My Age of Anxiety: Fear, Hope, Dread, and the Search for Peace of Mind
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Today, thousands of papers about anxiety are published each year; several academic journals are wholly dedicated to it. Anxiety research is constantly yielding new discoveries and insights not only about the causes of and treatments for anxiety but also, more generally, about how the mind works—about the relationships between mind and body, between genes and behavior, and between molecules and emotion. Using functional magnetic resonance imaging (fMRI) technology, we can now map various subjectively experienced emotions onto specific parts of the brain and can even distinguish various types of anxiety based on their visible effect on brain function. For instance, generalized worry about future events (my concern about whether the publishing industry will survive long enough for this book to come out, say, or about whether my kids will be able to afford to go to college) tends to appear as hyperactivity in the frontal lobes of the cerebral cortex. The severe anxiety that some people experience while speaking in public (like the sheer terror—dulled by drugs and alcohol—that I experienced while giving a lecture the other day) or that some extremely shy people experience in socializing tends to show up as excessive activity in what’s called the anterior cingulate. Obsessive-compulsive anxiety, meanwhile, can manifest itself on a brain scan as a disturbance in the circuit linking the frontal lobes with the lower brain centers within the basal ganglia. We now know, thanks to pioneering research by the neuroscientist Joseph LeDoux in the 1980s, that most fearful emotions and behaviors are in one way or another produced by, or at least processed through, the amygdala, a tiny almond-shaped organ at the base of the brain that has become the target of much of the neuroscientific research on anxiety over the last fifteen years.
We also know far more than Freud or Kierkegaard did about how different neurotransmitters—such as serotonin, dopamine, gamma-aminobutyric acid, norepinephrine, and neuropeptide Y—reduce or increase anxiety. And we know there is a strong genetic component to anxiety; we are even starting to learn in some detail what that component consists of. In 2002, to cite just one example among many hundreds, researchers at Harvard University identified what the media called the “Woody Allen gene” because it activates a specific group of neurons in the amygdala and elsewhere in the crucial parts of the neural circuit governing fearful behavior. Today, researchers are homing in on numerous such “candidate genes,” measuring the statistical association between certain genetic variations and certain anxiety disorders and exploring the chemical and neuroanatomical mechanisms that “mediate” this association, trying to discover precisely what it is that converts a genetic predisposition into an actual anxious emotion or disorder.
“The real excitement here, both in the study of anxiety as an emotion and in the class of disorders,” says Dr. Thomas Insel, the head of the National Institute of Mental Health, “is that it’s one of the places where we can begin to make the transition between understanding the molecules, the cells, and the system right to the emotion and behavior. We are now finally able to draw the lines between the genes, the cells, and the brain and brain systems.”
Fear arises from a weakness of mind and therefore does not appertain to the use of reason.
—BARUCH SPINOZA (CIRCA 1670)
And yet for all the advances brought by the study of neurochemistry and neuroanatomy, my own experience suggests that the psychological field remains riven by disputes over what causes anxiety and how to treat it. The psychopharmacologists and psychiatrists I’ve consulted tell me that drugs are a treatment for my anxiety; the cognitive-behavioral therapists I’ve consulted sometimes tell me that drugs are partly a cause of it.
The clash between cognitive-behavioral therapy and psychopharmacology is merely the latest iteration of a debate that is several millennia old. Molecular biology, biochemistry, regression analysis, and functional magnetic resonance imaging—all of these developments have made possible discoveries and scientific rigor, as well as courses of treatment, that Freud and his intellectual forebears could scarcely have dreamed of. Yet while what Thomas Insel of the NIMH says about anxiety research being at the cutting edge of scientific inquiry into human psychology is true, it is also true that in an important sense there is nothing new under the sun.
The cognitive-behavioral therapists’ antecedents can be traced to the seventeenth-century Jewish-Dutch philosopher Baruch Spinoza, who believed anxiety was a mere problem of logic. Faulty thinking causes us to fear things we cannot control, Spinoza argued, presaging by more than three hundred years the cognitive-behavioral therapists’ arguments about faulty cognitions. (If we can’t control something, there’s no value in fearing it, since the fear accomplishes nothing.) Spinoza’s philosophy seemed to have worked for him; biographies report him to have been a notably serene individual. Some sixteen hundred years before Spinoza, the Stoic philosopher Epictetus anticipated the same idea about faulty cognitions. “People are not disturbed by things but by the view they take of them,” he wrote in the first century; for Epictetus, the roots of anxiety lay not in our biology but in how we apprehend reality. Alleviating anxiety is a matter of “correcting erroneous perceptions” (as the cognitive-behavioral therapists say). The Stoics, in fact, may be the true progenitors of cognitive-behavioral therapy. When Seneca, a contemporary of Epictetus, wrote, “There are more things to alarm us than to harm us, and we suffer more in apprehension than in reality,” he was prefiguring by twenty centuries what Aaron Beck, the official founder of CBT, would say in the 1950s.*
The intellectual antecedents of modern psychopharmacology lie even further in the past. Hippocrates, the ancient Greek doctor, concluded in the fourth century B.C. that pathological anxiety was a straightforward biological and medical problem. “If you cut open the head [of a mentally ill individual],” Hippocrates wrote, “you will find the brain humid, full of sweat and smelling badly.” For Hippocrates, “body juices” were the cause of madness; a sudden flood of bile to the brain would produce anxiety. (Following Hippocrates, Aristotle placed great weight on the temperature of bile: warm bile generated warmth and enthusiasm; cold bile produced anxiety and cowardice.) In Hippocrates’s view, anxiety and other psychiatric disorders were a medical-biological problem best treated by getting the humors back into proper equilibrium.†
But Plato and his adherents, for their part, believed that psychic life was autonomous from physiology and disagreed with the idea that anxiety or melancholy had an organic basis in the body; the biological model of mental illness was, as one ancient Greek philosopher put it, “as vain as a child’s story.” In Plato’s view, while physicians could sometimes provide relief for minor psychological ailments (because sometimes emotional problems are refracted into the body), deep-seated emotional problems could be addressed only by philosophers. Anxiety and other mental discomfort arose not from physiological imbalances but from disharmony of the soul; recovery demanded deeper self-knowledge, more self-control, and a way of life guided by philosophy. Plato believed that (as one historian of science has put it) “if one’s body and mind are in generally good shape, a doctor can come along and put minor ills to right just as one might call in a plumber; but if the general fabric is impaired, a physician is useless.” Philosophy, in this view, was the only proper method for treating the soul.
Poppycock, said Hippocrates: “All that philosophers have written on natural science no more pertains to medicine than to painting,” he declared.‡
Is pathological anxiety a medical illness, as Hippocrates and Aristotle and modern pharmacologists would have it? Or is it a philosophical problem, as Plato and Spinoza and the cognitive-behavioral therapists would have it? Is it a psychological problem, a product of childhood trauma and sexual inhibition, as Freud and his acolytes would have it? Or is it a spiritual condition, as Søren Kierkegaard and his existentialist descendants claimed? Or, finally, is it—as W. H. Auden and David Riesman and Erich Fromm and Albert Camus and scores of modern commentators have declared—a cultural condition, a function of the times we live in and the structure of our society?
> The truth is that anxiety is at once a function of biology and philosophy, body and mind, instinct and reason, personality and culture. Even as anxiety is experienced at a spiritual and psychological level, it is scientifically measurable at the molecular level and the physiological level. It is produced by nature and it is produced by nurture. It’s a psychological phenomenon and a sociological phenomenon. In computer terms, it’s both a hardware problem (I’m wired badly) and a software problem (I run faulty logic programs that make me think anxious thoughts). The origins of a temperament are many faceted; emotional dispositions that may seem to have a simple, single source—a bad gene, say, or a childhood trauma—may not. After all, who’s to say that Spinoza’s vaunted equanimity didn’t derive less from his philosophy than from his biology? Mightn’t a genetically programmed low level of autonomic arousal have produced his serene philosophy, rather than the other way around?
Neuroses are generated not only by incidental individual experiences, but also by the specific cultural conditions under which we live.… It is an individual fate, for example, to have a domineering or a “self-sacrificing” mother, but it is only under definite cultural conditions that we find domineering or self-sacrificing mothers.
—KAREN HORNEY, The Neurotic Personality of Our Time (1937)
I don’t have to look far to find evidence of anxiety as a family trait. My great-grandfather Chester Hanford, for many years the dean of students at Harvard, was in the late 1940s admitted to McLean Hospital, the famous mental institution in Belmont, Massachusetts, suffering from acute anxiety. The last thirty years of his life were often agony. Though medication and electroshock treatments would occasionally bring about remissions in his suffering, such respites were temporary, and in his darkest moments in the 1960s he was reduced to a fetal ball in his bedroom, producing what my parents recall as an inhuman-sounding moaning. Weighed down by the responsibility of caring for him, his wife, my great-grandmother, a formidable and brilliant woman, died from an overdose of scotch and sleeping pills in 1969.
Chester Hanford’s son is my maternal grandfather. Now ninety-three years old, he is an extremely accomplished and graceful man—one of the sanest people I know. But one can perhaps see shadows of the obsessions and the rituals that plagued his father. For instance, when leaving a building, he will exit only by way of the door through which he entered, a superstition that sometimes leads to complex logistical maneuverings. My mother, in turn, is a high-strung and inveterate worrier and, though she enjoyed a productive career as an attorney, suffers from many of the same phobias and neuroses that I do. She assiduously avoids heights (glass elevators, chairlifts) and tends to avoid public speaking and risk taking of most kinds. Like me, she is also mortally terrified of vomiting. As a young woman, she suffered from frequent and severe panic attacks. At her most anxious (or so my father, her ex-husband, insists), her fears verged on paranoia: when I was an infant, my father says, she became convinced that a serial killer in a yellow Volkswagen was watching our apartment.§ My only sibling, a younger sister, struggles with anxiety that is different from mine but nonetheless intense. She, too, has taken Celexa—and also Prozac and Wellbutrin and Nardil and Neurontin and BuSpar. None of them worked for her, and today she may be one of the few adult members of my mother’s side of the family not currently taking a psychiatric medication. (Various other relatives on my mother’s side have also relied on antidepressants and antianxiety medications continuously for many years.)
On the evidence of just these four generations on my mother’s side (and there is a separate complement of psychopathology coming down to me on the side of my father, who drank himself into unconsciousness five nights out of every seven throughout much of my later childhood), it is not outlandish to conclude that I possess a genetic predisposition to anxiety and depression.
But these facts, by themselves, are not dispositive—because is it not possible that the bequeathing of anxiety from one generation to the next on my mother’s side had nothing to do with genes and everything to do with the environment? In the 1920s, my great-grandparents had a young child who died of an infection. This was devastating to them. Perhaps this trauma, combined with the later trauma of having many of his students die in World War II, cracked something in my great-grandfather’s psyche—and, for that matter, in my grandfather’s. My grandfather was in elementary school at the time of his brother’s death and can remember sitting alongside the tiny casket as the hearse drove to the cemetery. Perhaps my mother, in turn, acquired her own anxieties by experiencing the anxious ministrations of her worrywart mother; the psychological term for this is “modeling.” And perhaps I, observing my mother’s phobias, adopted them as my own. While there is substantial evidence that specific phobias—particularly those based on fears that would have been adaptive in the state of nature, like phobias of heights or snakes or rodents—are genetically transmittable, or “evolutionarily conserved,” isn’t it just as plausible, if not more so, to conclude that I learned to be fearful by watching my mother be fearful? Or that the generally unsettled nature of my childhood psychological environment—my mother’s constant anxious buzzing, my father’s alcoholic absence, the unhappy tumult of their marriage that would end in divorce—produced in me a comparably unsettled sensibility? Or that my mother’s paranoia and panic while pregnant with me produced such hormonal Sturm und Drang in the womb that I was doomed to be born nervous? Research suggests that mothers who suffer stress while pregnant are more likely to produce anxious children.‖ Thomas Hobbes, the political philosopher, was born prematurely when his mother, terrified by the news that the Spanish Armada was advancing toward English shores, went into labor early in April 1588. “Myself and fear were born twins,” Hobbes wrote, and he attributed his own anxious temperament to his mother’s terror-induced premature labor. Perhaps Hobbes’s view that a powerful state needs to protect citizens from the violence and misery they naturally inflict on one another (life, he famously said, is nasty, brutish, and short) was founded on the anxious temperament imbued in him in utero by his mother’s stress hormones.
Or do the roots of my anxiety lie deeper and broader than the things I’ve experienced and the genes I’ve inherited—that is, in history and in culture? My father’s parents were Jews who emigrated from Weimar Germany in the 1930s. My father’s mother became a nastily anti-Semitic Jew—she renounced her Jewishness out of fear that she would someday be persecuted for it. My younger sister and I were raised in the Episcopal Church, our Jewish background hidden from us until I was in college. My father, for his part, has had a lifelong fascination with World War II, and specifically with the Nazis; he watched the television series The World at War again and again. In my memory, that program, with its stentorian music accompanying the Nazi advance on Paris, is the running sound track to my early childhood.a The long-persecuted Jews, of course, have millennia of experience in having reason to be scared—which perhaps explains why some studies have shown that Jewish men suffer from depression and anxiety at rates higher than men in other ethnic groups.b
My mother’s cultural heritage, on the other hand, was heavily WASP; she is a proud Mayflower descendant who until recently subscribed wholeheartedly to the notion that there is no emotion and no family issue that should not be suppressed.
Thus, me: a mixture of Jewish and WASP pathology—a neurotic and histrionic Jew suppressed inside a neurotic and repressed WASP. No wonder I’m anxious: I’m like Woody Allen trapped in John Calvin.
Or is my anxiety, after all, “normal”—a natural response to the times we live in? I was in middle school when The Day After, about the dystopian aftermath of a nuclear attack, aired on network television. As an adolescent, I regularly had dreams that ended with a missile streaking across the sky. Were these dreams evidence of anxious psychopathology? Or a reasonable reaction to the conditions I perceived—which were, after all, the same conditions that preoccupied defense policy analysts through the 1980s? The Cold War, of course, has now long since
ended—but it has been replaced by the threat of hijacked airplanes, dirty bombs, underwear bombers, chemical attacks, and anthrax, not to mention SARS, swine flu, drug-resistant tuberculosis, the prospect of climate-change-induced global apocalypse, and the abiding stresses of a worldwide economic slowdown and of a global economy undergoing seemingly constant upheaval. Insofar as it’s possible to measure such things, eras of social transformation seem to produce a quantum increase in the anxiety of the population. In our postindustrial era of economic uncertainty, where social structures are undergoing continuous disruption and where professional and gender roles are constantly changing, is it not normal—adaptive even—to be anxious?
At some level, yes, it is—at least to the extent that it is always, or often, adaptive to be reasonably anxious. According to Charles Darwin (who himself suffered from crippling agoraphobia that left him housebound for years after his voyage on the Beagle), species that “fear rightly” increase their chances of survival. We anxious people are less likely to remove ourselves from the gene pool by, say, frolicking on the edge of cliffs or becoming fighter pilots.