One of the most common complaints I see in my practice as well is in the emergency department has to do with anxiety. When the COVID-19 pandemic started to ramp up in this country, the number of patients I was seeing in the emergency department with anxiety and panic-attacks spiked. The types of complaints typically associated with anxiety include chest pain, shortness of breath, nausea, abdominal pain, headache and even diarrhea.
One of the things I frequently hear from patients, when I tell them they’re experiencing these symptoms from anxiety is, “What are you saying, Doc, it’s all in my head?” The truth is it’s not all in your head. It is a physical, visceral, response to perceived danger. Anxiety is a normal human response to an abnormal situation. We all experience it in some way or another, and as we become exposed to more and more bad news or high risk situations, the most normal people in the world are going to experience high anxiety.
When we started evolving as a species amid the savannas of Africa, we were part of a very small family group, maybe up to 50 people at most. These were all the people we knew in the world. That group of people gave us place and position. We had a close and tight environment, our behavioral expectations were well known. In addition, the threats were fairly obvious. There might be a saber tooth tiger that wanted to eat you. Or, perhaps some large woolly mammoths are about to storm your campsite. These types of threats provoke a very basic, universal, response known as the “fight or flight response”. This response causes your heart rate to rise, your pupils to dilate, neck to feel very tight, your breathing to increase – blood gets shunted away from non-vital organs like the gut and the kidneys. This prepares your body to either fight the threat or run away from it.
But what do you do if there’s nothing obvious to run away from? What if the threat is existential or something un-nameable in your environment? One of the problems with today’s society is that we are exposed to the threats and dangers and tragedies that face the 8 billion people on our planet and more closely the 330 million people in this country. We are not wired to process that kind of information. Nor is our brain wired to understand that these are not people we know. A shooting at a nightclub in Florida feels just as real to any of us as if it happened in a nightclub in our own town. Our more primitive emotional brain cannot understand that Florida is an unfathomable 330 million people away from us.
In these cases, what will happen is that fight or flight response is going to translate into sensations in your body. This is because things are actually happening in your body. Blood is being shunted away from your gut so you might feel nausea. They muscles in the back of your neck are tensing for a blow so you might get a stress headache. Your heart is pumping faster and you feel like you’re short of breath as you try to get more oxygen to prepare to run away. You might feel chest pain. You might feel angry or irritable. It might make you tired and want to go to sleep. The important thing to emphasize here is that these are actually normal responses. People who have these responses are not crazy.
Often when I have people in my practice who are really struggling with the symptoms, to the point where they’re interfering in their daily lives, I will recommend treatment which ranges from basic exercise and meditation to medication. I always start with simple things like cardiovascular exercise, diet changes, and meditation. For some people these are adequate to control their symptoms.
However, for other people, these are not sufficient to make them able to function normally in this abnormal environment. I want to emphasize, this does not make somebody who takes anti-anxiety medications weak.
Without anxiety, none of us would get up in the morning to go to work, take care of our children, or take care of our basic daily necessities. Anxiety is the major driving force for all of our actions that build society. When we existed in small tribal groups it was people with naturally-selected higher levels of anxiety who worried about how much food we would have in winter, whether everybody had enough clothes, how the pregnant mothers were doing getting ready for delivery. In short, anxiety helped us survive as individuals and as a species. As a society, we still need these anxious people. We will always need people who worry about the rest of us and plan for the future.
Another thing I recommend is that people stop watching any kind of news. News operates on a “If it bleeds, it leads” premise, because we are hard-wired to pay attention to danger. That’s how they get our attention and make their money. When you watch bad news, and most news is bad, it goes directly into your limbic system without being processed first in the frontal part of your brain. This is pretty much guaranteed to trigger either anxiety or anger—in short, the “fight-or-flight” response. The frontal-lobe is the most recently evolved part and the best able to deal with problems. If you read the news, you at least get some processing from your frontal brain before it has a chance to go into the limbic, or emotional, part of your brain.
Having our fight or flight response constantly triggered leaves us in a high state of inflammation all of the time. It raises our cortisol (a stress hormone) levels, which makes us hungrier, more prone to obesity, more prone to eating sugary high-calorie foods, less apt to socialize, more apt to abuse drugs alcohol or other addictions to substances or habits, and more prone to diseases such as autoimmune disorders. There is also good evidence that also leaves us more prone to viruses and other infections.
So, what do you do? First, do all the things I recommended here:
o Read your news instead of watching it.
o Meditate for at least five minutes daily.
o Do 15 to 30 minutes of good cardiovascular exercise daily.
o Maintain daily contact with people in your life who make you feel uplifted and positive.
o Increase your community; join a church, club or volunteer organization.
o Rest. No seriously, take time for yourself where you sleep, relax and just allow yourself to be.
o Take a daily vitamin. Vitamin deficiency has been shown to increase depression and anxiety.
o Give yourself a break. Reframe negative self-talk to positive self-care.
o Reduce your social media time, and keep your contacts positive.
Finally, talk to your doctor (preferably me or another DPC Doctor) about what you’re experiencing. There are so many treatment options out there. If I recommend that you should get medication and therapy, please give it a chance. Unlike a traditional insurance-based practice, I don’t need get you out of my office as fast as possible with a prescription in your hand. We will discuss all the benefits and risks of the medication as well as potential side effects. I will work with you, to one get you off the medication as soon as possible, make sure we find the right medication for you, and to keep the medication dose as low as possible to be effective.
One of the benefits of being part of a direct primary care practice is, even if you have no insurance, your doctor is here to help you. There are ways to get inexpensive cognitive and behavioral treatment – which is been shown to work very well – as well as inexpensive medications to help you through periods of excess anxiety. There is no doubt that right now, in the middle of the COVID-19 pandemic as well as high stress politics in our country, we are in a period of excess anxiety.
Right now, stress and anxiety are high. If you are feeling it, this is not a sign of weakness. This is only a sign of being a normal human being in an abnormal environment. So, take care of yourself and let us take care of you!
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