Anxiety Everywhere

But Are We Helping? Or hurting?

Photo by Nik on Unsplash

I have had issues with anxiety in my life. There were times when I was anxious almost to the point of physical illness, with racing heart and squeezing chest. I think I can trace the genesis of some of this. For instance, my maternal grandmother once asked me, as a small child, “Edwin, wouldn’t it be awful if your mommy and daddy died? What would you do?”

I have no idea why she asked that. I loved her. She was doting and brother could she cook! But she was often cruel in word and deed. I feel a short story coming on about her someday. She was a wonderful character for Southern fiction.

I suspect that she did similar things to other members of my family at large, for whom anxiety is a constantly running program, always on in the background.

I myself was frequently anxious that something would happen to my parents, or my friends, or later my girlfriend. In college I was anxious about getting into medical school. (Premedical students are whirling balls of neuroses…) Later, when Jan and I married and had children, I was terribly anxious about my family’s safety. When I was working and would hear EMS tone out for a car crash, I would call her frantically to ensure that she and the kids were safe. My anxiety was truly terrible when Jan suffered a rough bout of cancer therapy, followed by an unexpected and life-threatening pulmonary embolus.

I remain anxious, at times, as a physician. Emergency medicine seems, on first pass, a bizarre choice for someone with anxiety. After 30 years in practice, there are some things that still fill me with a bit of trepidation, although I can navigate them. Oddly, I find that many of my colleagues are also anxious but seem to enter the specialty as a kind of therapy. It is a perhaps a confrontation of, and preparation for, their worst fears…loss of loved ones or inability to control dangerous situations. As a group we detest feeling powerless, or lacking understanding of something we might have to fix.

Fortunately Jan is a trained counselor and a good one. Decades ago she helped me to tamp down the intrusive, fearful thoughts. She taught me to recognize when I was ‘catastrophizing,’ imagining the worst possible outcomes for no good reason. She loved me despite it all.

She also encouraged me to see a Christian counselor who really helped me to dive into scripture and see where I was simply thinking incorrectly about a number of issues. His name was Jim Stephenson, may he rest in peace.

(I sometimes reflect on the wisdom and comfort Jim brought me from the words of the Bible; words available for free to so many who struggle. I think also about how modern people with resources, with money, with degrees, with recreation so often want to “liberate” the masses from what they see as their religious opiate…even as there are no other options for them, lacking money or insurance to seek the frequently unavailable psychiatrists or counselors and thus often turning to drugs or alcohol in despair. Seems rather mean if you ask me, whatever one may believe personally…)

Now, as I approach 60 years on this earth, my anxiety level has dropped dramatically. I joke with colleagues that my body simply can’t make adrenaline anymore. I’ve used it all up. But in fact, although I still have my moments, I’ve come to understand just how little I can control. Recognition of this makes anxiety less of an issue for me. It is a nice transition into my later life. (I mean, I’m a late Boomer/early GenX, so I still worry about commies. But what can you do?)

All of this is to preface what I’m about to say, which is that I am troubled by the level of anxiety that we see in healthcare today. I don’t have time to address the way it afflicts my colleagues. Trust me it’s a huge problem. But I want to talk about anxiety among our patients.

It is well known that we are in the midst of an epidemic of anxiety. It appears about 50% of young adults aged 18-24 may have anxiety and depression.

https://www.kff.org/mental-health/press-release/latest-federal-data-show-that-young-people-are-more-likely-than-older-adults-to-be-experiencing-symptoms-of-anxiety-or-depression/

Certainly COVID did its damage, but doubtless other forces are at play. There are factors like social media, family dysfunction, drugs, alcohol, or physical or sexual abuse. The causes are clearly legion.

When I ask patients their medical histories, anxiety is one of the most common conditions they list. And it isn’t only young adults but children, the middle aged, and particularly seniors who are often sick for other reasons as well, with their plights compounded by poverty and loneliness.

People of all ages come to us quite literally shaking with anxiety, hearts pounding, gasping for breath. Frequently without particular inciting events; anxiety of course does not need one. It just is.

Many times they come with severe headache, chest pain, vomiting or abdominal pain. They have been shaking enough that their families worry about seizure or stroke. They are temporarily confused. We look diligently for medical causes. And at the end, when the somatic tests are negative, they say ‘well, I have been under a lot of stress.’ They have somatisized so much of their stress, have lived so long in negative, toxic thoughts, that their bodies can barely handle the strain.

(Admittedly, emotional stress can cause severe physical problems. For instance it can cause heart disease in the form of ‘Broken Heart Syndrome,’ or Taketsubo Cardiomyopathy, which causes impaired cardiac function due to stressful events. https://my.clevelandclinic.org/health/diseases/22022-takotsubo-cardiomyopathy)

I feel badly for those struggling with anxiety. Not in a pity kind of way, because I have been anxious. Not in a dismissive way, because I know that the symptoms are real. And I know that help is often hard to find. But I also worry about the wider implications.

I worry about children and young adults who are so paralyzed by their anxiety that they simply can’t function. So fearful that they call out from work with regularity. So impaired that they stay at home, streaming movies, eating poorly, not exercising, not interacting, glued to screens in hope that the escape will bring solace. Or sometimes using marijuana which for a great many only makes the anxiety worse. These people will struggle with functional relationships and with raising children. Maybe this is one reason why I see so many seniors raising their grandchildren. (Illicit drugs likely the main issue there.)

I don’t know what to think when otherwise healthy young men and women are reduced to quivering and tears. Sadly, if they can see a professional, they will go from prescription to prescription in hopes of a cure. No, not a cure. It seems that nobody is now cured from a mental health disorder. They’re just given a new diagnosis. All of it becomes a kind of toxic, hope-crushing identity.

I wonder, too, what we expect as a society. What do we do when what is usually a productive segment of society is so afflicted by anxiety as to be nearly non-functional? What can we do when otherwise physically well people are unable to go out, or work, , unable to care themselves for anyone else?

Does this mean that someone else will have to step into their roles and responsibilities when they simply can’t do anything due to the profound debility of their anxiety?

I think a lot about the idea of survival. (No, I dont have a bunker…just a compound.) Our ancestors understood that every day was a day which could go very wrong, either from illness or injury, from famine or plague, from war or raid, from weather or wild animal. I suspect they were often anxious. But society wasn’t so forgiving. There was no option to simply stop doing. No real option to simply escape if one meant to live and meant for one’s family to live as well. There was no clinic, no ER, no pharmacy.

How does anxiety play into survival? A certainly level must make us more likely to survive. A certain level clearly makes us unfit to navigate danger or duress.

I think also about what the medical and mental health profession has done. Have we been the problem? Has our rush to sympathize and diagnose, our rush to categorize and prescribe been behind what I see?

We physicians hate to disbelieve anyone. We are taught to believe our patients, to offer them empathy. The very idea of suggesting that many of these patients don’t truly have a condition but simply have a thing common to all humanity, to suggest that their inadequate coping skills are the problem, not a thing on the DSM-5, is odd to physicians. In fact, to suggest something so radical might be to call down the wrath of other professionals.

And so, we have an ever growing list of mental illnesses and inclusion criteria because after all, those people need something to call their problem and something to take for it. As one of my medical school professors once said, ‘OK, if you don’t give people a prescription, they’ll think you’re an idiot!’ Sadly, he spoke some truth there.

Has the pharmaceutical industry contributed? Without a doubt. Drugs need diagnoses. It is symbiotic. A drug without a diagnosis is a corporation with less money.

We once were told that everyone with pain should be assigned a pain score, and that we should never hesitate to believe that score and should give them an opiate. Like the awesome and oh so safe Oxycontin. I was told in training, ‘you can’t create an addict in the ER.’ It appears we were wrong.

Could we have done the same with mental health as a profession? Could we have medicalized widespread anxiety, a thing common to all humanity and thus made it, well, ‘popular?’ We’ve certainly medicated it, over and over again. Have we even begun to consider the consequences?

We know that we overprescribe antibiotics, with terrible consequences. I see it too often done when there is no clear infection, simply mild cold symptoms or rash. ‘Here, take this for your fever.’ And yet the right thing is ‘source control,’ what’s the source of the infection? Where is it? Does it need to be opened and drained? Why does it keep happening? Maybe the same could be said of anxiety. We should ask ‘what is the source in the mind of the afflicted?’

So, have we ever considered, seriously considered, the idea that talking through a thing, learning to deal with the way an anxious person thinks, might be much better than handing out just one more pill, followed by another and another? I have enormous respect for those working in mental health; but I think their patients need to learn that thoughts aren’t wild animals we can’t control, but things to shape and bring into line with reality. A wilderness that can be made a garden of delight.

Have we made anxiety itself desirable, a kind of team to belong to? Have we, in the process, crippled a generation of people who might otherwise have moved on through their anxieties and been better for the struggle? Substack writer Freddie DeBour has written about this at length. His insights are profound and worth following.

A Broken Model of Brokenness

Anxiety can be terrible. I don’t wish it on anyone. But in order to survive as a nation, and as individuals, we need to recognize that 1) our culture makes it worse on many levels, 2) the healthcare system may do as much harm as good and 3) people need more than prescriptions. In particular they require connection, talk, counseling, physical activity, reduced time on social media, purpose and also a sense of transcendent hope.

Otherwise, in a world of stressful events, in a world of bad news, war, crime, disease, abuse, rampant pornography, drugs and all of it delivered every second to our phones, we’ll simply have so many anxious people we may just grind to a halt.

Edwin