Anxiety

Life is pain, Highness, and anyone who says otherwise is selling something.Wesley, from The Princess Bride

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Treating anxiety can make you feel like you are on a Mobius strip.

An anxious person is usually anxious because they are trying to control something they can\’t control.  You can\’t control other people.  You can\’t control the future or the past.  You can\’t control what happens in the country.  People die and get sick, and it is hard to predict when it will happen.

Most of us deal with this lack of control in one of several ways:

  • Watching television.
  • Other escapes, such as alcohol, blogging, or Oxycontin.
  • Becoming really busy so they don\’t have time to think about it.
  • Denial (\”Just don\’t think about it\”)

A few people can accept the lack of control – many of these do it by belief in a god who controls things beyond our understanding.  But my experience in the exam room (and personally) is that the words of Bruce Cockburn are right on target:

Even though I know who loves me, I\’m not that much less lost.
– From the song Civilization and its Discontents on the album The Trouble with Normal

Faith can provide comfort, but our natures and the world we live in makes it impossible to avoid anxiety.  Plus, people of faith often have an added problem: they feel like their anxiety is a personal and moral failure.

America is a place of plenty and so everyone has much more to lose.  Everyone also can hide in all the stuff they have and all the things they have to do and hope things don\’t fall apart in the mean time.  But they often come to my office struggling with \”stress\” and wanting to fix it.  The words I often hear them are, \”I look at my life and see all of the good things/blessings I have, and I wonder why I am anxious.  Look at all the advantages I have!  I shouldn\’t be anxious, should I?\”

To which I respond, \”So are you telling me that having a nice home, a nice marriage, healthy kids, lots of money, and a good job are the keys to a secure and happy life?\”  The truth is, the more you have, the more you have to lose.  The more cards that are stacked onto the house of cards – the more stories of the house you build – the more precarious things get.  You could get sick, the stock market could bottom out, your child could get cancer, your spouse may be unfaithful; all of these things are only amplified by how important each of these things are.

Hence, America is the land of the anxious.

In the exam room, the exchanges can be quite complicated.  When someone comes to me for anxiety, almost always that anxiety is causing collateral damage in their lives.  Either they are becoming angry, compulsively running to an addiction, obsessing about something, withdrawing from relationships, or driving other people nuts.  The fact that they are coming to their doctor to talk about anxiety makes them anxious.  They don\’t want to look crazy.

So I talk about feeling out of control, and about how behaviors can stem from that.

They become more anxious because my discussion is about things that they don\’t want to think about.  When they show more anxiety as I talk about this, they get anxious about how they are coming across to me.  Are they weak?  Are they stupid?  Are they crazy?

The problem is that anxiety is irrational.  You don\’t wake up in the morning and decide you are going to be anxious.  You don\’t become anxious out of conscious thought or reason.  It comes up despite your knowledge of its irrationality.  This is made even worse by people around them who give the simple instruction: \”don\’t be anxious,\” as if anxiety was a switch that can be flicked.  This is why people worry about being crazy; they act in totally irrational-appearing ways.  They act in ways they know they shouldn\’t act, but have no control to stop.  That\’s why they are seeing me.  That\’s why they worry about what I will think.

But at the same time that anxiety is irrational, it is reasonable.  It doesn\’t come without cause.  We are really out of control.  Bad stuff could happen at any time.  Life is uncertain.  The American psyche is obsessed with denying these facts, saying that things should be good, in control, and our futures should be certain.  When people are forced out of denial or escape, they burst out in anxiety.  There is certainly a lot to be anxious about, and this is magnified if we believe that things should be different.

So as I speak about anxiety, I observe the person getting more anxious.  Since my goal is to help, comfort, and give confidence to them, I start to get anxious.  What can I say that will help unroll this anxiety?  Am I saying the wrong thing?

And so the ping-pong match of anxiety goes on.

I talk of medications for anxiety that may help them deal with problems.  I tell them that these medications are not the fix, but they may allow them to work through the root-causes of their anxiety. I explain that the real treatment for anxiety is self-examination and discovery of what unchangeable things they are trying to change.

My talking about medications, of course, makes them anxious.  I must really think they are crazy to be suggesting medications!  They ask me if there are any side effects to the medication.  I can\’t lie to them, as many of them are going to go right to the internet or the drug PI and see the huge list of possible side effects.  So I tell them about the main ones, but do my best to reassure them that I wouldn\’t prescribe anything I didn\’t think would help.

Because I am not trying to scare them away from something that may help, I become uncomfortable – trying to craft words that will inform without worrying.  They pick up on this discomfort and become anxious that I am hiding things from them.  This makes me anxious as well.

There is no solution for this.  Life is uncertain, and we live much of our lives in the uncertainty.  Having faith that hardship will, in the end, turn out for the best can help people cope; but it doesn\’t take away the uncertainty, the fear, or the worry.

My conclusion is that we live a large part of our lives in uncertainty, suffering, and hardship.  The thing that leads us to anxiety is not the hardship itself, but the belief that we shouldn\’t be in that hardship in the first place.  The source of worry is the fact that we have bought the sit-com gospel of things working out by the end of the half hour show.  Life is far more complex, and is usually not as easily fixed.  I sit and see people suffering all day long, so why did it take me so long to figure this out?

I can\’t fix you.  I might be able to help, but I am not God.  Living life in the real world is painful and uncertain.  It stinks to live in suffering and worry, but you get through it, not around it.

25 thoughts on “Anxiety”

  1. Much more convincing than the serenity prayer — we try our hardest, and there are some things we can’t change.
    I’ve got a posting in a non-Internet-friendly country coming up, so I’ve written my last blog post for a while, about what we can change — hopefully I’ll still be able to come by, because you don’t have a blogspot/blogger address, but we’ll see. Anyway, feel free to stop by here. Same goes for your esteemed readership.

    Thanks!

  2. Much more convincing than the serenity prayer — we try our hardest, and there are some things we can’t change.
    I’ve got a posting in a non-Internet-friendly country coming up, so I’ve written my last blog post for a while, about what we can change — hopefully I’ll still be able to come by, because you don’t have a blogspot/blogger address, but we’ll see. Anyway, feel free to stop by here. Same goes for your esteemed readership.

    Thanks!

  3. First, you get major, ridiculous brownie points for quoting The Princess Bride at the top of your blog.. and second, being someone that has often dealt with anxiety issues, I couldn’t agree more – especially now that I’m in medical school. Some days are certainly pain, but I wouldn’t trade them for the world.

  4. First, you get major, ridiculous brownie points for quoting The Princess Bride at the top of your blog.. and second, being someone that has often dealt with anxiety issues, I couldn’t agree more – especially now that I’m in medical school. Some days are certainly pain, but I wouldn’t trade them for the world.

  5. This was a great description of why people get anxious and what it does to them. Eckhart Tolle refers to your “house of cards” as the “world of form”. His view is that not only can we not prevent these things from changing, but that change is an absolute certainty. So the solution is to maintain our conciousness in this moment, the present moment. This doesn’t mean you don’t plan for the future, it just means you choose not to stress and obsess over it.
    I was fascinated to read about how an experienced pcp works through these huge life issues with patients (since I’m a third year interested in primary care). Thanks for fighting the good fight, instead of prescribing some whatever and sending them down the road.

  6. This was a great description of why people get anxious and what it does to them. Eckhart Tolle refers to your “house of cards” as the “world of form”. His view is that not only can we not prevent these things from changing, but that change is an absolute certainty. So the solution is to maintain our conciousness in this moment, the present moment. This doesn’t mean you don’t plan for the future, it just means you choose not to stress and obsess over it.
    I was fascinated to read about how an experienced pcp works through these huge life issues with patients (since I’m a third year interested in primary care). Thanks for fighting the good fight, instead of prescribing some whatever and sending them down the road.

  7. Interesting. Anxiety has become entwined in our daily life. For some people accepting the anxiety is sometimes the difficult part.

  8. Interesting. Anxiety has become entwined in our daily life. For some people accepting the anxiety is sometimes the difficult part.

  9. Can’t tell you how less anxious I feel about talking to my PCP when I see him next about anti-anxiety meds. And it is in large part due to this post. Thank you for sharing your thoughts and how it affects your practice of medicine.

  10. Can’t tell you how less anxious I feel about talking to my PCP when I see him next about anti-anxiety meds. And it is in large part due to this post. Thank you for sharing your thoughts and how it affects your practice of medicine.

  11. Psychotics are often described as people who create an inner world because their experience of their own world is absolutely unbearable.
    I have heard doctors lecture their patients on the topic of “it’s not what happens to you but how you handle it” and I link it to something I was told by a pre-med student who went into chemistry instead. She told me that the doctors who are profoundly gifted come through med school easily because they are unaware of a struggle, – the phrases “they are naturally fit” and “he didn’t need to study, he just read things through once” are applied to these people. The others get through not by pushing themselves to their limits but by pushing PAST them and that goes a long way to explaining the personality profile that the general public often notices: the need for control and the need to reenact their own struggles.

  12. Psychotics are often described as people who create an inner world because their experience of their own world is absolutely unbearable.
    I have heard doctors lecture their patients on the topic of “it’s not what happens to you but how you handle it” and I link it to something I was told by a pre-med student who went into chemistry instead. She told me that the doctors who are profoundly gifted come through med school easily because they are unaware of a struggle, – the phrases “they are naturally fit” and “he didn’t need to study, he just read things through once” are applied to these people. The others get through not by pushing themselves to their limits but by pushing PAST them and that goes a long way to explaining the personality profile that the general public often notices: the need for control and the need to reenact their own struggles.

  13. New reader here. Came to your blog via codeblog.com and had to comment on this post, for two reasons: 1) Princess Bride is my favorite movie, ever, and 2) I’m about to graduate nursing school and have been on antidepressants/antianxiety meds for the last year of that journey.A few key points you mentioned hit it dead-on for me: that it’s a matter of trying to control the uncontrollable (I went through a divorce-like breakup during my first round of clinicals; it was really hard on my daughter and on me), and that telling someone to stop being anxious is, in a word, ridiculous. I remember discussing panic attacks with a friend/fellow nurse who also had experienced panic attacks before, and we laughed as she reiterated, “Rule number one of a panic attack: Don’t Panic” (conjuring _Hitchhiker’s Guide to the Galaxy_, which made me wonder if maybe I’d feel better if I only carried my favorite towel with me everywhere I went; speaking of not wanting to look/sound like a crazy person….!).

    Being a nursing student, and my doctor being a GP and not (by his own admission) accustomed to treating psychiatric problems, our exchange was entirely anxiety-ridden on both ends. I’m sure he could sense me assessing him as he was assessing me – the snake eating its own tail. In any case, I have to say it was reassuring to watch him literally flip through his drug guide in the exam room to help me find an antidepressant that would treat the underlying issue. It made the process of finding and receiving help that much more collaborative, and in essence made me feel like less of a crazy person.

    I think more people would seek help if they only understood that, as you said, “I can’t fix you. I might be able to help, but I am not God.” I’ll be scheduling an appt today to follow up with the doc and continue my Rx, and reading your post is already making me feel better (less intimidated, more self-accepting) about it. Thanks.

  14. Stephanie Thorvalson

    New reader here. Came to your blog via codeblog.com and had to comment on this post, for two reasons: 1) Princess Bride is my favorite movie, ever, and 2) I’m about to graduate nursing school and have been on antidepressants/antianxiety meds for the last year of that journey.A few key points you mentioned hit it dead-on for me: that it’s a matter of trying to control the uncontrollable (I went through a divorce-like breakup during my first round of clinicals; it was really hard on my daughter and on me), and that telling someone to stop being anxious is, in a word, ridiculous. I remember discussing panic attacks with a friend/fellow nurse who also had experienced panic attacks before, and we laughed as she reiterated, “Rule number one of a panic attack: Don’t Panic” (conjuring _Hitchhiker’s Guide to the Galaxy_, which made me wonder if maybe I’d feel better if I only carried my favorite towel with me everywhere I went; speaking of not wanting to look/sound like a crazy person….!).

    Being a nursing student, and my doctor being a GP and not (by his own admission) accustomed to treating psychiatric problems, our exchange was entirely anxiety-ridden on both ends. I’m sure he could sense me assessing him as he was assessing me – the snake eating its own tail. In any case, I have to say it was reassuring to watch him literally flip through his drug guide in the exam room to help me find an antidepressant that would treat the underlying issue. It made the process of finding and receiving help that much more collaborative, and in essence made me feel like less of a crazy person.

    I think more people would seek help if they only understood that, as you said, “I can’t fix you. I might be able to help, but I am not God.” I’ll be scheduling an appt today to follow up with the doc and continue my Rx, and reading your post is already making me feel better (less intimidated, more self-accepting) about it. Thanks.

  15. You’re welcome! Thanks for the comment!
    I see you are also a fan of the Hitchhiker’s Guide. Smart.

    The thing we all need to remember is that it’s OK to be weak. We are all weak and we are all needy in certain ways. There is a post coming on this, but some of the mantras of our society that we all seem to accept are absolutely killing our spirits. The praise of strength and of human potential fails to recognize that we are all flawed, weak, and ultimately mortal.

    And THAT’s OK! It is who we are!

  16. You’re welcome! Thanks for the comment!
    I see you are also a fan of the Hitchhiker’s Guide. Smart.

    The thing we all need to remember is that it’s OK to be weak. We are all weak and we are all needy in certain ways. There is a post coming on this, but some of the mantras of our society that we all seem to accept are absolutely killing our spirits. The praise of strength and of human potential fails to recognize that we are all flawed, weak, and ultimately mortal.

    And THAT’s OK! It is who we are!

  17. I liked the part when you talked about control and controlling the uncontrollable but then it went downhill. :p
    “So as I speak about anxiety, I observe the person getting more anxious. Since my goal is to help, comfort, and give confidence to them, I start to get anxious. ”
    If you get more anxious, or a lot more anxious in their presence it means that you still have some emotional issue. You should also work on your personal power so you are non reactive to it. Compassionate Yes, but emotionally reactive No.

    If you are very powerful, you don’t need to say almost anything to influence them. Of course, if you say something … depending what you say … you can influence their emotions even more.

    “What can I say that will help unroll this anxiety? Am I saying the wrong thing?”

    You are asking the wrong questions. Plus, you are trying to eliminate an emotion by using a cognition approach(asking questions) . It’s like trying to control your instincts but using rational thinking to change them. Obviously, it does not work. After a while your instincts will win again.

    “I can’t fix you. I might be able to help, but I am not God. Living life in the real world is painful and uncertain. It stinks to live in suffering and worry, but you get through it, not around it.”

    I can take each of the statements one by one. Basically, each one of them is a limiting belief.(especially the last one)

    Sam

  18. I liked the part when you talked about control and controlling the uncontrollable but then it went downhill. :p
    “So as I speak about anxiety, I observe the person getting more anxious. Since my goal is to help, comfort, and give confidence to them, I start to get anxious. ”
    If you get more anxious, or a lot more anxious in their presence it means that you still have some emotional issue. You should also work on your personal power so you are non reactive to it. Compassionate Yes, but emotionally reactive No.

    If you are very powerful, you don’t need to say almost anything to influence them. Of course, if you say something … depending what you say … you can influence their emotions even more.

    “What can I say that will help unroll this anxiety? Am I saying the wrong thing?”

    You are asking the wrong questions. Plus, you are trying to eliminate an emotion by using a cognition approach(asking questions) . It’s like trying to control your instincts but using rational thinking to change them. Obviously, it does not work. After a while your instincts will win again.

    “I can’t fix you. I might be able to help, but I am not God. Living life in the real world is painful and uncertain. It stinks to live in suffering and worry, but you get through it, not around it.”

    I can take each of the statements one by one. Basically, each one of them is a limiting belief.(especially the last one)

    Sam

  19. You misunderstand the purpose of this post. I was admitting my own weakness when talking about my own anxiety. One of the main themes of this blog is that doctors are not really different from anyone else, and I deal with my own issues just like everyone else. I know that I am asking myself the wrong questions and I know that “fixing” people with anxiety should not be the measure of my success, but the desire to make people better gets the best of me.
    What I have personally learned is that our quest for that “something missing” is the source of a whole lot of our (at least my) anxiety. We presume life should be different/better, but we don’t really know if that is true. I don’t preach in my posts (at least I try not to); I just muse about what life looks like from the chair of a person who happens to be a doctor.

  20. You misunderstand the purpose of this post. I was admitting my own weakness when talking about my own anxiety. One of the main themes of this blog is that doctors are not really different from anyone else, and I deal with my own issues just like everyone else. I know that I am asking myself the wrong questions and I know that “fixing” people with anxiety should not be the measure of my success, but the desire to make people better gets the best of me.
    What I have personally learned is that our quest for that “something missing” is the source of a whole lot of our (at least my) anxiety. We presume life should be different/better, but we don’t really know if that is true. I don’t preach in my posts (at least I try not to); I just muse about what life looks like from the chair of a person who happens to be a doctor.

  21. very much appreciate and got alot out of this post, even if 3 years later! Oh to be free of this isolated social anxiety prision someday!

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