Still, I worry. A lot. It’s my nature. (Besides, as many people have said to me, how can you not be anxious writing a book about anxiety?)
Dr. W., for his part, says: “Put your anxiety about the book into the book.”
The planning function of the nervous system, in the course of evolution, has culminated in the appearance of ideas, values, and pleasures—the unique manifestations of man’s social living. Man, alone, can plan for the distant future, and can experience the retrospective pleasures of achievement. Man, alone, can be happy. But man, alone, can be worried and anxious.
—HOWARD LIDDELL, “THE ROLE OF VIGILANCE IN THE DEVELOPMENT OF ANIMAL NEUROSIS” (1949)
In all the insights into history and culture that a study of anxiety might produce, is there anything that can help the individual anxiety sufferer? Can we—can I—reduce anxiety, or come to terms with it, by understanding the value and meaning of it?
I hope so. But when I have a panic attack, there is nothing interesting about it. I try to think about it analytically and I can’t—it’s just miserably unpleasant and I want it to stop. A panic attack is interesting the way a broken leg or a kidney stone is interesting—a pain that you want to end.
Some years ago, before embarking on the research for this project in earnest, I picked up an academic book about the physiology of anxiety to read while on a flight from San Francisco to Washington, D.C. As we flew smoothly over the West, I was immersed in the book and felt like I was gaining an intellectual understanding of the phenomenon. So, I thought as I read, it’s simply a flurry of activity in my amygdala that produces that acutely miserable emotion I sometimes feel? Those feelings of doom and terror are just the bubbling of neurotransmitters in my brain? That doesn’t seem so intimidating. Armed with this perspective, I continued thinking: I can exert mind over matter and reduce the physical symptoms of anxiety to their proper place—mere routine physiology—and live more calmly in the world. Here I am, hurtling along at thirty-eight thousand feet, and I’m not even that nervous.
Then the turbulence started. It wasn’t particularly severe, but as we bumped along above the Rockies, any perspective or understanding I thought I had gained was rendered instantly useless; my fear response revved up, and despite gulping Xanax and Dramamine, I was terrified and miserable until we landed several hours later.
My anxiety is a reminder that I am governed by my physiology—that what happens in the body may do more to determine what happens in the mind than the other way around. Though thinkers from Aristotle to William James to the researchers who publish today in the journal Psychosomatic Medicine have recognized this fact, it runs counter to one of the basic Platonic-Cartesian tenets of Western thought—the idea that who we are, the way we think and perceive, is a product of our disembodied souls or intellects. The brute biological factness of anxiety challenges our sense of who we are: anxiety reminds us that we are, like animals, prisoners of our bodies, which will decline and die and cease to be. (No wonder we’re anxious.)
And yet even as anxiety throws us back into our most primitive, fight-or-flight-driven reptilian selves, it is also what makes us more than mere animals. “If man were a beast or an angel,” Kierkegaard wrote in 1844, “he would not be able to be in anxiety. Since he is both beast and angel, he can be in anxiety, and the greater the anxiety, the greater the man.” The ability to worry about the future goes hand in hand with the ability to plan for the future—and planning for the future (along with remembering the past) is what gives rise to culture and separates us from other animals.
For Kierkegaard, as for Freud, the most anxiety-producing threats lay not in the world around us but rather deep inside us—in our uncertainty about the existential choices we make and in our fear of death. Confronting this fear, and risking the dissolution of one’s identity, expands the soul and fulfills the self. “Learning to know anxiety is an adventure which every man has to affront if he would not go to perdition either by not having known anxiety or by sinking under it,” Kierkegaard wrote. “He therefore who has learned rightly to be in anxiety has learned the most important thing.”
Learning rightly to be in anxiety. Well, I’m trying. This book is part of that effort.
* * *
* Seneca was also in some sense anticipating FDR’s famous formulation: “The only thing we have to fear is fear itself.”
† Hippocrates believed that staying in good physical and mental health required maintaining the right balance of what he called the four humors, or bodily fluids: blood, phlegm, black bile, and yellow bile. A person’s relative humoral balance accounted for his temperament: whereas someone with relatively more blood might have a fiery complexion and a lively or “sanguine” temperament and be given to hot-blooded explosions of temper, someone with relatively more black bile might have swarthy skin and a melancholic temperament. An optimal mixture of the humors (eucrasia) produced a state of health; when the humors fell into disequilibrium (dyscrasia), the result was disease. Though Hippocrates’s humoral theory of mind is now discredited, it persisted for two thousand years, until the 1700s, and it lives on still in our use of words like “bilious” and “phlegmatic” to describe people’s personalities—and in the biomedical approach to anxiety and mental illness generally.
‡ Or someone who followed him declared. Most historians believe that what have come down to us as the so-called Hippocratic writings were in fact produced by a number of doctors who were followers of Hippocrates. Some of the writings in the corpus seem to date from after his death and are believed to have been written by his son-in-law Polybus; Hippocrates’s sons Draco and Thessalus also became famous doctors. For simplicity’s sake, I treat Hippocrates’s writing as the work of one man, since the mode of thinking that the writings represent derives from him.
§ Today, my mother and father, now divorced fifteen years, disagree about the severity of the paranoia: my father insists it was considerable; my mother says it was minor (and that, for that matter, there was actually a serial killer afoot at the time).
‖ One study found that children whose mothers were pregnant with them on September 11, 2001, still had elevated levels of stress hormones in their blood at six months. Similar findings—showing as-yet-unborn children acquiring higher lifetime baseline levels of stressed-out physiology—have been reported during war and other chaotic times.
a When my mother was attending law school at night, my sister and I would spend evenings moping around the house while my father played Bach fugues on the piano and then parked himself with a bowl of popcorn and a bottle of gin in front of The World at War.
b There’s also evidence that the high IQ scores of Ashkenazi Jews are attached somehow to the high anxiety rates of that same group, and there are plausible evolutionary explanations for why both intelligence and imagination tend to be allied with anxiety. (Various studies have found that the average IQ of Ashkenazi Jews is eight points higher than that of the next highest ethnic group, Northeast Asians, and close to a full standard deviation higher than other European groups.)
c “For many, many people who have anxiety disorders—particularly agoraphobia and panic disorder—people would be surprised to find out that they have problems with anxiety because they seem so ‘together’ and in control,” says Paul Foxman, a psychologist who heads the Center for Anxiety Disorders in Burlington, Vermont. “They seem to be comfortable, but there’s a disconnection between the public self and the private self.”
d David Barlow, one of the preeminent researchers in the field, notes (in the jargon-intensive terminology of the specialist) that pathological, negative self-focus “seems to be an integral part of the cognitive-affective structure of anxiety. This negative self-evaluative focus and disruption of attention is in large part responsible for decreases in performance. This attention shift in turn contributes to a vicious cycle of anxious apprehension, in which increasing anxiety leads to further attentional shifts, increased performance deficits, and subsequent spiraling of aro
usal.”
e On the desk in front of me is a 1997 article from the Journal of Abnormal Psychology called “Hiding Feelings: The Acute Effects of Inhibiting Negative and Positive Emotions.”
f As I write this, I can hear the strains of what may be my better judgment: Even if you are so unfortunate as to be excessively anxious, at least have the dignity not to prattle on about it publicly. Keep a stiff upper lip, and keep it to yourself.
g For instance, S., a nonfiction writer in her midthirties, told of taking Xanax and Klonopin for her anxiety and about how she switched from Prozac to Lexapro because Prozac had killed her libido. C., a poet in his midforties, said that he’d had to take the antidepressant Zoloft for panic attacks. (C.’s first panic attack had landed him in the emergency room, convinced he was having a heart attack. Subsequent attacks, he said, “were not so bad because you know what they are—but they’re still scary because you always wonder, Maybe this time I really am having a heart attack.” Some epidemiological surveys have found that one-third of adults suffering their first panic attack end up in the emergency room.) K., a novelist, said that while she was trying to finish her last book, her anxiety got so bad that she couldn’t work. Fearing she was going crazy, she went to her psychiatrist, who prescribed her Zoloft, which made her fat, and then Lexapro, which increased her anxiety so much that she could no longer even bear to pick her children up at school.
h After dinner, yet another writer approached me. The woman—let’s call her E.—is a globe-trotting war correspondent and best-selling author in her late thirties who suffers, she told me, from a litany of depressive, anxious symptoms (including trichotillomania, a disorder that causes people, mainly women, to compulsively pull their hair out when under stress), for which a doctor had prescribed her the antidepressant Lexapro. I marveled that E., despite her anxiety and depression, had managed to travel all around Africa and the Middle East, filing dispatches from war-ravaged countries, often at great risk to her personal safety; for me, simply traveling more than a few miles from home can be miserably anxiety producing and bowel loosening. “I feel calmer in war zones,” she said. “I know it’s perverse, but I feel more calm while being shelled; it’s one of the few times I don’t feel anxiety.” Waiting for an editor to make a judgment about an article she’s submitted, however, can send her spiraling into anxiety and depression. (Freud observed that threats to our self-esteem or self-conception can often cause far more anxiety than threats to our physical well-being.)
i There is definitely some truth to that, and I will have a lot to say about the topic in part 3 of this book.
j Even though Ben now travels the world and walks red carpets and commands tens of thousands of dollars for a speech, I can still remember the times, in the lean years before his first book came out, when he would get overwhelmed by panic attacks if we strayed too far from his apartment and when the prospect of socializing at a party would leave him so nervous he’d vomit into the bushes outside beforehand.
k Perhaps he would have been better off feeling more stress—a greater intensity of worry about consequences might have prevented the adulterous misadventure that led to his downfall.
l Not that coolness and toughness on the field are guarantees of equanimity off of it. Terry Bradshaw, the Steelers Hall of Fame quarterback from the late 1970s, was a fearless gladiator who went on to be debilitated by depression and panic attacks. Earl Campbell, the burly, fearsome Houston Oilers running back from the 1970s, found himself, a decade later, housebound by panic attacks.
CHAPTER 2
What Do We Talk About When We Talk About Anxiety?
Although it is widely recognized that anxiety is the most pervasive psychological phenomenon of our time … there has been little or no agreement on its definition, and very little, if any, progress on its measurement.
—PAUL HOCH, PRESIDENT, AMERICAN PSYCHOPATHOLOGICAL ASSOCIATION, IN AN ADDRESS TO THE FIRST-EVER ACADEMIC CONFERENCE ON ANXIETY (1949)
For researchers as well as laymen, this is the age of anxiety … . [But] can we honestly claim that our understanding of anxiety has increased in proportion to the huge research effort expended or even increased perceptibility?
We think not.
—“THE NATURE OF ANXIETY: A REVIEW OF THIRTEEN MULTIVARIATE ANALYSES COMPRISING 814 VARIABLES,” Psychiatric Reports (DECEMBER 1958)
Anxiety is not a simple thing to grasp.
—SIGMUND FREUD, The Problem of Anxiety (1926)
On February 16, 1948, at 3:45 in the afternoon, my great-grandfather Chester Hanford, who had recently stepped down after twenty years as the dean of Harvard College to concentrate full-time on his academic work as a professor of government (“with a focus on local and municipal government,” as he liked to say), was admitted to McLean Hospital with a provisional diagnosis of “psychoneurosis” and “reactive depression.” Fifty-six years old at the time of his admission, Chester reported that his primary complaints were insomnia, “feelings of anxiety and tension,” and “fears as to the future.” Described by the hospital director as a “conscientious and usually very effective man,” Chester had been in a state of “anxiety of a rather severe degree” for five months. The night before presenting himself at McLean, he had told his wife that he wanted to commit suicide.
Thirty-one years later, on October 3, 1979, at 8:30 in the morning, my parents—worried that I, ten years old and in the fifth grade, had of late been piling various alarming new tics and behavioral oddities on top of my already obsessive germ avoidance and acute separation anxiety and phobia of vomiting—took me to the same psychiatric hospital to be evaluated. A team of experts (a psychiatrist, a psychologist, a social worker, and several young psychiatric residents who sat hidden behind a two-way mirror and watched me get interviewed and take a Rorschach test) diagnosed me with “phobic neurosis” and “overanxious reaction disorder of childhood” and observed that I would be at significant risk of developing “anxiety neurosis” and “neurotic depression” as I got older if I wasn’t treated.
Twenty-five years after that, on April 13, 2004, at two o’clock in the afternoon, I, now thirty-four years old and working as a senior editor at The Atlantic magazine and dreading the publication of my first book, presented myself at the nationally renowned Center for Anxiety and Related Disorders at Boston University. After meeting for several hours with a psychologist and two graduate students and filling out dozens of pages of questionnaires (including, I later learned, the Depression Anxiety Stress Scales and the Social Interaction Anxiety Scale and the Penn State Worry Questionnaire and the Anxiety Sensitivity Index), I was given a principal diagnosis of “panic disorder with agoraphobia” and additional diagnoses of “specific phobia” and “social phobia.” The clinicians also noted in their report that my questionnaire scores indicated “mild levels of depression,” “strong levels of anxiety,” and “strong levels of worry.”
Why so many different diagnoses? Did the nature of my anxiety change so much between 1979 and 2004? And why didn’t my great-grandfather and I receive the same diagnoses? As described in his case files, the general scope of Chester Hanford’s syndrome was awfully similar to mine. Were my “strong levels of anxiety” really so different from the “feelings of anxiety and tension” and “fears as to the future” that afflicted my great-grandfather? And anyway, who, aside from the most well adjusted or sociopathic among us, doesn’t have “fears as to the future” or suffer “feelings of anxiety and tension”? What, if anything, separates the ostensibly “clinically” anxious, like my great-grandfather and me, from the “normally” anxious? Aren’t we all, consumed by the getting and striving of modern capitalist society—indeed, as a consequence of being alive, subject always to the caprice and violence of nature and each other and to the inevitability of death—at some level “psychoneurotic”?
Technically, no; in fact, no one is anymore. The diagnoses that Chester Hanford received in 1948 no longer existed by 1980. And the diagnoses that I received in 1979 no l
onger exist today.
In 1948, “psychoneurosis” was the American Psychiatric Association’s term for what that organization would, with the introduction in 1968 of the second edition of psychiatry’s bible, the Diagnostic and Statistical Manual (DSM-II), officially designate as simply “neurosis” and what it has, since the introduction of the third edition (DSM-III) in 1980, called “anxiety disorder.”*
This evolving terminology matters because the definitions—as well as the symptoms, the rates of incidence, the presumed causes, the cultural meanings, and the recommended treatments—associated with these diagnoses have changed along with their names over the years. The species of unpleasant emotion that twenty-five hundred years ago was associated with melaina chole (ancient Greek for “black bile”) has since also been described, in sometimes overlapping succession, as “melancholy,” “angst,” “hypochondria,” “hysteria,” “vapors,” “spleen,” “neurasthenia,” “neurosis,” “psychoneurosis,” “depression,” “phobia,” “anxiety,” and “anxiety disorder”—and that’s leaving aside such colloquial terms as panic, worry, dread, fright, apprehension, “nerves,” “nervousness,” “edginess,” “wariness,” “trepidation,” “jitters,” “willies,” “obsession,” “stress,” and plain old “fear.” And that’s just in English, where the word “anxiety” was rarely found in standard psychological or medical textbooks in English before the 1930s, when translators began rendering the German Angst (as deployed in the works of Sigmund Freud) as “anxiety.”†
Which raises the question: What are we talking about when we talk about anxiety?
My Age of Anxiety: Fear, Hope, Dread, and the Search for Peace of Mind Page 4