“For God’s sake, Scott,” Dr. W. says when I tell him about this. “You’ve given yourself a new phobia.” (He advises that I practice getting injected by a physician soon—a form of exposure therapy—before the phobia becomes a serious problem.)
h William (along with his brother Henry and sister Alice and several other siblings) seems to have inherited his own anxious, hypochondriacal tendencies from his father, Henry James Sr., an eccentric Swedenborgian philosopher who, in an 1884 letter to William, provided a description of an experience easily recognizable to the modern clinician as a panic attack: “One day … toward the close of May, having eaten a comfortable dinner, I remained sitting at the table after the family had dispersed, idly gazing at the embers in the grate, thinking of nothing … when suddenly—in a lightning-flash as it were—‘fear came upon me, and trembling, which made all my bones to shake’ [he’s quoting Job here].… The thing had not lasted ten seconds before I felt myself a wreck; that is, reduced from a state of firm, vigorous, joyful manhood to one of almost helpless infancy.”
i The pure behaviorist view of fear conditioning is complicated, if not largely undermined, by the fact that humans and other mammals seem genetically hardwired to develop phobias of certain things but not others. Today, evolutionary psychologists say Watson misinterpreted his Little Albert experiment: the real reason Albert developed such a profound phobia of rats was not because behavioral conditioning is so intrinsically potent but because the human brain has a natural—and evolutionarily adaptive—predisposition to fear small furry things on the basis of the diseases they carry. (I explore this at greater length in chapter 9.)
j For example, here’s how the DSM-IV defines generalized anxiety disorder: “Excessive anxiety about a number of events or activities, occurring more days than not, for at least 6 months. The person finds it difficult to control the worry. The anxiety and worry are associated with at least three of the following six symptoms (with at least some symptoms present for more days than not, for the past 6 months): Restlessness or feeling keyed up or on edge; Being easily fatigued; Difficulty concentrating or mind going blank; Irritability; Muscle tension; Sleep disturbance.” (The DSM-IV does in one place provide a general definition of anxiety that I think is, although both generic and technical, fairly accurate: “The apprehensive anticipation of future danger of misfortune accompanied by a feeling of dysphoria or somatic feelings of tension. The focus of anticipated danger may be internal or external.”)
k I had this conversation with him before the new DSM-V was published in 2013.
l This schematic overview of the different theoretical approaches to anxiety is necessarily somewhat oversimplified.
m Modern science has eventually shown Hippocrates to be the more correct—the mind does arise from the physical brain and, in fact, from the whole body—but Plato’s influence on the study of psychology has nevertheless remained powerful and enduring, in part because of his influence on Freud. In the Phaedrus, Plato describes the soul as a team of two horses and a charioteer: one horse is powerful but obedient, the other is violent and ill behaved, and the charioteer must wrestle mightily to make them work together to move ahead. This view of the human psyche as divided into three parts—the spiritual, the libidinal, and the rational—presages the Freudian mind, with its id, ego, and superego. For Plato, even more than for Freud, successful psychological adjustment depended on the rational soul (logistikon) keeping the libidinal soul (epithumetikon) in check. This passage from Plato’s Republic uncannily prefigures Freud’s Oedipus complex: “All our desires are aroused when … the rational parts of our soul, all our civilized and controlling thoughts, are asleep. Then the wild animal in us rises up, perhaps encouraged by alcohol, and pushes away our rational thoughts: in such states, men will do anything, will dream of sleeping with their mothers and murdering people.” (When Wilfred Trotter, an influential British neurosurgeon of the early twentieth century, came across this passage, he declared, “This remark of Plato makes Freud respectable.”)
n The very best meditators seem even to be able to suppress their startle response, a rudimentary physiological reaction to loud noises or other sudden stimuli that is mediated through the amygdala. (The strength of one’s startle response—whether measured in infancy or adulthood—has been shown to be highly correlated with the propensity to develop anxiety disorders and depression.)
o For his part, William James, like Darwin, believed that purely physical, instinctive processes preceded awareness of an emotion—and, in fact, preceded the existence of a given brain state. In the 1890s, he and Carl Lange, a Danish physician, proposed that emotions were produced by automatic physical reactions in the body, rather than the other way around. According to what became known as the James-Lange theory, visceral changes generated by the autonomic nervous system, operating beneath the level of our conscious awareness, lead to such effects as changes in heart rate, respiration, adrenaline secretion, and dilation of the blood vessels to the skeletal muscles. Those purely physical effects occur first—and then it is only our subsequent interpretation of those effects that produces emotions like joy or anxiety. A fearful or angering situation produces a series of physiological reactions in the body—and then it is only the conscious mind’s becoming aware of those reactions, and appraising and interpreting them, that produces anxiety or anger. According to James-Lange, no purely cognitive or psychological experience of anything like anxiety can be divorced from the autonomic changes in the viscera. The physical changes come first, then the emotion.
This suggests that anxiety is primarily a physical phenomenon and only secondarily a psychological one. “My theory,” James wrote, “is that the bodily changes follow directly the perception of the exciting fact, and that our feeling of the same changes as they occur is the emotion. Common sense says, we lose our fortune, are sorry and weep; we meet a bear, are frightened and run; we are insulted by a rival, are angry and strike. The hypothesis here to be defended says that this order of sequence is incorrect … and that the more rational statement is that we feel sorry because we cry, angry because we strike, afraid because we tremble.” Physical states create psychic ones and not vice-versa.
The James-Lange theory was later undermined by research on patients with spinal cord injuries that prevented them from receiving any somatic information from their viscera—people who literally could not feel muscle tension or stomach discomfort; people who were, in effect, brains without bodies—yet who still reported experiencing the unpleasant psychological sensations of dread or anxiety. This suggested that the James-Lange theory was, if not wholly wrong, at least incomplete. If patients unable to receive information about the state of their bodies can still experience anxiety, then maybe anxiety is primarily a mental state, one that doesn’t require input from the rest of the body.
But various studies conducted since the early 1960s suggest that the James-Lange theory was not, after all, completely wrong. When researchers at Columbia gave study subjects an injection of adrenaline, the heart rate and breathing rate of all the subjects increased, and they all experienced an intensification of emotion—but the researchers could manipulate what emotion the subjects felt by changing the context. Those subjects given reason to feel positive emotions felt happy, while those given reason to feel negative emotions felt angry or anxious—and in every case they felt the respective emotion (whatever it happened to be) more powerfully than those subjects who had been given a placebo injection. The injection of adrenaline increased the intensity of emotion, but it did not determine what emotion that would be; the experimental context supplied that. This suggests that the autonomic systems of the body supply the mechanics of the emotion—but the mind’s interpretation of the outside environment supplies the valence.
Other recent research suggests that James and Lange were right in observing that physiological processes in the body are crucial to driving emotions and determining their intensity. For instance, a growing number of studies show that facial
expressions can produce—rather than just reflect—the emotions associated with them. Smile and you will be happy; tremble, as James said, and you will be afraid.
p Even as much of Freudianism has been substantially discredited, elements of Freud’s theories have gained empirical support in the recent findings of research like this.
q I should say here that I am not betraying any confidentiality in writing about these patients; Dr. W. has published (anonymous) case histories of them in various places.
r This therapy draws on a technique called systematic desensitization, which was pioneered in the 1960s by Joseph Wolpe, an influential behavioral psychologist, whose initial research was on how to eliminate fear responses in cats.
s I once suggested to Dr. W. that if I had a gun and knew that I at least had the option of escaping phobic terror, then maybe my anxiety would subside, since having the option of escape would give me the feeling of some control.
“Perhaps,” he conceded. “But it would also increase the chances of you offing yourself.”
t In their early work developing psychoanalytic techniques together during the 1890s, Sigmund Freud and his mentor Josef Breuer called this cathartic dredging up of suppressed thoughts and emotions “chimney sweeping.”
PART II
A History of My Nervous Stomach
CHAPTER 3
A Rumbling in the Belly
Anxiousness—a difficult disease. The patient thinks he has something like a thorn, something pricking him in his viscera, and nausea torments him.
—HIPPOCRATES, On Diseases (FOURTH CENTURY B.C.)
I have this recurring nightmare of being ill as a bride, running out of the church and abandoning my husband at the altar.
—EMMA PELLING, QUOTED IN THE JUNE 5, 2008, UNITED PRESS INTERNATIONAL ARTICLE “BRIDE’S VOMIT FEAR DELAYS WEDDING”
I struggle with emetophobia, a pathological fear of vomiting, but it’s been a little while since I last vomited. More than a little while, actually: as I type this, it’s been, to be precise, thirty-five years, two months, four days, twenty-two hours, and forty-nine minutes. Meaning that more than 83 percent of my days on earth have transpired in the time since I last threw up, during the early evening of March 17, 1977. I didn’t vomit in the 1980s. I didn’t vomit in the 1990s. I haven’t vomited in the new millennium. And needless to say, I hope to make it through the balance of my life without having that streak disrupted. (Naturally, I was reluctant even to type this paragraph, and particularly that last sentence, for fear of jinxing myself or inviting cosmic rebuke, and I am knocking wood and offering up prayers to various gods and Fates as I write this.)
What this means is that I have spent, by rough calculation, at least 60 percent of my waking life thinking about and worrying about something that I have spent 0 percent of the last three-plus decades doing. This is irrational.
A part of me protests instantly: But wait, what if it’s not irrational? What if, in fact, there’s a causal relationship between my worrying about vomiting and my not doing it? What if my eternal vigilance is what protects me—through magic or through neurotic enhancement of my immune system or through sheer obsessive germ avoidance—from food poisoning and stomach viruses?
When I’ve made this argument to various psychotherapists over the years, they respond: “Let’s say you’re right about the causal relation—your behavior is still irrational. Look how much time you waste, and what you’ve done to your quality of life, worrying about something that, while unpleasant, is generally rare and almost always medically insignificant.” Even if the cost of relaxing my vigilance was a stomach virus or bout of food poisoning every so often, the therapists say, wouldn’t that be worthwhile for what I’d gain in getting so much of my life back?
I suppose a rational, nonphobic person would answer yes. And they’d surely be right. But for me the answer remains, emphatically, no.
An astonishing portion of my life is built around trying to evade vomiting and preparing for the eventuality that I might. Some of my behavior is standard germophobic stuff: avoiding hospitals and public restrooms, giving wide berth to sick people, obsessively washing my hands, paying careful attention to the provenance of everything I eat.
But other behavior is more extreme, given the statistical unlikelihood of my vomiting at any given moment. I stash motion sickness bags, purloined from airplanes, all over my home and office and car in case I’m suddenly overtaken by the need to vomit. I carry Pepto-Bismol and Dramamine and other antiemetic medications with me at all times. Like a general monitoring the enemy’s advance, I keep a detailed mental map of recorded incidences of norovirus (the most common strain of stomach virus) and other forms of gastroenteritis, using the Internet to track outbreaks in the United States and around the world. Such is the nature of my obsession that I can tell you at any given moment exactly which nursing homes in New Zealand, cruise ships in the Mediterranean, and elementary schools in Virginia are contending with outbreaks. Once, when I was lamenting to my father that there is no central clearinghouse for information about norovirus outbreaks the way there is for influenza, my wife interjected. “Yes, there is,” she said. We looked at her quizzically. “You,” she said, and she had a point.
Emetophobia has governed my life, with a fluctuating intensity of tyranny, for some thirty-five years. Nothing—not the thousands of psychotherapy appointments I’ve sat through, not the dozens of medications I’ve taken, not the hypnosis I underwent when I was eighteen, not the stomach viruses I’ve contracted and withstood without vomiting—has succeeded in stamping it out.
For several years, I worked with a therapist named Dr. M., a young psychologist who had a practice at Boston University’s Center for Anxiety and Related Disorders. I had originally sought treatment for my public speaking anxiety, but after several months of consultations Dr. M. proposed that we also try applying the principles of what’s known as exposure therapy toward extinguishing my emetophobia.
Which is how I came to find myself not long ago at the center of an absurdist tableau.
I’m giving a speech about the founding of the Peace Corps—which feels a little artificial and awkward to begin with, because the venue is a small conference room off a hallway in the Center for Anxiety and Related Disorders. My audience consists of Dr. M. and three graduate students she’s corralled at a moment’s notice from around the building. Meanwhile, in the corner of the room, a large television is showing a video loop of a series of people throwing up.
“Originally, President Kennedy’s plan was to house the Peace Corps inside the Agency for International Development,” I’m saying as a man on the screen to my right retches loudly. “But Lyndon Johnson had been convinced by Kennedy’s brother-in-law Sargent Shriver that stuffing the Peace Corps inside an existing government bureaucracy would stifle its effectiveness and end up neutering it.” On the screen, vomit spatters onto the floor.
A device attached to my finger is monitoring my heart rate and levels of blood oxygen. Every few minutes, Dr. M. interrupts my speech to say: “Give me your anxiety rating now.” I’m to respond by giving her an assessment of my anxiety at that moment on a scale of 1 to 10, with 1 being completely calm and 10 being unalloyed terror. “About a six,” I say truthfully. I’m less anxious than embarrassed and grossed out.
“Go on,” she says, and I resume my lecture as the cacophony of puking continues on the screen. When I glance up, I can see that the graduate students, two young women and a young man, are trying to pay attention to what I’m saying, but they’re clearly distracted by all the literal upheaval in the background. The male student is looking green; his Adam’s apple is twitching. I can tell he’s fighting his gag reflex.
I’m feeling a little anxious, yes, but also frankly ridiculous. How is giving a fake speech to a fake audience amid cascading images of vomiting going to cure me of my phobia of public speaking or of throwing up?
As bizarre as this scene was, the therapeutic principles underlying it are well est
ablished. Exposure therapy—in essence, exposure to whatever’s causing the pathological fear, whether that’s rats or snakes or airplanes or heights or throwing up—has for dozens of years been a standard treatment for phobias, and it is now an important component of cognitive-behavioral therapy. The logic of this approach—which has lately been undergirded by neuroscience research—is that extended exposure to the object of fear, under the guidance of a therapist, makes that object less frightening. Someone with fear of heights would, accompanied by a therapist, walk farther and farther out onto the balconies of higher and higher buildings. Someone with siderodromophobia (train phobia) would take a short subway ride, and then a longer one, and then a still-longer one, until the fear diminished and was gradually extinguished completely. A more aggressive form of exposure, known as flooding, calls for a more intense experience. To treat, say, airplane phobia using the standard exposure technique, a fearful flier might be started off with visits to the airport to watch airplanes take off and land until his anxiety level comes down. He would progress to actually walking onto an airplane and getting acclimated to being on it, allowing the intensity of physical responses and fearful emotions to crest and fall, and then advance to taking a short commercial flight in the company of a therapist. Ultimately, he would graduate to taking longer flights alone. Applying flooding to aerophobia might entail, instead, starting the patient out on a tiny twin-engine plane, flying him up into the sky, and subjecting him to stomach-churning aeronautical gymnastics. According to the theory, the patient’s anxiety will spike initially but will then subside as he learns quickly that he can survive both the flying and the experience of his own anxiety. Some therapists maintain relationships with local pilots so they can offer this sort of therapy. (Dr. M. offered it to me; I declined.)
My Age of Anxiety: Fear, Hope, Dread, and the Search for Peace of Mind Page 8