Maybe it's all just anxiety after all

I graduated medical school eight years ago. I've been practicing psychiatry as an attending for the past three years. I'm definitely still fresh out of the water and onto land in my evolution as a doctor. I have not seen it all or heard it all. Yet my experience is pointing me towards an interesting understanding of the world. As I'm working more with patients, myself, my friends, and my family, I'm seeing the world particularly through the veil of anxiety. Not so much my own anxiety, but more that almost everything can be explained in some way by anxiety. What is anxiety? Fears, worries, nervousness, overwhelming sense of dread. Everyone feels anxiety at some point. I feel anxious Sunday night, worrying about the week I have ahead of me. I get anxious before a test or a performance. Anxiety is adaptive. It's an evolutionary advantage. If we didn't feel anxiety, we wouldn't know when we were in danger. If I didn't feel anxiety before a paper was due, I'd never finish it. There are many anxiety disorders in the DSM. I can't say this for certain, but I think there are more disorders that fall under the header of "anxiety disorders" than any other. There's generalized anxiety, social anxiety, PTSD, ATSD, separation anxiety, OCD, specific phobia, selective mutism, hypochondriasis, symptom anxiety syndrome (is that it's real name? I might be making that up), panic attacks, agoraphobia. The list goes on and on. When I'm asking patients about symptoms of anxiety, there are so many subtle hints. People who have headaches, or stomach aches. Kids who refuse to go to school. People who get so overwhelmed by everything they shut down. Sweating. Easily frustrated. tearful. Won't leave the house. Etc, etc, and so forth. When I look at my own anxiety, I've recognized it as a short fuse. I get so easily overwhelmed. I'm on high alert. Everything feels like an attack on my senses. I can be fine with a level of noise, then get overwhelmed, and all of a sudden I can hear every sound around me as if it's in stereo. If there are too many people around me, my sense of touch goes haywire, and I feel every brush of someone as if it were a slap. I get so tense, as if my every nerve fiber is taut. I want to scream, I can't breathe, I can't think, my ears ring. My mind races with "I've got to get out of here." Everyone has a fight or flight system. This is the part of your body that says "hey there's danger, you want to kick it's ass or run away?" Without your conscious awareness, your body prepares for this. Your heart starts pumping faster, your breath is more shallow, your digestive system goes on hold, your muscles tense up, your vision becomes more narrow. Everything is ready for whatever the danger is. Once the danger has passed, your body goes into rest mode. You're tired, your heart slows down, you might need the bathroom. The problem we see with anxiety is that your fight or flight is always going. Your mind thinks everything around it is dangerous, whether it truly is or not. And with our evolution, we're in different types of danger. We're rarely faced with a predator that we have to flee from, but our brains have decided that going to school when we're anxious is just as dangerous. And if our fight or flight is always going, we can't recognize when true danger is around. This level of hyper-alertness is exhausting. I so often hear my anxious patients say they feel tired all the time. It's understandable, given how much energy goes into the anxiety response. Both physical and mental energy. It takes so much work to be worried all the time. It uses up so much of your energy stores to feel tense, alert, and waiting for the next danger. And then, when it's finally time to sleep, and your defenses are lowered, the anxious thoughts start in. The tossing and turning. There's no break from it. So much of this happens on an unconscious level. We might not even know what the perceived danger is. All of a sudden we just feel it, headaches, stomach aches, tense, tired, sensory overload. The symptoms are different for everyone. And our unconscious minds do an amazing job of protecting us from these dangers. The amount of information our unconscious minds can take in, that are never put fully into our awareness, is amazing. But that makes it harder for us to realize that our mind has picked up on some bit of danger, and sets our fight or flight back into action. Information can be mis-perceived as danger. We see this with trauma responses. Someone who has experienced a truama often has what we call hypervigilance, or increased startle response. You see this when someone jumps up when they hear the smallest noise. Or need to constantly have their back to the wall when sitting. They're constantly looking over their shoulder. They think something bad is always right around the corner. And can you blame them? They've lived through something that was bad. They relive their bad situations. They feel like they're constantly triggered, but don't always have in their conscious awareness what that trigger might be. It could be the anniversary of the event, and they've buried it so deep they don't remember. But the body remembers, and acts up. We also see this in people who live in constant chaos. Multiple adverse life events can affect people the same way one big, terrible trauma can. We don't always recognize it for what it is, because we aren't always getting that history from someone about multiple small attacks to their safety. And we don't always recognize that something happening now is being perceived as a threat to safety by the unconscious mind. For instance, an child of a single parent might do really well when that parent remarries, but then start acting up when a new sibling comes around. That child's mind is telling him that he's being replaced by the sibling, and even though they might be very excited on a conscious level, their unconscious level could be stirring up trouble. Without the ability to recognize what is making the child feel uncomfortable, they might start acting out, having more explosive or angry behavior, and truly not know why. So often I have anxious patients tell me they feel paranoid. We generally think of paranoia as a sign of psychosis, but it's a mis-perception of the danger around us. Some anxious people think people are following them, or watching them. They perceive judgement from strangers, and misunderstand cues happening around them. On a lesser level, we see this when we think our boss is mad at us for something, and then every interaction with our boss that day can reinforce that, the wrong look, them not greeting us like usual, or being called into their office. More often than not, it's nothing. On a larger scale, people can think that the government has installed cameras in their house to monitor them. And in between is a level of anxiety driven paranoia that wouldn't be considered psychotic. I think the same can be said for certain hallucinations. Many people say they hear voices, which is usually a sign of psychosis. Sometimes though, that is also just our mind playing tricks on us. Or, our mind protecting us from our feelings/anxiety, because we've taught ourselves that feelings are dangerous, by convincing us there are voicing saying all of the negative things we were thinking. Mood swings and lack of sleep are the same. If we're too anxious, we can't sleep. Our bodies will keep us up for days if they think we're in danger. When we don't sleep, we definitely start losing our grips with reality. And when we're too anxious, we can't always manage our moods. One minute we can be fine, the next something throws us completely over the edge. How do we make this all better? Treating anxiety can decrease a number of symptoms we weren't even aware we were having. By improving our self awareness, we can recognize our triggers and responses. We can then adjust how we respond to our triggers. We can also use mindfulness and meditation to "reset" our fight or flight system. Exercise is a fabulous way of doing this. We physically wear out our bodies, make them stronger, increase endorphins, and lower our resting heart rates through exercise. Therapy gives us tools to be able to recognize and mitigate responses. In my own life, recognizing how my anxiety manifests, and how that might be different for others, has helped me become a better provider of care. It's also helped me understand myself and find tools that can keep me healthy and happy. I still, and will always, have anxiety. But through a combination of medication, therapy, and healthy living, I'm able to say I have better control over it. I hope that through education I can help others feel the same way