Anxiety ranks among my least favorite diagnoses. In medicine, we have a long history of blaming a variety of diseases on anxiety. Even in the recent past we attributed gastric ulcers to stress until it was proven that a bacteria that lives in the gut is responsible. Indeed, who would have thought: a bacteria living in the extremely acidic environment of the stomach designed to kill all bacteria? But it does! And it causes ulcers. There is no scientific doubt in the mind-body connection – indeed one need look no further than the placebo effect, which is quite powerful and results in the improvement of a variety of ailments in patients taking a pill that they believe will help them. All studies of new medications are required to have a comparison to placebo, rather than nothing, due to this well-recognized effect in order to avoid approving potentially harmful medications that are no better than a sugar pill when it comes to treating disease. And yes, stress, and anxiety are known to exacerbate a variety of diseases, including asthma, which, not coincidentally, was thought to be a psychiatric problem in the recent past as well.
The reason I dislike anxiety as a diagnosis, is that I fear it is a way of discounting the patient’s complaints. In medicine we worry about symptoms for two reasons. The first is that the symptom may be an early sign of a serious problem. Even mild chest pain in a middle-aged man (or woman) is concerning to us, because it could be a sign of a heart attack. The other reason we treat symptoms is that, although not serious or harmful, the symptoms themselves are bothersome. Chronic pain syndromes are an example of this. The low back pain has been evaluated and shown not to be due to metastatic cancer or other serious problems, but the patient is left with significant pain that prevents them from sleeping or going about their life. We treat the pain. Shortness of breath is a serious complaint, and it can be impossible to tell the difference between a panic attack and other, life-threatening causes just by symptoms and exam. For physicians, a diagnosis of anxiety classifies the patient’s complaints of shortness of breath in this latter category of symptomatic treatment without an underlying physiologic (at least not cardiac or pulmonary) problem.
This diagnosis of anxiety, of a mind causing physical symptoms, can be challenging for patients, and even leads some to discount their own symptoms. Recently I saw an 82-year-old man for episodes of shortness of breath. He had had no prior problems of anxiety but described having “panic attacks” over the previous several months, some of which landed him in the emergency department. At the emergency department he was noted to have low oxygen levels and a chest X-ray showed interstitial lung disease – scarring or inflammation of the lungs, which likely explained the low oxygen and symptoms. He thought the oxygen they prescribed for him at night seemed to alleviate the “panic.” We talked for a while and I explained that the “panic” he felt was likely the appropriate response of his body to the state of not getting enough oxygen. I wasn’t sure yet what the interstitial lung disease was, but that is why they had sent him to see me – to figure it out. “Thank god,” he said, “I thought I was ready for the nut house.” There was no delay in diagnosis for this patient. The doctors in the emergency department had evaluated his symptoms appropriately and had appropriate studies documenting a physiologic reason for his symptoms. They didn’t diagnose him with panic attacks. It was how he explained his constellation of symptoms to himself. But 82-year-olds tend to have a high enough prevalence of disease that we presume there is something underlying their symptoms. Not so for the apparently healthy young patients, particularly young women.
I was on my soap-box opining how I hate a diagnosis of anxiety for someone in pulmonary clinic, how in particular young women’s complaints get discounted with anxiety and depression, when one of the medical students agreed. She had come to see many doctors for over two years with the main complaint of fatigue and was treated for depression among other psychiatric diagnoses before finally being diagnosed with multiple sclerosis. It is easy to see how the proverbial patient on the psychiatry service who gets diagnosed with schizophrenia exclaims “Thank god, I thought I was going crazy.” Because for years this person went from doctor to doctor who couldn’t help her, who couldn’t fit her story together to make sense, who ended up telling her it was her fault – she was an unreliable narrator. She was depressed or anxious and it was her mind that was causing these symptoms. Easy to see how someone might finally say “Thank god it’s just multiple sclerosis. I thought I was going crazy.” To finally be understood, to finally be heard, to not be so utterly alone in the suffering is a large part of why patients seek doctors.
Yet sometimes it is the diagnosis of anxiety that lets the patient be understood. Another patient I had been seeing for asthma came for follow-up and on the whole felt well controlled, but was concerned about frequent sighs she had started having over the previous few months. She was not short of breath and didn’t have any other new symptoms. I started with my preamble. “Medicine has a long history of discounting people’s symptoms and labeling them as anxiety or depression,” I said. “And we are far from having an explanation or a full understanding of most of what occurs in the body,” I continued. “But sometimes, sighing like that, especially when not associated with other symptoms, can be due to anxiety.” Her eyes filled with tears. Yes, she told me, she is anxious. Her brother had died recently, her nephew had died a couple of weeks later and now her sister was about to go for major heart surgery. She was anxious, she was depressed, she needed help. She was glad to know she wasn’t crazy.