Okay, a common misconception is that if you're taking anxiolytics then anxiety will be abated. This simply isn't true and there is no amount of medication which can overcome certain apprehension levels. The fact that your symptoms arose when returning to your occupation is very telltale and you need to discern what it is specifically about the environment that invokes anxiety of a specific nature. People with this type of anxiety often experience it with bewilderment and frustration, exclaiming "but I don't feel anxious? How could all that is happening to me be the result of simple anxiety?"

It's not merely situational anxiety which invokes physical symptoms of the type being experienced, but rather a higher order of anxiety which generates fear that one's safety is in jeopardy by sensations that something is either seriously wrong or that some serious consequence of unpredictable nature and origin is very proximal, which establishes near constant internal vigilance to any signs of change that might constitute the oncoming event.

Experiencing exacerbation of anxiety when vagus nerve-induced palpitations arise is not the ilk of a chicken or egg analogy, but rather the mere elevation of irrational fears about the capacity of the palpitations to do imminent harm despite all facts to the contrary. It is the unwitting habit of placing trust in one's own interpretations and reactions to fear that causes the palpitations and other symptoms to become more prominent.

It is also a common misconception that the body is static rather than dynamic and that it operates on principles more like an on-off switch with respect to the presence of anxiety and physical symptoms, with a very rigid and narrow concept of how things should be rather than how they actually exist. People do not clinically measure their interaction with the environment on any given day and they tend to make clean separations between issues that they cite as causing stress and any physical symptoms which may subsequently arise.

People with anxiety must have order and everything must fit neatly into place within the rationale they expect rather than what may actually exist in any typical framework. If they evaluate their own physiological processes, they do so within the context of action-reaction and cause-and-effect thinking patterns, which most commonly draw forth skepticism and denial in the form of statements such as "how can all this be due to anxiety? I see no direct relationship between the presence of these darned palpitations and how I feel? I ought to know when I'm feeling stressed or anxious better than anyone and it seems very strange that the palpitations just come and go at odd times whether I feel anxious or not. I can be having a perfectly normal day and then BAM, they just get started again."

These are common expressions and extremely subjective in nature. It is only by your interpretations that the symptoms should fit within your own model rather than the actual circumstances which causes such frustration and doubt. It is the simplification of human physiology into very orderly processing, ie when I feel good, then there should be no symptoms and when I feel bad, then there should naturally be symptoms. If I experience symptoms when I'm feeling good, then it confirms my own suspicions that anxiety and stress do not cause the problems at all but rather exist due to something else which doctors cannot find.

The rationale and challenge is born out in a dichotomy wherein anxiolytic medications are designed to control anxiety and therefore when taken, should work. If they don't, then it's not anxiety causing the problem. That sort of rationale is analogous to concluding that when medications for migraines do not perform as intended, then it's not a migraine causing the pain.

You're going to be just fine and your perceptions are entirely common among persons with significant anxiety and/or stress. The fact that you question such a premise does have two potential conclusions- either my own assessment or yours is incorrect. So if we step back and consider both views, then take whatever time you need to explain to me what you believe to be the underlying cause.

Best regards,

Rutheford Rane, MD (ret.)