ANXIETY
"Fear has no brains. Fear is an idiot."
Ambrose Bierce in "The Moonlit Road," a ghost story.
"The only thing we have to fear, is fear itself."
Franklin Delano Roosevelt (1933 inaugural address)
migrant worker displaced by the dust bowl
by Dorothea Lange, 1936
"The best laid schemes o' Mice an' Men,
Gang aft agley,
An'lea'e us nought but grief and pain,
For promis'd joy!
Still, thou (to the mouse) art blest, compar'd wi' me!
The present only toucheth thee:
But Och! I backward cast my e'e,
On prospects drear!
An' forward, tho' I canna see,
I guess an' fear!"
Last lines of Robert Burns famous poem: TO A MOUSE: ON TURNING HER UP IN HER NEST WITH THE PLOUGH, NOVEMBER 1785.
Those who have already read some of these pages (e.g.The Meaning of Mind, Electroshock "Therapy") know that I do not believe in mental illnesses.
Anxiety, despite its categorization as a psychiatric condition by the powers that be (see scrolling banner below), is not a mental illness. Nor is it a disease.
Anxiety is a physical state of heightened autonomic nervous system activity (the central nervous system is first divided into the voluntary versus the autonomic) characterized by a myriad of very physical sensations, universally familiar to human beings.
PHYSIOLOGY
Agitation at a cortical level - stresses of all sorts - activate the hypothalamus at the base of the brain, the link with the ancient neuro-endocrine network of autonomic nerves to glands and viscera.
The hypothalamus secretes releasing factors down neurons to the pituitary where that small but powerful master gland hangs from the bottom of the brain, directly behind the bridge of our nose.
The pituitary in turn releases, among other hormones, ACTH, adrenocorticotrophic hormone which, circulating in the bloodstream, reaches the adrenal glands over the kidneys and causes them to increase production of adrenalin.
Our bodies are being prepared to fight, flee or feign death - there could be a dinosaur in the shadows even if it's just the boss having a bad day.
The heart increases its output, experienced as pounding or palpitations. The respiratory centers in the medulla, the most ancient of brainstem centers, are stimulated and we experience "air hunger," the sense of not getting a satisfying breath of air.
Imperceptibly, we begin to take deeper, faster breaths. Perhaps we sigh. Or yawn.
Now, if there really were a dinosaur to deal with, the increased respirations would expel the extra carbon dioxide and water, the final products of the combustion of glucose.
But if we just have to sit there and take it, overbreathing, even one breath a minute, sixty an hour, can lead to a slight relative deficiency of carbon dioxide. The deficiency of this negatively charged ion leaves the blood to basic or alkaline.
This condition, called alkalosis, is a true "chemical imbalance." Alkalosis distorts perceptions. It produces dizziness, lightheadedness, tingling of the extremities and around the mouth, tightness in the chest, sometimes a feeling of choking, the quaintly named but factual "globus hystericus" or hysterical ball in the throat. It feels like a child on the verge of tears. It may produce "autoscopy," the sense of being outside oneself looking in.
And accompanying all the many and varied and very real physical sensations, is a sense of rising panic, of impending doom, of something dreadfully physically wrong that no one can figure out.
Almost every patient has already thought of at least one or two nightmare diagnoses.
This apprehension acts to further agitate the nervous system amplifying the reaction, producing a postive feedback loop otherwise known as a "vicious circle."
DIFFERENTIAL DIAGNOSIS
This is what I get paid to do: be sure the symptoms aren't due to Multiple Sclerosis, B12 deficiency, complex partial epilepsy, pheochromocytoma, hypo or hyperthtyroidism, toxic encephalopathy, Lyme disease or any other truly pathologic cause for the anxiety.
TREATMENT
Not being a disease, anxiety can be "treated" only in the most metaphorical sense: with advice.
1. A careful, thorough workup prior to discussing the impression is essential if there is to be any trust. Anxiety is a "diagnosis" of exclusion: all other causes need to be excluded first.
2. Then I'm candid with my "impression," which remains just that. My "impression." If the patient is receptive and is interested in advice I BEGIN WITH:
CEASE AND DESIST:
from any overbreathing including habitual yawning, sighing, lamaze breathing, dragon breathing, going "oy vey me" on the exhale or just taking big breaths to "getting more air."
If the impression of anxiety is correct, more "air" is the last thing needed.
Many people slip unawares into the habit of sighing. Partners and co-workers may have commented. I suggest that the patient recruit partners and friends to bring habit to attention.
"Who do you trust, me or your lying eyes?" - Richard Pryor
But don't take my word for it. Test my theory by waiting for a time when the symptoms are very bad then re-breathing 10-15 ordinary breaths in and out of a paper bag. This will work the first time to reduce symptoms of alkalosis such as facial numbness, tingling hands and feet, but like all such strategems, it will not work every time.
4. Initiate/resume aerobic activity. When you feel like running, run. I'll bet the symptoms aren't very annoying while walking with maximum effort up 3 flights of stairs.
Aerobic activity increases the body's output of carbon dioxide - increased respiratory rate is essential. I've seen people develop hyperventilation almost as a replacement for exercise after a disabling injury or operation. Get back to aerobics.
5. Reduce or eliminate stimulants such as caffeine.
6. I have no problem prescribing a small number of a fast acting sedative, usually a benzodiazepine such as Ativan. I offer them but I'm careful not to encourage for the simple reason that like re-breathing from a paper bag, taking a pill works only for a little while and then stops working.
7. THE FINAL SOLUTION:
Finally, there is another medical, or more properly, neurosurgical solution, proven to work for anxiety - a complete "cure" in fact - which as of the end of the 20th Century, is in discredit and disrepute.
I mention it for those interested in the all-too-recent history of psychiatry, and those concerned in protecting the human brain from utopian zealots with M.D. degrees.
Lobotmy is just the ticket for anxiety. It's a proven fact.
LAST BUT NOT LEAST
7. The doctor must keep an open mind. "Impressions" are just impressions. They aren't cast in concrete. I'd rather say I was wrong than I'm sorry.
I have people return once for follow-up (I am opposed to inducing dependency and besides I can say all I know in two visits) and an EEG if indicated.
The EEG should be perfectly normal even during intentional hyperventilation, - or, at most, a "youthful" voltage buildup and slowing is associated with the subjective complaint of dizziness. As noted, this results from an existing (pre-existing, btw, is a tautology) low grade alkalosis.
If the patient is not improved at followup, the EEG abnormal or new symptoms develop I will get an MRI brain scan and labwork, ranging further afield until the patient is better or I'm out of ideas. Or I refer to appropriate specialists e.g. endocrinologists if pheochromocytoma is suspected.
As noted in the "Differential Diagnosis" above, the list of real physical conditions which can mimic and/or present as anxiety is enough to give one an anxiety attack just reading it but it should be conscientiously reviewed, with the patient if the patient is interested.
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