• Mentate

Issue 3: Anticipatory Anxiety

Updated: Jun 21, 2020

by Dr Jeremy Smith

These are strange and unsettling times.

It can feel a bit like standing on a deserted beach watching the tide suck out and further out, wondering when the tsunami is going to hit.

The waiting is hard.

Patients with Panic Disorder tell us that the anticipatory anxiety can be more difficult than the actual panic attacks. Not knowing when it will hit. Tensing yourself as you wait. The background tension that sucks the joy out of your day-to-day life.

I heard some people playing the Last Post at the end of their driveway at 6am on ANZAC day. I wonder what it was like for the young men waiting in the boats approaching Gallipoli, or crouched in a trench on the frontline.

“They have to stay there while shell after huge shell descends with a shriek close beside them. Each one an acute mental torture; each shrieking tearing crash bringing a promise to each man, instantaneous, I will tear you into ghastly these that you see smashed around you one by one to lie there rotting and blackening.”

Charles Bean, Australian war correspondent

Reading of war is sobering. The images of COVID-19 in Spain or Italy are sobering. You may feel like you are working on the frontline of a war. Our colleagues in the Emergency Department, in Intensive Care Units. When you started medicine, did you sign up to be a soldier heading into battle? I imagine some healthcare workers are not comfortable with the rhetoric of war.

As doctors we are willing to make sacrifices for our patients, to work hard, do overtime, and put them at the centre of what we do at work. But we don’t usually head to work with the chance of contracting a novel and potentially life-threatening illness. We are all aware of the uncertainties about the effective use of Personal Protective Equipment. But this is not just about fear for our own safety. What if we unknowingly take this virus home to our partner and children? Just going to work every day can be a challenging decision. We find ourselves between a rock and a hard place - caring for our patients and caring for ourselves and our families. These competing priorities can leave us in a state of tension.

An ED colleague of mine recounted the difficulty of responding to a Code Blue for a patient who had a cardiac arrest on the COVID-19 ward. Policy required full PPE prior to attending the resuscitation. I can just imagine the sweaty fingers fumbling with gowns as precious minutes pass, and the possibility of saving this patient’s life slipped away. I can imagine the frustration and even the guilt afterwards. Should we risk more for our patients?

We all feel for the doctors in Spain, and the moral injury of denying care and allowing some patients to die. No wonder our hearts are in our throats. We see on the horizon the potential for this sort of trauma. Actual soldiers with PTSD are often most troubled not by the near-death experience as much as the actions they partook in that were morally compromising or the guilt and shame when they helplessly watched others die.

I think there have been times in the last couple of months where some of us have felt like we have generals who are comfortably safe away from the fighting, telling us to charge on into the fray. Politicians and health management telling us that PPE will be adequate. Policies that allow ongoing exposure to risk in order to preserve resources, almost as if there is a calculation where it is ok to have a certain number of doctor 'casualties'.

How do we respond? How do we 'hold the line' in the face of all this?

I guess in writing this I want to start by validating the tension, the reality of the difficulty of facing up to work some days. I want to recognise the anxiety that can affect us even when we are simply waiting. I have heard from colleagues about the eerie q---- in many areas of our health system. Even now, when we seem to be winning and flattening the curve, we wait to see if new outbreaks will occur as the social distancing restrictions are gradually relaxed. We know it isn’t over yet.

We acknowledge the anticipatory anxiety, but we don’t get paralysed. We turn this into a frenzy of activity as we prepare for the worst. In my workplace we have had strong clinical leadership, in touch with the ‘troops’ on the ground. There has been a pulling together of the multidisciplinary staff, all staff actually, from cleaners to the ADON. It is reassuring to have clear methodical leadership pushing forward with thorough preparations. I have heard this elsewhere. Some of the worst anxiety was when we weren’t yet fully engaged in getting ourselves ready. When we didn’t even know what exactly we needed to do to prepare.

I think many of us are coping with the overwhelming scope of the worst-case scenarios by harnessing our perfectionistic, obsessional, driven, controlling doctor personality traits and focusing on really nailing the things we can control. There is some degree of relief from having had enough time in the last month to at least train most staff in correct use of PPE. I think many of us are now in a steady readiness. Some of us aren’t even particularly busy now, but we’re still feeling emotional, on-edge and stressed.

As I suggested above, I’m sure you’d agree that great colleagues make a great workplace. This is only more true in these times. If we can trust each other, have a laugh together, communicate easily, do simulated practices together, then maybe we know we can make it through this together.

I’ve seen the many helpful support networks that have popped up online. These are great. I’ve seen how keen your local GPs are to support you, and I know that we as psychiatrists want to be there for you also. If we can help, get in touch via Mentate.

Dr Smith is a psychiatrist who is currently working in Tasmania.

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