Side Project Podcast 3: Anxiety with Mimi Winsberg, MD

Leyla Seka (02:10.067)

Let’s start actually with Brightside. So you started a company focused on mental health. Why? What brought you to this? Why was this where you wanted to focus your energy?

Mimi Winsberg (02:22.29)

I’m a psychiatrist, and I’ve been practicing for over 30 years now. So I’m right there with you guys in the middle aged department. And for years I’ve been working with patients, helping them track their symptoms and helping them select the right kind of treatment for themselves. And it’s really exciting, I think, with the advent of digital tools to be able to leverage that kind of expertise and bring quality care to more people.

So when I met my co-founder, Brad Kittredge, we had a common mission. And it’s been really exciting to bring that to fruition and be able to provide care, quality care that’s really evidence-based and data-driven and also available for people through their commercial insurance, and now through Medicare and Medicaid too. So super exciting.

Julie Liegl (03:17.624)

Wow, that’s great. How do you know when you need to seek help for anxiety? I mean, the world today, like who isn’t anxious? How do you know when it’s something that is more serious than just something situational?

Mimi Winsberg (03:31.802)

Yeah, I think it’s really important to acknowledge that anxiety, is hardwired in our brain. Humans are wired to feel anxiety. We can’t survive without anxiety. We wouldn’t be able to survive in a primitive world, and we wouldn’t be able to even cross the street or survive in our current world without some level of anxiety. So I think it’s very important when we talk about anxiety to not just think of it as something we need to rid ourselves of, but more something we need to understand, manage, and live with. 

And so what does that mean? It means understanding what sets it off and then how to filter it when we feel it. So like understanding the signals that our brain and bodies are giving us and what lies beneath that too. So when you’re feeling anxiety, to register it as such and think about what does it mean, why is it being triggered and what feelings might be underneath it. 

And having a better understanding of those things can then help us figure out whether we need to be practicing some self-care, whether we need to be making better decisions for us, or whether we maybe need to be bringing a more, like just to use a cliché term, more authentic version of ourselves to the table. Like maybe the anxiety is masking something that’s underneath that’s actually more authentic.

Leyla Seka (05:07.507)

We worked in tech for a long time and everyone’s like, Leyla, you run in the red. You’re just high RPM, or whatever. But there was a period of time where I was moving up and everyone was like, you just have to calm down, Leyla. Just calm down. And, you know, the way I was brought up, anxiety was weakness and the way out of it was to work harder. Like, oh, you feel anxious? Get up and do all the things on your list. Oh, you don’t feel like you’re not getting enough done? Get up earlier and get more done. 

But at that time, when everyone was telling me to calm down, I got a meditation coach because I had no idea how to calm down. So that helped me understand I had anxiety and get through it. But as middle age approaches, it really does feel like this is coming on. Even my most “nothing’s wrong with me, I’m the happiest person in the world” friends are like, what the hell? And I get why it gets more acute in middle age, but how do we navigate that or think through that?

Mimi Winsberg (06:13.38)

Yeah, and I think these two questions tie together. So a lot of things happen in middle age, which I’m sure you guys have discussed in other episodes, but women in particular go through some pretty dramatic hormonal changes in middle age. Hormones and moods are bedfellows, they’re very closely related. So when we get hormonal changes, we are inevitably going to feel differences in our moods and anxiety levels. There’s another important change that happens in middle age, and that’s one of identity too. So, you know, we go from perhaps one stage of life, of maybe parenting young children, to a different stage of life where we have to redefine ourselves that may have career implications, it may have family identity implications.

So all of these things are sort of converging, and unlike many other stages of life where we have rituals to sort of acknowledge a change that’s happening, like in teenage years or college graduation or weddings, we don’t have a lot of ceremony around middle age. So I think a lot of people don’t know where to turn and don’t have a point of comparison to understand what they’re going through. Perhaps we need to implement some ceremonies of middle age to think about, OK, this is a new phase. How do we celebrate this? Or how do we acknowledge this?

Julie Liegl (07:37.354)

A “no more babies” shower.

Mimi Winsberg (07:42.608)

Yeah, yeah, something like that, right? Like something to kind of acknowledge what’s happening.

Leyla Seka (07:48.699)

Right? Because no one even talks about it. I mean, that’s how we started, right? We were all in the bathroom at dinner and our husbands are outside talking about football or something inane, not to be such a generalist, right? But, we were all in the bathroom talking about sweating at night and wanting to kill people because we were so unhappy. 

Julie Liegl (08:12.312)

Well, I was gonna say like in some ways, Mimi, what you’ve kind of done is almost the thesis for this whole thing. And I was thinking, is this Leyla’s and Ruthie’s and my ritual to mark this moment? And then I’m also thinking about, Leyla, just keep working harder. It’s like, well, we can’t figure this stuff out. So we’re just gonna get a bunch of people who will answer all of our questions so we can get all the information and we’ll put it together. Like we still can’t get away from our sort of “problem solver” and “get stuff done” mentality.

Mimi Winsberg (08:39.858)

Sure, and information is power, right? And comparing stories is both helpful and healing. So I think you’re on the right track with that. In a sense, information gathering is helpful because you’re dealing with a new set of problems. I think to circle back to the question that you guys both posed in different ways: is this normal and when is it a problem? And that’s obviously a spectrum of when is this a normal part of life versus when is it presenting issues that you may need help for. And I think the key there is really understanding how persistent the symptoms are. How disruptive are the symptoms? How intense, you know, and how much do they interfere with things like relationships and ability to get through the day. How much are you experiencing really intense symptoms of anxiety, things like hypervigilance or fear of like, fear of doing things that you weren’t afraid of before, or a state of physiologic arousal that’s like, that’s overpowering and hard to live with. That’s when you start getting into, okay, I need to get some professional help here to manage these kinds of symptoms versus adjusting to a new identity or a new state of being. Therapy and self-knowledge may be really helpful in those situations, but you might not need a medical intervention per se. 

Julie Liegl (10:21.324)

Yeah. You talk about getting treatment and it’s just springing up for me. First of all, I think it’s hard when you’re in a state of crisis to do the steps. And I’m assuming that’s part of where Brightside helps is just removing the barriers to getting the help. it’s also, I’d say a stigma thing. I don’t know that I’ve ever said this in a formal way, but I have been in therapy on and off for decades. And I felt like when I was going to therapy, I had to hide it. And I felt like when I went on a medication, I would rip up the Walgreens receipts and then I got a shredder. I thought there was such a stigma. 

And now I don’t feel that way at all. And I’m so thrilled that my friends go to therapy. So I feel like things are more destigmatized in my personal circle, but are things becoming more destigmatized overall, or how can we help destigmatize this idea of needing additional help?

Mimi Winsberg (11:53.99)

Yeah, I think we’re seeing slow and steady change around this and granted certain geographic bubbles are probably more receptive to this notion, you know, and so maybe there is a bubble per se, but I think still we’re seeing a slow acceptance of and welcoming of mental health interventions. So an acceptance that it’s okay to struggle with these things and that 1) they real illnesses and not just figments of people’s imagination. And 2) that it’s okay to get treatment. On the therapy front, I also think it’s good to acknowledge that, to take more of a sort of growth mindset approach to things that you’re not like sick or not sick, but that there’s learning and growth that can happen and that going to therapy is a learning process that you’re learning about yourself and what can be wrong with that really like if you’re learning how to cope better or manage feelings better or manage stress better, then those are all helpful things for for anyone.

And I think this gets into sort of an important idea of the relationship between anxiety and stress. Because a lot of people might use those terms synonymously, to say anxiety and stress are the same things. But actually, it’s really important to distinguish acute stress from chronic stress. And acute stress is good actually and healthy and we learn from it. actually our brains learn from stress. You put somebody in an acutely stressful situation they will learn their their brain will go through an adaptation where they they learn from that. Whereas chronic stress actually works against the learning process and when somebody’s experienced daily and persistent chronic stress or chronically elevated cortisol levels their brain loses that ability to be plastic and learn and it has a detrimental effect on their health. So sort of distinguishing those two things I think is really important in that we don’t want to live in a world where we have no anxiety and no stress and just like sit on a big comfy pillow. That’s not good for us. But it’s also not good to be chronically in a state of agitation too. You know what I mean?

Leyla Seka (14:26.385)

Right. So I want to talk more about the identification thing a little bit, because I think that that’s like a brilliant way. Your identity is changing. Like there are even in just the simplest way, like they’re the people that were under 40 in the workforce. And then we got like protected when we turned 40 and that was 11 years ago for me. But you know, I was just working, working, working, working, working. And then I stopped working.

And certainly I’ve had some like, okay, what is my identity? And one thing, which is a little bit practical, but to manage anxiety, I would certainly have a drink, right? I mean, I would drink some wine or have a drink, whatever it was. And now with this age stuff, drinking really does not work for me anymore. 

Mimi Winsberg (15:20.254)

Yeah, right, right. And with anything, be it alcohol or other substances, you have to understand there’s an immediate effect. Like alcohol absolutely has an immediate anxiolytic effect. So you drink and you will feel reduced anxiety, reduced fear. It reduces those things in the moment. But what does it do longer term? It’s not necessarily aid in that reduction longer term. And we definitely see a shift in the dose response curve with alcohol. So, you know, what works for a little while might not continue to work at the same dose, right?

Julie Liegl (16:01.196)

Wait, is that a fancy way to say build up a tolerance: a “shift in the dosage”? That’s so great. A shift in the dosage curve.

Mimi Winsberg (16:05.234)

Totally, right? I mean, you get a response to it and then the same dose doesn’t do it for you and then you find yourself going down a path of addiction, right? Because you need more to get the same feeling. And so I don’t think anybody, any clinical person would recommend alcohol as a way to to medicate anxiety per se, you know, because of those factors.
What I think is important is that you can find other techniques to reduce anxiety that are in general healthier. Exercise would be a really good example of that, where you are creating an acute stress by exercising. So you’re actually stressing your body. And then what happens is that you’ll see an ensuing relaxation after the fact.

You can build some tolerance to exercise, but not in the same way that you will to alcohol. So it will continue to work for you. And I think there are other good examples of that, like body relaxation techniques, spending time in nature with animals. All of these things kind of show to have, they will reduce cortisol levels in people and have a good repeated effect.

Julie Liegl (17:34.892)

Talk to us about medication and when you think it’s recommended. Are there general guidelines? And I’d also be curious how that interacts with, or are there supplements or things? I remember at one point, like St. John’s wort was something people talked about, but are there, in addition to medication, are there other things we could consider that are maybe healthier than the glass of vodka-soda?

Mimi Winsberg (18:01.618)

Absolutely, absolutely. And I would put medications and supplements sort of both into those categories with probably, you know, using severity as a guide to decide, do you want to use just the adjunctive techniques we talked about, like exercise and so forth versus supplements versus medication. Think of those as sort of increasing strength or dose. And it’s great to combine them in many ways. They can be mixed and matched. So you can be on medication and still doing the behavioral techniques that you would do to manage anxiety or still maybe taking a supplement. 

How do you decide? It’s usually based on how persistent and how bothersome are the symptoms. We have questionnaires that you can take yourself at Brightside. If you log on to our website, you can take a quick questionnaire to gauge your anxiety levels and see if they fall into a subclinical or more over a clinical threshold that might where we might recommend medication. Typical go-to medications for anxiety are things like selective serotonin reuptake inhibitors that most people have heard of at this point. These are drugs like Prozac and Zoloft and Lexapro. Those tend to be good for anxiety. But we have other good medications too that can be explored. I think finding the right medication for the particular symptoms you’re having is a really important endeavor and one that we’ve tried to make very precise at Brightside where you’re getting a personalized assessment of your symptom clusters with the right medication selection. And I think with regard to supplements, there are also a lot of good supplements on the market that can help. Lavender, for instance. There’s a lot of evidence for lavender’s ability to reduce anxiety. And there are good GABA-URGIC supplements that can also overall reduce stress and anxiety symptoms in the brain. 

So I think there are a lot of different options at people’s disposal. The key is to make an informed selection. And I would say whether it’s supplements or whether it’s a prescription, talking to a professional about what’s right for you is probably a good thing. A lot of people struggle with just going onto Amazon and ordering a slew of supplements on their own. It’s kind of nice if that recommendation comes from more of a trained provider who can assess what your particular symptoms are.

Julie Liegl (20:31.555)

So other than Lavender room spray, maybe hold off and talk to a doctor before you go get like Brain Health Be Mine on Amazon Prime.

Mimi Winsberg (20:41.17)

Yeah, and with lavender, actually, we can give it at much higher doses orally, not just aromatherapy. There’s good evidence for aromatherapy, but you can actually take a lavender supplement pill that actually performs just as well as antidepressants for anxiety. 

Leyla Seka (21:03.087)

Do you smell like lavender?

Julie Liegl (21:09.472)

Is your sweat like just a Crabtree & Evelyn store come to life?

Mimi Winsberg (21:10.994)

I haven’t heard a report of that side effect either. But the point is that there are natural substances, I think, like lavender oil, that do have anxiety-reducing capabilities. But antidepressants are an effective way to address anxiety symptoms too. Depression and anxiety are related in many ways, you know.

Julie Liegl (21:40.482)

Thank you. I was just going to ask you that because I’m like, if it’s antidepressants for anxiety, what is the difference?

Mimi Winsberg (21:47.964)

Well, as I mentioned, anxiety is a very normal brain process, right? But when it gets out of control, that can result in symptoms of depression. So the best animal model we have for this is the model of learned helplessness. Put a rat in a cage and have it press a lever to get a little pellet food reward on one side and a shock on the other side of the cage. It very quickly learns to go get the food and avoid the side of the cage that gives it a shock. Right? But if it just gets randomly shocked, no matter what it does, eventually that animal just curls up in a ball in the center of the cage and gives up. You know, if you just feel like you are not in control of where you’re getting rewards and where you’re getting punishment or shocks, you give up and you get into a state of learned helplessness. And that’s probably the best animal model for depression that we have where it feels like it’s a little out of control and I don’t know how to manage the responses that I’m feeling in my body or that are coming from external. And sometimes it’s hard to distinguish what’s coming from the outside versus what’s coming from the inside, right? So if you think about it, what creates anxiety over time can then lead to depression.

Leyla Seka (23:07.525)

Okay, so this is a slightly different direction, but I have a number of friends who are like, they’re taking psychedelics and microdosing and like going on journeys where they get super high, for lack of a better way of talking about it, and kind of have these spiritual things happen to them and they come out and they’re like, I’m a changed person. So those are kind of two different things, but sort of like back to the 60s with everyone being excited about psychedelics. Do you have thoughts on that? 

Mimi Winsberg (23:46.098)

I do, I have lots of thoughts on that and I think it gets back to the notion that we were talking about a little earlier about stress and learning, right? So as I said, an acute stress can help you learn, whereas chronic stress doesn’t help you learn. And taking a dose of psychedelics, in particular psilocybin, can create a little bit of stress response that lends itself to brain plasticity. At least this is what research seems to be showing. So that’s probably the mechanism of action there, is that as you take what are natural substances, but have both effects on the serotonin and receptors in the brain and other effects in the brain, you’re creating a stress in the brain that is opening your brain up to learning new patterns and new interpretations. Many people, of course, you know, on psilocybin will say, it feels like I’m seeing something for the first time again, and so what that does is it lets you then recreate a new learning pattern in response to a particular stimulus. And so all of these tie back to the notion of learning and brain plasticity, which are very inherent in growth and I would say treatment, you know, so is there a role for these substances for psychedelics? Absolutely. But I think, as far as where we are with good clinical trials, we’ve got a way to go. And I suspect it’s going to be some years before we see widespread approval for these kinds of substances on labels. In current states, it’s not legal for any licensed provider to prescribe them. And if you are going to get them, it has to be in the context of an FDA controlled study that happens with a lot of controlled elements to the study.

Julie Liegl (27:41.922)

That’s great. I’m so anxious. I live in an anxious house, which means I’m an anxious parent, and I am also raising anxious children. And by the way, I think it was probably true for my parents as well, but that’s not something that was ever discussed or acknowledged. But now many of us are people who are diagnosed with anxiety, who are raising children who are either diagnosed or clearly exhibiting the same signs.

What advice do you have on how to manage that and short of putting ketamine in my kids’ breakfast cereal or psilocybin? How do we navigate that as anxious parents? I was kidding. I do not do that. I would never do that. Maybe a Melatonin gummy at night when they’re having trouble sleeping, but that’s it. I don’t slip illegal drugs to my children. But seriously, how do you advise this new generation of, not new parents, but parents who are now raising the next generation of anxious children?

Mimi Winsberg (28:38.394)

Yeah, well, I mean, there are a couple of factors. One is there’s You know, as we live in a sort of more comfortable society where we’re struggling less with basic units of survival, there’s more room to get anxious about more esoteric things, right? And we are also raising children in an environment where they have pretty much 24-7 access to social media now, which, you know, I think there’s clear evidence that that’s driving anxiety and depression levels in teens as well. Girls are comparing themselves a lot. They’re taking many selfies a day, comparing those selfies to retouched images from professionals basically. And all of this can take a toll on self-esteem. I would really encourage back to the notion that anxiety can be sort of a mask for other kinds of emotions, I would really encourage sitting with your kids if you notice that they’re exhibiting some aspect of anxiety and just finding ways to talk about what they might really be thinking or feeling and seeing if there is another layer below that layer of manifest anxiety. What else might be going on? What can you discuss? What can you uncover? What might be below the surface. 

And I think that’s basically the approach that will be taken in therapy as well. I mean, there two ways to sort of manage anxiety in therapy. One is to sort of take a cognitive approach and sort of rethink, okay, do I need to have the anxiety that I’m having about this particular event? But also to explore what other feelings might be there. A really nice framework to use is to think about, okay, what was the trigger for what you’re feeling right now? Just write that down. Like think about what was the trigger? What is the thought behind what you’re feeling right now? What is the feeling? And then what is the behavior and what is the outcome? But I think thinking about trigger, thought, and feeling is super important because you’re identifying, okay, what triggered it? And then what’s the thought that I had that preceded the feeling.

And then is there any way to modify that thought that creates a different feeling in you? And so these are just really basic tools and the kinds of conversations you can even have with a younger child where you can just say, hey, before you felt this way, what were you thinking? And is there some way we can rewrite that thought that feels good to you?

Leyla Seka (31:34.131)

Yeah, I spend a lot of time telling my kids that they’re telling themselves a narrative that isn’t true. I’m like, not a thing, you’re getting into college, kids. I don’t know why you keep telling me you’re not getting into college. I feel for them. But all the kids in my life are in some kind of therapy or getting some kind of help. I’m glad that we have these things and we can talk about them. Cause I’ve been in therapy since I was a kid, right? Like I just was chubby and I was dyslexic and all the things that you’re not supposed to be. So into therapy I went, but no one talked about it, right? It was like the big family secret that Leyla’s in therapy. So yeah, I mean, I do think with the kids, I loved the way you thought about kind of how to, how to talk to them about what happened and why they’re saying it or thinking about it this way. And then trying to switch the narrative around while they’re considering it, like maybe you’re anxious about something that isn’t really there, because that’s often the case with my kids.

Mimi Winsberg (32:34.66)

Yeah, the narrative’s important. The stories we tell ourselves are very important. And a lot of times therapy is about telling that story in a new way. But even breaking it down into smaller pieces of what was the one sentence thought you had and how can we rewrite that one sentence. It doesn’t even have to be the whole story or the whole narrative. It can just be one sentence. And lots of times in working with patients, if you can find a way to just change that one sentence, it results in a really different feeling in your body than you had before. And the experts can do this mid-meeting. They can be sitting in a boardroom, have a thought, and say, I just got a weird feeling. I’m going to rewrite that thought and then have a different feeling mid-meeting, and actually shift not a whole narrative about themselves, but just shift the way they’re perceiving things in the moment.

Leyla Seka (33:31.443)

Brilliant, brilliant. I think, well, we had one more question, but it’s a little gratuitous, and I think we know the answer, but it was sort of like, so Mimi, is it bad that we get anxious and eat a whole bunch of cookies and then scroll Instagram and look at dumb shit and buy it? Or is that kind of acceptable at some level?

Julie Liegl (33:49.32)

Well just like the vodka soda, maybe it’s not the best way to cope, but like, why do we do that? What are we seeking? Why do I think that, you know, eating the bag of Cheetos and buying my 10th pair of jeans, like, why is that what my brain is trying to do to cope with that anxiety?

Mimi Winsberg (34:06.542)

Well, don’t you think, I mean, I’m not the source of truth for this, but don’t you think that’s a lowest common denominator solution? I mean, I don’t know what they put in Cheetos. Is it heroin? Is that what they put in Cheetos? 

Julie Liegl (34:21.016)

You know what, Mimi, I feel very seen right now. Thank you. Thank you for validating my Cheeto problem.

Mimi Winsberg (34:32.482)

Your brain wants the easiest path, right? Instagram and Cheetos, they’ve come up with the perfect algorithm to make it easy and addictive. Watching Reels and eating Cheetos, it just doesn’t get less downhill from there, right?

Julie Liegl (34:54.146)

My dream Friday night, yeah.

Mimi Winsberg (34:56.114)

So I think you have to sort of encourage yourself in those situations to step back and say, right, okay, this is easy, but is it like having the drink of alcohol that causes the easy reduction and anxiety? Is this going to be long-term what makes me feel good? And yeah, I feel good after four or five Cheetos. I don’t feel good after a bag of Cheetos. I feel good after a minute or two of social media, but after 20 I feel horrible. As opposed to exercise where you feel horrible the first two minutes of running, but you feel great after 20 minutes, you know? And so think about the activity that’s going to result in the longer term better feeling, not the shorter term better feeling is what I would say there.

Julie Liegl (35:43.18)

Because is it dopamine that we’re looking for? Is that, like I keep seeing things that like, is it like I’ll look at cute dogs on Instagram and I will like shoot a little dopamine and that’ll offset?

Mimi Winsberg (35:48.178)

So I think there’s a little bit of a misunderstanding about the role of dopamine. I’m happy to clarify it. So dopamine exists in our brain to alert us as to when we are about to get a reward. So, you know, I mentioned how anxiety is obviously adaptive. We needed to be anxious about getting chased down by the saber tooth tiger, right? Or we would have never survived. But dopamine exists to help you remember where a reward is or to anticipate a reward. So if you found some berries in a particular area, then as you approach that area again, you’re going to get a little dopamine boost to remind you, there’s a reward around here. Or if something is associated with a pleasurable feeling, you will get a dopamine release in anticipation of the pleasure, not during the pleasure. It’s an anticipatory cue. And so it’s a learning thing. So dopamine reinforces learning because if something was associated with a reward in the past, you’re going to have a dopamine release when you’re in the vicinity of that potential reward again.  Social media is designed to give you intermittent rewards. That’s the most addictive kind of reward where you’re not sure you’re going to get it, but you might get it, and then you get a dopamine release. And so you stick with it. Just like the slot machine doesn’t pull up every time, but it’s intermittently rewarding. 

The animal model for this, of course, is that like, again, if an animal, if a rat can press a lever and get a pellet of food every single time, it won’t keep pressing the lever. But if it gets it intermittently, it just sits there and presses and presses and presses. And so we’re looking for situations that are a little unpredictable that intermittently reward. And the algorithm around social media is perfectly designed for that. 

Julie Liegl (38:09.272)

I think that helps come up with a way to like not only talk to myself, but also candidly going back to the prior question, talk to my kids about things like, yes, the iPad’s great, but not for six hours. Let’s talk about other things. 

I feel like we could literally talk to you all day, and at some point you’d have to start billing at least me for therapy and that would be a conflict with my current therapist and it would become a whole thing. So, Leyla, I think maybe we say thank you.

Leyla Seka (38:37.299)

Mimi is a baller and a wealth of information. Everyone should follow Mimi and pay attention to Mimi. She knows everything. Unbelievably helpful. Thank you. I can’t even say thank you enough. You are absolutely amazing.

Mimi Winsberg (39:04.402)

Well, thanks for having me. I’m so glad you guys are giving some lip service to this notion of middle-aged transition. We didn’t get into that that much, but I think it’s just, you know, it’s just you consider particularly the journey of women through life. It involves a whole lot of change in role and change in hormones. And I think not enough attention has been put on this. And I just look forward to having more attention on it and having more resources and education for people such that they can better navigate these stages of life.