Andrew Kuhn, PH.D.

Yes, anxiety can and frequently does cause breathlessness. And the breathlessness can increase anxiety, in a vicious circle, sometimes to the point of triggering a panic attack. That's why learning simple techniques of relaxation breathing can be so helpful in managing anxiety. The basics of this kind of breathing have been known for centuries, and are routinely practiced in yoga classes, for example. The essentials involve slowing and deepening your breathing, so that you inhale down into your "belly" rather than panting up in your chest. A good way to practice is to lie down in comfortable clothes, place a palm on your belly button, and breathe in slowly. Try to make the hand on your stomach rise, rather than your chest. Count slowly while you're doing this, to six or eight or whatever feels comfortable. Release your breath evenly and slowly through your nose, and inhale again. Concentrate on the breathing itself rather than other thoughts or feelings that occur to you. When distracting thoughts do come, don't latch onto them or battle with them, but let them pass through your mind, visualizing them as a cloud passing, or a chyron on the bottom of a screen that you don't need to pay close attention to. Do this for ten minutes a couple of times a day when you are NOT feeling especially anxious, if possible. Then, when you notice that you're feeling breathless and anxious in the course of a day, take a short breathing break to re-center and feel calmer. *andrewkuhnphd.com <http://andrewkuhnphd.com>* *Manhattan* (212) 480-2426 *Westchester* 275 East Main Street Mt. Kisco, NY 10549 <https://goo.gl/maps/pgmU6Z77hgL2> (914) 261-2657 <(914)+261-2657>

I am not an MD, a psychiatrist, so I am not the best person to ask about medication combinations. Given your description of your history and symptoms, however, I hope that in addition to medication treatment, you are receiving or plan to receive individual psychotherapy. Cognitive Behavioral Therapy in combination with medical treatment has been shown to be more effective in treating panic than medication alone. In terms of dealing with trauma, there are many methods and practitioners. I would urge you to approach finding a therapist as an active process in which you have agency and choices to make. In an introductory session or sessions, pay particular attention to how curious and attentive the therapist seems to be. Do they ask good follow-up questions, and give you time to elaborate on your answers? Do they seem comfortable with not knowing everything about you right away? Or do they seem anxious to jump to conclusions about who you are, how you got to be like this, and what you need? The person who presents themselves in the most authoritative way is not always the wisest or most effective practitioner. Give yourself time to find someone who is respectful and makes you feel heard.

The time required to treat social anxiety can vary quite a bit. The age of the patient, the pervasiveness and severity of the social anxiety, other symptoms and diagnoses that may also be present, can all have an effect on the course of treatment. The aims of treatment also come into play. Some clients are looking for a transformation of their social experience, and in some respects their character, which can require intensive work. Others are looking for more limited symptomatic amelioration--learning to cope with inevitable and necessary social encounters without undue distress or avoidance. It is reasonable to expect, however, that some significant degree of improvement will be achieved after three to six months of treatment. *andrewkuhnphd.com <http://andrewkuhnphd.com>* *Manhattan* 5 East 94th Street NYC NY 10128 (212) 480-2426 *Westchester* *New address:* 275 East Main Street Mt. Kisco, NY 10549 <https://goo.gl/maps/pgmU6Z77hgL2> (914) 261-2657 <(914)+261-2657>

Psychotherapy makes an important and unique contribution to the treatment of bipolar disorder. Psychotherapy alone, however, is not likely to be as effective in treating bipolar disorder as psychotherapy plus medication. Ideally, a psychotherapist and psychiatrist (a medical doctor who can prescribe appropriate medications) will--with the informed consent of the patient, of course--be in communication to coordinate care. In terms of the specific contribution psychotherapy makes, this may start with psycho-educational support in understanding what bipolar disorder is and what it does, particularly important in the period immediately after a diagnosis has been given. It's a lot to take in, and no patient will be able to grasp or cope with the full implications right away. The diagnosis itself can be a major challenge to a person's self-esteem, mood, and sense of agency. It is not uncommon for newly diagnosed patients to go through a process somewhat akin to grieving, with reactions of denial, anger, bargaining, and sadness, which themselves can complicate a client's buy-in to a plan of treatment. Psychotherapy can also be crucially helpful in identifying ways in which the client is attached to the "highs" associated with the run-up to a manic episode (hypo-mania, meaning not-quite-mania). Helping to develop and strengthen tools for emotional self-regulation is another aim of psychotherapy for bipolar. And recognizing how bipolar symptoms can impact relationships, and vice versa, is also a fruitful area to address. *andrewkuhnphd.com <http://andrewkuhnphd.com>* *Manhattan* 5 East 94th Street NYC NY 10128 (212) 480-2426 *Westchester* *New address:* 275 East Main Street Mt. Kisco, NY 10549 <https://goo.gl/maps/pgmU6Z77hgL2> (914) 261-2657 <(914)+261-2657>

Does psychotherapy have side effects? That's a very interesting question. Typically one thinks of side effects as being relevant to medication, but it's fair to ask it about talk therapy as well. While I am not aware that it is an especially well-researched topic, if we take "side effects" to mean unanticipated and possibly uncomfortable results, there are some observations on the basis of clinical experience that can be made. Psychotherapy involves an unusual experience of talking, thinking and feeling, which can give rise to some anxiety, especially in the early going. Acknowledging that anxiety and working through it can be a useful piece of the therapy. Facing discouraging or disappointing aspects of one's life, which is likely to be a part of the therapeutic experience at some point, can be challenging, and it is possible that a patient will leave a given session feeling worse than they felt beforehand. If the work is going well, these bumps in the road will be more than compensated by increased insight, behavioral flexibility and emotional self-regulation. But progress is seldom entirely steady and smooth. Another sometimes unanticipated effect of therapy is to lead the client to question problematic aspects of their close relationships which they have long overlooked or minimized. Attempts to make changes in relational patterns can be stressful and may in the short term at least lead to increased conflict. Knowing in advance that these issues may arise can be helpful in maintaining one's commitment to treatment. If you experience any of these difficulties in the course of therapy, it doesn't mean the work is going terribly wrong--rather that you are coming to grips with some of the aspects of your life that led you seek help in the first place. *andrewkuhnphd.com <http://andrewkuhnphd.com>* *Manhattan* 5 East 94th Street NYC NY 10128 (212) 480-2426 *Westchester* *New address:* 275 East Main Street Mt. Kisco, NY 10549 <https://goo.gl/maps/pgmU6Z77hgL2> (914) 261-2657 <(914)+261-2657>

Divorce is one of the more stressful developments a person may encounter in the course of a lifetime, and while many people muddle through without support, it can be very helpful to speak to a psychologist during and after divorce. There are two major streams of stress, at least, a divorcing person needs to navigate. One is the onslaught of logisitical challenges: moving, visitation schedules, support, financial changes. Another is the emotional backwash which may include anger, sadness, regret, guilt, confusion. A psychologist can help you regain and maintain equilibrium, redirect impulses that aren't helpful, develop realistic plans, and recover a realistically hopeful outlook.

The best way is to seek a referral and a consultation at a sleep medicine clinic, for example the Cornell Weill center for sleep medicine in New York City. If on the basis of structured interviews you meet criteria, you will be asked to stay overnight in a special room attached to various monitors assessing your heart function, breathing, oxygen saturation, breathing interruptions (apneas) and other important information. This will provide the information necessary to make a definitive diagnosis, which will guide the course of treatment. One example is a CPAP machine, for Continuous Positive Airway Pressure. This directs a stream of air through a mask into your nose and mouth which keeps your airway from closing up during sleep. Such closings can cause multiple interruptions in breathing per minute and severely disrupt sleep.

Depression leads to inactivity, typically. Trying to activate yourself, even when you don't feel like it, can help in fighting back against the depression, and lead to more hopeful feelings. Activities can also distract a depressed person and get them away from moody ruminations that reinforce the depression. Activities do not need to be especially strenuous or time-consuming. Light exercise, especially with a friend or family member, is almost always a good move. When doing it, resist the tendency to reflect on how out of shape you are now compared to how you used to be, etc. That is the depression trying to talk you out of doing something good for yourself. Just concentrate on putting one foot in front of the other, looking around, feeling your breaths.

This is a big question. Many in the addiction treatment field would challenge the terms in which you ask it, focusing on the word "cured". The 12-step Alcoholics Anonymous (AA) approach to treatment stresses letting go of the idea that alcohol addiction, or alcoholism can be cured; even people 20 years sober refer to themselves as "in recovery" or "recovering"--never "recovered". AA is a treatment model that stresses following the steps and seeking support in meetings from other recovering alcoholics over treating the problem with medications. To rephrase your question, alcohol addiction can be successfully treated without medications. That said, certain medications may be helpful in addressing other conditions which may contribute to a tendency to abuse alcohol, for example depression. Before adding an antidepressant, however, sobriety needs to be established, because mixing alcohol abuse and psychotropic medications can be dangerous.

Counseling can indeed be effective in addressing social anxiety. In the early sessions, supportive inquiry helps the client identify and begin to challenge automatic negative cognitive and emotional responses to social situations. This prepares the way for planning a series of intentional exposures to social situations that the person has found difficult and has therefore begun to avoid. Techniques for managing anxiety before, during, and after social encounters are rehearsed. Debriefing in session what went wrong and (especially) what went right in these new attempts provides further opportunities to develop greater reality-based social confidence and to continue to expand one's a social experience and social competence.

There are several medications that can be helpful in treating anxiety, but whether you "need" to take any of these is a judgment call you should make in consultation with a psychiatrist and/or a trained psychotherapist (psychologist or social worker). Medications are not your only option in treating anxiety, and typically would not be your first option. Psychotherapy, in particular Cognitive Behavioral Therapy (CBT), can help you change how you respond to and feel about life situations that are causing disruptive and painful levels of anxiety. For panic disorder, for example, which involves episodes of acute, sometimes paralyzing anxiety that may seem to "come out of the blue", a combination of medication and psychotherapy has been found to be particularly effective.

To deal with alcohol addiction, it may be helpful to see either a psychologist or a psychiatrist, and quite possibly both. You should also consult with an internist, as there are numerous medical implications to alcohol addiction and the process of withdrawal and recovery. In addition, participation in a 12-step program is often recommended. Whatever step you decide to take first is less important than taking the first step in getting help.

Exercise can help with anxiety, and with your mood in general. The way this question is put, it seems that you believe that your tendency to get angry too often is caused by anxiety, which is an interesting idea. Anger can be a response to getting anxious; anxiety is often also a response to anger. I will respond to both parts of the question.

Exercise can help with anxiety, but not all kinds of exercise work well with all kinds of anxiety. For people who have a tendency to panic, aerobic exercise can in the short term make them more anxious. The reason for this seems to be that people with a high level of background anxiety often breathe in a shallow way, which can help to trigger a panic attack. Aerobic exercise can of course make you feel, at least initially, "out of breath", which your body and mind may associate with panic ("I am having trouble catching my breath, I must be having a panic attack"). This association will need to be unlearned, with the help of a therapist, most likely.

Having a good workout may help if you are feeling angry, but the kind of workout and the thoughts you have during the workout matter in this respect. Whacking away at the heavy bag while fantasizing about punching out your boss will not help you solve your anger issue; on the contrary, it may reinforce the repetitive angry thoughts and fantasies. Contrary to popular belief, "blowing off steam" or "blowing your stack" on a regular basis does not tend to make the frequency or intensity of angry feelings and interactions diminish over time. Rather, "venting" in this way may tend to normalize angry reactivity and make it feel more natural, even justified.

The relations between anxiety, anger, and exercise are complex. It is worthwhile to explore them with a trained psychotherapist who can help you make a plan to feel more in control of these feelings and behaviors.

A panic attack by definition has a beginning, middle and end; typically, it runs its course, whether or not the person suffering from it receives any immediate treatment. For people who are suffering a panic attack, it can feel like the most dire emergency imaginable, as if the person is literally about to die; that is why so many panic sufferers end up in the Emergency Room. Typically, though, once a heart attack or asthma attack has been ruled out, not much actual treatment happens there, other than reassurance, until the panic storm has passed, and the person is released, often after only a few hours, with a recommendation to seek therapeutic help.

Repeated panic attacks may amount to a panic disorder, which if it goes untreated can have significant major negative effects on a person's emotional, work, social and family life. The sufferer starts fearing that if they go out, they may suffer another attack; they start restricting their activities, avoiding work, social engagements, even shopping. This is termed "agoraphobia", which is borrowed from the Greek, meaning "fear (phobia) of the market (agora).

Naturally these kinds of restrictions are at the very least inconvenient for family, friends, and employers, and can lead to friction, resentment, conflict. The panic sufferer may feel guilty about their increased dependence and decreased capabilities and contributions to family and workplace, and a growing sense of isolation and discouragement. A persistent and untreated panic disorder thus may lead to depression.

The good news is that panic disorder is highly treatable, usually with a combination of medication and psychotherapy. There is no good reason to tough it out and suffer in silence, or alone, when effective help is available.

Both individual and couple treatment can help make marital relationships better. Doing both kinds of work at the same time can be particularly helpful. Here are a few things to keep in mind about psychotherapy and marriage.

There is a temptation in individual therapy to turn it into a gripe session about one's partner. If "venting" is all that's going on, however, this is unlikely to be helpful, as it may lead to a hardening of negative opinions and attitudes about your spouse. You want a therapist who will be able to hear you, but also empathically help you to reflect on what your own contributions to the conflict might be. It may be that relatively minor adjustments to your habitual ways of responding to your partner may lead to a "virtuous cycle" in which he in turn is more considerate, less annoying, etc.

That's the best-case scenario. Typically more is required, including a willingness on the part of the spouse to acknowledge that something is not going well in the relationship; that it's worth trying to fix it; and that both parties will need to make and effort to change the dynamic. It is certainly worth trying to do this with each other on your own. If this only leads to impasse and the same old conflicts, you should seek an experienced couple's counselor.

For this professional, their client is the couple, rather than either one of you individually. And it is best that if you have an individual therapist, that person should not also be your couple's therapist. It's not a good idea for a therapist to be wearing two hats in that fashion, and is likely to make your spouse feel outnumbered, and at a disadvantage from the start.

A good couple's counselor will probably initially focus on your strengths as a couple, and what drew you together, before addressing areas of conflict. In couple's counseling, you should be able to maintain a difficult conversation with your spouse that normally would get off track or out of control. This can be hard, even very tiring, but if it's working you will each begin to understand the other's perspective better, and to better accommodate each other's needs.

Clinical anxiety can be treated and made much less painful and disruptive. But anxiety itself cannot be gotten rid of entirely, and no one should want to be entirely free of anxiety. We are hard-wired to be able to experience anxiety (or fear) in circumstances when we sense a threat, which may be concrete (that we're about to run out of money if we keep over-spending) or more abstract (that if we successfully cheat on a test, we'll be violating our own sense of what's right). The right amount and the right kind of anxiety can provide useful information that we should not ignore.
That said, an overabundance of anxiety and exaggerated anxiety reactions can lead to misery and dysfunction. How best to treat harmful or painful anxiety depends on how it manifests. Sometimes the anxiety is relatively limited and focused--a fear of spiders, the dark, or being alone. Or the anxiety may be most pronounced in social situations. Anxiety may seem to come out of nowhere, in an attack of panic, which can lead to secondary anxiety, about being away from "safe spaces" in case one has a panic attack (on a bridge, in an elevator, on a subway). Or it may show up as a fear that if things aren't done in a certain way, or a certain order, something bad is going to happen.
Successful treatment of harmful anxiety requires a careful assessment of the circumstances in which it is experienced and the thoughts and beliefs associated with it. In the context of a trusting therapeutic relationship, automatic thoughts that reinforce anxious reactions can be challenged and modified. With the support and careful step-wise progress, formerly feared situations can be experienced in controlled ways so that the anxiety abates over time. Psychiatric medications may also be useful as adjuncts to the treatment. It is important to note that treatment will not be a passive process--it requires hard work on the part of both patient and therapist.
If your feelings of anxiety are interfering with your work, your relationships, or your hopefulness about life in general, it makes a lot of sense to seek professional help. While you can't expect an instant cure, you should experience some relief after a period of several weeks. A note of caution: progress is unlikely to be smooth or continuous. You may experience setbacks. It is important to discuss these with your treatment provider, in order to understand what's going on, and in order to remain hopeful and engaged with the treatment. In time, as you acquire new habits of mind and new abilities to control your emotional reactions, you can arrive at a place where your anxiety is working for you, instead of bossing you around.