Anxiety, simplified

I thought it would be good to return to a more “bread and butter” informational psychiatry post for once.  Consider this a drastic reductionism of a complex field.

Following the prior post about avoiding benzodiazepines, many have asked — What else can I do to feel less anxious besides take benzodiazepines?

The short answer is other (safer) medications, and/or psychotherapy.

Like any other blog post, this isn’t a substitution for medical advice, since there can be causes of anxiety that require medical intervention, such as hyperthyroidism. Make sure you get evaluated properly before trying to chalk your anxiety up to a “mental” problem. Even after that, it’s useful to see a professional who can help you tease out what’s contributing to it and the options to change how you’re feeling.

Anxiety usually refers to a common cluster of symptoms, such as shakiness, sweating, heart racing, panic attacks, restlessness, and just an internal feeling of nervousness. These are physiological aspects of anxiety. They occur during an activation of the sympathetic nervous system, the “fight-or-flight” response.  What evolved to protect us from something life threatening (Bear attack!) now activates to things that feel life threatening.  And then there are of course the emotions that those sensations add up to (e.g. nervous, anxious, worried, etc), and the thoughts we think in response to them as well (“I’m dying,” “this will never end,” “there’s something wrong with me”).

There’s different anxiety diagnoses, from panic disorder to generalized anxiety disorder to PTSD (sorta). A simple way to lump them, though, is to ask if the anxious feelings go on throughout the day, or only in short bursts (situationally or episodically). Of course people can also feel a baseline level of anxiety all day with short bursts of worsening (such as panic attacks) as well.

So let’s talk about Jack and Jill.

Jack was born anxious. He was a nervous kid, and he grew up to be a nervous adult. People just wrote him off as “that’s the way he is,” so he never explored if he could do things to feel different. Now as an adult he’s nervous all day long and his new girlfriend is telling him this isn’t “normal.” Jack comes in for an evaluation wondering if it’s “normal” or not. I tell him that “normal” is less useful than thinking about the terms “common” and “’healthy.” Anxiety is common. It isn’t necessarily healthy.

I go on to tell Jack about how meds work for someone with anxiety all day long, which is to lower the baseline level of nervousness, like turning the volume down on it. But it means taking a medication every day. Usually this is an SSRI (prozac, zoloft, lexapro, etc), considered the first line medication by most psychiatrists for anxiety. It’s taken at a scheduled time, and gradually the anxiety comes down. It’s not an instantaneous fix, but it lasts.

Jack and I go on to discuss ways that therapy can also help him, from challenging his thoughts that there’s something wrong with him or that bad things will continue to happen, to practicing ways to relax, to learning to control feelings that feel out of control. He might even try therapy where he thinks about his family relations as a the “cause” of anxiety (though I have a little less confidence in that). Over time Jack feels like he has more space to breathe and think, as his anxiety decreases. It takes some time and patience, though.

Jill is a young working woman who has never had any problems with anxiety or depression, but has never been particularly introspective, either. She just moved to a new city and after hearing about the dangers of some areas, finds herself wracked with anxiety whenever she steps outside. She just had her first panic attack, and is especially worried about having more. Even worse she’s been tasked to do public talks for her new job, and has a lot of worry about public speaking.

If someone has anxiety only episodically and feels completely normal in between these episodes, they might be able to get by with an as-needed medication. These are medications like vistaril (hydroxyzine), or in the case of phobias something like propranolol (a beta blocker).

Jill and I sit down for a talk, and we discover that anticipation is a big part of her anxiety. She anticipates how bad things could be. As do many people with anxiety. In many ways this is about fearing what might happen, which feeds the anxiety itself. So we have a talk about therapy, and how an approach like CBT might be able to challenge this anticipation, and break the habit of anticipating every bad thing that might happen.

There are of course exceptions situations where meds should be used more cautiously. Such as situational anxiety. As in someone didn’t have anxiety, and then something in their life changes, and now they’re feeling so much “stress” that they’re feeling anxious. I have several patients who have been in jobs that they hate, are overworked, but don’t have an easy way to leave it. The demands on them are overwhelming, from the hours to the workload to quotas. They are in a situation without an escape. So they tell themselves that they’ll just deal with it until things change. They don’t change their job, they just hope things resolve on their own. This is not usually a successful strategy. Anxiety can be taxing emotionally, and can lead to burnout. So in this case I’m a bit more cautious about prescribing a medication. I believe in relieving suffering, but I’m upfront with the person that it might just lead to tolerating an intolerable situation, which removes the pressure to figure out a better lifestyle. So in that case it’s their choice, and I encourage to look deeper at all of their options and make sure they’re not staying in a terrible situation.

PTSD is its own animal, though I still think about it in the anxiety spectrum. I’ll be writing a more complete post on PTSD soon.

For every kind of anxiety, medication can help. For every kind of anxiety, therapy can help. Using both together can help all the more. It’s just a matter of finding the right balance for the individual, something in line with what they’re willing to try.  We want to be able to engage the parasympathetic system, or challenge the sympathetic from taking over and snowballing in a way that’s hard to break out of.  This of course then should include meditation, relaxation exercises, even hypnosis, since they can all help with relaxation.

I may include some easy exercises in future posts that can help.


Not a Lab Rat

Minnie was forty years old, and came to see me in my office to discuss being depressed. She had felt depressed off and on for many years, but had rarely told anyone about it. It was like dragging a weight around. She could still get things done in her, just not quite as well as she’d like.

At one point she had told her family physician about this, and she was offered an antidepressant, lexapro. She took it for a few days, didn’t like how it made her feel, and stopped it. Her physician told her they could try something else, which might work better. She responded: “I don’t want to be a lab rat.”

Now of course the first thing I would tell her is that the first few days on antidepressants are not a good indication of whether it will work or not. There are potential early side effects that will go away, often within the first week. That isn’t the issue I wanted to address here, though.

I hear from people that they don’t want to be “experimented on,” or “feel like a lab rat.” As if doctors are purposely sitting in labs running experiments on their patients, for some other endgame. The only purpose of trying out different medications is to find what works for YOU. This seems to come from the expectation that the psychiatrist has to “try” different medications in an effort to find one that works.

It’s absolutely true that we do not know that a certain medication works. I tell this to people all the time. The current state of the science in medicine cannot predict if a medicine will work for you. What the research says, for example, is that in a group of a 1000 people somewhat like you, 30% got better on this. Which means 70% didn’t. We don’t have the science, quite yet, to be able to say which group you will fall into. So it comes back to trial and error. Even with a blood pressure medication, where we understand just about all the physiological changes occurring from the medication, only has the desired effect in 20% of individuals. And again, we don’t know which 20%. So meds are often combined to get the desired change in blood pressure.

“Personalized medicine” is an emerging approach, where factors like genetics can be used to predict if someone will respond to a medication. We’re juuuuust beginning to crack this area, such as with tests for the blood thinner warfarin. We can identify who might be sensitive to it, and who might not respond. We’re still some steps away from being able to reliably do this in the field of psychiatry, but it’s well on the way. Ideally, a finger-prick blood test will be able to tell us whether a medication will benefit you or not. That will still be a far distance away from understanding and treating all aspects of depression, but maybe it’ll help people stop believing their doctor is experimenting on them.


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