In modern life, occasions for what James called “genuine” human fear of the sort occasioned in the state of nature—being chased by a saber-toothed tiger, say, or encountering members of an enemy tribe—are relatively rare, at least most of the time. The threats that today tend to activate fight-or-flight physiology—the disapproving look from the boss, the mysterious letter your wife got from her old boyfriend, the college application process, the crumbling of the economy, the abiding threat of terrorism, the plummeting of your retirement fund—are not the sorts of threats the response is designed to help with. Yet because the emergency biological response gets triggered anyway, especially in clinically anxious people, we end up marinating in a stew of stress hormones that is damaging to our health. This is because whether you are in the throes of neurotic anxiety or responding to a real threat like a mugging or a house fire, the autonomic activity of your nervous system is roughly the same. The hypothalamus, a small part of the brain located just above the brain stem, releases a hormone called corticotropin-releasing factor (CRF), which in turn induces the pituitary gland, a pea-size organ protruding from the bottom of the hypothalamus, to release adrenocorticotropin hormone (ACTH), which travels through the bloodstream to the kidneys, instructing the adrenal glands sitting atop them to release adrenaline (also known as norepinephrine) and cortisol, which cause more glucose to be released into the bloodstream, which increases heart and breathing rates and produces the state of heightened arousal that can be so useful in the case of actual danger and so misery inducing in the case of a panic attack or of chronic worrying. A large body of evidence suggests that having elevated levels of cortisol for an extended period of time produces a host of deleterious health effects, ranging from high blood pressure to a compromised immune system to the shrinking of the hippocampus, a part of the brain crucial to memory formation. An anxious physiological response deployed at the right time can help keep you alive; that same response deployed too often and at the wrong times can lead to an early death.
Like animals, humans can easily be trained to exhibit conditioned fear responses—that is, to associate objectively nonfrightening objects or situations with real threats. In 1920, the psychologist John Watson famously used classical conditioning to produce phobic anxiety in an eleven-month-old boy he called Little Albert. After Watson repeatedly paired a loud noise—which provoked crying and trembling in the boy—with the presence of a white rat (the “neutral stimulus”), he was able to elicit an acute fear response in the boy simply by presenting the rat alone, without the noise. (Before the conditioning, Little Albert had happily played with the rat on his bed.) Soon the boy had developed a full-blown phobia not only of rats and other small furry animals but also of white beards. (Santa Claus terrified Little Albert.) Watson concluded that Little Albert’s phobia demonstrated the power of classical conditioning. For the early behaviorists, phobic anxiety in both animals and humans was reducible to straightforward fear conditioning; clinical anxiety, in this view, was a learned response.i
For evolutionary biologists, anxiety is merely an atavistic fear response, a hardwired animal instinct triggered at the wrong time or for the wrong reasons. For behaviorists, anxiety is a learned response acquired, like Pavlov’s dogs’ propensity for salivating at the sound of a bell, through simple conditioning. According to both, anxiety is as much an animal trait as a human one. “Contrary to the view of some humanists, I believe that emotions are anything but uniquely human traits,” the neuroscientist Joseph LeDoux writes, “and, in fact, that some emotional systems in the brain are essentially the same in … mammals, reptiles, and birds, and possibly amphibians and fishes as well.”
But is the sort of instinctive, mechanistic response that a mouse displays in the presence of a cat, or when it hears the bell associated with a shock—or even that Little Albert displayed after he’d been trained to fear the rat—really anxiety of the sort that I feel when boarding an airplane or obsessing about my family’s finances or about the mole on my forearm?
Or consider this: Even Aplysia californica, a marine snail with a primitive brain and no spine, can demonstrate a physiological and behavioral response that would, if exhibited by a human, be biologically equivalent (more or less) to anxiety. Touch its gill and the snail will recoil, its blood pressure will rise, and its heart rate will increase. Is that anxiety?
Or what about this: Even brainless, nerveless single-celled bacteria can exhibit a learned response and display what psychiatrists call avoidant behavior. When the pond-dwelling paramecium encounters a shock by an electric buzzer—an aversive stimulus—it will retreat and thenceforth seek to avoid the buzzer by swimming away from it. Is that anxiety? By some definitions, it is: according to the Diagnostic and Statistical Manual, “avoidance” of fearful stimuli is one of the hallmarks of almost all the anxiety disorders.
Other experts say that the presumed analogies between animal and human behavioral response are risibly overextended. “It is not obvious that a rat’s display of an enhanced startle reaction … [is a] fruitful model for all human anxiety states,” says Jerome Kagan. David Barlow of Boston University’s Center for Anxiety and Related Disorders asks whether “entering a seemingly involuntary state of paralysis when under attack”—the sort of animal behavior that clearly does have a strong evolutionary and physiological parallel in humans—“really [has] anything in common with the forebodings concerning the welfare of our family, our occupation, or our finances?”
“How many hippos worry about whether Social Security is going to last as long as they will,” asks Robert Sapolsky, a neuroscientist at Stanford University, “or what they are going to say on a first date?”
“A rat can’t worry about the stock market crashing,” Joseph LeDoux concedes. “We can.”
Can anxiety be reduced to a purely biological or mechanical process—the instinctive behavioral response of the rat or the marine snail retreating mindlessly from the electric shock or of Little Albert conditioned, like Pavlov’s dogs, to recoil and tremble in the presence of furry things? Or does anxiety require a sense of time, an awareness of prospective threats, an anticipation of future suffering—the debilitating “fears as to the future” that brought my great-grandfather, and me, to the mental hospital?
Is anxiety an animal instinct, something we share with rats and lizards and amoebas? Is it a learned behavior, something acquirable through mechanical conditioning? Or is it, after all, a uniquely human experience, dependent on consciousness of, among other things, a sense of self and the idea of death?
The physician and the philosopher have different ways of defining the diseases of the soul. For instance anger for the philosopher is a sentiment born of the desire to return an offense, whereas for the physician it is a surging of blood around the heart.
—ARISTOTLE, De Anima (FOURTH CENTURY B.C.)
One morning, after months of wrestling in frustration with these questions, I dump myself on my therapist’s couch in a heap of worry and self-loathing.
“What’s wrong?” Dr. W. asks.
“I’m supposed to be writing a book about anxiety and I can’t even work out what the basic definition of anxiety is. In all these thousands of pages I’ve pored through, I’ve come across hundreds of definitions. Many of them are similar to one another, but many others contradict each other. I don’t know which one to use.”
“Use the DSM definitions,” he suggests.
“But those aren’t definitions, just a list of associated symptoms,” I say.j “And anyway, even that’s not straightforward, since the DSM is in the process of being revised for the DSM-V!”k
“I know,” Dr. W. says ruefully. He laments that the mandarins of psychiatry had recently considered dropping obsessive-compulsive disorder (OCD) from the anxiety disorders category in the new DSM, placing it instead into a new category of “impulsive disorders,” on a spectrum alongside ailments like Tourette’s syndrome. He thinks this is wrong. “In all my decades of clinical work,” he says, “OCD pati
ents are always anxious; they worry about their obsessions.”
I mention that at a conference I’d attended a few weeks earlier, one of the rationales given for why OCD might be reclassified as something other than an anxiety disorder was that its genetics and its neurocircuitry seem to be substantially different from that of the other anxiety disorders.
“Goddamned biomedical psychiatry!” he blurts. Dr. W. is ordinarily a gentle, even-keeled guy, and he is aggressively ecumenical in his approach to psychotherapy; he has tried, in his writing and in his clinical practice, to assimilate the best of all the different therapeutic modes into what he calls an “integrative approach to healing the wounded self.” (He is also, I should say here, the Best Therapist Ever.) But he believes strongly that over the last several decades the claims of the biomedical model generally, and of neuroscience particularly, have become increasingly arrogant and reductionist, pushing other avenues of research inquiry to the margins and distorting the practice of psychotherapy. Some of the more hard-core neuroscientists and psychopharmacologists, he feels, would boil all mental processes down to their smallest molecular components, without any sense of the existential dimensions of human suffering or of the meaning of anxious or depressive symptoms. At conferences on anxiety, he laments, symposia on drugs and neurochemistry—many of them sponsored by pharmaceutical companies—have started to crowd out everything else.
I tell Dr. W. I’m on the verge of abandoning the project. “I told you I was a failure,” I say.
“Look,” he says. “That’s your anxiety talking. It makes you excessively anxious about, among other things, finding the correct definition of anxiety. And it makes you worry relentlessly about outcomes”—about whether my definition of anxiety will be “wrong”—“instead of concentrating on the work itself. You need to focus your attention. Stay on task!”
“But I still don’t know what basic definition of anxiety to use,” I say.
“Use mine,” he says.
No one who has ever been tormented by prolonged bouts of anxiety doubts its power to paralyze action, promote flight, eviscerate pleasure, and skew thinking toward the catastrophic. None would deny how terribly painful the experience of anxiety can be. The experience of chronic or intense anxiety is above all else a profound and perplexing confrontation with pain.
—BARRY E. WOLFE, Understanding and Treating Anxiety Disorders (2005)
As it happens, I had chosen Dr. W. as a therapist a few years earlier precisely because I found his conception of anxiety interesting and his approach to treatment less rigid or ideological than previous therapists I’d worked with. (Also, I thought the author photo on his book jacket made him look kindly.)
I discovered Dr. W.’s work when, while in Miami attending an academic conference on anxiety, I stumbled across a book he had recently published on a display table outside a hotel ballroom. Though the book, a guide to treating anxiety disorders, was geared toward professional psychotherapists, his “integrative” conception of anxiety appealed to me. Also, after reading so many specialized books on the neuroscience of anxiety that featured sentences like “Theta activity is a rhythmic burst firing pattern of neurons in the hippocampus and related structures which, because it is synchronous across very large numbers of cells, often gives rise to a high-voltage quasi-sinusoidal electrographic slow ‘theta rhythm’ (approximately 5–10 Hz in the unanesthetized rat) that can be recorded from the hippocampal formation under a variety of behavioural conditions,” I found his writing to be clear and nontechnical and his approach to his patients refreshingly humanistic. I recognized my own issues—the panic attacks, the dependency problems, the sublimated fear of death masked as anxiety about more trivial things—in many of the case studies in his book.
I had recently moved from Boston to Washington, D.C., and found myself for the first time in a quarter century without a regular psychotherapist. So when I read in Dr. W.’s author’s note that he had a practice in the Washington area, I e-mailed him to ask if he was accepting new patients.
Dr. W. has not cured me of my anxiety. But he continues to insist that he will, and in my more hopeful moments I even sort of think he might. In the meantime, he has provided me with useful tools for trying to manage it, good and steady practical advice, and, perhaps most important, a usable definition—or a taxonomy of definitions—of anxiety.
According to Dr. W., the competing theories of and treatment approaches to anxiety can be grouped into four basic categories: the psychoanalytic, the behavioral and cognitive-behavioral, the biomedical, and the experiential.l
The psychoanalytic approach—crucial aspects of which, though Freudianism has been widely repudiated in most scientific circles, still permeate modern talk therapy—holds that the repression of taboo thoughts and ideas (often of a sexual nature) or of inner psychic conflicts leads to anxiety. Treatment involves bringing these repressed conflicts into conscious awareness and addressing them through psychodynamic psychotherapy and the pursuit of “insight.”
Behaviorists believe, like John Watson did, that anxiety is a conditioned fear response. Anxiety disorders arise when we learn—often through unconscious conditioning—to fear objectively nonthreatening things or to fear mildly threatening things too intensely. Treatment involves correcting faulty thinking through various combinations of exposure therapy (exposing yourself to the fear and acclimating to it so your fear response diminishes) and cognitive restructuring (changing your thinking) in order to “extinguish” phobias and to “decatastrophize” panic attacks and obsessional worrying. Many studies are now finding that cognitive-behavioral therapy, or CBT, is the safest and most effective treatment for many forms of depression and anxiety disorders.
The biomedical approach (where research has exploded over the last sixty years) has focused on the biological mechanisms of anxiety—on brain structures like the amygdala, hippocampus, locus coeruleus, anterior cingulate, and insula, and on neurotransmitters like serotonin, norepinephrine, dopamine, glutamate, gamma-aminobutyric acid (GABA), and neuropeptide Y (NPY)—and on the genetics that underlie that biology. Treatment often involves the use of medication.
Finally, what Dr. W. calls the experiential approach to anxiety disorders takes a more existential perspective, considering things like panic attacks and obsessional worrying to be coping mechanisms produced by the psyche in response to threats to its integrity or to self-esteem. The experiential approach, like the psychoanalytic, places great weight on the content and meaning of anxiety—rather than on the mechanisms of anxiety, which is where the biomedical and behavioral approaches concentrate—believing these can be clues to unlocking hidden psychic traumas or convictions about the worthlessness of one’s existence. Treatment tends to involve guided relaxation to reduce anxiety symptoms and helping the patient to burrow into the anxieties to address the existential issues that lie beneath them.
The conflicts between these different perspectives—and between the psychiatrists (MDs) and the psychologists (PhDs), between the drug proponents and the drug critics, between the cognitive-behaviorists and the psychoanalysts, between Freudians and Jungians, between the molecular neuroscientists and the holistic therapists—can sometimes be bitter. The stakes are high—the future stability of large professional infrastructures rides on one theory or another predominating. And the fundamental conflict—whether anxiety is a medical disease or a spiritual problem, a problem of the body or a problem of the mind—is age-old, dating back to the clashes between Hippocrates and Plato and their followers.m
But while in many places these competing theoretical perspectives conflict with one another, they are not mutually exclusive. Often they overlap. Cutting-edge cognitive-behavioral therapy borrows from the biomedical model, using pharmacology to enhance exposure therapy. (Studies show that a drug called D-cycloserine, which was originally developed as an antibiotic, causes new memories to be more powerfully consolidated in the hippocampus and the amygdala, augmenting the potency of exposure to extinguish pho
bias by intensifying the power of the new, nonfearful associations to override the fearful ones.) The biomedical view, for its part, increasingly recognizes the power of things like meditation and traditional talk therapy to render concrete structural changes in brain physiology that are every bit as “real” as the changes wrought by pills or electroshock therapy. A study published by researchers at Massachusetts General Hospital in 2011 found that subjects who practiced meditation for an average of just twenty-seven minutes a day over a period of eight weeks produced visible changes in brain structure. Meditation led to decreased density of the amygdala, a physical change that was correlated with subjects’ self-reported stress levels—as their amygdalae got less dense, the subjects felt less stressed. Other studies have found that Buddhist monks who are especially good at meditating show much greater activity in their frontal cortices, and much less in their amygdalae, than normal people.n Meditation and deep-breathing exercises work for similar reasons as psychiatric medications do, exerting their effects not just on some abstract concept of mind but concretely on our bodies, on the somatic correlates of our feelings. Recent research has shown that even old-fashioned talk therapy can have tangible, physical effects on the shape of our brains. Perhaps Kierkegaard was wrong to say that the man who has learned to be in anxiety has learned the most important, or the most existentially meaningful, thing—perhaps the man has only learned the right techniques for controlling his hyperactive amygdala.o
My Age of Anxiety: Fear, Hope, Dread, and the Search for Peace of Mind Page 6