Ep. 16: PRACTICAL STRATEGIES FOR MANAGING ANXIETY AND DEPRESSION w/ Dr. Rami Nader

Andrew Marcus:

Hey, this is Andrew Marcus. Thank you for joining us. Welcome to THE INDOUBT SHOW. We have a great show for us today. We have Dr. Rami Nader. He is all the way in North Vancouver. He is a psychologist, registered psychologist, cognitive behavioral therapy. Now, I can say for myself personally, I’ve done some cognitive behavioral therapy and it’s been such a gift to me and help me. And so we’re going to talk about a lot of things. It’s going to get pretty deep, pretty heavy. We’re talking about depression, anxiety, panic attacks. Many people are facing these things and more, and so we thought it’s important for us to just dive in. So we hope this encourages you, it blesses you, gives you good information that will be good for your soul. So God bless you. Enjoy the show.

All right. Well, we have Dr. Rami Nader with us all the way in North Vancouver. How are you doing today, man?

Dr. Rami Nader:

I’m great, thank you.

Andrew Marcus:

I am so blessed to have you. I’ve watched many of your YouTube. You have a bunch of YouTube videos, kind of short videos just talking about informational. Obviously, it’s not a substitute to seeing a professional, but it just kind of informational. And that has helped me immensely when I was going through clinical burnout last year. I was having anxiety, panic attacks, depression, all these things that I’ve never had before. And talking to a friend of mine who knows you, and he just recommended, so he sent me a video links and I got to just watch these video links about what is anxiety and how does it happen, what is panic attack and what are they and how do they happen. And so it was so resourceful to me because I think a big part of going through these journeys is just understanding. I finally understood the saying knowledge is power. When you just understand the root of what’s going on, it just gave me a whole perspective and almost the sense of “I can overcome this now that I can identify what it is.”

And so of course, I did a bunch of counseling as well with a cognitive behavioral therapist, but at least I could bring him… At first, I’d come to him and say, “I don’t know what’s going on. I don’t understand. This is crazy.” And then I watched all your videos and I said, “Hey, I know what’s going on. This. That.” And then he’s like, “Wow, how did you…” I’m like, “I know a guy.” Well, I didn’t know you. Now, I know a guy, because I get to see you. So I just wanted to personally thank you for all that you do. You’re such a blessing. But tell us a little bit about your life and your journey, your story of, and what you’re doing today.

Dr. Rami Nader:

Yeah, so I’ve been in psychology and been working as a psychologist since I think it was 2005 I’ve been working as a psychologist. I did all my graduate training and undergraduate training all at UBC. So 13 years and four degrees later, I came out of graduate school and I was like, “Okay, well what am I going to do?” And so I went straight into private practice and been in private practice ever since. Over the years, my practice has evolved a bit, so I’m doing more sort of assessments for medical legal purposes now. But the YouTube channel, that was something I started during the pandemic. And that’s really grown. I’m actually very, very proud of that because it is, it’s reaching out to hundreds of thousands of people around the world and millions of views on these videos.

With the type of therapy I do, cognitive behavioral therapy, the key is to understand and developing a new understanding of the difficulties. Because for a lot of people with anxiety and depression, they don’t really get it. They don’t really understand what’s going on. And so if you can give them a model to understand and then give them tools based on that model that they can do and they can use to make changes, that’s so powerful. And so I’ve just found that with the YouTube, I can get that knowledge out there and then people can start incorporating that knowledge to the best of their abilities. And so that’s been a real blessing and I’ve really enjoyed doing that. And that’s just something I continue to do now.

Andrew Marcus:

That’s amazing, man. I know they’ve been so resourceful to me as I mentioned. Did you notice a big… Obviously the pandemic has done a lot to us emotionally and mentally. Have you seen a spike in your line of work after the last couple years?

Dr. Rami Nader:

Oh yeah. Yeah, all of the psychologists I know are completely full. It was kind of predictable with what happened during the pandemic, with the shutdowns. We know that human beings do not do well in social isolation. We have a need for connection with others. At least the vast majority of people have a need for connection with others. And so the health needs were as they were and that happened, but you just knew there was going to be a tsunami of mental health difficulties that stem from it. Not only just the stress of the pandemic, but then the stress and the consequences of what we had to do to protect society during that time. And so it’s still going on now and there’s a lot of people who are struggling post pandemic.

Andrew Marcus:

Yep. Yeah, I see it a lot. I was actually talking to a friend this morning on the drive in to the studio and he’s on the other side of the country. I was kind of just sharing my story. I haven’t talked to him in a long time, and he said, “Man, I can’t count how many pastors I’ve been on the phone with where they’ll preach on a Sunday morning and they’re in the fetal position weeping right after their message. They’re just pastors dropping like flies.” And it’s just a real thing. And it’s not just pastors, it’s just people are really struggling.

I think what you said is huge, giving them resources and a knowledge of why this is happening, what happens in the brain, in the body. Maybe we can even walk through some of those models to even help some of our listeners, give them a little bit of a window of some of your YouTube videos. But yeah, I’d love to walk through a few of them. For example, I want to walk through anxiety and panic attacks, for example. That’s stuff that I never felt before, and then all of a sudden it was becoming an everyday thing for me. I think it was in one of your videos, I think it was Panic Attacks where you gave the analogy of going through a trail and you see a “beware of bear” sign, you hear crackling in the woods. Just maybe walk through some of the information of why panic attack, what they are and how they happen and why they happen.

Dr. Rami Nader:

Yeah. So we’ll start with anxiety, so anxiety and then sort of panic attacks. So a lot of people think anxiety is a bad thing and that we should never feel anxious. But anxiety is actually really important. It’s actually really adaptive for people to experience anxiety, because anxiety is kind of like the smoke detector in your home. It’s there to alert you when there’s danger and threat. And so if I’m walking down a path and a bear jumps out at me, my body’s going to kick into this anxiety response to either fight the bear or to run away from it. And so there’s all sorts of physiological reactions and responses that happen when I’m encountering actual physical threat and danger.

So the obvious things, like my heart’s going to start racing. So why does my heart race? Well, my heart races in order to pump the blood more quickly through my body. My breathing is going to increase. Why is my breathing increasing? My breathing is going to increase so I can get more oxygen into the blood that’s going to the muscles that’s going to be burning that oxygen for energy. It’s going to create carbon dioxide and I need to breathe that carbon dioxide out. I’m going to experience muscle tension. Why am I experiencing muscle tension? Because I’m preparing. My muscles are preparing to either fight the bear or to run away from it.

I’m going to experience other things. Sometimes people experience like blurred vision or almost feelings of unreality. Well, the blurred vision results from the pupils dilating. The pupils are dilating to let in more light, to let in more visual information that you can use to help get you out of a dangerous situation. But that opening up of the pupils lets more light in and it can create this sort of dreamlike or almost sort of hazy vision. But that’s also that sort of that sense of dreaminess or unreality, that’s also an effect of the hyperventilation because you’re actually getting more oxygen into your body than you’re used to.

So you have all of these physical reactions and responses, and all of them make perfect sense if you’re face-to-face with a bear. You either have to fight the bear or you have to run away from it. But when in panic disorder and panic attacks, what ends up happening is it’s almost like that smoke detector has become way too sensitive, and that smoke detector is going off every time you make toast. So a person’s alarm reaction or anxiety system just becomes way too sensitive. And so in response to even minor sort of stressors, a person experiences this big physiological response. And what can sometimes happen is that people will have some of these physical sensations and they’ll then interpret those sensations in a catastrophic way.

So I’ll notice my heart’s beating quickly, and then I say to myself, “Uh-oh, what’s going on here? Uh-oh, am I having a heart attack? Am I having a stroke? Am I having a panic attack?” Because sometimes people will… If they’ve had a panic attack, they worry about having future panic attacks. And so I have these “uh-oh” thoughts, these thoughts that something bad is going to happen. Well, what does that do to my anxiety? Well, that just makes me even more anxious. So I’m either going to hurry up to get out of the situation that I’m in or I’m going to tense up to prepare myself for whatever it is that’s coming. And so what happens as I’m hurrying up or tensing up, that just increases the physical sensations. And so now my heart’s beating even faster. “Uh-oh, it really is a heart attack. This really is terrible.” I’m tensing up even more. And then you enter what I call the fear of fear cycle.

So panic attacks are caused by a catastrophic misinterpretation of normal body sensations. And so if you’ve had panic attacks, what ends up happening is there’s sort of two things that tend to maintain the panic attacks. One is anxious apprehension. It’s sort of this worry of when the next panic attack is going to happen. And so you’re constantly experiencing this sense of anxiety and tension because you’re worrying about when the next one’s going to happen. And if you’re experiencing more anxiety and tension just in general, you’re going to have more of those physical sensations, which you’re then going to notice and you’re going to enter that fear of fear cycle.

The second thing that tends to happen with panic attacks and panic disorder is that people get really, really good at scanning their bodies.

Andrew Marcus:

I’m getting a free counseling session right now. This is amazing because I’m like, “Man, it’s like you’re reading my journal.” Continue.

Dr. Rami Nader:

You know what? This is really common. This is what happens. So people get really, really good at scanning their body. And that’s sort of the example I gave. If I’m about to go out for a walk and on the radio I hear that there’s a bear in the neighborhood and they’re warning people to be very cautious because that bear has attacked a number of people, so as I’m walking through the forest on my walk, I’m going to be scanning the forest for any sign of that bear. So I’m going to be much more likely to hear that little rustling of leaves in the distance and I’m probably going to interpret that it’s the bear when in fact it’s probably just squirrels, right?

And so people with panic disorder get really, really good at scanning their body. And so they’re much more likely to notice that they’re sweating a little bit, or that their respiration rate is a bit faster, or their heart’s beating a little bit more quickly. And because you’re in this state… So the two things combined, “I’m really good at scanning my body. I’m physiologically more tense and anxious because I’m worried about having the next panic attack.” You put those two things together, I’m much more likely to enter that fear of fear cycle. I’m much more likely to have panic attacks. And it’s all based on my misinterpretation of what these physical sensations actually mean.

Andrew Marcus:

Yeah. And this has been exactly word for word my situation last year where I began scanning very easily. You have spicy tuna roll, and all of a sudden I’m sweating. And then it was like this, I’ve had spicy tuna roll a million times. But the sensation of the sweating, now all of a sudden I’m panicked and then I spiral very quickly. Or I’m driving and I get lightheaded. Something happens with lightheadedness, and all of a sudden I’m like, “Oh, no, what was that?” Then my heart starts racing, “Oh no.” And then it happens so fast. But for me, it was always triggered with lightheadedness or if I’m nauseous, my stomach. It was always a physical sensation and, “Uh-oh, what’s going on?” And then the quick spiral down to a panic attack, which I’ve never had before.

Dr. Rami Nader:

Yeah. And the trap that will happen for people is that they’ll try to have to figure out why they’re feeling this way, right? So you mentioned the spicy tuna roll. Our bodies are constantly in a state of homeostasis. They’re constantly adjusting based on environmental factors. So if I walk in from outside where it’s really hot into an air-conditioned room, there’s going to be changes in respiration rate, there’s going to be changes in heart rate and blood pressure and all of those things. I can’t possibly be consciously aware of every single factor that might be changing my physiological state. And so if you have to be able to explain every single physical sensation you’re noticing, you’re not going to be able to do it because you can’t possibly be aware of all of the variables that are happening that may be contributing to those physical reactions. So the key point isn’t that you have to know why you’re having the physical sensations. The key point is the physical sensations aren’t dangerous. They’re normal. They’re adaptive. It’s just that your smoke detector’s too sensitive.

Andrew Marcus:

Yeah, that’s huge. I think a big one for me was a feeling of trapped, like if you’re trapped. I think it was like say I’m stuck in traffic and my thought was like, “Oh no. What if I had a panic attack when I’m in traffic and there’s no escape?”

Dr. Rami Nader:

Yeah, that’s really common. So being stuck in traffic, stuck in line at a supermarket, going to a restaurant and you’re stuck waiting for the bill, being in sort of crowded spaces, public transit, any place where you can’t escape easily if you were to start experiencing a panic attack.

Andrew Marcus:

Yeah, it’s so helpful. It’s so helpful to have the knowledge of what’s going on. Just a sensitive smoke detector. Yeah, that’s all that it is. Okay, so can we switch gears and talk a little bit about depression?

Dr. Rami Nader:

Yeah.

Andrew Marcus:

I feel like when I was having my seven, eight, or nine months, however long it was when I was having anxiety and panic attacks and I was going through a lot, there were moments of deep depression, and I used those terms. I’m careful because sometimes people just throw out, “Oh yeah, I’m depressed.” It’s like, “Well, are you actually?” It’s like, how would we define depression? Because I feel like a lot of times we just kind of throw that word out, and I’m guilty of this as well.

Dr. Rami Nader:

Yeah, it happens a lot with psychological terms, right? Somebody’s tends to be overly clean or overly organized, “Oh, you’re being so OCD.”

Andrew Marcus:

Yeah, yeah.

Dr. Rami Nader:

Or, “Oh, the Canucks lost in the playoffs. I’m so depressed.” It’s like-

Andrew Marcus:

Get over. They will lose all the time. So just get over it. What are the statistics? 100%.

Dr. Rami Nader:

Exactly. It’s just acceptance there. It’s just acceptance.

Andrew Marcus:

Exactly. That’s a different problem.

Dr. Rami Nader:

There’s a difference between depression and sadness, right? Sadness is a normal emotional state to loss and grief and things not going the way you wanted them to go. But depression is sort of a constellation of symptoms. So there is the sadness component, but there’s also a loss of interest and pleasure in activities that a person enjoy doing. So it’s like they have no motivation or drive to do hobbies, recreational activities, socializing. And even when they do those activities, it’s almost like there’s something missing. It’s like they’re just going through the motions and they feel kind of an emptiness or a nothingness while they’re doing it. It can affect appetite. So people tend not to eat very much, don’t tend not to have much of an appetite. They’ll go all day and they haven’t eaten anything, but they don’t feel hungry. It affects sleep. So either they’re sleeping too much or sleeping too little, not able to fall asleep, or they wake up in the middle of the night and can’t get back to sleep.

It affects energy level. So, “I get really easily fatigued with activities. I just don’t have an very much energy. It feels like I’m walking through water all the time.” It can affect feelings about yourself, feelings of worthlessness, hopelessness, excessive, inappropriate guilt. It can affect cognitive functioning. This is one that people don’t really understand or think about because that can affect your ability to concentrate. It can affect your ability to remember things. It can affect your ability to make decisions and just process information. You might find that your thinking is just slower, or it’s like you’re in a brain fog.

Another symptom of depression and tends to happen with more severe forms of depression but not necessarily is to get thoughts about self-harm, thoughts about death, thoughts about suicide, and just, “It’d be better if I wasn’t here.” So it doesn’t necessarily have to be active suicidal thoughts, but more passive thoughts of just, “I wish I was dead.” So with depression, you don’t have to have all of those symptoms, but you have to have some of those symptoms. And that’s much different than just, “The Canucks lost, and I feel sad.”

Andrew Marcus:

Mm-hmm. Yeah. Yeah. Huge difference. And would you say… I mean, for me, I feel like I’ve felt many of those symptoms when I was in that state of burnout. I just didn’t want to do anything, didn’t want to leave the house, constantly weeping, not eating at all. I lost 50 pounds in 10 months or something crazy. And it was many of those things. And I just knew, “Okay, I’m not well. This is not like me.” And then I was able to, with CBT, cognitive behavioral therapy, all that kind of stuff, able to get out of it. I think it’s important for our listeners to know not to face these battles alone. Talking through it with a counselor changed my life dramatically.

Dr. Rami Nader:

Yeah, I think one of the things with depression in particular, it’s pretty nasty condition in that the things that you’re tempted to do and the things that the depression pushes you to do while you’re in that depressed state are the things that are going to perpetuate the depression. So people often think about depression as, “Oh, well, the person’s given up. They’re not really trying.” When in reality what’s happening is the person with depression is trying too hard. They’re trying to push themselves too hard to live up to goals and expectations that they have of themselves before they were depressed. So if my energy drops because I’m having stressors in a relationship, or I’ve had lost my job, or I’m having difficulties at work and my energy and motivations drop down because of that, but I still expect myself to function at the same level, I’m not going to be able to achieve that level. I’m not going to be able to succeed at those expectations.”

When you fail to achieve an expectation or a goal of yourself, that’s going to sap energy and motivation. And so the trap depression will set for you is that, “You just need to try harder. Pick yourself up by the bootstraps. Come on. Just do it.” And so you try really hard now, but your energy and motivation isn’t at a level that you can achieve those goals and expectations. You can try as hard as you want, you’re still not going to be able to achieve it. So now I’m trying really hard and I’m still failing. And so my energy and motivation just drops even more until I get to a point where I have no motivation, no energy, and I feel like a complete failure. And it’s all because depression is telling you, “You should be trying harder. You should be trying to do more things. You should be trying to get out of this faster. What’s wrong with you?” Then the person falls into the trap and listens to that depression gremlin.

Andrew Marcus:

Totally. And even the other side effects of what could happen with depression, not sleeping or not eating properly, okay, well that happened to me. And of course, if I’m not sleeping cognitively, I’m going to be foggy and I can’t make any decision. I can’t put cutlery down on the table because I just don’t even know how, I just have no capacity to do anything. It’s a very deflating, demotivating. It’s hard. It’s like, “What’s wrong with me?” Just put the cutlery down on the table and I don’t know how to do that. My brain was just toast.

Dr. Rami Nader:

Yeah. Yeah. And depression, you can think of it as just a bunch of negative feedback loop where the symptoms of the depression actually feed in and make the depression worse. And that’s very different than when we think of other sort of health conditions. Like if I have the flu, the underlying cause of the flu is of viral infection. The symptoms of the flu, fever, achiness, runny nose, sneezing, coughing, that sort of thing, those are all my body’s reaction to getting rid of the flu. It’s not actually causing the flu virus to replicate more. Whereas in depression, the symptoms of the depression, the lack of sleep, just feed into the depression and make you feel even worse, even less energy. You have less energy, you’re not doing things that may motivate you, they may feel good about achieving, and that just makes you feel even more depressive. And so it’s this series of negative feedback loops where the symptoms of the depression make the underlying depression all that worse.

Andrew Marcus:

Okay. So I wonder, is there an aspect where, and this is probably hard to navigate, where there’s a spiritual aspect to some of these things? Because I felt like when I was in deep depression, it was very dark and there was a sense of just a presence of darkness. That might not be all the time. I’m not sure. That might be a hard conversation to even navigate, but tell us your thoughts maybe on some of that. Because I know sometimes it’s just an actual physical thing, like chemically, I guess. But is there a spiritual side to it?

Dr. Rami Nader:

Well, I mean hard to answer that question, but I think it can relate to that sense of disconnect that I was talking about earlier, that sense of that loss of interest and pleasure in things that you used to get interest and pleasure from, right? And so if you have a really strong, or you feel like you have a really strong connection to God and you have a very deep spiritual relationship with him, a deep spiritual life, in depression what can happen is just like that. It sucks the interest and motivation and energy out of everything. It can suck the interest and motivation and sense of connection out of your spiritual life as well.

And so maybe you just don’t feel like you have the energy to do some devotionals or to read your Bible or you don’t even really want to go to church, or you’re there but you’re just kind of going through the motions of being there. And then you beat yourself up over the fact that, “Yeah, I just went to the church service and I got nothing. I didn’t really engage in it at all. Am I just going through the motions?” And you just feel like a pew warmer and then you’re beating yourself up because “I thought my spiritual life was deeper than this” and you get into those negative spirals with depression. So I think in terms of how depression can affect your spiritual life, I think that’s probably one of the ways that it does that.

Andrew Marcus:

Totally. I see that. And I feel like I’ve had the opportunity to experience all that. And I’m grateful to God that when I was in the lowest of low with anxiety, depression, and panic attacks, all that kind of stuff, I’m grateful that I did lose interest in all hobbies except I just stuck close to God. I think that really helped me. And so for people who are listening or watching, just clinging close, abiding in Him, staying in Him, that was a huge gift to me. And I know a lot of people who gave that up too. They just lost interest in everything. And so I know I’m grateful for just His mercy and grace on me.

So now that we’re understanding, “Okay, anxiety’s not a bad thing and all the sadness is not bad and all these things are not bad, it’s just how sensitive the smoke detector is,” that kind of gets things all mixed up, what are some encouraging words? Because I know there’s a lot of people who are watching and a lot of young people who are watching who are going through anxiety and panic attacks and depression and all sorts of things. What are some words of encouragement to our young listeners who are in the midst of some of these things?

Dr. Rami Nader:

Well, I mean, all of these things are treatable, right? All of these conditions. Anxiety and depression are actually very treatable. In terms of cognitive behavioral therapy, it has very high success rates. The thing is that we don’t have direct control over how we feel, right? If we did, we would just choose to feel happy all the time. So if I could just choose to not feel anxious, I would choose to not feel anxious. So we don’t have control over how we feel, but we do to some extent have control over what we do. And we do, to some extent, have control over how we think.

And so the idea is that, “Yeah, I have control over what I do. So if I’m feeling really depressed and I don’t want to socialize with my friends,” that’s probably the depression that’s talking to you. And when you’re in depression and when you’re in anxiety, I always like to use the metaphor of it’s kind of like you got a depression gremlin on your shoulder, you got an anxiety gremlin on your shoulder and they’ll tell you the things that you ought to be doing to actually feel more depressed or more anxious.

So the idea is to take whatever that voice is telling you to do and generally just to do the opposite. So if the depression voice is telling you, “Don’t bother returning that text message. Your friend doesn’t like you,” you return the text message. “What’s the point of going out? You’re not going to enjoy yourself.” Go out. You might enjoy yourself, you might not. It’s better though to go out and not enjoy yourself than to stay at home and to think that, “Look at me. I’m not even going out anymore.” So just try and do little things to get back to what you used to enjoy doing even if you don’t enjoy it. Just essentially forget about the enjoyment aspect of it and just go through the motions of doing it. Eventually, the enjoyment will return.

Andrew Marcus:

Amazing. Well, I really, really appreciate your time, man. Thank you for your time. And all the best to you and all that you’re doing for the people that you’re working with.

Dr. Rami Nader:

Yeah, that’s awesome. Thank you, Andrew. That was really fun. Thank you for talking to me.

Andrew Marcus:

Hey, thanks so much for joining us today. For more great content, check out THE INDOUBT SHOW on YouTube, Spotify, Apple Music or wherever you stream your podcast. We hope you enjoyed it today. Feel free to check out indoubt.ca. We have some great resources available to you. Have an awesome day.