Anxiety Among Physicians by Doris C. Gundersen, MD, Colorado PHP Medical Director, and President-Elect of the Federation of State Physician Health Programs

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Anxiety Among Physicians by Doris C. Gundersen, MD, Colorado PHP Medical Director, and President-Elect of the Federation of State Physician Health Programs

Because of stigma (feared or real), overwork and denial of vulnerability, many physicians do not take good care of themselves. Yet we are not immune to those conditions or illnesses we encounter in our medical practices on a routine basis, independent of specialty. Anxiety disorders are remarkably common in the general population and despite our wish for immunity, among physicians.

Physicians tend to share certain personality traits that contribute to good patient care while concurrently increasing vulnerability to anxiety. We are conscientious and at times, develop an exaggerated sense of responsibility. While we prefer to be in control, there are circumstances beyond our influence. For the most part, knowledge of the future is provisional. For instance, while we are preparing for “healthcare reform” the Supreme Court is simultaneously deciding whether or not the Affordable Care Act is constitutionally sound. Finally, we continually strive to be better which taken to an extreme becomes perfectionism, an impossible standard and strong driver of anxiety.

The anxiety among physicians is not just personal. Anxiety is to some extent, built into the structure of a physician’s role as healer and expert. The sources of physicians’ anxiety include moral overtones associated with the possible failure of fulfilling an expected social role. While uncertainty is an inherent part of medical care that physicians cannot avoid, our patients expect accurate diagnoses and prognostications, uncomplicated therapeutic interventions and good outcomes. In this context, we are sure to feel anxiety related to fears of medical iatrogenesis, patient complaints and medical liability risks, even in the absence of frank culpability.

On a regular basis, physicians face exposure to communicable diseases such as HIV and tuberculosis as well as the risk of violence. Many physicians witness gruesome injuries and contend with patient deaths, both expected and unexpected. Routine exposure to over stimulating life threatening events can lead to symptoms of Post Traumatic Stress Disorder in physicians, including nightmares, irritability, insomnia and emotional numbing/distancing.

Occasional worry or nervousness is a normal part of everyday life. Everyone frets or feels anxious periodically and not all anxiety is pathological. Mild to moderate anxiety can serve to motivate, increase focus and attention as well as improve performance. Anxiety and apprehension generally precede positive events including purchasing a home, the birth of a child or promotion at work. However, when episodes of anxiety become severe and/or prolonged, the exact opposite holds true. Efficiency and productivity suffer, not to mention the quality of one’s life.

The Diagnostics Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) classifies anxiety disorders into the following categories: Generalized Anxiety Disorder, Panic Disorder, Obsessive Compulsive Disorder, Acute and Post Traumatic Stress Disorders, Social Phobia and Specific Phobias. Anxiety disorders are generally thought to be caused by an interaction of biological, psychological and social factors that produce clinically significant syndromes. While psychodynamic theory suggests that the core cause of anxiety relates to unresolved, unconscious emotional conflicts, functional and structural imaging studies of the brain in recent years have demonstrated abnormalities in anatomy, neurocircuitry and neurotransmission in the brains of patients diagnosed with anxiety disorders. For example, patients with anxiety are observed to show heightened amygdala responses to anxiety cues. The amygdala, or fear center of the brain, responds to perceived threats and the associated anxiety is only extinguished if the prefrontal cortex examines the threat, and based on past history, declares a false alarm. Prefrontal-limbic activation abnormalities have been shown to reverse with clinical response to psychological or pharmacologic interventions. These scientific findings have served to reduce some of the stigma associated with mental illness and will likely pave the way for even more efficacious treatments.

Because most anxiety disorders begin in childhood or adolescence, new onset anxiety in an adult warrants prompt medical evaluation to rule out conditions associated with symptoms of anxiety including hyperthyroidism, obstructive lung disease, substance abuse (stimulants like cocaine) or substance withdrawal (alcohol, sedatives), the latter of which are commonly missed diagnostically.

While most anxiety disorders cannot be prevented, there are some things you can do to control or lessen symptoms. Reduce or eliminate the use of stimulants such as caffeine, nicotine or over-the-counter sympathomimetics, including herbal remedies. Avoid or limit alcohol intake knowing that the metabolites of alcohol can lead to insomnia and heavy alcohol consumption can lead to daytime withdrawal symptoms including anxiety. Schedule time for yourself during the workday to engage in some kind of exercise: a short walk, stretching, yoga and other mind-body activities can go a long way to reduce stress and attendant anxiety symptoms. Most importantly, maintain social connections. Debriefing a difficult day with a trusted friend allows you to move forward and avoid an accumulation of unresolved stress. Finally distinguish between what is in your immediate control and what is not. Focus on those areas in which you have influence. Otherwise, a good deal of anxiety and stress is generated for no good purpose.

If you experience symptoms of anxiety that persist beyond a week or two, seek professional help. Fortunately, effective treatment is available for the entire spectrum of anxiety disorders in the form of pharmacotherapy and psychotherapy. CPHP [the MPHP in Missouri] is happy to assist you in identifying mental health resources.


 

References:

Christakis, N. (2003). On the Sociological Anxiety of Physicians. In: Missikemer, CM., et al. Essays in the Honor of Renee C. Fox: Society and Medicine, New Brunswick, NJ: Transaction Publisher, 135-144.

Nooryman, K., et al. (2012), Controlling Anxiety in Physicians and Nurses working in Intensive Care Units Using Emotional Intelligence Items as an Anxiety Management Tool in Iran. International Journal of General Medicine, 5: 5-10.

Yates, WR., et al. (2012). Anxiety Disorders, Medscape Reference httt://emedicine.medscape.com/article/286227-overview www.webmd.com (Anxiety and Panic Disorders Health Center)

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