The job of our brains is not to make us happy, but to keep us alive long enough to reproduce. The priority is “do not die.” Anxiety is the feeling of dread we get in anticipation of a future event that could make that less likely. The problem is that your amygdala does not know if there is a lion chasing you or you are stuck in traffic. The amygdala activates the hypothalamic-pituitary-adrenal axis and releases cortisol.
Many people have a tinge of anxiety in the background, and it affects their day-to-day existence, but they do not realize it. This affects how they function at their job, interact with their friends and family, and may give them trouble sleeping. They do not think of themselves, as being nervous or anxious, but they have higher sympathetic tone that creeps into other places in their lives. Awareness of this is the first step towards management.
Anxiety is contagious and as physicians, we are at the front line of suffering, so it is impossible to not feel it. On top of that, there are systemic factors that make us more vulnerable to anxiety, like loss of autonomy, high student debt, the changing landscape of healthcare, increasing workloads, and the threats of adverse outcomes and litigation. Reading all of that in one sentence may have increased your cortisol level. We sometimes do not give ourselves enough credit for how much pressure we are under.
Even before we are put in this pressure cooker for creating anxiety, we are predisposed to anxiety. Medicine selects for people that are Type A, perfectionists, self-reliant, and achievement-oriented. Just because we are in a career that self-selects for anxiety and put in a situation that amplifies it, does not mean it cannot be addressed.
Where do we begin? Worrying. The brain is a master storyteller and comes up with worries. Some are reasonable and others are unlikely catastrophes, but all seem plausible. However, it becomes harder to dwell on the worry when we turn our focus towards gratitude; appreciating the things we have, enjoying them, and not that they could (and inevitably will) be taken from us.
Worry leads to physical symptoms, which are physical cues to worry more. This is the biopsychosocial model of anxiety. A model for breaking this cycle is cognitive behavioral therapy (CBT), reflecting on the likelihood of something catastrophic happening, using logic to reason with our irrational, intrusive thoughts. We can rationalize that being stuck in traffic is not the same as being chased by a lion, but if you deny someone’s anxiety, or your own, it tends to get amplified. CBT is not denying the worry, but rather using logic to diminish its influence.
We can focus on the source of the worry, but we should also try to manage the physical symptoms. Symptoms of anxiety can present from head to toe. A common physical symptom is insomnia. Sympathetic tone can be such that it is difficult to fall asleep or stay asleep, despite the exhaustion caused by that ever present sympathetic tone.
If you are having trouble falling asleep, recognize that there are places in your body that carry tension; actively relax those joints. Some people keep their tension in their calves, or neck, or jaw; some keep it in their chest so breathing gets rapid and shallow. Telling your brain to relax is like denying the anxiety; it makes things worse. Instead of telling your brain what not to do, tell it what it should do (I need to do this more with my children!).
Cognitive behavioral therapy can still help in situations where there is a significant chance of something catastrophic actually happening. For instance, emergency room physicians during the height of Covid-19 were at significant risk of contracting a disease about which we knew very little. Even in that situation, we can drill down on the fears, identifying which are plausible, which are implausible, and for those that are plausible, finding ways to mitigate those risks. Some of the anxiety comes from a sense of lack of control, and so taking steps towards lowering risk, takes back some of that control. Then manage the physical symptoms.
This has all helped me immensely. I now acknowledge that what I do is hard, even though I do not treat as high acuity issues as some of my colleagues. I tend to keep my tension in my jaw, so I actively remind myself to relax it when I am trying to sleep. When I feel turbulence on an airplane or am surfing in the ocean, I remind myself that airplane crashes and shark bites, are as likely as getting struck by lightning. Between these tactics and therapy, I am cool as a cucumber.
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