Commonly known as somatization, the body and brain work together in an integral way to illustrate a complicated interface between the mind and the body. Anxiety often is at the root of this interface. We know that, neurobiologically, the anxiety system is linked to the rest of the brain through other central parts called the hypothalamus and the pituitary gland. These regions, when anxious, fire multiple kinds of hormones, including cortisol, epinephrine, and norepinephrine within the body.
These hormones travel down the vagus nerve and hit all of the major organ systems, including the head (headache); the voice (the raised-pitch voice); the jaw (TMJ, teeth grinding); the lungs (shortness of breath); the heart (palpitations); the gut (diarrhea, constipation, and nausea and/or vomiting); the back (pain); the limbs (trembling); or the peripheral nervous system (sweating and shaking).
When some people are feeling anxious, their brains convert this emotional sensation into the physical experiences of nausea, aches, pains, numbness, contractions of the uterus, or hives of the skin. This transaction serves as one of the body’s ways to display its anxiety. It is very difficult for patients to believe that the original problem itself might be anxiety, since they actually experience physical distress.
After ruling out the major causes of any kind of medical problem and an appropriate referral to a psychiatrist, careful history can reveal links between the mind and the body and allow one to address the mental component involved in the physical display of these symptoms. Physical discomfort can represent an unusual way of remembering a past bodily or emotional experience.
For example, a man who had asthma as a young boy could find himself with an asthmatic attack on the anniversary of the death of his mother— a way to remember and memorialize her death through shortness of breath, which might be a more emotionally acceptable version of crying.
In classic examples of conversion disorder, a patient might experience paralysis of his right arm at a time he wants to punch his boss; or an entire group of Laotian women who witnessed the massacre of their families might develop blindness for the rest of their lives, despite normal functioning of the nerves and retinas of their visual systems.
Temporomandibular joint. The joint that connects the jaw to the skull.
How does anxiety show itself in generalized pain, back pain, or irritable bowel syndrome?
Pain is a highly subjective symptom, which has both psychological and physiologic causes. Back pain serves as the classic example of the multidetermined nature of pain. However, numerous examples exist. Anyone who has worked with pain or experienced pain knows that it is not correlated just to the level of tissue pathology. For example, consider 100 patients with objective findings on MRIs of their spines. It is not possible to correlate the level of tissue pathology observable on MRI with the level of pain that a patient experiences.
Similarly, people can experience nausea as a way to contain their anxiety. This nausea infrequently leads to vomiting, but the fear of losing control and the pain and concern that come from the nausea are just as prominent.
Psychotherapy in these cases addresses whatever component of the pain might be anxiety-laden. Patients with back pain, for example, often report that as they are able to identify their anger, their back pain itself lessens. Or, patients who have suffered bad menstrual cramps report after 6 months of psychotherapy that their disturbance of menstrual functioning may still be present, but that it does not bother them nearly as much as it did before.
Irritable bowel syndrome (IBS) is an extremely common condition in which the patient experiences— without any other acute gastrointestinal pathology—a variety of intestinal or abdominal symptoms, including but not limited to pain, bloating, cramping, and constipation and/or diarrhea.
Interestingly enough, the patients who have been diagnosed with irritable bowel syndrome do have, at an actual tissue level, abnormal neuronal functioning which can create the overactivity or underactivity of their gut. However, any clinician who has worked with patients suffering from irritable bowel syndrome or any patient who lives with irritable bowel syndrome knows that there is a clear connection between anxiety and the gut.
Irritable bowel syndrome. A group of symptoms, often associated with anxiety and more frequently found in women, that involves abdominal pain, constipation, diarrhea, and other gastrointestinal complaints without any clear medical reason.
The gastrointestinal nervous system (the gut) contains one third the number of nerve cells as does the entire central nervous system (brain and spinal cord), which includes the brain and spinal cord. The brain chemical serotonin, which is central to the body’s regulation of anxiety, plays a major role in gastrointestinal function as well. So, there are many good reasons physiologically that anxiety and the chemicals that mediate anxiety also have a major impact on gastrointestinal functioning.
Any patient with IBS will tell you that he notices particular specific reactions between his anxiety and his bowel functioning. Some patients will report that during times of stress they become acutely constipated; others will report not being able to control their diarrhea. Many things can be done through seeing the gastroenterologist, including adding certain kinds of medications or making changes in diet.
However, it is always important for a patient with irritable bowel syndrome to consult at least with a psychiatrist to discuss treatment options from a psychiatric and psychotherapeutic point of view. Medications in the Serotonin Reuptake Inhibitor (SRI) family can alter the constipation as well as treat the anxiety, while some of the older tricyclic antidepressants can manage both the diarrhea and the anxiety.
Can anxiety ever make me feel that I am not real?
Commonly known as dissociation, overwhelming anxiety can precipitate symptoms of loss of time or sense of personality. Usually, patients realize it has happened after the fact. For example, a patient may miss three subway stops before realizing that she needed to get off three stops back. Another example would be a man who hears his friends talk about a night where they all celebrated, but he has no conscious memory of the event. A woman who experiences herself talking to you from the perspective of herself looking down at the two of you having the conversation is yet another example.
Dissociation is one of the body’s responses to overwhelming anxiety—it takes the conscious mind out of the actuality of the moment. Perhaps this strategy reflects a survival tool that helped a child who was suffering from neglect or abuse create a belief that the abuse was happening to someone else while he watched, thus creating a sense that the abuse was not actually occurring to him. These moments of dissociation can occur both outside of therapy or within the session itself; either way, the precipitating trigger is one of anxiety.
Learning to identify the anxiety as it emerges can, over time, help to prevent the need for the dissociation. More importantly, it can provide access to the walled off, unconsciously buried painful emotional memories that are so intimately connected to the patient’s conscious experiences of anxiety or panic.
The most profound examples of dissociation are either the fugue state or the multiple personality disorder. Occasionally you might read in the newspaper a story similar to that of a man who “woke up” in the hospital three weeks from his last conscious memory, only to learn that over that time period he had invented a new identity for himself and gone back to the state where he did his military training.
While there, he attempted to reengage in training maneuvers on base, only to be discovered in the woods wearing fatigues and face paint. The history might then reveal that his marriage was crumbling and that he had recently been fired from his job. In the extreme form, patients can shift between alternating personalities (“alters”) without awareness of the distinction between the two.
These patient histories invariably have detailed accounts of overwhelming abuse, which then leads to such overwhelming anxiety that the brain splits the mind of the person off from that anxiety via the invention of a new personality.
How is lying connected to anxiety?
Lying—the conscious attempt to manipulate the truth in order to deceive the listener—often stems from anxiety. We try to hide that of which we are ashamed, and that of which we are ashamed generates anxiety. Hence we lie about affairs we have had or cheating we have done so as to avoid the shame of owning those feelings and having our actions made known to others in our community. Perhaps even the mind’s defense mechanisms—like denial or rationalization—are ways to lie to ourselves to protect ourselves from a greater truth.
A painkiller addict may lie to himself by saying that he takes pills in order to feel love and bliss but hide from himself the truth: that he wants to destroy himself because he feels so worthless, just as he felt his parents hated him for his lack of perfect behavior when he was a kid. It is not surprising that most lie detector tests in history, like the polygraph, draw their scientific evidence from the measurement of physiologic signs of anxiety, such as pulse rate, respiration rate, sweating rate, and blood pressure.