Episode Transcript

Faith: Welcome to Health Matters, your weekly dose of the latest in health and wellness from NewYork-Presbyterian. I’m Faith Salie.

Today we’re going to unpack a topic that many of us can relate to: anxiety.

Anxiety can manifest in lots of different ways. For some, fleeting worries only mildly disrupt their day. For others, the anxiety can be visible and debilitating.

This week, I talked with Dr. Adrian Jacques Ambrose, a psychiatrist at NewYork-Presbyterian/Columbia, about a specific kind of anxiety: high-functioning anxiety.

It’s the anxiety that high-achieving, successful individuals may struggle with. They keep it together on the outside, but may be filled with self-doubt and racing thoughts on the inside.

Faith: Hey, Dr. Ambrose. Thanks for joining us.

Dr. Ambrose: Aloha, everyone.

Faith: Aloha! I don’t get to say that often. I like it. That’s right, you’re from Hawaii.

Dr. Ambrose: Yes

Faith: So I am excited to talk to you today. I’ve been thinking about this adjective “high” — as in high performance, high quality, high functioning. And so when you pair it with the word anxiety, it can almost seem like a badge of honor, right?

Sure, I’m anxious. I live in the modern world, but I’m high functioning. And I suspect today you’re going talk to us about how kind of debilitating and harmful, high-functioning anxiety can be.

Dr. Ambrose: It speaks to what kind of culture we’re currently living in, how much pressure people are in, in their day-to-day activities in their jobs. And when you don’t perform up to that standard, there’s a lot of just bad feelings that come out of the gap between where you are and where you think you ought to be.

Faith: Yes. And in our high=functioning culture, it also normalizes this thing. I think of a New Yorker cartoon, right? Or somebody on a first date saying like, “How high functioning is your anxiety?”

Dr. Ambrose: I have the highest functioning anxiety!

Faith: Exactly! So before we talk about how we can diminish anxiety, let’s define what high-functioning anxiety is.

Dr. Ambrose: I think of high-functioning anxiety as a condition where you’re experiencing all these symptoms of anxiety where you’re feeling fear, nervousness, worries, while at the same time you are doing all the things that you need to do in order to get through the day. You are meeting all of the demands of your job. You are going through life, but underneath there’s all this turmoil and worries that seems to permeate more and more into your everyday activity.

Faith: I read a statistic that says something like 40 million Americans suffer from anxiety, and about 18% of those are thought to be suffering from high-functioning anxiety, right? But most likely, most often undiagnosed.

So these can be people — and we all know them and may even be one — who everybody’s like, “Oh, you’re crushing it. You’re a superhero! I don’t know how you do it!”

Dr. Ambrose: Absolutely. One of the things that I hear most commonly from really high achieving, high-performing individuals is they feel like they are the only one who is struggling so much despite, like you mentioned, everyone else is looking at them and saying that, “Oh my gosh, you, you are just a rockstar.” And on the inside, they’re carrying all the weight of maintaining that performance and maintaining the appearance and making it look so flawless.

Faith: Dr. Ambrose, I know you work with children as well as adults. What do you think these highly successful adults could learn from children when it comes to feelings and emotions?

Dr. Ambrose: One of the things that I really admire about children is just the sheer honesty. If they’re angry, they hit their fist against the wall, and then they say, “Ouch! that hurts!”

And I think one of the things that has been really challenging in working with this really high-achieving population, is it’s hard for them to say, “Ouch, it hurts” to other people. It takes a very concerted effort and a safe space for them to even acknowledge it to themselves that, “Wow, all these endless hours that I’m devoting and investing in this work, it’s hurting me. There’s a toll that I’m paying in order to maintain that level of perfectionism.”

And I think that’s really hard for a lot of people to recognize is when they cross over to the unhealthy and unhelpful space.

Faith: What is the long-term impact of leaving high-functioning anxiety untreated?

Dr. Ambrose: One of the concerns that I hear a lot from patients is when they’re addressing this, they worry that the message we’re saying overall is: “Don’t perform highly, don’t reach for the stars.”

I want to clarify that that’s not the message.

It’s more of recognizing what is it that you’re putting in and what is it that you’re getting out? And just making sure that it’s sustainable. We’re not making any value judgment. We’re not telling people not to shoot for the stars. It’s more along the line that when you’re shooting for the stars, just making sure that you have enough fuel so that you can get there. We want you to get there. We want to help you get there.

I think just reflecting back and giving yourself some space to ask like, “Is the journey really worth it?” Like is that worth all of the suffering and all of the fuel, all of the investment?

And second, if it is, if realistically I don’t have an option to take a step back from my job in order to take care of my life, then even in that acknowledgement, it gives that person a little bit more agency.

And I think that’s ultimately the goal, is just to improve that insight. This really sucks. I’m suffering. I’m hurting. But I choose to do that.

Faith: I use that every day and I can’t not show up a hundred percent. And every time I get stressed about it, which is reliable — I will get stressed — I think, “I get to do this, I get to do this.”

Dr. Ambrose: Absolutely. And I think there are hidden components in which I would love for us to talk a little bit more about, because I think often time what I hear a lot is, women and ethno-racial minorities tend to stress that “You don’t understand. This is like my one shot. This is my one chance to prove that I can do this, to demonstrate to people that I can step up and step in.”

And I think just, just reflecting back that some of these conversations are beyond the individuals. This is where our society is and this is where our culture is. But just acknowledging for both ethno-racial and sexual minorities that you have an additional burden because society is looking at you and waiting for you to fail. And that’s real.

Sometimes there’s something really, really validating in hearing someone say that everything that you’re experiencing is valid and real and at the same time, I hope that this is not permanent because for a lot of the symptoms, if you don’t address it and it keeps progressing in terms of the stresses, it becomes at a point where you are no longer able to even shoot for the star.

And I think that’s what we want to avoid is that rock and a hard place where you can find at least some kind of sustainability so that you can continue doing the really important work and really meaningful work for yourself, for your loved ones, and for everyone else.

Faith: It sounds like part of it is reframing this notion of relentless busyness to purpose.

Dr. Ambrose: Hmm. Yeah. There’s not, unfortunately, a simple solution. For a lot of people they — and I want put a really big quote on this — is they weaponize their anxiety, they use that as a tool. They use that as fuel. Because you are much more motivated when you have that burning anxiety to say, “Oh, you should really, really make sure this presentation is up to snuff. You should really make sure that this product is, like, a thousand percent better.”

And I want to be mindful that at a certain point for a subset of people, that anxiety is really intense. And to mitigate it and to address it, unfortunately some people look for ways to shortcut that anxiety by using substances.

They try to find a way to deal with the anxiety short term, and that might look like drinking. That might look like a lot of smoking. It might look like vaping. It may look like —

Faith: Prescription drugs, maybe?

Dr. Ambrose: Starting to use — prescription drugs are very, very common.

I think it is challenging because I think that’s that really pernicious and really difficult line to demarcate for people is when have I crossed the line?

That’s the part that I hope that we can increase folks’ awareness that it’s actually, it’s not normal if you feel like you need to pound shots after shots in order to get your anxiety low enough to get to work the next day.

Faith: Right or to turn your mind off at night so that you can release the day that keeps hounding you. So if someone comes to you to seek help for high-functioning anxiety, what do you prescribe? What happens?

Dr. Ambrose: Yeah, I think that is a really astute question because I think as a psychiatrist, the misperception is that people assume that I’m going to throw some pills at people. And I want to clarify that a lot of times it’s just having that conversation and trying to better understand the person. So the first step is often just trying to better understand and create insight for the individual that one, do you realize that you’re, you’re paying a toll for your performance?

Faith: Because these people are often getting accolades.

Dr. Ambrose: Exactly. Which then reinforced that notion that they need to perform at this level. And unfortunately for some people there’s conflating their accolades with their worth.
So the really difficult and nuanced piece oftentimes for people is, like, what are elements that you can integrate into your identity so that work is not your sole identity? When your whole identity is your work, it becomes really destructive.

The next thing is just trying to expand your identity. Create a little bit more of a multifaceted aspect to your own identity, so that way you don’t feel like everything I have, all I am and all I ever will be is my job.

Faith: Diversify your portfolio…

Dr. Ambrose: Yes. Invest in yourself and then diversify yourself.

Faith: How do people figure this out? How do they self-diagnose if they don’t have a psychiatrist?

Dr. Ambrose: I think first of all, I’ll step slightly off on my platform to share that I hope that we can destigmatize mental health to a point where we can even proactively look for mental health care.

Faith: Which we do with our physical health. Right.

Dr. Ambrose: Exactly. So I hope that we can get to a place where everyone feels comfortable enough to just have enough empathy for themselves, to feel like, “I deserve to have my mental health taken care of in the same way that I would take care of any other aspect of my medical health.”

You know what, “I’m just going to make an appointment with a psychiatrist. It doesn’t seem like it’s too severe yet, but I would just — I just want to check in.”

Faith: Right.

Dr. Ambrose: I hope that we can eventually move to that space because what I hear a lot, a lot from this population is that they feel like they don’t deserve the mental health care that they’re getting because they feel like that’s just part of life. That’s just me. Like this is my fault. I’m doing something wrong.

And I often have to really, really very gently redirect them and say it like, you would never say that to any of your loved ones if you see your loved ones, struggling, you would absolutely want them to get the necessary treatment to get better.

And at the same time, I want to validate that for a lot of this population, it’s hard to think of themselves in the same lens, to give themselves the same kind of empathy.

Faith: Dr. Ambrose, thank you so much. I’m really grateful that we get to talk with you.

Dr. Ambrose: I hope our paths cross again.

Faith: Our many thanks to Dr. Ambrose.

I’m Faith Salie.

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