Guidance for Uncertain Times: Managing Anxiety
Podcast date: April 3, 2020
- Learn strategies to identify and manage anxiety and feeling overwhelmed
- Learn how to be aware of physical and mental needs
- Learn strategies for parents to manage their own anxiety
- Learn information on current healthcare issues and medication
- Follow a guided relaxation meditation
Announcer: You are listening to a special podcast of All Things ADHD. In this time of crisis, we know everyone in our community is facing tremendous pressures, and CHADD and its National Resource Center on ADHD are here to help.
Susan Buningh: Hi. I am your host, Susan Buningh. And I am here today with Dr. Craig Bruce Surman. After the interview section of the podcast, Dr. Surman has offered to lead a guided meditation, especially for people with ADHD. Dr. Surman, could you tell us a little bit about yourself?
Dr. Craig Surman: I'm a neuropsychiatrist by training. I do clinical and research work at Mass General Hospital in Boston. I have an appointment with Harvard Medical School where I teach and I am very proud to be on the professional advisory board of CHADD, and to be here with you today.
Susan Buningh: Thank you so much for joining us today. Due to all the present disruption and uncertainty, we are all experiencing big changes in our daily lives, practicing physical social distancing, working from home, children being schooled at home in some cases, among many other things. So, what can people do to manage anxiety?
Dr. Craig Surman: The number one thing that helps anybody with anxiety is to identify it. And anxiety can lurk in lots of different ways. As we are talking, I want to be mindful that this is being posted with CHADD, and individuals with ADHD already have a long list of to-dos that they have a troubled relationship with. And proving their anxiety can be yet another to-do item. So, we kind of must think about how what works for anxiety can be embraced by folks with ADHD most easily. And I think there's sort of the couple of general principles that go beyond what I said already that we can get into, but the number one task is identifying it in its many forms. Processing that for folks that are ADHD may be quite like the kind of stress state that they've needed to harness to work for a long time. And this is where I think it gets tricky for some folks. Is this the all too familiar way I get things done, last minute, under pressure? Is this where I usually live? Distracted, multitasking, lots of things on my mind, lots of loose ends? Or is this extra busy mindedness? That is not helpful. So, it can help, I think, to take a moment and notice if there are signs of anxiety that can tell you this is not productive stress energy. This is unhelpful, draining, straining.
One of the primary signs, although it is different for different people, is a physical one. And each of us carries stress in a different way. Some people have a very clear tell, that the shoulders are up here by the end of the day and the tension, right? I mean, that is such a body posture in the ergonomics that a lot of us are in right now, working at computers from home. Or maybe you're back, picking up a little one little more than you've ever done before off the floor to help try to take care of them while you're running around the house now, and you used to have daycare. Maybe it is that back that is going to show it. But our bodies are going to tell us where the strain is. But how you are holding your body affects the fact that you are even having strain at all. So, this is all sympathetic nervous system stuff, muscle tension, fight, or flight. So, what we talk about is vital to our survival.
There is an opposite system though we can tap into and that is the parasympathetic nervous system. And this is what people talk about when they think about the relaxation response. When people are talking about being grounded, people are talking about being mindful, that is not running around and racing around. So, when I talk about identifying anxiety, some of the physical signs may be obvious, that tension in the body, racing heart. Well, it is basically feeling a sweatiness. There is something going on in the sympathetic nervous system. But it can be more insidious and less physical. It can be the mindset that a person is operating from. One of concern of not consideration and thoughtful planning. One of fear, not of poise and feeling in command. And we want to identify these unhelpful sorts of mental states and try to cultivate and strengthen both the physical and mental ability to harness the balancing force of that parasympathetic nervous system.
Susan Buningh: What tools can people use to manage feeling lost and overwhelmed?
Dr. Craig Surman: I want to make the distinction, and I am glad you are asking this, between everyday anxiety and sort of unique stressors. And each of us has faced them. And the answer to the question of how to deal with being lost and overwhelmed really is being in touch with what has helped you before. Or if you are thinking about a child that you are trying to help, think about what helped you when you were feeling lost and overwhelmed. There are some basic creature comforts that all of us need. Our brain knows if we are not getting them. Grounding the body in nutrition, in sleep, in activity pattern, dare I say exercise, which is great for anxiety, of course, but grounding the body in a schedule if its needs being met is very different than staying up all night streaming media busy, busy, busy. If you think about how active your mind is, how searching your mind is, that is a very different sort of space for the brain to be then grounded, digesting, processing, getting what it needs from the world. You can train yourself and train your body and start to not feel lost and confused by taking care of bodily needs first and calming the mind second.
Now this is only possible if you feel safe. And when there's scary stuff out there, something that you are worried about in your own health, something that is in the news, well, you have to take care of, are we safe? And there's good information about how to be safe. Checking that information all the time, am I safe, how can I be safe, is there new information out there as lots of media streaming services would want us to, is really telling your brain, "There's something wrong. There is something wrong. There is something wrong. Seek, seek, seek, explore, explore, explore." That is strange queuing.
So, I tend to like to think that way, way, way down the list of how to deal with lost and confused, just checking the news. And one should probably do it about as often as you check the weather. How often do you check the weather? Is there going to be a storm outside or not? You kind of know seasonally, right? When there is a new crisis, a new issue, people check more often, but then you kind of know what is going on. Can you move on? So once or twice a day, figuring out if there is something new that I need to do to stay safe. I think that is reasonable. Otherwise, I really feel that people should focus on structuring their lives around their bodily needs and being in touch with whether there is some inefficient, uncomfortable thought physical or mental state that they are unwillingly cultivating.
Susan Buningh: When things feel overwhelming, where do we start?
Dr. Craig Surman: I think you start with the body with the bodily needs, bedtime, eating. But we are talking about folks with ADHD. If it is a child, a lot of these things are not in their control. You can maybe as an adult help set a regular schedule for them. But that would take starting with yourself, or if you have ADHD yourself, say making a mealtime plan, tucking yourself into bed at night. I usually hear at my clinical work about anxiety the most at bedtime, where people are lying there, and their minds are busy. That is very different from the sleep phase delay we often see of the night owl who suddenly has gotten onto a project because the deadline is tomorrow. And they are cultivated to sort of be up late at night when no one else is around distracting them. It is a very ADD time for a lot of people. Taking care of the bodily needs there means what you would normally do to take care of a sleep phase delay, or sleep phase shift. That is different from what is going to help with a busy mind that's fearful and nervous. So, there is lots of sleep hygiene, and you can click that on the internet, and there's relaxation techniques that can help people settle the mind as well. But if you are not real about the need to begin with, to be “what does it take for me to have a good bedtime, what does it take for me to eat nutritious meals." If you are not prioritizing that, then you will not cultivate what I was talking about earlier, which is this nurtured, comfortable sort of rhythm for our bodies and minds.
I think however that some people that are listening to this, if you have ADHD or trying to help someone with ADHD, you can recognize that some people, this is just another to-do item. There are folks with ADHD who have trouble getting around the boring things, right? And then there's people with ADHD where it is about doing the right thing at the right time. Why am I off doing this other thing when I told myself that I was going to do this other thing, right? And that is a routine problem, problems with routines really needs to be homed in on. It's not going to be appropriate for everybody that's listening to this, but where it's present, it really can breed more, I think, possibility for anxiety because people end up with the disconnection between the daily rhythm kind of, and a pleasant mental rhythm, if you will. So, what helps people maintain a routine is noticing pitfalls. When we did our book, Fast Minds on ADHD, you realize people kind of have critical moments from which a lot of things fall. And it is often the planning time, the planning selfishly that they ended up deferring or putting off, "Oh yeah, I'll get to that. I can throw my clothes on and whip out the door in seconds flat." Forgetting that you are exhausted in the morning usually. And that is really, really going to be hard to do.
What is the cozy self-care? What bodily functions need that you need to prepare for? And beyond the shopping list for things that you are going to need for yourself to feel comfortable, what helps you then make that shopping list? Beyond the bedtime that you know, I am going to set this bedtime, what helps you execute on sort of winding down at bedtime? These are different things for different people, but they are usually beyond just the person themselves. There is an audience to it. There is someone else they are doing it with. There's accountability in some way. A reminder, an alarm system, sort of these kinds of things are useful. But lots of people just get stuck, keep doing whatever they are doing, living a disorganized rhythm to their day.
So, you would want to find some kind of accountability, ideally a teammate. And you can do that over the internet. You can do that over the phone. You can decide for someone else, and this is I think a lovely thing to do, needs your help too with that so if you are not alone in this. Who would benefit from a call from me as I am in my pajamas, getting ready for bed? Who would benefit from a FaceTime chat over lunch with me? Who could I do these kinds of things with? How am I not in this alone? And this is an absolute key for folks with what we call executive function or self-regulation kind of challenges when they have trouble with planning and organization. It is to not be in it alone.
Susan Buningh: Let's talk for a minute about our parents who have children with ADHD. If children are getting special support at school, and now suddenly, the parents are dealing with their schooling at home, how can we help them at home?
Dr. Craig Surman: So CHADD has some lovely resources for homeschooling links to the current situation when it comes to special education support within the US school system when people are now being schooled at home. And I really encourage you to look for those resources, but this does start with taking care of yourself first. And the kids are going to be less self-regulated than the adult is. And you want to anticipate that. If you're doing it alone and taking care of a child alone, some kind of rhythm that you can have together of, again, meeting each other's needs, we'll meet for dinner, we'll meet for lunch, I think is a really good way to model both self-care and what can they can do to help themselves. I'm hearing all sorts of, actually, opportunities that have come out of we're talking about this during the context of the COVID virus public health crisis, and all sorts of opportunities people have had to notice the native abilities of their children and notice what their children do naturally. And to find ways of joining in on that and to just be available in some way, that is helpful. You can get into battles over screen time. You can decide that screen times are a babysitter, or you can realize that there is some conversation to be had about what just happened on the screen. Joining a child where they are at is always a lovely strategy. What is their concern? What are they worried about?
I often think there's this fear that “I need to fix this, I need to change this, I need to make this right for the child.” Whatever the age you are, what people want to know during a public health crisis is, are you safe? “Am I going to be safe and how long is this going to be? What do we know about the latest on how long we're going to have to be living our lives differently?” You can answer those questions and you can be honest about your own feelings. If you are not, if you're holding it inside, I think people can tell. Folks with ADHD, if you are an ADHD parent, often will have challenges regulating how they come across because it's kind of dual work to interact with an individual and also stay on task. When you treat ADHD, I think it makes it easier, but there's sort of a prep that it takes to sort of be present. In my mind, this again gets back to something I was talking about earlier, which is attending to bodily needs. I have parents who get up early so they can work out in their homes so they can feel comfortable and present and calm during breakfast. I have parents who are sort of leaning on other people they know, like to come up with lesson plans and resources and sort of putting kids in front of computers, but then checking in on some kind of schedule. It is happening all different ways. But unless people sort of figure out “what's going to make this most pleasant for me,” it is going to form anxiety. There will be stress. Change creates stress. That is very different from an anxiety disorder. It is very different from the old fear that ADHD tends to breed of, “Am I going to be able to be on top of things?” Folks with ADHD traits are sometimes a little primed to be in that fight or flight and that stress space. So, coming back to that I think this is really important even as you think about how to interact with the child.
Susan Buningh: So how do I decide what to let go and what to work on when I fear there's so much wrong?
Dr. Craig Surman: I think it's beautiful if people can think about what they can control and what they can't. What is under their control? If you are feeding your mind with distant concerns as the international news does all too efficiently for us, as opposed to living in the actual world you can control much of your day, it's exhausting. You have this long list of things you cannot manage. Take care of yourself first, number one, and other things will follow. Be clear about what is possible within a day. And some things just need to be deferred. Many folks in an anxiety state will be future-oriented and thinking about the future, wondering about things that can happen, distant things. Many people in an anxiety state will be in the past, mulling over something, concerned about something that isn’t present in the here and now. If you can somehow sit with what is under my control and what is not, and make a list, make an intention, bring that to somebody else, it is very powerful.
One of the tools that we recommend in our project, Fast Minds, when you are looking at what helps folks with ADHD is the thought record. This is a typical tool for cognitive behavioral therapy. And a lot of the thinking that we do is not actionable. Thoughts, feelings and behaviors are connected. And you can do a lot about your thoughts and feelings if you control your behavior. One of the behaviors that we can do is we can look at what our thoughts are. So just doing a thought inventory, looking at that, I call it the scene of the crime mentally. What is crossing your mind? If you're thinking about, gosh, there's all this stuff that I've left undone, there's all these concerns I have that I can't control, what other thoughts do you have you can actually do something about? There's sort of a gift in the rest of the world being on a bit of a pause.
Susan Buningh: So, what can I control that will help me to continue to get healthcare? I'm sure this question is on the minds of a lot of the adults with ADHD in our community at this time especially.
Dr. Craig Surman: Fortunately, there is a legal position now to allow providers to do telemedicine and telehealth. And you can ask your current provider if you have one or you can seek another provider online through several services. So, access to care is still quite possible even if people need to take distance from each other physically, which is probably a transitory thing. How long it will last should not be predicted. But there will be a time when people can meet with their providers again soon. The fears about health insurance that come from worry about employment and employment-based insurance are very real. There fortunately are state-based programs which can help transition people and keep them in treatment. They are still very active. So, state health insurance programs should be looked into. They are a safety net that have been there for a long, long time.
People worry about running out of medication. And I hear this. I do not know at this point if there is any reason to be worried about that. But logistically speaking, if people are now far from maybe where they usually could get medication from, mail order is a possibility. And the amount of medication you can get for ADHD depends on the state, but it could be two months, it can be three months of coverage that a provider may be able to provide. So there really is access to all the same kinds of services except in two dimensions, as opposed to three dimensions. And I don't think that it's a burden in terms of logistics, but care is still available.
Susan Buningh: Well, many of the adults in our ADHD community are going to find this so helpful. Dr. Surman has offered to lead a guided meditation, especially for people with ADHD with listening.
Dr. Craig Surman: I am offering a progressive muscle relaxation adapted for folks with busy minds. I say this because many meditations and relaxation techniques require you to focus. It is easier if you include other senses. So today I'm going to offer a very old technique, which involves tensing and relaxing muscle groups, which tells your brain as your muscles relax at the end of each tension that your body is relaxed so it can be too.
At the end of this, I suggest that you do a special thing. It can be a hand gesture, or it can be a pattern of breathing again through the nose, out through the mouth. You can do it anytime, anywhere without anyone knowing. This can serve as a trigger to get back to the relaxation state. So, it will be progressing from head to toe tensing and relaxing muscle groups over a couple of minutes. You can always extend this if you like but listening to a guided meditation helps the wandering mind. Using your body helps a wandering mind. And you might consider sounds. You might consider scents, a scented candle, something else that would help you with a wandering mind.
Please just close your eyes if you are comfortable and sit in a comfortable place or lie down in a comfortable place and start with your forehead by raising your eyebrows. Tense them up. Build the tension for a count of three. One, two, three. Now let your forehead fall. Say, "My forehead is heavy, loose, limp, and relaxed" to yourself or in your mind. Do the same with facial muscles. Squinch up your eyes. Squinch up your nose. Make a grimace. Tense your teeth. Do that again for a count of one, two, three. Let it fall. Again, my face is heavy, loose, limp, and relaxed. Tense up those shoulders. Put them up by your ears. One, two, three. Let them fall. Notice the release in the relaxed state. Heavy, loose, limp, and relaxed. Tense up your stomach muscles by pulling the belly button into the spine. Count of three. One, two, three. Let it go. Be loose, limp, relaxed.
Tense up your hands, your forearms. Make a muscle, your bicep, and set up your shoulders, whole arm systems for a count of one, two, three. Let it fall. Heavy, loose, limp, and relaxed. Do the same with your legs. Tense up your toes. Tense up your feet. Bend your knees a little bit. Tense any muscle you can find in those legs for a count of one, two, three, and let them flop. Heavy, loose, limp, relaxed. Your sitting muscles are powerful, and you tighten them up for a count of one, two, three. Let them go. Heavy, loose, limp, and relaxed. You can now go from head to toe, tensing up your forehead, squinting up your face, facing the shoulders, tensing your belly, raising your arms, tensing, making those biceps, tensing up through your legs, clawing your feet. As you are comfortable you can sit on your buttocks for a count one, two, three, and then we'll go, all go. Heavy, loose, limp, and relaxed.
Now I invite you to do something that you could do anywhere, any time to remind your body, which now feels less tense when you started. Muscles have worked as they do all day. And now they are resting. Breathe in through your nose and out through your mouth. You can make a hand gesture or hold a pose, posing fingers, your hand, something you can do anywhere. I'm going to count to five to hold that behavior. One, two, three, four and five. Get your eyes open. Refreshed. Continue about your day. If you train your body using this technique or a similar one that you adapt twice a day for 10 days or even shorter, you'll find that you can bring back the relaxation response whenever you need it as long as you pause and take the time.
Susan Buningh: So helpful. Thank you.
Dr. Craig Surman: Thank you for the time.
Announcer: You are listening to a special podcast of All Things ADHD in response to the coronavirus pandemic. In this time of crisis, we know everyone in our community is facing tremendous pressures, and CHADD and its National Resource Center on ADHD are here to help. We are committed to continuing to be the resource on which you can rely. For more information, visit our website at CHADD.org and follow us on Facebook, Instagram, Twitter, LinkedIn, and Pinterest.