*Sana was a 20-year-old unmarried girl sitting in the modest examining rooms of a government hospital’s emergency room, with complaints of chest pain and “ghabrahat”.
This was her third visit in three days, and her family was beside themselves trying to understand why the doctors weren’t helping their daughter.
They had witnessed her attacks. She would be fine one minute and then, all of a sudden, she would have difficulty breathing; she would report a sense of “ghabrahat” and “dum ghutna”.
She would start wailing and they would rush her to the emergency. So far all her heart test results were normal.
*Asif was someone I knew since kindergarten, but as schools changed and career paths diverged, we lost touch, till my last year of medical school. We all met at a reunion, and upon hearing that I wanted to be a psychiatrist, he started talking about some of his struggles.
As his story unfolded, I learned about his mysterious illness; he had headaches, felt like something was stuck in his throat at all times and had difficulty sleeping.
Being unemployed and living with his grandparents wasn’t helping his peace of mind, and he confided that the only thing that made things better for a while was “Relaxin”, a tablet first prescribed by his family doctor. He had started buying it in bulk from three different pharmacies without prescriptions.
His struggles and physical symptoms were as real as the last breath he took in another friend's lap on the way to the emergency room, after taking one too many Relaxins to feel better.
Thankfully, we’ve started talking about mental illness, and the common man today has more information available now than I did while growing up.
You stumble across the occasional conversation about depression and suicide, and sometimes anxiety gets a mention in passing, but it deserves more than that.
What is anxiety?
Anxiety can be described as a state of apprehension, uncertainty or fear arising from the anticipation of an event. In Urdu, it has various terms, like “beychaini”, “paraishani”, “ghabrahat”.
We all experience some anxiety at different periods in time; it is the brain’s way of getting us ready to face or escape danger, or deal with stressful situations. For example, anxiety before exams can make one study more and, hence, do well on a test.
However, at times, the anxiety can be quite severe or exaggerated, and as a result, impair physical and psychological functioning.
That can lead to intense physical sensations, ‘worst case scenario’ thoughts, worrying and avoidant behaviours to the point where they start affecting one’s life. An example would be skipping school on the day of a test out of anxiety or panic attacks.
Why does it manifest with physical symptoms?
Consider this simplified explanation: The brain is an extremely powerful organ. It is, in a way, the central command centre for the rest of the body and has an influence over all the different organ systems.
When this central command system is hijacked by anxiety, the anxiety has free reign to cause havoc in the different organ systems, creating actual physical symptoms even though there is nothing wrong with the organ itself.
Headaches, shortness of breath, stomach issues, skin eruptions, muscle aches and pains – you name it, and anxiety can cause it.
Things are never quite that simple though.
When evaluating mental illness, one has to keep in mind the “bio-psycho-social” approach. There is always a multitude of factors at play.
The explanation above hints at the biological aspect of anxiety, however, social situations, such as loss of employment, difficulty with the in-laws, financial issues, political unrest, religious persecution, etc. can all contribute to difficulties with anxiety.
Then, of course, there is also the individual’s psychological make-up. The way one person may deal with and react to a situational stressor may be completely different compared to another, and hence, different levels of stressful situations could cause anxiety in different people.
According to a 2007 study (of a varied community) conducted at a private hospital in Karachi, anxiety disorders were twice as common in women as in men. Factors associated with anxiety disorders included middle age, low level of education, being a housewife or being divorced, separated or widowed.
Other studies find a higher prevalence of anxiety amongst patients with other medical problems as well.
Is the “beychaini” treatable?
Primary care physicians and emergency room doctors are usually the first line of defense. Their methodical approach to first rule out medical causes, such as thyroid, heart and other hormonal problems, and then diagnose an anxiety disorder, is a positive approach to diagnosing an anxiety disorder.
There are a number of non-medication ways of managing anxiety. These include reducing stress, exercising, practicing breathing and yoga techniques. Therapy or counselling can be extremely effective, especially cognitive behavioural therapy, which teaches one to modify thought patterns.
There are medications to help in the short and long-term. The stumbling block, of course, is lack of awareness and stigma along with a cultural desire to have a quick fix.
It is not uncommon in Pakistan to think that a doctor who prescribes more is better than one who doesn’t. Treating a common cold with antibiotics and the copious use of “drips and injections” drive up patient satisfaction and hence guarantee repeat business.
Writing a prescription is a “knee jerk” reaction, which leads to overuse of medications that should be used judiciously and for short periods of times. Benzodiazepines such as Alprazolam, Lorazepam, Diazepam under various brand names (commonest ones being Xanax, Ativan, and Valium) are prescribed casually and without warning of being highly addictive.
The easy availability of over-the-counter medications makes things worse.
Although, things have improved slightly in Pakistan over the years, it is still just a matter of who you know at what pharmacy and how motivated you are to get the medicine without a doctor’s prescription.
Asif had no mysterious illness. He suffered from an anxiety disorder that led to a prescription of benzodiazepines, to which he became addicted. Soon, he needed much more than the recommended dose, and at one point, he was taking 10 times the recommended dosage in a day.
His story may have been different if there was recognition of an anxiety disorder and a conversation about how to treat it. When medications are warranted, the popularly known (and misnamed) anti-depressants, under the supervision of a doctor, are good long-term, non-addicting solutions.
So, hopefully, if you have been experiencing ghabrahat, beychaini, or paraishani, or have been having multiple physical symptoms without any known cause, you will hear the term “anxiety disorder” and when you do, don’t despair or think that no one is taking you seriously.
Be relieved that there is no life-threatening medical problem causing your symptoms, and ask your doctor about the best way for you to gain control over your anxiety.
*Names have been changed to protect identity.