Responding to anxiety: a thread.

As a trainee psychiatrist, I often find myself the 2nd line in responding to anxiety in service users/patients. Nurses are a fantastic first line, but sometimes extra help is needed, so in these situations it's worth thinking about a few things

Anxiety is a natural response to threat, but ancient and designed as a blunt instrument to work in a very narrow time window with very dichotomised outcomes, death or survival. As such, the response is very strong and takes several forms; the classic fight/flight or freeze

In the fight response we gear ourselves up for battle, our heart and respiratory rate increase, our aggression builds, our complex decision making reduces, and our actions and perceptions sharpen. This is all secondary to hormones and brain chemistry.

In the flight response we see a more predominant fear, and with that fear, the need to escape. Our physiology upregulates to favour blood pumping to our legs and muscles, away from complex analysis and simply getting away.

And in the freeze response, we drop to the floor or don't move. This is argued to be a hangover from when we were smaller creatures and could use a lack of motion to hide from predators. It also works with surgeons, as their vision is based on movement.

These reactions are very powerful (and efficient,) but served their primary purpose during a different epoch. Their design is short-lived, and chronic anxiety (stress) becomes maladaptive. If we cant exact a response, we are stuck with energy and emotion.

This 'anxiety' is a prompt to action, which is fine with a tiger because you have seconds to act, but with a feeling of being trapped by economic circumstances, or a paranoid delusion, escape is not so easy. To rectify anxiety, you must first understand the source.

When I meet patients who are anxious there are a variety of possible reasons, the major ones:

1) Anxiety due to mood state (depression/GAD/ocd)
2) Anxiety due to psychosis (hallucination/delusion)
3) Anxiety due to drug effect or withdrawal
4) Anxiety due to physical symptom

You can substitute all of these categories into one simple equation to understand and operationalize a response:

perception of experience + unmet need = anxiety

and more comprehensively

(previous experience + expectation) + unmet need = anxiety.

The crucial correlate here is unmet need, the patient requires something to be done. Whether that's addressing the pain, or the imagined consequences of it, or reassurance about their fear, by considering this need and how it is communicated we can intervene.

Sometimes a need is communicated verbally 'I am in pain doctor', or sometimes by action 'kicks the wall' because 'i need a cigarette' or 'screams at another patient' because the test has been delayed. Every action has a reaction, and there is a logic if you look for it.

My first step in this situation is to ask what it is the patient wants, and what their understanding of the situation is. I will ask what the worry is, and how they feel it can be rectified. I ask what other options may be available, and how they feel they will tolerate it.

By doing this you have already addressed the major problem (if known,) why it exists (in the short term,) the level of perception and perceived risk, and potential solution. You have also recognized the need; ie pain relief, reassurance, change.

This will not always allow you to understand the deeper meaning behind differences in perceived need, but allows you the time and avenue to investigate it. So for me, I tend to take the approach of allowing time and space to address the subject properly.

I usually ask the nurses to walk away (based on risk, to remove the perception of being overcrowded,) slow my speaking down, speak in questions, listen and clarify points. I sympathise, use touch when appropriate (on the shoulder or upper arm in non-covid times)

The core element here is to show empathy and understanding, and actually have them both. It may not be possible to agree on a delusional belief, but you can certainly appreciate and agree with the anxiety.

By asking the patient to explain their plan, or to pick a plan of shared choice, you not only address the unmet need, but give them control of finding it. It also teaches them, often when forgotten, that they do exercise power over their environment.

Obviously there are rare exceptions where risk of such approaches is too large, for example an extremely aggressive person holding a weapon, or someone very drunk and not able to think clearly, but most cases of anxiety do not fulfil these criteria.

So if I can offer you two major points, its these

1) Learn to understand and identify the unmet need
2) Use time and empathy to empower the patient

As always, I love your tips and stories. So please #retweet

A further note: what if the expectation is unrealistic?

In essence, this does not overall matter. What matters is the perception of it being addressed, either in immediacy (which is how anxiety is designed to function) or toward an outcome in sequence. Example (amalgamated)

A patient is terrified that the government is spying on him and tells the nurses he needs to escape. He worries the nurses are part of the conspiracy. Attempts to relate to him and discuss this have not succeeded.

By using the approach above we are able to identify the major need; to feel safe and empowered. The simplest approach is to first dial down the threat, talk in a quiet room, use open body postures, and let the person explain. Answer their questions, and validate their worry.

I dont mean validate the delusion; but validate how they feel. Allowing them to express this discharges this psychic energy and allows them the space to consider how to rectify it. Ultimately the treatment will be medical, but planning a short term compromise helps.

I asked the patient to talk to me when they feel anxious and we can address their concerns 1 by 1. This empowered them to create action and provide an alternative to feeling without escape. Although I could not remove the delusion, I could provide hope.