I am beyond delighted to have Dr. Ellen Vora joining us to talk about something so important: how to have the healthiest emotional experience as a fertility patient.
If that sounds like an oxymoron to you, I get it. But Dr. Vora is going to tell us why it shouldn’t be.
Dr. Ellen Vora is a holistic psychiatrist, acupuncturist, and yoga teacher. She takes a functional medicine approach to mental health, considering the whole person and addressing imbalance at the root.
She received her BA from Yale University and her medical degree from Columbia. She’s board certified in psychiatry and integrative holistic medicine. She lives in New York City with her husband and daughter and is the author of The Anatomy of Anxiety.
I was so excited to sit down with her and talk about anxiety – which is kind of strange to say… who is ever really excited about anxiety? But the thing is: we need to talk about it because so many people are experiencing it now more than ever, and Dr. Vora has so many helpful things to share with us.
Dr. Aimee: I would love to hear more from you about what drew you to psychology, psychiatry, and to working with people who have anxiety.
Dr. Ellen Vora: In a way, I actually am excited to talk about anxiety, for two main reasons. The first is it’s just such a big problem, we need to be talking about it. It was already a big problem, and then the pandemic, and it feels like who among us is not in some way subjectively touching with anxiety.
The other reason I like talking about and focusing on it is that there is actually a lot of low hanging fruit with anxiety. People struggle and suffer so much, and there is actually a lot that we can do. I sort of feel like I salivate at the opportunity to support somebody with their anxiety because I like to relieve human suffering. People can feel better quickly.
Dr. Aimee: I love that you say that. I guess that’s how you can describe how passionate you are. This morning I was doing an ultrasound on someone, and I was like, “Have you ever seen a doctor this excited to see your eggs?” I swear, it’s almost like you’re salivating at these beautiful eggs. So, I can totally relate to your passion about what you do.
You talk about this paradigm shift in your book, and it’s something called “anxiety as a neck up problem.” Can you talk to us more about what that means and what is really going on with anxiety?
Dr. Ellen Vora: That’s the paradigm that we were both trained with. The way that we think about mental health is just limited to the neck up, just the confines of the cranium. We’re thinking about brain chemistry, we think about mental health as a genetic chemical imbalance. There is validity to that theory, absolutely, but it is not the whole story. There are multiple determinants of our mental health, some of them genetic, some of them epigenetic, and some of them just environmental in our day to day lives. Not to mention the fact that as human beings we have certain psycho-spiritual needs that impact our mental health.
I like this view of panning out further than just thinking about brain chemistry, because that’s the part we can’t do a whole lot about. We can take medication to support that, certain therapy modalities can be supportive of our brain chemistry, but at the very end of the day, it’s somewhat of a destiny. I prefer to focus on what we can change.
By focusing on how the physical body impacts our mental health, how our psycho-spiritual needs impact our mental health, that’s a much more empowering and hopeful view. It’s basically saying you’re struggling, but there’s something we can do about that.
Dr. Aimee: I love that. What are the things that you can do about that, as far as handling the anxiety?
Dr. Ellen Vora: Basically, the thought that went through my head is: “can I explain it more concisely than 270 pages,” but I’m going to try.
Dr. Aimee: Aside from getting your book The Anatomy of Anxiety, which I think everyone should get, and I love it.
Dr. Ellen Vora: I will try to say it in less than 10 hours. I think that basically it starts by first acknowledging that our physical body impacts our mental health. We can really even just start walking around and repeating to ourselves physical health is mental health, mental health is physical health. Our brain is a physical piece of flesh in our body like anything else. If something is going on in the physical body, it’s impacting our brain.
Some of those chemical imbalances that we’re so focused on are actually a downstream effect of some state of imbalance happening elsewhere. When our body is inflamed, when our blood sugar is crashing, if we have subtle micronutrient deficiencies, if something is off with the health of our digestive tract, if something is off with our thyroid, all of this is going to impact our brain, and it will impact how we feel.
These are some of the areas we can start. A lot of the interventions are themselves relatively straightforward. A big area of focus in my practice is on sleep quality. Many of us, whether it’s a matter of habits or it’s something a little bit more out of our control like sleep apnea, a lot of us are not getting adequate quantity or quality of sleep. I spend an entire chapter just helping people troubleshoot how they can actually successfully and realistically get the right amount of sleep.
It’s interesting how I’ve had patients in my practice over the years where every once in a while there is a silver bullet. Not often, but sometimes I just fix somebody’s sleep and that actually has this ramification impact on the rest of their mental health. Really so much of what was considered a lifelong diagnosis was really just how chronic sleep deprivation was showing up for them.
Dr. Aimee: I definitely notice when I don’t sleep, there’s a threshold that I start to feel really anxious, and I know it’s because of my sleep. I started wearing the Oura Ring maybe three months ago, and I wish it would actually make me sleep more, but it doesn’t, it just tells me how well I’m sleeping, so I’m still trying to do better. I totally agree with you.
There’s this concept that you bring up in your book that I actually hadn’t heard of before, this concept of false anxiety and true anxiety. Can you tell us what that is?
Dr. Ellen Vora: It’s a concept that I more or less made up, but it’s based on the work of a woman named Julia Ross who wrote a book called The Mood Cure where she defined this concept of a false mood. She’s like we have our real moods, that’s when something happened and we’re in a mood as a result. You’ve had a loss and you’re grieving is a classic example.
Then we also have our false moods. Those are those times when seemingly out of nowhere we’re suddenly irritable, or anxious, or sad, or angry. Our brain is always all too happy to swoop in with a story, because that’s what our brains do, they’re meaning makers. They’re happy to tell us I’m anxious right now, it must be because of that email that I got from my boss that suggests that I’m a little bit underperforming at work, so we’ll swoop in with a story to explain the sensations.
In that moment, if we could omnisciently look under the hood of the body, what we would see is that there is some state of imbalance happening. Maybe you’re hungry, your blood sugar is crashing. Maybe you didn’t get good sleep the night before. Maybe you are due for a dose of a psychiatric medication, which can put your body in the pharmacologic nadir, which can create, in my opinion, a form of a false mood.
There are these states of physical imbalance that trip our body typically into a stress response. That tracks up to the brain, our brain feels the stress response and says, “I’m anxious because of my job, my relationship, and the world is barreling towards certain destruction.” I’m not here to invalidate any of our very real concerns. The stories that we tell ourselves have a basis in truth. But in that moment, the cause of our anxiety is physical.
That’s nice because there is something we can do about that. It doesn’t change the fact that we still have problems, but we can then handle those problems from a place of calm and resilience, and everything feels a lot more manageable.
Dr. Aimee: How do we manage that false anxiety? What kind of tips would you share with us so that we could do that so that those small changes don’t really impact our mental health?
Dr. Ellen Vora: I break it down into several different areas. As we mentioned before, sleep is a big one. I love to fix people’s sleep and get them a solid night’s sleep on a consistent basis, and then everything in life feels a little easier, everything in the body works a little bit better as well.
Nutrition is a big one. That is such a big topic. If we lived in simpler, more straightforward times, we could say that the only goals with our food are to nourish our body and to not inflame us. Even that alone is a pretty tall order with our modern food landscape, with processed foods and a lot of very nutritionally bankrupt foods, so it’s hard to actually nourish ourselves and it’s hard to not to be inflamed from our foods.
That’s not even everything that we’re up against with food. We also live in this tension of the pressures of diet culture and some people take on an excessive approach to healthy eating, which kind of tips into a form of an eating disorder called orthorexia, or an almost obsessiveness with eating the right way. Then sometimes we run the other way and, as one of my colleagues put it, she rebelled against toxic diet culture and then just started eating like a teenager for a decade. That’s not a solution either.
We really want to nourish ourselves, but not for any of the reasons the world is pressuring us to. It’s really not to lose weight or for the patriarchal male gaze or the right number to be on a scale. It’s not any of these reasons. It’s an act of self-love.
I focus a lot on technology, our relationship with our phones. There is so much about how that is impacting our anxiety levels, but I would say one central issue is that we’re living in the attention economy. Our attention at this point is the commodity being competed for by very smart companies. They’ve done their homework, they know their neuroscience and their behavioral psychology. They know that if they give us a dose of uncertainty, fear, doubt, controversy, we’ll rubberneck, we’ll give an increasingly large share of our attention, they’ll get more clicks and more ad revenue, but our mental health is often the collateral damage.
When we’re just being manipulated by our technology, we can feel strung out, we don’t sleep well, we fall into those pits of compare and despair and relational aggression, and we don’t actually scratch that itch of real social connection. There’s a lot about how we can realistically set boundaries with our technology so that we can still live in this world, but preserve our connection to real community and to good sleep.
Dr. Aimee: Beautiful. I could sit here and listen to you for hours. I’m learning so much, this is fabulous. I think everything that you’re saying is very powerful for people, just anyone, no matter what the diagnosis is that you’re dealing with as it relates to your anxiety.
So many of my patients are obviously struggling with having a baby and they’re going with fertility treatment. Being in infertility treatment can be so stressful. Can you share any tips that you have for fertility patients to lower their anxiety?
Dr. Ellen Vora: In a perfect world, all practitioners that they’re working with are like you and bring humanity to this work. I think often, if I’m really being honest, a big part of how people struggle is in the interpersonal dynamics of going through the process, on top of everything else that’s hard about it.
I think that there is a tension that exists between wanting to do everything we can to support our bodies and to help with the success, and then to not feel so responsible because that invites this feeling… First of all, it can just drive us crazy to be running around going to every acupuncture appointment, and meal prepping, and feeling like, “This is all on me.” Then it invites in a feeling that we failed if it doesn’t work, that we didn’t do enough or that we did something wrong.
I’m sure I’m not alone in this, probably your whole audience just prays for less shame, less self-blame in the entire, what I would call the psychospiritual journey of childbearing. I think that I have a big perspective on how to support our bodies. Taking the false mood view, I think that as I’ve witnessed patients of mine, friends of mine, going through fertility treatments, I think we have to be a little bit more cognizant of the fact that taking any kind of exogenous hormones can impact our moods.
I’ll see a lot of swiping me away with that, people being like, “I know, but I can handle it. I’m okay. This is hard, it’s stressful, but I’m okay.” Then you see someone feel really dark, and they’re like, “I’m feeling dark because of how it’s going,” or because of how it went. Yes, and the hormones are impacting the mood. I just always want cognizance around this so that we can at least identify that and take the littlest bit of charge out of those mood states and say this is challenging and we don’t invalidate that it’s challenging, but also the hormones are almost doubling down on the mood and it’s just making it harder. I think there is power in being able to identify that.
Dr. Aimee: That is so powerful. I always tell my patients, “These are the symptoms that you’re going to feel at this period of treatment.” Moodiness, anxiety, severe PMS, I always bring that up. I say, “If you’re feeling really snarky, just blame it on me, it’s totally my fault, I’m the one that caused it, and it’s because of the hormones. It’s not you, so just give yourself a little bit of grace and love yourself extra and realize that this will pass. The hormones will come out of your system, and you’re going to feel better again.” So, I’m glad that you brought that up.
The other thing that I tell my patients is to channel a superhero. You know that saying, if you believe it, you can achieve it. But there’s something that you brought up in your book about how true anxiety can actually be a superpower. Can you just tell me a little bit more about that?
Dr. Ellen Vora: Yes. I start with the false anxiety, that’s the low hanging fruit. It’s like let’s just eliminate all this unnecessary suffering. It doesn’t serve us, it’s not our deep inner truth. Being sensitive to caffeine or chronically sleep deprived, or our nervous system jacked up from our phones, or we’re inflamed, the anxiety that all of that causes is not helping anybody.
Within reason, whatever is accessible, you basically identify what is causing imbalance, address it, walk away from that aspect of anxiety in your life. But that does not eliminate all anxiety. Often what happens is when someone gets really clear and removes a lot of their false anxiety, it clears the air and it reveals what’s behind that, which is our true anxiety, which is not something that I think we should be pathologizing. It’s not something that we could decaf coffee or gluten free our way out of.
It’s our inner compass here nudging us, telling us “slow down, pay attention, you know that there is something not right here.” Usually, it has some kind of call to action baked in. It’s saying something is not right in our personal life, maybe it’s a relationship, maybe it’s a career. Maybe something is not right in our family, in our communities, in the world at large. It’s basically saying we have a unique perspective and a unique passion, and there is something that needs our attention.
I think that we don’t feel well if we ignore this. I call one chapter The Body Whisperer. It starts out gently, lovingly whispering, but eventually it shouts. I think about my patients who have a panic attack on the elevator ride up to work. At that point, your body is not whispering anymore, it’s shouting.
I think that we live out of alignment in some way and we’re ignoring these messages from our body, we really suffer. It feels so terrifying to confront these truths, but what ends up happening invariably is we slow down, we say I’m paying attention, I’m listening, I’m tuning into this, and then there is some often kind of scary truth. Something that feels like this will blow up my life, or I don’t have the strength, or I’m not capable of this, I’m not good enough for whatever is being asked of me.
If we do just translate some of that anxious feeling into purposeful action, no matter how small, no matter how bite-size that first step is, it takes away the feeling of anxiety. Now we feel fueled with purpose, and that gives us the strength to make the next incremental change. So, I encourage people to slow down and listen.
Dr. Aimee: What do you think other doctors, specifically fertility doctors, should know about their patients and their anxiety?
Dr. Ellen Vora: I don’t know. I remember when I was in med school and I was trying to decide whether to do psychiatry or another specialty. I think we were on our consult liaison section of our psychiatry rotation and the guy said, “I’m talking to a room of med students, you guys can become anything at this point. I know that not all of you are going to become psychiatrists. I’m talking to orthopedic surgeons, I’m talking to OBGYNs. But listen, all of you are going to be psychiatrists, whether or not you’re going to become a psychiatrist.” I really like that. I found that helped me make my decision, because I was like I’m going to be a psychiatrist anyway, might as well have the full 45 minutes to just sit and talk with patients.
I think that we sometimes think that there is professional gatekeeping to knowing what the right thing to say is when someone is struggling. I think I thought that maybe I had learned that information in residency, but it’s really been in the 10+ years since residency that I’ve stripped away that learning and just become more and more a human being in the room with my patients.
I think that if there are any physicians who are in a position where they’re holding heavy stuff, they’re holding space for patients going through something tough, just remember that you don’t need special training, you don’t need to say the right thing. You really need to just be your full human self in the room there and validate what someone is going through and feel it with them, witness what they’re going through. That’s one thing.
I would say the other piece, and this is drawing back to how I mentioned that the food piece is complex and there are a lot of pitfalls. I do think that especially with conditions like postpartum anxiety and anxiety that can happen in the wake of fertility treatments, I just think that it’s a big ask on the body what happens here. If we grow a baby, if we are birthing a baby, if we are feeding a baby, if we’re going through IVF cycle after IVF cycle, this is really draining of our resources and people’s bodies get nutritionally depleted.
I think that we’re not trained to focus on that, it’s considered kind of a soft science, we overlook its importance. But then people start to feel like a machine with the springs falling out. They don’t feel well, they’re not thinking clearly, they’re not sleeping well, their mood is all over the place, their anxiety is through the roof. Sometimes that is their body’s way of communicating, “I am missing certain critical nutrients.” It’s understandable, it would make sense that people get nutritionally depleted.
We need to focus on repleting, and we need to do it in a way that doesn’t drive that person crazy, because it’s hard to nourish ourselves in this modern food landscape. We need to invite help in. We need to feel comfortable occasionally receiving or accepting help, or sometimes outsourcing, but figuring out how to actually nourish ourselves when we’re tired, exhausted, depleted, and to do it in a way that doesn’t drive us even more crazy.
Dr. Aimee: If someone is feeling anxiety, let’s say right now, or they’re in a clinic and they’re waiting for a doctor and feeling anxiety, what recommendations and tips would you suggest for them?
Dr. Ellen Vora: Just to just clarify, if they’re waiting for a…?
Dr. Aimee: Let’s say someone is experiencing anxiety right now, just in this moment, no matter what is going on. Or the other scenario is someone is sitting on an exam table waiting for the doctor to come in. What are some things that they can do actively to help themselves decrease anxiety?
Dr. Ellen Vora: This is great. Now that you put it that way, I realize how the book is structured, the first several chapters are just about preventing your body from getting tipped into anxiety in the first place. Then there’s more chapters around being at the point of no return and you are anxious and what do we do about that.
Within that, there is a lot around discharging the stress we’ve already taken on and cultivating the state of relaxation in the body. These are two different ways to approach that problem. We’ll all feel drawn to different techniques.
For some people, it appeals to them to discharge stress. For that, you can exercise, you can dance, you can journal, chant, sing, make art, play with a puppy, cuddle, cry. I think that crying is such underrated, good, free medicine. We have this cultural need to rebrand crying. When we start to cry, we start to apologize, we try to make it as small as possible and say, “I’m sorry,” but really we should not apologize, if we can help it. Normalize crying and allow it to be bigger, not smaller. Let it be complete.
A practice that I have a lot of my patients do that is super weird but very effective is a shamanic shaking practice. I learned this when I studied integrative medicine. You basically put on drumbeats and then shake for a couple of minutes. It’s so weird, but I wouldn’t love it if it weren’t so effective. The shamanic drumbeats help sync up the brain waves with beta wave patterns, so it’s relaxing in its own rite. Then shaking seems to both excavate what gets stuck in our tissues and it seems to tell the nervous system almost Control+Alt+Delete, and tells the nervous system the threat has passed, now I’m safe.
For people that prefer to cultivate a state of relaxation, breath work is always a really nice free, efficient technology to get you there. The technique I usually employ is the 4-7-8 breath where we just inhale to the count of 4, hold to the count of 7, and exhale to the count of 8. If you do maybe four cycles of that, more if you have time, it’s free, it’s easy, and what it does is it almost tricks our sweet little gullible brains into believing that we are not anxious just because our exhale is longer than our inhale and that’s how we would breathe if we were relaxed.
Our brain is apparently gullible enough that it can be convinced that we are relaxed, even if we just breathe the way a relaxed person would breathe. Then a whole neural hormonal cascade ensues and it’s a really nice way to tip your body out of stress.
I’ll just caveat that by saying if you’re sitting on the exam table, maybe in a paper gown, no back support, you’re nervous, you’re anxious about what is coming on, and if breath work ends up being triggering, then that’s counter-therapeutic and there is no need to keep going with that. You can release it at any moment. If you need to just cut it off, you can put your hands on your belly and just take what I call a cleansing breath, inhaling deeply through the nose, exhaling through the mouth with a sigh, and that can be your breathing exercise.
Dr. Aimee: There’s nothing weird about the shamanic drums. What I do, I don’t know why, but now you’ve just explained it. For me, when I feel a little anxious, I actually listen to electronic dance music, and it’s that repetitive beat. My husband thinks it’s like the strangest thing. He’s like, “I don’t understand how you can listen to that and feel relaxed.” I don’t know either, but it just works. It just makes me feel happy, and I feel better. I just do it in little spurts throughout my day, not every day. You’ve now explained why it works, I think, for now.
Dr. Ellen Vora: That has me thinking. I think it almost can be like a weighted blanket neurologically. It gives us a lot of sensory input and that can be soothing. Also, anything that gets us to move and puts us in a trance state, I think is really helpful for our nervous system working with something.
Dr. Aimee: You just mentioned a weighted blanket. I have always thought that my patients should have a weighted blanket at night. Do you have a recommended one that you suggest to your patients?
Dr. Ellen Vora: No, I don’t have a particular brand. I’m personally someone who always errs on the side of more natural materials. Basically, it’s not rocket science. If you find one that you find comforting and soothing, then that’s your weighted blanket.
Dr. Aimee: Yes. And you don’t necessarily need to buy one that is called a weighted blanket. There are other ways of doing it. For me, I have this very big heavy pillow, and I just put it on top of myself. I just lay it on top and I just go to sleep, and it just feels so comfortable. It’s strange, but it works.
Dr. Ellen Vora: DIY weighted blanket. The official weighted blankets are shockingly, like, clinically heavy.
Dr. Aimee: They are. I do have an actual clinical one. They’re not cheap either, they’re pretty expensive.
Dr. Ellen Vora: Yes. And they’re really hard to launder. I always worry about my washing machine when it’s 50 pounds of beads going around in it.
Dr. Aimee: Was there anything else that you’d like to add for us today?
Dr. Ellen Vora: I think that there is something to be said for, I’m very focused on the physical body and I play a lot of Mr. Fix-It, like how is the physical body out of balance, how can we nudge it gently and lovingly back into balance so that you can feel well, so that you can thrive in your life. But I also think that we should just recognize that we as humans have these fundamental human needs. Need for community. Need for connection to nature. I think even a need for purpose, meaning in our lives. I think especially if we’re undergoing the psychospiritual journey of childbearing.
This is something we weren’t taught in our medical training, this was like off-limits. But I’m a psychiatrist and I’m here as a custodian of my patient’s mental health, and I can’t overlook the fact that their relationship to meaning and purpose in their lives has a bearing on their overall mental wellbeing. I’m certainly not here to proselytize, it’s not like you need a particular belief system. But I think we are ready to give ourselves permission to ask the questions. Wherever we come out is fine, but we don’t want to be doing ourselves a disservice and completely overlooking the questions.
Ask the questions. Bring your head up from your mortgage at some point and look at the stars and be like, “Also, that.” Everything myopically we’re focused on in life is true and it matters, and the cosmos are there, and that does call it all a bit into question.
Community is the sort of sine qua non of overall wellbeing. I think this has to do with our hardwiring. We’re not the strongest species on the proverbial savannah of evolution, we’re not the fastest, we’re really just the ones that figured out how to cooperate effectively. For that reason, it’s in our hardwiring that when we feel a part of a group, a sense of belonging, we feel safe. When we feel rejected, or on the outside, or just isolated, which is a part of modern life, we feel uneasy on some very deep level.
Especially as we’re at this phase of a pandemic and we’ve had additional barriers put up to social connection, can we figure out a way that is safe, that is responsible, that feels good, that is appropriate for what we like to do socially? It doesn’t always have to be “hang out in big groups” or “go to a bar,” but to connect with the people that we care about in a way that feels good to us, and to make sure that we’re prioritizing that.
Dr. Aimee: Have you recorded your book as an audiobook?
Dr. Ellen Vora: It’s narrated by a professional narrator. I was bummed about that initially, but now that I’ve listened to it, she does a really good job.
Dr. Aimee: I want to make sure that people know that they can get your book as an audiobook as well, and also read it. Tell us more. If someone wants to work with you or read your book, where can they find you?
Dr. Ellen Vora: I’m not currently taking new patients for individual therapy, but I am starting at least the brainstorming process of how to make this approach a little bit more affordable and accessible. I think online groups, something along those lines is coming down the pipeline. I’m pretty active on Instagram, @EllenVoraMD. Then my website is EllenVora.com.
Dr. Aimee: Thank you, Ellen. Thank you so much for being on the show today and sharing all of your wisdom with us. I hope to see the update about your groups so my patients can join in and learn some more from you. Thank you so much.
Dr. Ellen Vora: Aimee, truly, thanks for having me on, and thank you for doing the important work that you do.
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