My Age of Anxiety: Fear, Hope, Dread, and the Search for Peace of Mind

by Scott Stossel

  Darwin observed that the equipment that produces panic anxiety in humans derives from the same evolutionary roots as the fight-or-flight reaction of a rat or the aversive maneuvering of a marine snail. Which means that anxiety, for all the philosophizing and psychologizing we’ve attached to it, may be an irreducibly biological phenomenon that is not so different in humans than in animals.

  What, if anything, do we lose when our anxiety is reduced to the stuff of its physiological components—to deficiencies in serotonin and dopamine or to an excess of activity in the amygdala and basal ganglia? The theologian Paul Tillich, writing in 1944, suggested that Angst was the natural reaction of man to “fear of death, conscience, guilt, despair, daily life, etc.” For Tillich, the crucial question of life was: Are we safe in some deity’s care, or are we trudging along pointlessly toward death in a cold, mechanical, and indifferent universe? Is finding serenity mainly a matter of coming to terms with that question? Or is it, rather more mundanely, a matter of properly calibrating levels of serotonin in the synapses? Or are these somehow, after all, the same thing?

  Perhaps man is one of the most fearful creatures, since added to the basic fears of predators and hostile conspecifics come intellectually based existential fears.

  —IRENÄUS EIBL-EIBESFELDT, “FEAR, DEFENCE AND AGGRESSION IN ANIMALS AND MAN: SOME ETHOLOGICAL PERSPECTIVES” (1990)

  Not long ago, I e-mailed Dr. W., who has specialized in treating anxiety for forty years, to ask him to boil his definition of it down to a single sentence.

  “Anxiety,” he wrote, “is apprehension about future suffering—the fearful anticipation of an unbearable catastrophe one is hopeless to prevent.” For Dr. W., the defining signature of anxiety, and what makes it more than a pure animal instinct, is its orientation toward the future. In this, Dr. W.’s thinking is in line with that of many leading theorists of the emotions (for instance, Robert Plutchik, a physician and psychologist who was one of the twentieth century’s most influential scholars of the emotions, defined anxiety as the “combination of anticipation and fear”), and he points out that Darwin, for all his emphasis on the behavioral similarities between animals and humans, believed the same. (“If we expect to suffer, we are anxious,” Darwin wrote in The Expression of the Emotions in Man and Animals. “If we have no hope of relief, we despair.”) Animals have no abstract concept of the future; they also have no abstract concept of anxiety, no ability to worry about their fears. An animal may experience stress-induced “difficulty in breathing” or “spasms of the heart” (as Freud put it)—but no animal can worry about that symptom or interpret it in any way. An animal cannot be a hypochondriac.

  Also, an animal cannot fear death. Rats and marine snails are not abstractly aware of the prospect of a car accident, or a plane crash, or a terrorist attack, or nuclear annihilation—or of social rejection, or diminishment of status, or professional humiliation, or the inevitable loss of people we love, or the finitude of corporeal existence. This, along with our capacity to be consciously aware of the sensations of fear, and to cogitate about them, gives the human experience of anxiety an existential dimension that the “alarm response” of a marine snail utterly lacks. For Dr. W., this existential dimension is crucial.

  Dr. W., echoing Freud, says that while fear is produced by “real” threats from the world, anxiety is produced by threats from within our selves. Anxiety is, as Dr. W. puts it, “a signal that the usual defenses against unbearably painful views of the self are failing.” Rather than confronting the reality that your marriage is failing, or that your career has not panned out, or that you are declining into geriatric decrepitude, or that you are going to die—hard existential truths to reckon with—your mind sometimes instead produces distracting and defensive anxiety symptoms, transmuting psychic distress into panic attacks or free-floating general anxiety or developing phobias onto which you project your inner turmoil. Interestingly, a number of recent studies have found that at the moment an anxious patient begins to reckon consciously with a previously hidden psychic conflict, lifting it from the murk of the unconscious into the light of awareness, a slew of physiological measurements change markedly: blood pressure and heart rate drop, skin conductance decreases, levels of stress hormones in the blood decline. Chronic physical symptoms—backaches, stomachaches, headaches—often dissipate spontaneously as emotional troubles that had previously been “somaticized,” or converted into physical symptoms, get brought into conscious awareness.p

  But in believing that anxiety disorders typically arise from failed efforts to resolve basic existential dilemmas, Dr. W. is, as we will see, running against the grain of modern psychopharmacology (which proffers the evidence of sixty years of drug studies to argue that anxiety and depression are based on “chemical imbalances”), neuroscience (whose emergence has demonstrated not only the brain activity associated with various emotional states but also, in some cases, the specific structural abnormalities associated with mental illness), and temperament studies and molecular genetics (which suggest, rather convincingly, a powerful role for heredity in the determination of one’s baseline level of anxiety and susceptibility to psychiatric illness).

  Dr. W. doesn’t dispute the findings from any of those modes of inquiry. He believes medication can be an effective treatment for the symptoms of anxiety. But his view, based on thirty years of clinical work with hundreds of anxious patients, is that at the root of almost all clinical anxiety is some kind of existential crisis about what he calls the “ontological givens”—that we will grow old, that we will die, that we will lose people we love, that we will likely endure identity-shaking professional failures and personal humiliations, that we must struggle to find meaning and purpose in our lives, and that we must make trade-offs between personal freedom and emotional security and between our desires and the constraints of our relationships and our communities. In this view, our phobias of rats or snakes or cheese or honey (yes, honey; the actor Richard Burton could not bear to be in a room with honey, even if it was sealed in a jar, even if the jar was closed in a drawer) are displacements of our deeper existential concerns projected onto outward things.

  Early in his career, Dr. W. treated a college sophomore who had trained his entire life to become a professional concert pianist. When the patient’s professors told him that he wasn’t talented enough to realize his dream, he was beset by terrible panic attacks. In Dr. W.’s view, the panic was a symptom produced by the patient’s inability to reckon with the underlying existential loss here: the end of his professional aspirations, the demise of his self-conception as a concert pianist. Treating the panic allowed the student to experience his despair at this loss—and then begin to construct a new identity. Another patient, a forty-three-year-old physician with a thriving medical practice, developed panic disorder when, right around the time his older son went off to college, he began getting injuries playing tennis, a sport at which he had formerly excelled. The panic, Dr. W. concluded, was precipitated by these dual losses (of his son’s childhood, of his own athletic vigor), which in combination aroused existential concerns about decline into decrepitude and death. By helping the physician come to terms with these losses, and to accept the “ontological” reality of his eventual decline and mortality, Dr. W. enabled him to shake free of the anxiety and depression.q

  In Dr. W.’s view, anxiety and panic symptoms serve as what he calls a “protective screen” (what Freud called a “neurotic defense”) against the searing pain associated with confronting loss or mortality or threats to one’s self-esteem (roughly what Freud called the ego). In some cases, the intense anxiety or panic symptoms patients experience are neurotic distractions from, or a way of coping with, negative self-images or feelings of inadequacy—what Dr. W. calls “self-wounds.”

  I find Dr. W.’s existential-meaning-based interpretations of anxiety symptoms to be in some ways more interesting than the prevailing biomedical ones. But for a long time, I found the modern research literature on anxiety—whic
h has much more to do with “neuronal firing rates in the amygdala and locus coeruleus” (as the neuroscientists put it) and with “boosting the serotonergic system” and “inhibiting the glutamate system” (as the psychopharmacologists put it) and with identifying the specific “single-nucleotide polymorphisms” on various genes that predict an anxious temperament (as the behavioral geneticists put it) than with existential issues—to be more scientific, and more convincing, than Dr. W.’s theory of anxiety. I still do. But less so than I did before.

  Not long ago in my own therapy with Dr. W., we moved gingerly into “imaginal” exposure for my phobias.r Dr. W. and I established a hierarchy of frightening situations and then did a gentle “staged deconditioning,” in which I was supposed to picture certain distressing images while doing deep-breathing relaxation exercises, hoping to reduce the anxiety these images stimulated. Once I’d conjured an image and was trying to hold it in my mind without panicking, Dr. W. would ask me what I was feeling.

  This proved to be surprisingly hard. Although I was sitting safely in the consulting room of Dr. W.’s suburban home and was free to stop the exercise at any time, merely imagining frightening scenarios became an agony of anxiety. The smallest, most unlikely-seeming cues—seeing myself riding on a chairlift or a turbulence-racked airplane; picturing the green bucket that would be placed by my bed when I had an upset stomach as a young boy—set me to sweating and hyperventilating. So intense was my anxious response to these purely mental images that several times I had to leave Dr. W.’s office to walk around in his backyard and calm down.

  In these deconditioning sessions, Dr. W. has tried to get me to focus on what, precisely, I’m anxious about.

  I have a hard time answering this question. During the imaginal exposure—let alone when I’m actually confronted with a “phobic stimulus”—I cannot focus at all on answering the question. I just feel complete, all-consuming dread, and all I want is to escape—from terror, from consciousness, from my body, from my life.s

  Over the course of several sessions, something unexpected happened. When I tried to engage with the phobia, I’d get derailed by sadness. I’d sit on the couch in Dr. W.’s office, doing deep breathing and trying to picture the scene from my “deconditioning hierarchy,” and my mind would start to wander.

  “Tell me what you’re feeling,” Dr. W. would say.

  “A little sad,” I would say.

  “Go with that,” he would say.

  And then seconds later I’d be racked by sobs.

  I am embarrassed to recount this little tale. For one thing, how unmanly can I be? For another, I am not a believer in the magical emotional breakthrough or the cathartic release. But I confess that I did feel some kind of relief as I sat there shuddering with sobs.

  This outburst of sadness occurred each time we tried the exercise.

  “What’s going on?” I asked Dr. W. “What does this mean?”

  “It means we’re onto something,” he said, handing me a tissue to dry my tears.

  Yes, I know, everything about this scene makes me cringe, too. But at the time, as I sobbed there on the couch, Dr. W.’s statement felt like a wonderfully supportive and authentic gesture—which touched me and made me cry even harder.

  “You’re in the heart of the wound now,” he said.

  Dr. W. believes, as Freud did, that anxiety could be an adaptation meant to shield the psyche from some other source of sadness or pain. I ask him why, if that’s the case, the anxiety often feels much more intense than the sadness. As hard as it’s making me cry, this “wound” that I’m supposedly in feels less unpleasant than the terror I feel when I’m on a turbulent flight, or when I’m feeling nauseated, or when I was enduring separation anxiety as a child.

  “That’s often the case,” Dr. W. says.

  I’m not sure what to make of this. Why do I feel so much better—happier and relatively less anxious—after swimming around in my putative “wound”?t

  “We don’t know yet,” Dr. W. says. “But we’re getting somewhere.”

  * * *

  * The anxiety disorders have persisted through the publication of the DSM-III-R (in 1987), the DSM-IV (in 1994), the DSM-IV-TR (in 2000), and the DSM-V (in 2013).

  † There are long-running debates among psychologists and philologists about the differences between, say, angoisse and anxiété (not to mention inquiétude, peur, terreur, and effroi) in French and between Angst and Furcht (and Angstpsychosen and Ängstlichkeit) in German.

  ‡ Kierkegaard, the son of a Danish wool merchant, was the first nonphysician to write a serious book-length treatment of anxiety. Some fifty years before Freud, Kierkegaard distinguished anxiety from fear, defining the former as a vague, diffuse uneasiness produced by no concrete or “real” danger. Kierkegaard’s father had renounced God (cursed him, in fact), and so young Søren was much preoccupied with whether to believe in or to reject Christ; the freedom to choose between these two options—and the inability to know for certain which one was correct—was what Kierkegaard believed to be the principal wellspring of anxiety. In this, Kierkegaard was arguing in the vein of Blaise Pascal, his seventeenth-century philosophical predecessor and fellow anxiety sufferer. Kierkegaard was also giving birth, more or less, to existentialism; twentieth-century successors like the psychiatrist Karl Jaspers and the philosopher-novelist Jean-Paul Sartre, among others, would take up similar questions about choice, suicide, engagement, and anxiety.

  When man lost his faith in God and in reason, existentialists like Kierkegaard and Sartre believed, he found himself adrift in the universe and therefore adrift in anxiety. But for the existentialists, what generated anxiety was not the godlessness of the world, per se, but rather the freedom to choose between God and godlessness. Though freedom is something we actively seek, the freedom to choose generates anxiety. “When I behold my possibilities,” Kierkegaard wrote, “I experience that dread which is the dizziness of freedom, and my choice is made in fear and trembling.”

  Many people try to flee anxiety by fleeing choice. This helps explain the perverse-seeming appeal of authoritarian societies—the certainties of a rigid, choiceless society can be very reassuring—and why times of upheaval so often produce extremist leaders and movements: Hitler in Weimar Germany, Father Coughlin in Depression-era America, or Jean-Marie Le Pen in France and Vladimir Putin in Russia today. But running from anxiety, Kierkegaard believed, was a mistake because anxiety was a “school” that taught people to come to terms with the human condition.

  § Some of Freud’s first writings on the subject boil anxiety down to pure biomechanics: neurotic anxiety, he theorized, was mainly the result of repressed sexual energy. Trained as a neurologist (his early research was on the nervous system of eels), Freud subscribed to the principle of constancy, which held that the human nervous system tends to try to reduce, or at least hold constant, the quantity of “excitation” it contains. Sexual activity—orgasm—was a principal means by which the body discharged excess tension.

  Such beliefs about the relation between sexual tension and anxiety had ancient precedent. The Roman physician Galen describes treating a patient, whose brain he believed was affected by the rotting of her unreleased sexual fluids, “with a manual stimulation of the vagina and of the clitoris.” The patient “took great pleasure from this,” Galen reports, “and much liquid came out, and she was cured.”

  ‖ His acolytes and would-be successors then spent a generation arguing over what those conflicts might be about: Karen Horney said “dependency needs,” Erich Fromm said “security needs,” and Alfred Adler said “the need for power.”

  a This Freudian view of Angst has a Kierkegaardian “quality of indefiniteness and lack of object.”

  b The bitter fights over revisions for the DSM-V—which have included public denunciations of it by the chairmen of the task forces that produced the DSM-III and DSM-IV, respectively—suggest that psychiatric diagnosis may be more a matter of politics and marketing than either art or s
cience.

  c Some historians of science lump all the syndromes with this “matrix of distress symptoms”—psychological symptoms like worry and sadness and malaise, as well as physical ones like headaches, fatigue, back pain, sleeplessness, and stomach trouble—under the broad category of the “stress tradition.” “Stress” can refer to both psychological stresses and physical ones, in the form of the “stress” placed on the biological nervous system that doctors since the eighteenth century believed caused “nervous disease.”

  d Burton wrote that in the daytime melancholics “are affrighted still by some terrible object, and torn in pieces with suspicion, fear, sorrow, discontents, cares, shames, anguish, etc., as so many wild horses, that they cannot be quiet an hour, a minute of the time.”

  e I’m oversimplifying—the full neuroscientific picture is more complex and detailed—but this is the gist of what research has found. During intensely anxious moments, the primitive effusions of the amygdala overpower the more rational thinking of the cortex.

  f Defecation rate—the number of pellets dropped per minute—is a standard measure of fearfulness in rodents. In the 1960s, scientists at a psychiatric hospital in London bred the famous Maudsley strain of reactive rats by pairing animals with similar poop frequencies.

  g Here’s another way in which writing this book has been bad for me: before I started researching it, I wasn’t familiar with blood-injury phobia—a condition that causes the estimated 4.5 percent of people it afflicts to get extremely anxious and sometimes, because of a drop in blood pressure, to faint when injected with needles or at the sight of blood—and was therefore able to get shots and have my blood drawn without distress, a rare area of relative noncowardice for me. Now, having learned about the physiology that produces this phenomenon, I have become phobic about fainting in these situations and have, by the power of autosuggestion, nearly done so several times.