Young Woman Smiling

Anxiety - it’s all in your head, but it’s just as real

Feb 11, 2020

By: Stephen Vogel

One of my memorable patients recently was a young woman I’ll call Sarah. Age 16, she came to see me in clinic as a new patient with a troubling set of symptoms. Almost daily, and often without a pattern, she would experience overwhelming chest and stomach pain. Soon after, she would feel as though her throat was swelling shut, making it difficult to breathe. Sometimes, she would feel as though she was going to pass out. These episodes would come and go within minutes, and she was extremely worried that something was wrong with her heart.

As doctors, we serve patients best by thinking of a problem or a set of problems as broadly as we can first and then, through our history taking & exam, begin to narrow the scope of our concern. I built an understanding of Sarah’s risk of heart, lung, and stomach (abdominal) disease, all of which appeared low. Our discussion then turned to something as important as any of these, her mood.

Sarah had had a difficult upbringing. Her parents divorced after years of creating a household filled more often with fighting than love. She was bullied at multiple schools and struggled to find a lasting group of friends. All of these experiences, which we call Adverse Childhood Events (ACE), had conditioned her into developing anxiety with panic disorder.

We are just now appreciating the depth with which a person’s upbringing can affect them mentally, emotionally but also physically. They can feel impacts from those that last a lifetime. Studies show that those with high ACE scores have higher risk of depression, anxiety, post traumatic stress disorder (PTSD), but also heart disease, hypertension, diabetes, among many other diseases we wouldn’t often associate with mental health. This stirring evidence only strengthens the idea of the mind-body connection.

In Sarah’s case, her body’s way of channeling her stressful experiences came in frequent panic attacks. Panic attacks may come in certain situations, like large crowds, or those related to a past traumatic event. Often, though, they can occur without notice. They can feel chest pain or fast, irregular heartbeats, severe nausea or abdominal pain, sweating, shaking, or lightheadedness in any combination. Be it in the grocery store, while driving, or while on the sofa watching television, it’s an event that is understandably scary and difficult to deal with.

Not all with anxiety experience panic attacks. Mostly, they will deal with regular and persistent stressful thoughts that prevent them from feeling calm, and often interfere with daily life, including sleep. They can make school and social situations tough, which in turn makes the feelings worse. It can be a difficult cycle to break. Often, it can lead to depression, as well. If one is dealing with toxic stress to the point of not sleeping, socializing or working, it is all too easy to begin feeling hopeless, lose interest in hobbies, lose or gain appetite, and feel unavoidably sad.

Perhaps what’s most important to me as a physician is not to promise a quick fix or solution to the mental health struggles of my patients but to connect with and address their deepest worries. There are so many stigmas around mental health disorders. In our society, where success and outward happiness are often valued most, it’s no wonder that people with mental health disorders can feel unappreciated and forgotten. Depression, Anxiety, Panic Disorder do not discriminate age, gender, race, or social status. They can affect us all, and those with family members who have them are at even higher risk. Thankfully, there is more transparency emerging about these issues and we in primary care are skilled with the tools to help.

Although Sarah was saddened to realize how much her life’s stressors were affecting her, she was relieved to understand. After a shared discussion on treatment options, we decided to start her on a low dose antidepressant that also works well for anxiety, and set her up to see our clinic’s behavioral health provider. Although the chance to see a therapist regularly was difficult for her given our resources available, she agreed to see us very frequently over the next 6 months and began feeling better.

I hold my deepest respect for people like Sarah, as it is their resilience in life and their willingness to seek help, in a healthcare system that sometimes does not make it easy, that has graced us with the opportunity to help them.