High Achievers with High Anxiety
August 22, 2018
BY RAYMOND J. KOTWICKI, MD, MPH, SKYLAND TRAIL CHARLES B. WEST CHIEF MEDICAL OFFICER
Do you know someone who is a successful entrepreneur, coach of the neighborhood soccer team, and PTA treasurer? Does he also drink heavily, struggle to feel loved or appreciated by his family, and find it impossible to enjoy the present moment?
What about the captain of the lacrosse team who is a straight-A student, violinist, and shelter volunteer who also complains of frequent headaches and stomach pain, avoids spending time with peers, and insists she’s not doing enough?
How do you know if a high-achieving person has a “type A” personality or an anxiety disorder?
The difference is really about functionality and a subjective sense of whether or not someone is “happy.” If you draw a graph plotting anxiety against functionality, you see an upside-down U shape. There’s a midpoint, at the top of the U, where having some anxiety that compels action actually maximizes functionality. But at the ends of the graph, no anxiety or too much anxiety reduces functionality.
Someone with no anxiety would have no motivation and could possibly eat junk food on the couch all day without a second thought. Someone with too much anxiety could experience disabling symptoms that interfere with their work, family, and social lives and even their physical health.
Some people who might be labeled as “type A” personalities have enough anxiety to drive them to achieve success without experiencing pain or disability, and they probably do not have a mental illness. Other individuals are successful AND miserable because their perceptions do not align with reality. They are never as successful as they believe they should or could be, the success they achieve doesn’t result in the love or reward they desired, their friends or rivals are always more successful than they are, they are afraid that they really don’t deserve the success and it will all be taken away at some point in the future, etc. These individuals likely have an anxiety disorder and would benefit from psychiatric assessment and mental health treatment.
How do you know when someone needs mental health treatment for anxiety?
Unfortunately, “high-achievers” or “successful” people sometimes find it more difficult to ask for help than others. In their minds, they have successfully achieved other goals with their talents and hard work, and they believe they should similarly be capable of overcoming these feelings. Or they may believe that revealing their vulnerability will cause everything – their success, their reputation, their relationships - to unravel. Furthermore, loved ones and friends may not recognize when someone needs help because, on the outside, everything looks fine.
For example, high school and college students may not exhibit signs of an overt disability, such as a decline in grades or a change in performance with sports, arts, or academic activities. Parents and close friends may notice, in a more subjective sense, that something is “wrong.” The loved one is not happy. You may sometimes detect a feeling of existential angst that goes along with a disparity between real and perceived functioning.
One sign that may be a more visible red flag is a dramatic change in social habits. If someone starts isolating and avoiding social activity or abruptly abandons one social group to join another, that might be a reason to encourage a loved one to be evaluated by a mental health professional.
Physical symptoms could also trigger an evaluation. Anxiety can significantly affect your physiology. Solid research shows that anxiety changes your cortisol levels and activates the parts of your brain that are responsible for autonomic physiological functioning, such as control of heart rate, blood pressure, etc. Many people with anxiety may report or seek treatment for GI problems, chronic headaches or sexual dysfunction before revealing any psychiatric symptoms. These physical symptoms can be the body’s way of externalizing some of the internal pain caused by anxiety.
Finally, consider how the individual uses alcohol. Studies show that high-achieving adolescents in higher socioeconomic populations tend to drink alcohol to mitigate their anxiety as compared to other high school students who more often drink alcohol for social reasons. The young people drinking to address anxiety were more likely to develop alcohol problems as college age students and adults. If a college student tends to rely on alcohol or other substances to mask anxiety and be able to function in social situations, this could be another red flag.
Day Treatment for Anxiety
What are effective treatments for high-achievers with anxiety?
Fortunately, there are highly effective treatments for anxiety disorders.
Psychiatrists generally believe that anxiety is one of the most responsive diagnoses to treatment with medications. The classic approach for people with generalized anxiety is to prescribe SSRIs, the same medications that are helpful for depression. However, the medications have to be dosed differently to effectively treat anxiety.
For people with physical symptoms, a class of medications called beta-blockers can be very helpful because they have no side effects that impact cognition. Beta-blockers may be helpful for people who are performing artists or public speakers because the medication mutes most of the physical symptoms of anxiety - sweating, dry mouth, racing pulse - without impacting performance.
Some classes of medications for anxiety, like benzodiazepines, can be abused. They work well initially but with long-term use (greater than a couple weeks), they tend to cause cognitive slowing, and they are very addictive, especially for people who misuse alcohol. If indicated for a patient with severe symptoms, Skyland Trail psychiatrists limit the time of use of these medications, only until longer-term solutions can be identified and initiated.
Evidence-based psychotherapy is also important. When people with anxiety engage in evidence-based psychotherapy matched to their specific diagnosis, the outcomes are good. Cognitive behavioral therapy, or CBT, often is effective. Through CBT, individuals learn to understand the relationship between their thoughts, behaviors, and mood, and then develop skills to change one of those three elements to affect the other two. For example, they may learn to recognize and reframe an unhealthy automatic thought: “I always fail.” Using CBT skills, they may be able to train their brains to instead think: “I might fail, but I will be OK. But I also often succeed, and could be successful in this situation if I prepare appropriately.” A healthier thought pattern could lead to improved mood and behaviors.
At Skyland Trail, we are increasingly using biofeedback as an adjunctive therapy to CBT to help patients understand the connection between their internal anxious feelings and their bodies’ external reactions, and how they can use one to control the other. For example, a patient can connect to a monitor that measures how much her hands are sweating. While connected, the patient works with a therapist to try to change her thinking and behaviors. If she can effectively modify her thought patterns, she can see immediate results on the monitor of how her body is responding to those changes by sweating less. Biofeedback can provide a sense of empowerment for people, when they see evidence that they have some control over their own thoughts and physical reactions even in stressful situations.
Exposure therapy, though often really difficult for people with anxiety, is often the best approach. Experiencing the thing you fear, in a safe environment while receiving compassionate support from mental health professionals, can be helpful in many ways. The experience can challenge your perception; over time, you may be able to associate different feelings or outcomes with the object, activity or situation you have been avoiding. Living through the experience also gives you evidence, or proof, that even if the experience is painful, you can endure it and survive.
Residential Treatment for Anxiety
What are some unhealthy thought patterns of high achievers with anxiety?
Overall, the Skyland Trail treatment model is built on a “temporal” philosophy which is useful in CBT. By definition, anxiety is about what is going to happen in the future and being afraid of a loss of power, prestige, resources, etc. On the other hand, depression is about what happened in the past. However if you are mindful and focused on the present, you cannot be either anxious or depressed. We incorporate mindfulness training and compassion-based meditation into our treatment program, which is really helpful for people who have anxiety and depression. If you can adopt skills to prevent yourself from constantly forecasting into the future, you can greatly reduce your symptoms of anxiety.
The Skyland Trail treatment model also helps patients shift from an external locus of control to a more internal locus of control. Locus of control means “why you are doing something.” People who are high achievers often have more external loci of control. They may feel driven by a need to please or impress others or may evaluate their self-worth by comparing themselves with others. This mindset is reinforced by their experiences. If you excel in school, win awards, and are celebrated for superlative performance, it’s easier to start looking externally for why you do things.
Through psychotherapy, we try to help clients shift an external locus of control to an internal locus of control. In the field of recovery and mental health, we often call it discovering “your true north.” If you have a reliable internal compass, you always know where to go. That internal locus could be your values, which does not necessarily refer to a moral code; but instead refers to identifying what is meaningful to you rather than what holds some kind of valance to someone else.
This is why psychotherapy is so important. Medications may mitigate the current symptoms of anxiety, but those symptoms will morph from one form to the next unless you can address the root internal cause of the anxiety. Converting from an external to an internal locus of control can do just that.
What are the best protective factors against anxiety?
Having meaningful relationships is one of the best protections against developing anxiety and other mental illnesses. You don’t want to sit around with your friends and talk about your anxiety all the time, but there is real value in being able to externalize some of the stress and pain you feel with people you trust. If you think about it like a balloon, if anxiety is the air inside a balloon, it may be helpful to let some of the air out before the balloon pops. You can do that through having meaningful conversations with people you trust. Such meaningful conversations are best had in person, without distractions of a cell phone, the internet or other technology. Research shows that virtual social connections are very poor substitutions for the “real thing.”
This is sometimes where social determinants of health come into play. Your gender, socioeconomic status, or cultural background may influence your willingness to reveal or discuss vulnerability with others. You may feel that sharing your anxiety or fears with others will be misinterpreted as weakness, which may feel like more of a risk for some groups of people than others. This also may influence the likelihood you would ask for help from friends, family or professionals.
Parents employ many strategies to help protect their children from danger, disappointment, or discomfort. For example, it’s generally good to teach children how to socially monitor what’s going on in their communities. They should be able to pick up on social cues for when someone is mad or is trying to be manipulative. That ability is really protective. But if all you do is socially monitor because you’ve experienced trauma or because you’ve been bullied or ostracized, intense social monitoring can become a recipe for anxiety because you’re paying too much attention to what’s going on with other people and less attention to what you’re experiencing yourself. That can be especially important for young people who are constantly concerned about their safety or young people who have been conditioned to be overly concerned about their social status. Social media also can drive an overuse of social monitoring and reinforce an unhealthy focus on the external rather than the internal.
Parents can also provide protection from anxiety by helping young people choose activities based on their own interests and values, instead of solely on what looks best on a college application or resume. If a student is overscheduled and overextended because his goal is to have a perfect college application to get into an Ivy League school because that’s what his family expects, that’s very unhealthy. If, on the other hand, the student is passionate about social justice and he has a really busy schedule full of activities that revolve around that goal, that can be very healthy.
One of the best ways parents can help young people avoid developing anxiety problems is to help them develop resiliency instead. Instead of always protecting children from bad situations, find opportunities to encourage young people to be OK in uncomfortable or stressful situations, which we know are inevitable. When young people are allowed to fail early and often when the stakes are low, they are given valuable opportunities to build resiliency, which is incredibly protective. Starting when kids are young, enroll children in activities that they are not already skilled in so that they can experiment with new things and realize that an activity may be valuable or meaningful to them even if they do not win medals or rank at the top. Show them that they can still be valued and celebrated by friends and family for just participating and putting in the effort.
What should you do if you suspect someone is suffering from anxiety?
A psychiatric assessment from a mental health professional is the best next step for someone experiencing symptoms of anxiety. An initial physical examination to rule out potential physical causes of anxiety likely is one of the first steps, followed by a thorough and structured assessment by a psychiatrist. Family involvement can be very helpful in the assessment process as well as in treatment. Select a mental health provider with specialized experience in treating anxiety, who adheres to evidence-based treatment approaches, and who can develop a treatment plan using both medications and psychotherapy to help effectively address the specific diagnoses and goals of the patient.
To learn more about residential and day treatment programs for anxiety at Skyland Trail, please contact our admissions team at 866-504-4966.