Our early evolutionary ancestors relied on the fight or flight response to help ensure their survival and ability to propagate their genes. It was this successful trait that helped allow for the evolution and survival of our species to date. However, as we will discuss, the evolutionary and ecological history of this trait is perhaps an significant culprit in the increasing prevalence of anxiety related disorders that we are current witnessing.
Thousands of years ago, as early Homo sapiens, our fight or flight response helped direct our actions – to run away from predators, build fire, acquire food and deal with environmental threats. We lived in what is known as an immediate return environment; where our actions had an immediate and measurable results1. The vast majority of animal species continue to live within these immediate return environments – when a mouse is hungry, it forages for food, but when it notices a hawk in the sky it will go into hiding. The mouse’s fight or flight response is tailored to living in the immediate return environment.
Humans have certainly evolved beyond the immediate return environment, and entered a delayed return environment2, whereby many of the choices made on a daily basis do not yield immediate results, but have delayed ramifications or consequences (i.e.: you invest in your education, to find a profitable career later in life). Ultimately, this sociological change occurred as our survival as a species became more entrenched. We typically don’t fear external predators, basic necessities of life are relatively easy to obtain and we have an substantial life expectancy. However, this profound shift in genetic prosperity has really only occurred in the last few hundred years (and has truly advanced in the last 70 years) – which is a minuscule amount of time from an evolutionary standpoint. As a result, we still have a very basic fight or flight response coded within us, with few profound outlets for this innate trait.
Manifestations in the 21st century
To some degree, we all experience this response on almost a daily basis – remember the last time you were late for a meeting; as you’re stuck in traffic your heart rate is elevated, you feel sweaty and anxious. Many people harness the fight or flight response and direct it to their goals or ambitions – ultimately using fear as intrinsic motivation (i.e.: if I don’t do well on this test, I can’t get into grad school).
However, for an increasing number of individual’s, this fight or flight response may manifest itself with physical symptoms, fear, anxiety and panic.
This is further compounding by the availability of information (or mis-information) on the internet. People google everything, and this is certainly no different when it comes to their symptoms. If one were to google ‘chest pain and shortness of breath‘ (a common presentation) – the first result on WebMD lists some rather alarming diagnoses (myocardial infarction, myocarditis, aortic dissection, to name a few). So it is no surprise that patient’s are concerned are increasingly anxious about their symptoms.
In patient’s with anxiety related disorders, this combination of biological stimulation and (concerning) information can lead to worsening of their symptoms. While we’re often reassured by normal investigations, patient’s typically aren’t – for patient’s with low probability disease, diagnostic testing does not decrease symptoms, health anxiety or concerns3.
As physicians, we tend to work patients up, and when we are unable to uncover an etiology for their symptoms, we inform them that nothing is wrong without much further clarity. In patients with panic or anxiety related disorders, this is unlikely to help their conditions(s), unless the underlying issue has been addressed. We certainly can’t pretend to fully understand the biochemical or organic nature for these patient’s complaints – but we can appreciate the evolutionary and sociologic causes for these patients, and it is through this understanding that we may help them4.
In these patients, it is important to discuss with them the nature of the fight or flight response, providing a basis for their symptoms. In understanding this, patients will appreciate a biological basis for their symptoms. Importantly, because the theory suggests that the fight or flight response is the culprit for their symptoms, a way to address this is to have the patient incorporate this response into their daily living. This is done by goal setting – to have a patient set daily and meaningful goals, to satisfy their biological needs. In essence, this allows people to shift the focus of their anxiety onto productive means (i.e.: taking walks, working on a project, etc).
Ultimately, this information is important for physicians to appreciate, because we can utilize this to help explain to patient’s the source of their symptoms, and provide them with some other outlets or management techniques to aid with their anxiety. We would love to hear your thoughts, and your approach to anxiety related concerns in a primary healthcare practice below.