A little anxiety is good for our civilization.  If our ancestors had been perfectly content we would never have developed tools, medicine, or technology.  We’d just sit outside in the rain until we were eaten by wild animals.  A little worry makes us strive to be better.  Too much anxiety can overwhelm us and prevent us from functioning.

As I write today, in June of 2020, many people are worried.  We are coping with climate change, Corona virus, and political unrest.  We fear the future.

The best predictor of what will happen in the future is what has happened in the past.  Humans are resilient and have survived for eons.  Put in perspective, this is a lucky time to be alive.  The average person in the US lives more comfortably than a king in the Middle Ages.  Heat, running water, hot showers, the Internet were unheard of and would have seemed like magic.  The average life expectancy was under 40 years.

Things improved because people were anxious to live better.  Today’s problems will lead to a better future if people are worried enough to cooperate with each other.  We will develop methods to improve the environment, lead healthier lifestyles, fight disease, and live in peace with each other.

What kind of anxiety might people experience today?  Here are fictional examples in adults:

Jessica always tended to worry but now is never worry-free.  She worries about illness, droughts, fires, riots.  While driving to work she worries about a deer leaping in front of her car.  At work she worries about making a mistake and getting fired.  Because of the worry, she can’t concentrate and does make simple mistakes, which make her worry even more.  At home she worries something bad will happen to her family.  She feels restless, irritable and tired.  The muscles in her neck and back feel like hard knots and she has headaches that feel like a band across her forehead.  She has trouble falling asleep because she can’t stop worrying.

Jessica suffered from Generalized Anxiety Disorder, a pervasive pattern of worrying about important life situations that make it difficult to function.

Matthew had always been healthy until he suddenly felt as if he were having a heart attack.  His chest hurt, he couldn’t breathe, his lips and hands felt numb, he felt faint, and was sure something terrible was happening.  He was rushed to the emergency room but his doctors could find nothing wrong with him.  He later had a full evaluation by a cardiologist but all tests showed that his heart was healthy.  He felt a little better when he learned that he most likely had a panic attack, which was not physically dangerous.

However, the feeling had been so awful that he continued to worry it would happen again.  Sure enough, a few weeks later he had a panic attack at work, then again when he was driving home.  He had begun experiencing anticipatory anxiety – the fear that he would have a panic attack made him so nervous that it triggered another panic attack.  He became scared to leave the house.  The more he stayed at home, the harder it was for him to leave.

Mathew had developed Panic Disorder- the fear of having a panic attack caused him to have difficulty functioning.  A panic attack is a discrete episode of at least 4 of the following physical sensations: racing or pounding heart, feeling of choking, chills or sweats, dizziness, trembling, sweats.  nausea, shortness of breath, trembling, tingling or numbness around hands, fear of losing control or dying, feelings of unreality.  Panic attacks can lead

What causes the sensation of having a panic attack?  All animals breathe in oxygen and breathe out carbon dioxide.  When we are nervous, we may hyperventilate – take quick, shallow breaths that rid our bodies of carbon dioxide too quickly.  The physical symptoms of panic attacks are the body’s way of saying, “I need more oxygen-slow down and take deep breaths.” You will not die if you hyperventilate- at the very worst you would pass out and your body would breath normally again.  Learning deep breathing techniques is a great treatment for anxiety.  You can try the 4-7-8 breathing technique right now.  Inhale for 4 seconds, hold your breath for 7 seconds, then breath out for 8 seconds.  Don’t you feel more relaxed already?

Jill is an emergency room doctor.  She has always been a high achiever, a perfectionist, proud of her ability to work quickly and efficiently.  Two months ago, however, the emergency room became inundated with patients with COVID-19, and short-staffed since some of her coworkers became ill.  Jill was dismayed that she could not save all of the patients.  At first, she was able to put her emotions on hold as she worked long, intense hours and took on extra shifts.  However, she gradually became anxious and irritable.  She had trouble sleeping even though she was exhausted.

Finally, the cases slowed down and work went back to normal.  Instead of feeling relief, Jill felt depleted.  She couldn’t stop thinking of the patients who had died and had nightmares about them.  She always felt irritable, tense and jumpy, expecting something bad to happen.  When riding the elevator, she stood in a corner because she didn’t like the sensation of people standing behind her where she couldn’t see what they were doing.  She felt detached and lost interest in socializing.  She felt guilty that she survived but others didn’t.

Some of her colleagues had symptoms which gradually decreased over the next few weeks until they felt back to themselves.  Jill’s symptoms only increased until she was considering changing to a job in the pharmaceutical industry.

 

Jill’s colleagues who had only a few symptoms (brief insomnia, worry, irritability, nightmares, fatigue) were having a normal reaction to a stressful situation.  Those who had more symptoms that resolved within a month had Acute Stress Disorder.  Jill had multiple symptoms that didn’t go away.  She had Posttraumatic Stress Disorder, or PTSD, a more serious condition now classified in the ICD 10 (International Classification of Diseases-10th Revision) as a trauma-related disorder instead of an anxiety disorder.  Anxiety is a prominent feature, however.

Sophia had always been described as “quiet” and “shy.” She felt very nervous when meeting new people but was comfortable with her small friendship group.  She got good grades in elementary and middle school but they plummeted her first year of high school.  There were two high schools in her town and most of her friends had been placed in the other school.  She began making tearful excuses to stay home from school.  Although invited, she never went to parties.  When her school physically closed and she had only online classes due to the Coronavirus, she felt much better but refused to participate in group videoconferences.  She refused to return to school when it physically reopened.  She told her parents that she would attend online classes only.

With the help of her psychotherapist, Sophia learned she had Social Anxiety Disorder, the fear of being scrutinized by others.  A person with social anxiety constantly feels judged and found deficient.  Sophia’s social anxiety had worsened during a required public speaking class in high school.  As she stuttered and stammered through her first presentation, a few of her classmates had snickered.  This confirmed in her mind that she was inferior to her peers and she stopped participating in all classroom discussions.  The more she avoided social situations, the harder it was for her to convince herself that normally she spoke okay.  She would ruminate on something she had said to a friend the day before, thinking “Why did I say that?  That was such a stupid thing to say! I must have hurt her feelings! I’m an idiot!” Her self-esteem plummeted.

Oliver was a fourth grader who was sent to the principal’s office for running out of his school and hiding in the bushes.  When the principal tried to talk to him, Oliver would not answer.  He began crying, yelling, and throwing things when the principal tried to question him.  He finally communicated by shrugging his shoulders.  When his parents picked him up, he started speaking normally once they were in their car.

Oliver had selective mutism– intense fear of speaking to others often associated with social anxiety.  He was “scared speechless” about talking to unfamiliar people.  Children who have selective mutism may be able to speak normally with family members at home, but become mute in other situations such as school, social gatherings, or restaurants.  They may be only able to nod, shrug, or point.  They may seem irritable and poorly-behaved in school due to crying, tantrums, hiding under their desks, or running out of the room to avoid speaking.

Ava always wanted to leave her third-grade classroom to go to the nurse’s office.  She complained of horrible stomach aches and asked to be sent home.  She had another condition beginning in childhood, Separation Anxiety Disorder.  Fear of being separated from primary caregivers is normal from mid infancy through the toddler years and generally ends by ages 3-4.  Children who continues to fear separation from their attachment figures beyond this developmental stage may have Separation Anxiety Disorder.   They fear that something bad will happen if they are away from their primary caregivers.  They are terrified of being kidnapped or their parents dying.  They may complain of illness to avoid going to school or try to sleep in their parents’ bed.  If everyone else in the family is on the first floor of the house, they may refuse to be alone on the second floor.  They can also present with tantrums, tearfulness, and irritability when they are away from their family.

In my practice, patients often have more than one anxiety disorder.  It’s very common to have a mishmash of different symptoms- panic attacks, generalized anxiety, social anxiety, and trauma history all rolled into one.   Anxiety is often associated with depression.

Luckily, most of the treatments are similar.  Antidepressants work even better for anxiety than they do for depression.  However, psychotherapy is very important.  The general premise is “face your fears” Cognitive Behavioral Therapy (see Treatments for Depression section) is a great treatment for anxiety and/or depression.  People with Generalized Anxiety Disorder learn techniques to decrease their unrealistic fears.  Patients with Panic Disorder learn that the sky won’t fall on their heads if they have a panic attack.  If they have agoraphobia, they learn how to gradually increase the time and distance they can tolerate away from their homes.