Really great question. I appreciate your concern. I can totally see what that would be scary to you. I think it is important that you keep your therapist in the know. Topics related to suicide are one of those limits to confidentiality, but a lot of people misunderstand what that means. That doesn’t mean that if you have a single thought about suicide, that you will no longer have any right to confidentiality and you will be whisked off to a hospital. It means that if your therapist or doctor recognizes that you have an intent to kill yourself or you are at high risk of doing so, they can initiate a psychiatric hold to get you the immediate help that you need. BUT it’s something that therapists and psychologists understand exists on a continuum. There’s a big difference between having the flash of a thought of suicide that scares you and the last thing you want is to die vs feeling like you are just a burden on the world and planning to kill yourself to help everyone else.

These could just be fleeting temporary thoughts that don’t really have any huge implications. But it’s important to keep track of them. You don’t need to blow them up and make them super super important, but just be aware of how you are doing. That is how you could present it to your therapist. You did a great job of explaining yourself to me in this question. You could just say that you are doing relatively well altogether, but you’ve been having fleeting thoughts of suicide that startled you. You could tell them that you are nowhere near killing yourself (if that’s true), but you just wanted them to know what is going on with you so that you guys can keep track of it.

If you haven’t yet, practicing some mindfulness exercises might be really useful. Mindfulness exercises help you to stop fighting back and trying to force unwelcome thoughts out of your mind. Instead, you can practice acknowledging that they are there, but not giving them so much weight. Just let them be in the background with all of your other thoughts and focus instead on what is right in front of you. I have a video all about mindfulness on youtube and a blog post about it.

Hey Dr Duff, I bought your book the other day. It was helpful but I need so much more help. I’ve been having anxiety attacks since I was 19 (off and on with much time without any panic attacks). I’m 39 now. Currently I have been having these daily episodes of anxiety and worry with strong mental and physical symptoms which either can start first. I say I’m not going to let the mental triggers in my mind all day then I’ll get to the afternoon and boom I’ll have a big physical anxiety initiator (such as laying down to relax and I feel my heart beating like it’s on it’s last beats with tingling sensation on my heart and chest) and then that makes me doubt mentally if it is real. Anyway, this has never happened to me before where I have this feeling reoccuring throughout the day everyday with 1-2 panic attacks. I’ve been to my doctor to run tests on my heart and have one more series to go EKG with Stress Test. So far the CT Scan Cardiac Score came back phenomenal. This is so scary to be daily!! All of the things I’ve read on anxiety seems to be random but this has grown to a daily haunting.  So tired of dealing with this fight every day (even on vacation at a resort with low stress environment). I’m out of bed at 12:10am writing this because my heart which feels enlarged is 10X on my mind while trying to sleep. This has gone way past the panic I’ve felt in the past and now feels like a full blown daily phobia. One last thing interestingly I do have knotted muscles in my chest (I’m an athlete). I noticed through my wife rubbing my chest and trying affirmations with me that I have a shit ton of emotional connections in those tissues and every time she does this it makes me want to break out in tears. Thank you so much for listening! Also I’m curious if there is anyway I’m literally losing my mind and if this level of issue could cause a heart problem? Grateful for your work, Robbie.

Hey there. I’m glad that you wrote this question because I think yours is an experience that a lot of people could relate to. It sounds like you have crossed the threshold from having occasional panic attacks to having panic disorder. Panic disorder is essentially like a phobia of panic attacks. So you have an attack and then you develop a strong fear of having future panic attacks.
You become super sensitized to the idea of having panic attacks. And so when you start to get any symptoms that seem like panic in your mind, your body blows them up and reacts even more strongly. Typically this leads to avoidance of situations that are likely to elicit a panic attack. Maybe that’s avoidance of public places where you have no “escape” or avoidance of the gym where your heart will be working hard.

Listening to how you’re talking about this, I really think that you could benefit from short term therapy to help deal with this. Basically, you are going to need to build tolerance to the sensations of anxiety that you are having and learn to call bullshit on your anxiety. Rather than giving it power of your life to make you stop in your tracks and avoid things, you need to be able to reduce your sensitivity to the sensations that you are having. Have you ever had ants in the house? I don’t know about you, but I get this experience where if I know there are ants and I am thinking about it, I feel like there are ants all over me even if they aren’t. Our minds are great at taking a small sensation and amplifying it. Likely you’ve had some of these sensations the whole time, but since you started having panic attacks, now your mind is holding a giant magnifying glass up to them. The anxiety component is your catastrophic associations with them. You assume that they are a sign of something dangerous.

In addition to my book, the Anxiety and Phobia workbook is more dense and in depth. My course would also be super helpful for you. I actually just reopened the course for enrollment, so you could definitely check that out for additional step-by-step guidance. Again, best case scenario is that you get some therapy. Short term cognitive behavioral therapy has really good outcomes for these sorts of issues. It’s great that you have been doing the leg work and ruling out real physiological issues. That’s the first step. Now you can be a little more confident that there is not something that’s going to harm you (anxiety will not harm you) and you can use that knowledge to push yourself to gain that exposure and build that tolerance.

Here’s what I’d suggest you do. First go to amazon and get the anxiety and phobia workbook. If you haven’t yet, also go to duffthepsych.com/guide – that will give you my anxiety quickstart guide and in the subsequent email you get, you also get my common thinking traps mini ebook as well. Those should get you started on the right path. If those aren’t doing the trick or you are simply ready to hit this hard, get yourself some therapy.

Hi there,

Bought your anxiety and depression book, and have worked mostly through the anxiety one.  Been listening to the podcast lately as well.  Started with the oldest episodes, so hopefully I’m not asking something that’s already been answered.  If so, kindly point me in the right direction. Maybe there’s a chapter in the depression book too, but I haven’t read it just yet.

Anyway, my main question is in regards to depression and its potential link to pornography and masturbation.  I dabble in some psychology reading, so the concept of dopamine and all that isn’t new.  I’m wondering if it’s possible that my use of pornography is heavily contributing to my depression because it’s upping the threshold for pleasure, and thus, “normal” activities aren’t as satisfying.  I tried to quit porn, and I think I made it a week or two, but the depression seemed to get worse during that time (withdrawal symptoms of sorts?).

I want to give it up for good, because I do think it’s detrimental to my life, but I just don’t know how to go about it other than cold turkey, which proved somewhat difficult.  I don’t know if you have any recommendations for a plan to quit porn, but I’m open to suggestions.

If you do happen to feature this on the podcast, I would love it if you’d let me know, since I’m about 2 years behind, having just started listening recently.

This is a really interesting question. Thank you for writing it in. I want to first make my stance on porn clear. I’m a pretty sex-positive person. I have absolutely no moral issue with porn, kink, sex work etc. So the porn itself may not carry the same amount of weight for me as it does for you. I think this question may involve a bit of correlation vs causation. What I mean by that is just because two things tend to co-exist together does not mean that one causes the other. Causation can only be reasonably determined through controlled experiments.  For instance, the classic example is that there is a significant correlation between ice cream sales and violent crime. Does that mean that ice cream causes people to get violent? Possibly, but probably not. More likely, ice cream sales go up on hot days and tempers also tend to flare when it’s super hot out.

When you are bottoming out in depression, you do have a tendency to move toward things that give you a quick shot of dopamine. Drugs, sex, porn, and other intense experiences. I doubt that the porn is making you less sensitive to the excitement of other things. More likely it’s just that it’s one of the only things that breaks through all the static in your head. When someone has strong depression, especially the type that is very physiological, the chemistry of the brain tends to look different. There’s a sort of cycle that happens. I describe this in my book F**k Depression. Basically, you start to lose motivation and at a certain level, the feeling of pleasure that you derive from things gets dulled. This is called anhedonia – literally inability to feel. That usually causes you to DO less. You engage in less activities, even those that may have been pleasurable to you before.  When you do that, you produce less of the neurotransmitters that are associated with pleasure and reward, such as dopamine. When your receptors notice that there is not enough of those neurotransmitters to justify them remaining open for business they start to close down.
When that happens, even something that does cause pleasure or excitement will fall flat. So I think it could be that this is happening to you and it’s just that you are now in a place where it takes a really strong basic reward like sex or food to break through that cloud.

There are many treatments for depression. One of them is called behavioral activation. This is where you basically force feed your brain with activities that should be pleasurable to you. Things that you used to enjoy and benefit from. I don’t really have any suggestions about how to quit porn because I don’t actually know if it’s necessary. Instead, I think that it could be useful for you to focus on the other side of the equation, which is pushing yourself to heavily engage in non-porn activities. Write down a list of all the things that used to be interesting and engaging for you. Things that used to provide you with some reward before your depression was so oppressive. If you can’t think of anything look at what your friends do and write down some activities that they seem to like. Then you just treat it like a job. Make a point to schedule in time for you to do these activities each day. When you begin to do these things even if you don’t want to, you can start to actually retrain your brain to feel pleasure again. If you are having a hard time getting moving, you can try using the 5-minute rule, which I describe in my book and also at http://duffthepsych.com/doitanyway So if you want to stop porn, go ahead. But if you try to stop porn cold turkey and don’t do anything to replace that, you are going to probably just fall back into the cycle. And of course, if the self-help efforts are proving to simply not be powerful enough to make the difference that you need, it may be time to look into therapy and/or medication. I have a lot of information about how to do those things on my website.

Thanks for listening!

Interested in having Duff answer a question on the podcast? Email Duff at robert@duffthepsych.com and maybe you’ll hear it on a future episode!

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