Staying Sane in Insane Times

“The end is nigh” I say under my breath as I see articles about the spreading wildfires in Colorado and California, read headlines about continued covid cases, see that hurricanes and tropical storms are bearing down on us, think about the draught, police brutality, homelessness, unemployment, online schools, and whatever else is out there right now (what happened to the murder hornets?) threatening the safety of the world and its inhabitants. I grew up attending religious school. Catholic school by week, Islamic school on Sundays. We learned a lot about the apocalypse, end of times, whatever you want to call it. As I watch the news unfold, I can’t help but notice a link to the stories in the testiments and Quran about how the end will come about. I have a sinking feeling of dread every time the news is on. If I let my mind wander too much, I worry that we are reaching the end. How will it all end? Will there be some survivors, or none? This leads me to wonder, what is the point of all of this? Should I bother worrying if nothing actually matters and we’re all going to die soon? This is definitely starting to leak into my daily life. Looking into the future, a small part of me thinks that everything is futile. Should I recycle? Is there any chance of saving the world now? Do I need to save money for my daughter’s education, or will we all be gone? Will the world end tomorrow, ten years from now, or a thousand years from now? I’m finding it harder to work with my patients who are worried about day to day problems, when I don’t think the world is going to survive. I have a young patient with autism who has been struggling for about a year now with suicidal thoughts in the context of not thinking there’s a point to living. Never has active thoughts, just questions about what the point is, why we’re alive, and why it’s necessary to feel pain. We call it the existential crisis of their time. It’s been hard for me and the parent to walk the patient through this, and increasingly I’ve felt helpless in trying to figure out a way to explain to this patient why they shouldn’t feel hopeless. And yet, even with all of this “end of the world” nonsense, I still find myself happier than I’ve ever been in my life. Things seem to be going well for my small family, with no major set backs. The stress though, seems to weigh on me. THe constant fear of something bad happening, or the stress of caring for people under stress, or the uncertainty of it all, can sometimes get to me if I’m not careful. And I can only imagine how hard it’s been on everyone else. So how do we manage and keep our sanity. The answer to that is different for everyone of course. However, I think there are common themes we can hold onto. 1). Try to create some form of structure in your day People really don’t think about how important structure can be. We all think it would be great to live a completely carefree, unscheduled life. The truth is, most humans strive off structure. We need some sort of routine to get through our day. Kids in particular need structure, and they need someone to help provide it for them. Work and school are great in providing a sense of structure and stability. We know when we have to get up, how to get ready, when we need to leave, what’s going to happen through the day, and when we go home. This has been one of the hardest things for us to give up. So if you don’t have school or a trip to the office to provide this for you, make a schedule for yourself each day. It doesn’t have to be as strict as it would be if things are “normal,” but something to keep you realizing that today is a separate day from yesterday, and this moment is a separate moment from the last. Otherwise everything feels monotonous and pointless. I like to tell families to wake up at the same time every weekday (even if it’s a little later than it would be for school), get dressed, eat breakfast together, and do something that signals the start of their work/school day. This could be going for a walk, or getting all their work organized. There should be a space that is dedicated to home work that is (if possible), different from where you eat, have fun, or sleep. You should hang out in that space during “work” hours, and set times for how you’ll get work done, breaks you’ll need, and meals to eat (no mindless snacking! Set meal/snack times!), and a specific end of work time. Once it’s end of work time, do something to signify that your day is over (like another short walk). Have dinner at a specific time, and go to bed at a specific time. You can allow some spontaneity in your day, but the skeleton of structure helps keep you focused. 2). Take care of your own health as best you can We all can do things that will keep us healthy even in an uncertain time. This includes washing our hands, socially distancing, wearing our masks, and not having big get togethers. We may not be able to control what everyone else is doing, but we can do our part. Even if no one else is cleaning down your work station, you can clean it before you start. You can choose not to spend time with people who refuse to wear masks. Eating healthy, exercising, and staying on a sleep schedule is also very important to staying healthy. Take your medications, go see your doctor for your medical needs, etc. This also involves taking care of your mental health, which is very tied into your physical health, and the other things I list below will be helpful with this step as well. Make some time for yourself. Take a shower. Do your hair. Try yoga. Take a day off from work if you can to relax and reset. Turn off the news. I only allow myself one hour tops of news a day. I check headlines a few times a day on my phone, read the most important articles, and leave the rest. Limit your time on social media, we don’t need that trash right now. Watch cat videos. Take up a relaxing hobby, something that can distract you from everything. 3). Find people who are supportive of you Human beings are social creatures. Prolonged isolation is not good for us, even the self proclaimed introverts. We need to be able to interact with other people. Doing so over text message, zoom, or the phone doesn’t feel as comforting as in person, but it’s what we’ve got to reach out for. Make connections, talk to people, and ask for help when you need it. Find people who can give you love when you’re asking for it. Find people who understand your desires and needs. Set boundaries with those who can’t. As the days become weeks and months, it’s hard to remember when the last time I called my best friend was, but as soon as I do, I feel better. Check in with your support groups. 4). Practice “going with the flow.” This one is tough for a lot of us. Many people don’t like uncertainty, and it’s hard for plans to change so frequently. How do we plan for the future if everything is constantly changing? I find it so hard to pivot to a new plan when my plan goes to hell, but sometimes having multiple contingency plans helps me out. “If this happens, I’ll go do it this way, but if this happens, I’ll do it another way.” It’s a good exercise in flexibility. You get to be angry that your plans didn’t work out. All of this sucks, and that doesn’t change. And still being able to find a way to move forward and do what you can. 5). Take control of what you can, let go of what you can’t. This is similar to going with the flow, but more about knowing what you can change, can’t change, and how to be ok with those distinctions. For example, I can’t control whether my neighbors wear masks. But I can choose to always wear a mask when I’m out, not let anyone in my house who isn’t wearing a mask, and not engage in neighborhood parties. I can’t control that I’m back at work, but I can wear my mask and limit my other activities. I can decide I’m going to continue recycling whether others do, and teach my child kindness, and provide as structured of an environment as I can for my family. I can do my job within the systems, and work towards trying to change the system, without taking responsibility for everything. 6). Stay physically active “exercise releases endorphins, and happy people don’t kill their husbands.” If nothing else, remember this “Legally Blond” quote when you ask yourself why you have to get up and work out. Remember that there are multiple ways to be physically active. Running, swimming, biking, weight lifting, dancing, going for walks, or doing yoga/pilates are all important ways to get your blood flowing, keep you in good shape, and calm down your overactive nervous system. Making sure you plan breaks in your day to get up and move around. This is a great time to get involved in a home workout. Make it a family affair, have everyone go for a walk together. Or have it be your alone time. There are great apps and youtube videos for home workouts, no equipment needed! 7). Practice mindfulness Mindfulness is my new love affair. I used to think mindfulness was only about meditation, and I hated meditating. I’m learning that mindfulness is so much more. It’s the practice of being physically, emotionally, and mentally present in a moment. And now, more than ever, we need to be using mindfulness to cope with the uncertainty of the world. There are so many great apps, workbooks, webpages, and books about how to be mindful. My advice is to try a bunch of different things to see what suits you best. My favorite form of mindfulness is taking a moment to check in with myself. Between each patient, I take a huge, long, steady deep breath in and back out. I sometimes close my eyes for a bit. I willingly let go of all the stress I’m feeling in that moment so I don’t take it into the next appointment. This five second practice helps me get back into myself and calm down before I move on with my day. Other forms of mindfulness I use include actively stopping my thoughts (this take a lot of practice), listening to music, rubbing my fingers together while on a run to focus in on something else besides how much I hate running, taking some deep breaths, and doodling. I am not in love with meditation yet, but I like short ones. Progressive muscle relaxations help me get to sleep when I’m too anxious, or really short guided meditations from apps like Headspace. Practicing mindfulness helps you use it when you’re stressed. Because I do daily mindfulness exercises, when I get super stressed out I have the skills I need to bring me back (most of the time). I can actually use the deep breathing techniques to get me feeling better. Sometimes I have to do something bigger, like taking a break, or crying in the corner. But I’m less often getting to that point because I’m more in control of my emotions, and my baseline is low. 8). Keep hope alive. Imagine the future you want. I recently saw a cartoon in which two characters made comments about how important it is to imagine, dream, and day dream. “It keeps hope alive” the last caption said. I hadn’t thought of it before. If we can imagine a better world, we can keep hope alive that we can create it. And hope is what will get us through this. Having hope that things can get better is the first step in being willing to take action to make things better. Dream of that future, when all this is over. Create it in your mind how you want it to be, and then take steps to reach those goals. Allow the dream to change as things change. Most of all, remember that this is hard, and we’re going to get through it as best we can. Stay safe and healthy out there

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