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

by Scott Stossel

  Psychologists have developed several standardized scales for measuring control-freakiness—there is, for instance, Rotter’s Locus of Control Scale and also the Health Locus of Control Scale. That anxiety and depression are bound up tightly not only with self-esteem issues but with control issues (anxiety disorder patients tend both to feel like they don’t have much control over their lives and to be afraid of losing control of their bodies or their minds) has been thoroughly established by generations of researchers—but that connection seems to be especially pronounced in people with emetophobia. A study published in the Journal of Clinical Psychology observed that “emetophobics appear completely unable to negate their insatiable desire for the maintenance of control.”f

  Dr. W. has pointed out what he believes is the obvious multilayered symbolism of my emetophobia. Vomiting represents a loss of control and also my fear of letting my insides out, of revealing what’s inside me. Most of all, he says, it represents my fear of death. Vomiting, and my unruly nervous stomach generally, are inarguable evidence of my embodiedness—and consequently of my mortality.g

  Someday I’m going to vomit; someday I’m going to die.

  Am I wrong to live in quivering terror of both?

  I find the noodle and the stomach are antagonistic powers. What thought has to do with digesting roast beef, I cannot say, but they are brother faculties.

  —CHARLES DARWIN TO HIS SISTER CAROLINE (1838)

  I try to draw solace from the knowledge that I am hardly alone in having both a mind and a belly so easily perturbed by anxiety. Observers going back to Aristotle have noted that nervous dyspepsia and intellectual accomplishment often go hand in hand. Sigmund Freud’s trip to the United States in 1909, which introduced psychoanalysis to this country, was marred (as he would later frequently complain) by his nervous stomach and bouts of diarrhea. Many of the letters between William and Henry James, first-class neurotics both, consist mainly of the exchange of various remedies for their stomach trouble.

  But for debilitating nervous stomach complaints, nothing compares to that which afflicted poor Charles Darwin, who spent decades of his life prostrated by his upset stomach.

  In 1865, he wrote a desperate letter to a physician named John Chapman, listing the array of symptoms that had plagued him for nearly thirty years:

  Age 56–57.—For 25 years extreme spasmodic daily & nightly flatulence: occasional vomiting, on two occasions prolonged during months. Vomiting preceded by shivering, hysterical crying[,] dying sensations or half-faint. & copious very palid urine. Now vomiting & every passage of flatulence preceded by ringing of ears, treading on air & vision.… Nervousness when E[mma Darwin, his wife] leaves me.

  Even this list of symptoms is incomplete. At the urging of another doctor, Darwin had from July 1, 1849, to January 16, 1855, kept a “Diary of Health,” which eventually ran to dozens of pages and listed such complaints as chronic fatigue, severe stomach pain and flatulence, frequent vomiting, dizziness (“swimming head,” as Darwin described it), trembling, insomnia, rashes, eczema, boils, heart palpitations and pain, and melancholy.

  Darwin was frustrated that dozens of physicians, beginning with his own father, had failed to cure him. By the time he wrote to Dr. Chapman, Darwin had spent most of the past three decades—during which time he’d struggled heroically to write On the Origin of Species—housebound by general invalidism. Based on his diaries and letters, it’s fair to say he spent a full third of his daytime hours since the age of twenty-eight either vomiting or lying in bed.

  Chapman had treated many prominent Victorian intellectuals who were “knocked up” with anxiety at one time or another; he specialized in, as he put it, those high-strung neurotics “whose minds are highly cultivated and developed, and often complicated, modified, and dominated by subtle psychical influences, whose intensity and bearing on the physical malady it is difficult to apprehend.” He prescribed the application of ice to the spinal cord for almost all diseases of nervous origin.

  Chapman came out to Darwin’s country estate in late May 1865, and Darwin spent several hours each day over the next several months encased in ice; he composed crucial sections of The Variation of Animals and Plants Under Domestication with ice bags packed around his spine.

  The treatment didn’t work. The “incessant vomiting” continued. So while Darwin and his family enjoyed Chapman’s company (“We liked Dr. Chapman so very much we were quite sorry the ice failed for his sake as well as ours,” Darwin’s wife wrote), by July they had abandoned the treatment and sent the doctor back to London.

  Chapman was not the first doctor to fail to cure Darwin, and he would not be the last. To read Darwin’s diaries and correspondence is to marvel at the more or less constant debilitation he endured after he returned from the famous voyage of the Beagle in 1836. The medical debate about what, exactly, was wrong with Darwin has raged for 150 years. The list proposed during his life and after his death is long: amoebic infection, appendicitis, duodenal ulcer, peptic ulcer, migraines, chronic cholecystitis, “smouldering hepatitis,” malaria, catarrhal dyspepsia, arsenic poisoning, porphyria, narcolepsy, “diabetogenic hyperinsulism,” gout, “suppressed gout,”h chronic brucellosis (endemic to Argentina, which the Beagle had visited), Chagas’ disease (possibly contracted from a bug bite in Argentina), allergic reactions to the pigeons he worked with, complications from the protracted seasickness he experienced on the Beagle, and “refractive anomaly of the eyes.” I’ve just read an article, “Darwin’s Illness Revealed,” published in a British academic journal in 2005, that attributes Darwin’s ailments to lactose intolerance.i

  But a careful reading of Darwin’s life suggests that the precipitating factor in every one of his most acute attacks of illness was anxiety. According to Ralph Colp, a psychiatrist and historian who in the 1970s combed through all the available Darwin journals, letters, and medical accounts, the worst periods of illness corresponded with stress either about his work on the theory of evolution or about his family. (The anticipation of his wedding produced a “bad headache, which continues two days and two nights, so that I doubted whether it ever meant to allow me to be married.”) In a 1997 article from The Journal of the American Medical Association called “Charles Darwin and Panic Disorder,” two doctors argue that, according to his own account of his symptoms, Darwin would easily qualify for the DSM-IV’s diagnosis of panic disorder with agoraphobia since he demonstrated nine of the thirteen symptoms associated with it. (Only four symptoms are required to receive the diagnosis.)j

  The voyage of the Beagle, four years and nine months long, was a pivotal experience, enabling Darwin to develop his scientific work.k The months in port prior to the launch of the Beagle were, as Darwin would write in his old age, “the most miserable which I ever spent”—and that’s saying something, given the terrible physical suffering he would later endure.

  “I was out of spirits at the thought of leaving all my family and friends for so long a time, and the weather seemed to me inexpressibly gloomy,” he recalled. “I was also troubled with palpitations and pain about the heart, and like many a young ignorant man, especially one with a smattering of medical knowledge, was convinced I had heart disease.” He also suffered from faintness and tingling in his fingers. These are all symptoms of anxiety—and in particular of the hyperventilation associated with panic disorder.

  Darwin forced himself to overcome his low spirits and embark on the voyage, and though he was beset by both claustrophobia (which put him in “continual fear”) and grievous seasickness, he was mostly healthy on the trip, gathering the evidence on which he would make his name and build his life’s work. But after the Beagle docked in Falmouth, England, on October 2, 1836, Darwin would never again set foot outside England. After nearly five years of traveling, Darwin found his geographical ambit increasingly circumscribed. “I dread going anywhere, on account of my stomach so easily failing under any excitement,” he told his cousin.

  It’s remarkable that On the Origin
of Species ever got written. Soon after his marriage, when Darwin was beginning in earnest his work on evolution, he suffered the first of his many episodes of “periodic vomiting,” stretches where he would vomit multiple times daily and be bedridden for weeks—or, in several cases, years—on end. Excitement or socializing of any kind could throw him into great physical upheaval. Parties or meetings would leave him “knocked up” with anxiety, bringing on “violent shivering and vomiting attacks.” (“I have therefore been compelled for many years to give up all dinner-parties,” he wrote.) He installed a mirror outside his study window so he could see guests coming up the drive before they saw him, allowing him time to brace himself or to hide.

  In addition to Dr. Chapman’s ice treatment, Darwin tried the “water cure” of the famous Dr. James Gully (who also treated Alfred Tennyson, Thomas Carlyle, and Charles Dickens around this time), exercise, a sugar-free diet, brandy and “Indian ale,” chemical concoctions (scores of them), metal plates strapped to his torso meant to galvanize his insides and “electric chains” (made of brass and zinc wires) meant to electrify him, and drenching his skin with vinegar. Whether the result of the placebo effect, distraction, or actual efficacy, some of these sort of worked some of the time. But always the illness returned. A day trip to London or any mild disturbance in his well-ordered routine would bring on “a very bad form of vomiting” that would send him to bed for days or weeks. Any work, especially on Origin—“my abominable volume,” as Darwin called it—could lay him low for months. “I have been bad, having two days of bad vomiting owing to the accursed Proofs,” he wrote to a friend in early 1859 while going over printer’s corrections. He installed a special lavatory in his study where he could vomit behind a curtain. He finished with the proofs amid fits of vomiting on October 1, 1859, ending a fifteen-month period during which he had rarely been able to work free of stomach discomfort for more than twenty minutes at a time.

  When On the Origin of Species, more than twenty years in gestation, was finally published in November 1859, Darwin was laid up in bed at a hydropathy spa in Yorkshire, his stomach in as much tumult as ever, his skin aflame. “I have been very bad lately,” he wrote. “Had an awful ‘crisis’—one leg swelled up like elephantiasis—eyes almost closed up—covered with a rash and fiery Boils … it was like living in Hell.”l

  Darwin continued in poor health even after the book’s publication. “I shall go to my grave, I suppose, grumbling and growling with daily, almost hourly, discomfort,” he wrote in 1860. Those who argue that Darwin suffered from some germ-based or structural disease point to the severity and duration of his symptoms. (“I must tell you how ill Charles has been,” his wife wrote to a family friend in May 1864. “He has had almost daily vomiting for 6 months.”) But in rebuttal there is this: When Darwin would stop working and go riding or walking in the Scottish Highlands or North Wales, his health would be restored.

  Charles is too much given to anxiety, as you know.

  —EMMA DARWIN TO A FRIEND (1851)

  If I seem unduly preoccupied with Darwin’s stomach, perhaps you can understand why. It seems both apt and ironic that the man responsible for launching the modern study of fear—and for identifying it as an emotion with concrete physiological, and especially gastrointestinal, effects—was himself so miserably afflicted by a nervous stomach.

  Then there is the matter of his excessive dependence on his wife, Emma. “Without you, when I feel sick I feel most desolate,” he wrote to her at one point. “O Mammy I do long to be with you & under your protection and then I feel safe,” he wrote at another.

  Mammy? No wonder some Freudians would later argue that Darwin had dependency issues, as well as Oedipal ones. I suppose this is the place to say that—based on my burdensome overreliance on my wife and, before that, on my parents—Dr. W. has diagnosed me with dependent personality disorder, which is, according to the DSM-V, characterized by excessive psychological dependence on other people (most often a loved one or caretaker) and the belief that one is inadequate and helpless to cope on one’s own.

  Finally, of course, there is the matter of Darwin’s decades of constant vomiting. For an emetophobe like me, this holds a morbid fascination. His anxiety produced vomiting, yet his vomiting did not (or so it seems) produce additional anxiety. Moreover, Darwin lived, despite his years of vomiting, to the old-for-the-time age of seventy-three. Shouldn’t Darwin’s accomplishments in defiance of such a debilitating gastrointestinal affliction provide reassurance that if, say, I were to throw up just once, or even five times, or even five times in a day—or even, like Darwin, five times a day for years on end—I might not only survive but perhaps even remain productive?

  If you’re not an emetophobe, this question surely seems impossibly strange—patent evidence of the irrational obsession at the core of my mental illness. And you’re right. But if you are an emetophobe—well, then, you know exactly what I’m talking about.

  * * *

  * On the other hand, a lot of the evidence suggests that phobic anxiety is much more easily formed than extinguished. Barlow himself has a phobia of heights that he admits he has been unable to cure himself of.

  † Incidentally, the very existence of these vomit videos—and I’ve now seen several—is evidence of how common emetophobia is; using them has become common practice in treating phobics. Some therapists also try to gradually decondition their emetophobic patients by exposing them to fake vomit. (In case you’re interested, here’s a recipe recommended by two Emory University psychologists I met at a conference in 2008: Mix one can of beef and barley soup with one can of cream of mushroom soup. Add small quantities of sweet relish and vinegar. Pour into a glass jar, seal, and leave on a windowsill for one week.)

  ‡ I’ve since read that up to 15 percent of people—a disproportionate number of them emetophobes—don’t vomit from a single dose of ipecac.

  § Eventually, she moved away, accepting a tenure-track faculty position at a university in the Southwest. I run into her occasionally at academic conferences on anxiety. Despite everything, I like her. But I always wonder: does it feel weird to her to be talking to a former patient who’s now at these conferences with a notebook, posing as a journalist and a kind of lay expert on anxiety? How often does she think, That’s the guy I gave ipecac to, the guy I watched retching and weeping and shaking on the floor of a public restroom for hours?

  ‖ As further evidence that a great deal of stomach trouble starts in the brain, not in the gut, no stomach medication has yet been proved consistently effective against the symptoms of irritable bowel syndrome—but substantial evidence suggests that certain antidepressant medications can be effective. (Before the 1960s, one of the most frequent prescriptions for IBS was a cocktail of morphine and barbiturates.) In a recent study, IBS patients injected with the SSRI antidepressant Celexa reported reduced “visceral hypersensitivity.”

  Michael Gershon, a professor of pathology and cell biology at Columbia University, says that the reason antidepressants reduce IBS symptoms is not that they affect neurotransmitters in the brain but that they affect neurotransmitters in the stomach. Some 95 percent of the serotonin in our bodies can be found in our stomachs. (When serotonin was discovered in the 1930s, it was originally called enteramine because of its high concentration in the gut.) Gershon calls the stomach “the second brain” and observes that stomach trouble is as likely to beget anxiety as the other way around. “The brain in the bowel has got to work right or no one will have the luxury to think at all,” he says. “No one thinks straight when his mind is focused on the toilet.”

  a I’d just met him for the first time the day before. “I’m John Kennedy,” he had said when he extended his hand in introduction. I know, I had thought as I extended mine, thinking it funny that he had to pretend courteously that people might not know his name, when in fact only a hermit or a Martian wouldn’t have known who he was, so ubiquitous was his face on the cover of checkout counter magazines.

  b As bad
as my own agoraphobic belly sometimes seems to me, others have it worse. One of the more alarming case studies I’ve come across was of a forty-five-year-old man who showed up at a mental health clinic in Kalamazoo, Michigan, in 2007. He had been suffering from acute travel anxiety for twenty years, ever since the time a panic attack caused him to vomit and lose control of his bowels. Since then, the man had not been able to travel more than ten miles from home without experiencing uncontrollable vomiting and diarrhea. Clinicians later mapped his comfort zone by his symptoms: the farther from home he went, the more dramatic his eruptions. So violent were his gastrointestinal reactions that on several occasions he had to be rushed to emergency rooms because he was vomiting blood. After physicians ruled out ulcers and stomach cancer, he was finally referred to the psychology clinic, and he was, his therapist told me when I met him at a conference in 2008, successfully treated with a combination of exposure therapy and cognitive-behavioral therapy.

  c Alvarez observed that the most common source of his patients’ chronic stomach discomfort was the “challenges of modern living”: “The stomach specialist has to be a psychiatrist of sorts,” he wrote. “He must spend hours each week trying to teach neurotic persons to live more sensibly.”