it’s this swan thing, isn’t it, that swans are really graceful when they’re floating across the lake but that’s because you can’t see that underneath their feet.


K: Exactly.


E: Are paddling extremely quickly just to keep themselves afloat.


K: Exactly.


W: Another great analogy!


K: Yes.


W: lots of amazing analogies today, aren’t we?


E: Yeah, we’ve had quite a few over the episodes, I’m thinking of putting together a book of analogies. [laughter]


W: Another area I just want to just touch on, Karen, is this idea that I’ve kind of called the Worry Cycle. I’m not sure whether it’s got a proper name or not, but I was once watching a YouTube video, a lecture delivered by a guy called Martin Rossman, who’s based in the States. And he said something which, when he said it, it just felt on the one hand, the most common sense idea around worry and anxiety. But at the same time, it was like a real penny drop moment for me. And so he, he talking about how one of the problems with worry is if you actually analyse it and look at how many things that people with clinical anxiety worry about and then ask how many of those things actually happen, you’ll find that it’s a very very low number, certainly in my case it’s again just talking from personal experience the vast majority of things that I worry and worry and worry and worry about don’t happen. But what Dr. Rossman says is the thing is, that the trouble is that the mind tells itself the reason why it didn’t happen was because you worried about it. And so it becomes this loop whereby you’re telling yourself, if I worry about this, it won’t happen and again, it could become this paradoxical thing. There’s so many paradoxes and ironies in mental health, I find that yeah, and breaking that cycle therefore becomes a really important thing to do.


K: Yes.


E: But I would have thought that that particular example is more to do with kind of like the obsessive compulsive mindset because it’s like than it is to do with generalised anxiety because it’s confirming that your actions resulted in whatever. So it’s like determining your own frame of causality.


W: hmmm


K: However, people with generalised anxiety disorder also tend to have this feeling that they, when they’re worrying about something, that they’re somehow taking steps to control it. And then once again, they go into that cycle, which perpetuates it. And I think it’s really important in this moment to, to understand that therapy is the one that helps challenge the distorted thoughts, which is what leads to the cycle.What would the distorted thoughts be in this case? A person worries about something and it doesn’t happen. Somehow, in the moment that they’re feeling that it’s because they worried about it or they did little steps towards it, then they feel that those are the things that led them to have control over the situation. And the truth is, the person didn’t have control over the situation in the first place. Okay?


Like, let’s go back to a very common situation. We have to do a presentation in front of people. So if we do that, if we’re anxious about it, and we start getting anxious about it, and we do it right, and we have to do it again, and we start getting anxious about it again, we’re going to feel that our anxiety is the one that somehow made the presentation go right. But we’re not really taking into account the fact that we prepared for it. The fact that maybe I was feeling good that day, maybe my mental state was good that day, maybe the people I was with were making me feel comfortable that day. Maybe the temperature was good. I was feeling physically fit. I don’t know. There are so many factors that can influence whether something goes good or bad. And it’s an illusion to think that we’re in total control over the outcome of the situation. But we somehow have the need to attribute that little control we have because it helps us feel better.


W: Yeah


K: But in reality, it is an illusion.


W: Will


K: You know, like the idea of us cooking, you know, what we said before for the kids, the food that I’m going to give them, you know, I’m really scared that they’re going to have a health issue if I do it wrong. Of course, I’m going to do it right. But the truth is, it’s not completely and entirely up to me that their health is completely fine. There are so many other factors that inside in their health.


W: Karen, can you take us through the difference between anxiety and panic?


K: I like to see it as, as if we’re on a roller coaster. When we’re going up, we are freaking out. Okay, we’re, we’re looking at that peak of the mountain of the roller coaster, and we can feel ourselves going up in the little cart, and we look down and we’re like, “Oh my gosh, we’re going to go down, we’re going to go down.” Okay, so we’re thinking about what’s going to happen. We’re really, really stressed out and worrying and dreading what’s going to happen in that moment. So then we get to the peak and we start falling down. At that moment, we’re not thinking about what’s going to happen. We’re actually feeling panic. We’re panicked. We’re going down. So in that moment, we’re in the moment. Before, we weren’t in the moment. We were thinking about what was going to happen. And that’s the way I like to, to explain the difference because the symptoms that come along with it are pretty evident right there.


Anxiety, you’re kind of sweating when you’re going up, you know, when you’re anxious, you’re kind of sweating. You’re kind of your heartbeat is going a little bit higher. You’re kind of having a little bit of difficulty breathing. Maybe your thoughts are, “I shouldn’t have gotten on here. I want to go. I want to leave.” But then when you’re in there, when you’re going down, which I, I connected to the panic part, in that moment, you are really just freaking out. And then that’s where the responses come, the fight, flight or freeze.


Now, when you’re on a roller coaster, you can’t really do much. You can’t really, you know, you’re just there. But the nature of what’s going to come out is going to. So in this sense, the fight, flight or freeze response would be:

The fight – why am I on here? I don’t want to be on here. I shouldn’t have gotten on here. You know, I’m kind of fighting the idea that I’m on the roller coaster.

The flight one would be I want to get down, just stop the roller coaster. I need to get down.

And the freeze would be I’m just going to close my eyes, bite down hard on my, you know, my teeth and bear it.


E: Cause it’s like the anxiety is what’s leading up to the panic event. You’re anxious about there being a panic event?


W: It’s quite possible to experience one and not the other as well, isn’t it?


K: Exactly


W: I mean, for me as an anxiety sufferer myself, it’s incredibly rare that I’ve ever had panic attacks or I really experienced what would be called panic. For me, my anxiety and my anxiety problems are all about what I call the worry churn, which is just this sort of cycle of worry going on and on and on and on. So I, I,  it’s funny how when you were telling that analogy, identify much more with the going up the roller coaster part and the dread and the fear of the thing that’s coming up, the experience that’s about to arrive, rather than the actual moment of dropping off the roller coaster itself.


To finish off, Karen, could we go into some of the therapeutic options for anxiety?


K: Yes, of course.


W: Yeah, sort of, what options are for them to alleviate it?


K: So regarding anxiety, we have two major factors that we need to address. One of them is the symptoms and the other one is the root. Usually the symptoms are, if they are very, very intense and the person is having difficulty functioning and doing their everyday life tasks, then there are psychiatric medications such as SSRIs, which is a type of antidepressant or benzodiazepines to help manage the symptoms. However, the medication is not gonna address the root of the anxiety. For this, we need to also touch very quickly another subject and it is where anxiety comes from. Because for some people it might be genetic or a chemical imbalance, but for other people it might be the way they were brought up, the way they learned how to experience life or how to process things. If it’s a chemical imbalance, definitely the symptoms are well-off managed with medication and there might be a need to continue the medication to ease the symptoms or to keep the balance within the brain chemistry. But for the root, they root of the disorder it’s really important to try to understand it and for this psychotherapy is really good.


Also psychotherapy can help manage certain symptoms if they are not too intense or unmanageable for the person. Things that we do in psychotherapy, aside from trying to understand the root, which is done through an exploration of the person’s past and their experiences in life, we also talk about certain tools that will help them ease these symptoms. Part of it is managing the distorted thoughts, which we have spoken about many times during this podcast.


And in these distorted thoughts, we can include catastrophization, which we also spoke about. It’s also a good idea to learn how to put things into perspective, to try to understand what is my role in a certain situation and what are my limitations and at what point I need to back off and let it be, and until what point I need to actually keep on having control and doing certain things.


So yes, there, there are different ways to address anxiety and it’s largely based on each a

the person’s needs. Sometimes the root cause is a lot more identifiable, other times it’s a little bit more difficult, but as soon as it is aware, it starts becoming a lot easier to deal with anxiety.


Another thing that is really, really important to do in therapy is the part of psychoeducation, which is to learn what anxiety looks like, what to expect from it, what is normal anxiety, what is not normal, how to break the cycle of anxiety when we have the panic attacks so that it doesn’t keep on perpetuating itself, and also to help the person gain awareness as to what their process is. And here’s something important. I remember when [laughter] I remember when I went to a doctor the first time because I was having panic attacks. I described it to this doctor and she told me, “Oh, that sounds like a panic attack. It’s okay. Nothing’s going to happen.” In my mind, I was thinking, “Clearly, you’re not talking about the same thing that I am because you’re telling me that nothing’s going to happen when I am freaking out. I feel like I’m going to die every single time I expose myself to a trigger so you’re just saying it, but it’s not real for me.” And so, I’ve encountered that same situation on the other side, me being the professional and having patients and me being incredulous, because when somebody tells you it’s not the same as you experiencing it, sometimes a person needs to experience it two, three, four, five, 10, 15 times and realise that they’re going to be okay for them to be able to go on through with it. So it’s to help that person realise and see, “Hey, this is a process you’re doing. Don’t let me tell you, but look at your own experience.”


You Know, you just said Will, the doctor, I think it was Rosenberg, the one from the United States,


W: Rosman, yeah.


K: Rosman, yes, I’m sorry, Rosman. He said that the worries perpetuate itself because there’s a feeling that if we kept on with the anxiety, then the outcome would stop, that the bad outcome would stop. In that case then it’s really important for the patient to be able to realise that these are not the factors that necessarily made it stop. That anxiety takes us to the worst case scenario and there’s a lot of things that could happen between that and the worst case scenario. Okay, so those are certain tools that would help ease the anxiety and you know, overcome the disorder.


W: And I guess it’s really important to say at this point that if people are listening and they feel like they need help, then they really should go and see their general practitioner and yeah aim to get that help. Because I think another thing that I’ve found is that it’s very easy to get stuck into that idea of feeling like you don’t deserve help, and especially when you’re having those negative thoughts about yourself, like I was talking about earlier. It’s very, very easy to, to feel like there’s no point or that, as I say, you don’t really deserve to go out there and actually get help. And I would encourage people to go and get help if they can. And if anyone’s having a mental health challenge that they need support with right away, then our website,, has a lot of links across the world to various crisis lines etc but Karen thank you so much for such an incredible conversation


K: Thank you guys for having me it was really good


E: Thank you so much Karen it’s been brilliant always a pleasure to talk to you


K: Likewise


Lively Minds is an Anya Media //// Still Ill OK co-production

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