The anxiety engine

Tim Senior is a GP working in Aboriginal and Torres Strait Islander health in Australia

There’s almost always an extra condition hiding in plain sight. Sometimes it’s there out in the open right from the start of a consultation. “I’m worried it might be a brain tumour, doctor.” More often, though, it’s hidden in gestures, and in silences. Either way, there’s often this powerful driver behind our consultations that pushes people to present to us, maybe in words that are too frightening to say out loud, maybe in a nebulous wordless sense of angst. Either way, people don’t just present with their symptoms, they present with anxiety about their symptoms. Recognising this means that our role is not just managing the patient’s symptoms, but is managing the anxiety about their symptoms. Allaying this fear is a skill in itself, especially as anxiety may not be dismissed purely with facts and evidence. People can know things in their head as true, but the feeling about its significance is what drives the concern.

Often, what people are worried about is entirely predictable – headaches always seem to be potential brain tumours, back pain is always a slipped disc. Sometimes, however, the worry is one we just would never guess without asking. I once met a person who wouldn’t use their oxygen because they were terrified that it would inflate them like a balloon! You can only reassure someone that won’t happen if you know they’re worried about it! And sometimes the worry gives another differential diagnosis we need to take seriously.

I’m not suggesting this is easy or quick. One of my longest consultations recently was for a simple urinary tract infection, where the combination of strange health beliefs and anxiety created a perfect storm. Outwardly I was very patient as I explained that fungi don’t cause symptoms like that, and there’s no way this could have come from a throat infection (with diagrams).

While anxiety is often the driver of patient presentations, it doesn’t always belong to the patient. We are constantly reminded (because we constantly forget) the importance of recognising parental anxiety about their ill child. But anxiety can also be possessed by a partner, ensuring that a loved one get their symptoms checked.

The other person who may hold the anxiety is ourselves of course. That weight loss, that lymph node that’s been around just a bit too long.

Identifying who is holding the anxiety helps determine who it is we are treating. It maybe we’re managing symptoms in one person and anxiety in another, perhaps ourselves. Identifying anxiety and who is holding it makes us more effective, of course. There’s a fair amount of research now showing that GP intuition can be a useful source of clinical information.¹ There’s now evidence starting to come through about the importance of parental anxiety² and about patients’ own anxiety.³

Reducing anxiety is not a call for more defensive medicine, but recognises that we need to Identify anxiety in the consultation, and who it belongs to, and that this is crucial clinical information that affects, and can enhance, our decision making.

References

1. Stolper E, Van de Wiel M, Van Royen P, Van Bokhoven M, Van der Weijden T, Dinant GJ. Gut feelings as a third track in general practitioners’ diagnostic reasoning. J Gen Intern Med. 2011 Feb;26(2):197-203. doi: 10.1007/s11606-010-1524-5. Epub 2010 Oct 22. PMID: 20967509; PMCID: PMC3019314.
2. Mills, Erin et al. Association between caregiver concern for clinical deterioration and critical illness in children presenting to hospital: a prospective cohort study The Lancet Child & Adolescent Health, Volume 9, Issue 7, 450 – 458
3. Stolper, C.F., van de Wiel, M.W.J., van Bokhoven, M.A. et al. Patients’ gut feelings seem useful in primary care professionals’ decision making. BMC Prim. Care 23, 178 (2022). https://doi.org/10.1186/s12875-022-01794-9

Featured Photo by Sam Loyd on Unsplash