Anxiety Should Be the Diagnosis of Exclusion, Not the Diagnosis of Default

Recently, I met Lindsey J. Gurin, MD, a neuropsychologist whose office is a repository for “lost cases.” Whenever doctors in her network can’t figure out what is wrong with their female patients, they send them to her—because if the doctors can’t figure out what’s wrong, they assume that whatever’s happening with these women must be psychosomatic.
Dr. Gurin told me about a patient who had excruciating spinal pain that went away every time she took Valtrex for her oral herpes. Her doctors said it was psychosomatic, probably related to her anxiety. She insisted that she had herpes in her spinal fluid; to her, it was the only thing that made sense, fit all her symptoms, and explained why Valtrex was the only thing that affected her pain level. All she wanted was for someone to order a lumbar puncture to see what was really happening, get the treatment she needed, and stop the pain.
Dr. Gurin couldn’t understand how this woman had ended up in her office with an anxiety diagnosis. After all, it’s well known that herpes maintains a latent state in the nerves of the spinal cord, so this wasn’t an out-of-left-field assertion. “A lumbar puncture sounded reasonable to me,” she said, shrugging. “So I ordered one.”
Turns out, the woman did have cerebrospinal herpes. And because one person finally listened to her, she received the treatment she needed.
This story has a happy ending, but so many others don’t. If my colleague hadn’t been willing to listen to her patient, the woman might still be living with excruciating pain.
We’ve covered in previous chapters how anxiety has become the “go-to” diagnosis for women—meaning, when providers aren’t sure what’s wrong, anxiety is their default explanation. As you now know, the symptoms of anxiety can indeed mimic the symptoms of major diseases, such as heart attack and stroke, as well as a plethora of other ailments. So why, when a woman comes into her local ED with a racing heart, chest pain, and labored breathing, is she more likely to be given a diagnosis of anxiety than a man in the same situation? Why is a woman who comes in with abdominal pain more likely to be sent home with antianxiety meds than an IBS protocol?
The answer, of course, is the presence of implicit bias and society’s conditioning of women to discount their own inner wisdom and apologize for their feelings instead of trusting them.
I’ve seen so many women come into the ED with heart attack–like symptoms. As they wait to be seen (which often takes longer than it should, because the symptoms of female-pattern heart attack are not as pronounced as those for men, and therefore they aren’t prioritized in triage), women often “talk themselves down.” They try to rationalize the way they’re feeling, in part because they don’t want to be seen as hysterical.
Perhaps when a woman calls her husband to tell him that she’s in the ED, he asks her, “Are you sure it’s not your anxiety acting up?” She considers this as she waits to be seen by the doctors on duty. Then, when the intern or resident shows up to speak to her, she says, “My chest hurts, and I feel really shaky, but… it’s probably just my anxiety acting up.” For some reason, she feels like she needs to apologize for her symptoms, and so she reaches for the least offensive explanation. Her physician, noting that she had self-reported anxiety, will now be more likely to dismiss her symptoms than to investigate them.
Once a diagnosis of anxiety is on a woman’s record, every subsequent visit to providers will be colored by that one line item. “Oh, you have anxiety listed here. So you probably don’t need that X-ray for your IBS; your anxiety is probably causing a flare in your digestive tissues, but it’s likely not a blockage or other serious emergency.” Or, “Oh, I see you have anxiety. Did you know that that can cause chest pains?”
Or, in the case of the neurologist I mentioned, “You have anxiety listed here. You’re probably not having a stroke.”
A study on cardiac misdiagnoses published in the New England Journal of Medicine, which looked at more than 10,000 cardiac patients, noted that women under the age of fifty-five who went to the ED with chest pain or other significant heart attack symptoms were seven times more likely to be sent home than their male counterparts. This more than doubled their risk of death and drastically impacted their outcomes otherwise.5
I observed an example of this dynamic playing out in my own emergency department recently.
A lot of women experience something called supraventricular tachycardia (SVT). This is an abnormal heart rhythm that comes and goes. The heart will, without warning, suddenly start to race. The woman will get short of breath and start to sweat. But the abnormal rhythm can come and go without warning—and, often, by the time she gets to the ED and is seen, her heart rate is back to normal.
Sandee was one of those women. She kept coming in with self-reported symptoms of a racing heart, flushing, and chest discomfort. She also had an anxiety diagnosis on her chart. And so, over and over, she was told, “You’re having panic attacks.”
“I know what a panic attack feels like,” she replied. “This isn’t the same.”
Finally, she was sent home with a Holter monitor—basically a personal electrocardiogram (EKG) machine that monitors heart rate activity for twenty-four or more straight hours. When she came back, Sandee’s results clearly showed that she was suffering from episodes of SVT. But if she hadn’t insisted that something was happening beyond anxiety symptoms, she might not have gotten the treatment she needed to get her tachycardia under control.
I’m not the only educator working in my ED, and I can’t be present for every patient interaction, but I still feel partly responsible when mistakes like this happen. Since we are a teaching hospital, it’s my job to supervise the interns and residents and help them learn on the job.
“What do you think the solution to this situation would be?” I later asked my resident, who’d been the one to send her home originally.
Of course, she knew where I was coming from with this, but I was still pleased with her answer: “I think we should offer Holter monitors to women who exhibit classic SVT symptoms before we diagnose them with panic attacks.”
In other words, instead of making anxiety the default diagnosis for women with a certain set of symptoms, we should consider it only after other physical factors have been ruled out.
The thing that really gets under my skin about all of this is that—at least in my ED—a large percentage of the women who come in with a diagnosis of anxiety on their charts don’t actually meet the diagnostic requirements for anxiety!
Generalized anxiety disorder (GAD) and panic disorder (PD) are among the most commonly diagnosed mental disorders in America today. However, both disorders have specific symptoms associated with them. The Diagnostic and Statistical Manual for Mental Disorders (known as the DSM) defines GAD as
A) Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least six months, about a number of events or activities (such as work or school performance).
B) The individual finds it difficult to control the worry.
C) The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past six months): Restlessness, being easily fatigued, difficulty concentrating (or mind going blank), irritability, muscle tension, sleep disturbance.
D) The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
E) The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., hyperthyroidism).
F) The disturbance is not better explained by another medical disorder.
The American Psychiatric Association, which produces the DSM, is clear that “feeling anxious sometimes” or anxiety about one symptom or event does not constitute GAD. These guidelines also clearly state that other common physical and mental issues should be conclusively ruled out before a diagnosis of GAD is applied.
In my experience, a large percentage of women who are given a diagnosis of anxiety do not actually meet the DSM criteria for this specific (and truly debilitating) condition. But seeing this diagnosis in your medical chart invites a huge set of assumptions about everything from physical symptoms to emotional responses and can drastically color your doctor’s impression of your subjective retelling of your symptoms. It will impact which tests are ordered, which medications are prescribed, and whether certain physical symptoms are dismissed as “normal” or treated as warning signs of something more serious. In short, this one offhand note in your chart about your anxiety could lead to a plethora of misdiagnoses—up to and including mistaking a heart attack for a panic attack.
Of course, there are many women out there who legitimately struggle with GAD (and PD, its cousin) every single day. I am in no way attempting to minimize their experience here. In fact, women with full-blown GAD may be even more likely to be misdiagnosed because of the severity of their physical symptoms.
But what about the women who don’t meet the clinical definition of GAD? Why do they keep getting handed these anxiety diagnoses? The answer may lie in how the female body deals with stress.
A study published in the Industrial Psychiatry Journal titled “Gender Differences in Stress Response: Role of Developmental and Biological Determinants” found that men and women had measurably different responses to acute stressors in laboratory settings, including “activities of the Hypothalamic-Pituitary-Adrenal (HPA) axis (eg, cortisol) and sympathetic nervous system (eg, heart rate and blood pressure).”6
The study determined that “HPA response patterns differ markedly between males and females.” Without getting too technical, the study basically concluded that while men are more likely to exhibit the classic “fight or flight” response to stress, women are more likely to operate on a “tend and befriend” model, which increases limbic activation. (The limbic system is the part of the brain responsible for processing emotion and memory.) The study went on to say that “HPA hyperactivity is a common finding in major depression, social phobia, panic disorder, generalized anxiety, obsessive-compulsive disorder, susceptibility to infectious diseases, and cardiovascular disorders.” So the same heightened stress response that characterizes GAD can also be present in cardiovascular disease—in a way that’s completely unique to women.
While much more research is needed to bear out the findings of this and other studies, it’s my personal feeling that, to those who don’t know what to look for, the normal female response to stress can look like anxiety without actually being anxiety.
Of course, the flip side of this would be to say that all women are medically “anxious” when under stress—which is what I’m afraid is happening on a widespread basis with anxiety misdiagnoses. We are only seeing the tip of the iceberg in terms of the repercussions of this—but it makes studying men and women differently even more imperative.
While those of us who know the difference are working to change this literally life-threatening trend, it’s vitally important for women to advocate for themselves (whether or not they believe that they truly suffer from anxiety).
You own the information in your medical record. You can ask for copies in order to have more collaborative discussions with your doctors. And if there are notes or diagnoses in there that you feel are inaccurate, you can request that they be changed. (Just note that you will probably be asked to provide reasoning and/or evidence for this change before a provider will consent to make it.)
But, if you do ask to review your medical record, I want to give you fair warning: you may be assigned yet another inaccurate and undesirable label.…

References:

  • J. H. Pope et al., “Missed Diagnoses of Acute Cardiac Ischemia in the Emergency Department,” New England Journal of Medicine 342, no. 16 (2000): 1163–1170. doi: 10.1056/NEJM200004203421603.
  • Rohit Verma, Yatan Pal Singh Balhara, and Chandra Shekhar Gupta, “Gender Differences in Stress Response: Role of Developmental and Biological Determinants,” Industrial Psychiatry Journal 20, no. 1 (2011): 4–10. doi: 10.4103/0972-6748.98407.

 

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