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

by Scott Stossel

  One young woman was referred to Alvarez after vomiting “day and night for a week.” When he learned that she had recently received an ominous letter from the Internal Revenue Service, he treated her by paying her back taxes—it turned out she owed only $3.85—and she was instantly cured. Another patient, whom Alvarez described as “a tense, high-pressure type of sales manager,” came to him because he loved poker but couldn’t play it: If he got a good hand, he would become “nauseated and chilly” and his face would turn red. Bluffing was impossible because any time he was dealt a full house or better, he would immediately have to get up and vomit. But “the cruelest prank of nature” Alvarez ever saw was the way nervous stomachs could destroy the love lives of the anxious. He treated one woman who would get stomach cramps and have to move her bowels whenever she was touched by a man, another who belched uncontrollably whenever a date became intimate, and numerous others who would break wind or vomit in romantic moments. (In his memoirs, the legendary lover Casanova reported on his escapades with a woman who, whenever she became sexually excited, would pass large quantities of gas.) Alvarez also treated “several men who were divorced by outraged wives because of their having to stop and run to the toilet whenever they became sexually excited.”

  d According to emerging research data, emetophobes also tend to demonstrate “a heightened sensitivity to the opinions of others.”

  e Among celebrities who have reported themselves to be emetophobic are the actress Nicole Kidman, the musician Joan Baez, and Matt Lauer, the host of the Today show.

  f I once dated a woman whose aunt had for decades been a full-blown bulimic. From her teens into sometime in her thirties, my girlfriend’s aunt had made herself vomit after most meals. To me, this was as fascinating as it was unfathomable. Someone would actually choose to make herself vomit? I had known about anorexia and bulimia since junior high, when I’d watched after-school specials about them on TV, but hadn’t to my knowledge ever met anyone who voluntarily regurgitated on a regular basis. My whole life was built around trying not to vomit—and here was someone who vomited, all the time, by choice? True, this person was mentally ill, easily diagnosable according to the DSM: “Bulimia: Eating, in a discrete period of time, an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances [combined with] recurrent inappropriate compensatory behavior to prevent weight gain [such as] 1. Self-induced vomiting.” But wasn’t I also, according to the very same authority, ill? “Phobia: A. Marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation. B. Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response, which may take the form of a situationally bound or situationally predisposed panic attack.”

  Even at the time, it struck me that our disorders were oddly self-canceling. If I could get my mind to embrace the idea that some people vomited by choice to make themselves feel better, could that maybe lead me to accept that vomiting was not so catastrophic? And if bulimics could assimilate some of my horrified aversion to vomiting, mightn’t that help to decondition them away from the practice?

  A modest proposal: Why not fill a group home with bulimics and emetophobes and hope that they model themselves out of their pathologies? The emetophobes, watching the bulimics make themselves vomit routinely, will learn that throwing up is not that big a deal; the bulimics, seeing the terror and disgust of the emetophobes, might be conditioned against such casual regurgitation.

  And anyway, aren’t we fundamentally both, bulimics and emetophobes alike, afraid of the same thing: the loss of control? It’s not so much being fat that anorexics fear—it’s feeling out of control, a feeling that purging helps them perversely to combat. They binge and then, not feeling in control of their own appetites, seek to exert dominion over their bodies by purging. But locked into this cycle of binge and purge, they are not really in control at all.

  g As the British physician and philosopher Raymond Tallis has put it, “One sure-fire cure for … any whimsical or philosophical stance on one’s own body … is vomiting.… Your body has you in its entire grip.… There is a kind of terror in vomiting: it is a shouted reminder that we are embodied in an organism that has its own agenda.”

  h “What the devil is this ‘suppressed gout’ upon which doctors fasten every ill they cannot name,” Darwin’s friend Joseph Hooker wrote to him when informed of this diagnosis. “If it is suppressed how do they know it is gout? If it is apparent, why the devil do they call it suppressed?”

  i The authors, two Welsh biochemists, studied Darwin’s journals and health diary to draw correlations between his diet and his bouts of upset stomach.

  j In 1918, Edward J. Kempf, an early American psychoanalyst, suggested in The Psychoanalytic Review that the trembling and eczema that afflicted Darwin’s hands were evidence of “neurotic hands”—which would, Kempf concluded, “lead one strongly to suspect an auto-erotic difficulty that had not been completely mastered.” Less outlandish psychological explanations ventured in the years since include hypochondriasis, depression, repressed feelings of guilt about his hostility toward his father, “severe anxiety neurosis in an obsessional character, certainly much complicated by genius,” and “bereavement syndrome” produced by the loss of his mother at a very young age. (Creationists have seized upon all this with zealous aplomb, implying in one pseudoscholarly paper I came across that the evidence of mental illness suggests Darwin was “psychotic” and that therefore his theory of evolution was the product of delusion.)

  k Darwin’s discovery of variant species of finches in the Galápagos Islands would eventually prompt his realization that species were not fixed for all time but rather transmuted—or, as he would later say, evolved—over time.

  l One of Darwin’s biographers, the British psychoanalyst John Bowlby, noted in the 1980s that the sorts of eruptions of boils and rashes that Darwin endured were thought by dermatologists to be associated with people who “strive to suppress their feelings and who are given to low self-esteem and overwork.” Bowlby, like other biographers, also observed that any stress or “increase in arousal, however trivial,” would produce physical symptoms in Darwin.

  CHAPTER 4

  Performance Anxiety

  Many lamentable effects this fear causeth in men, as to be red, pale, tremble, sweat; it makes sudden cold and heat to come over all the body, palpitation of the heart, syncope, etc. It amazeth many men that are to speak or show themselves in public assemblies, or before some great personages; as Tully confessed of himself, that he trembled still at the beginning of his speech; and Demosthenes, that great orator of Greece, before Philippus.

  —ROBERT BURTON, The Anatomy of Melancholy (1621)

  All public speaking of merit is characterized by nervousness.

  —CICERO (FIRST CENTURY A.D.)

  I’ve finally settled on a pretalk regimen that enables me to avoid the weeks of anticipatory misery that the approach of a public speaking engagement would otherwise produce.

  Let’s say I’m speaking to you at some sort of public event. Here’s what I’ve likely done to prepare. Four hours or so ago, I took my first half milligram of Xanax. (I’ve learned that if I wait too long to take it, my sympathetic nervous system goes so far into overdrive that medication is not enough to yank it back.) Then, about an hour ago, I took my second half milligram of Xanax and perhaps twenty milligrams of Inderal. (I need the whole milligram of Xanax plus the Inderal, which is a blood pressure medication, or beta-blocker, that dampens the response of the sympathetic nervous system, to keep my physiological responses to the anxious stimulus of standing in front of you—the sweating, trembling, nausea, burping, stomach cramps, and constriction in my throat and chest—from overwhelming me.) I likely washed those pills down with a shot of scotch or, more likely, of vodka. Even two Xanax and an Inderal are not enough to calm my racing thoughts and to keep my chest and throat from constri
cting to the point where I cannot speak; I need the alcohol to slow things down and to dampen the residual physiological eruptions that the drugs are inadequate to contain. In fact, I probably drank my second shot—yes, even though I might be speaking to you at, say, nine in the morning—between fifteen and thirty minutes ago, assuming the pretalk proceedings allowed me a moment to sneak away for a quaff. And depending on how intimidating an audience I anticipated you would be, I might have made that second shot a double or a triple. If the usual pattern has held, as I stand up here talking to you now, I’ve got some Xanax in one pocket (in case I felt the need to pop another one before being introduced) and a minibar-size bottle or two of vodka in the other. I have been known to take a discreet last-second swig while walking onstage—because even as I’m still experiencing the anxiety that makes me want to drink more, my inhibition has been lowered, and my judgment impaired, by the liquor and benzodiazepines I’ve already consumed. If I’ve managed to hit the sweet spot—that perfect combination of timing and dosage where the cognitive and psychomotor sedating effect of the drugs and alcohol balances out the physiological hyperarousal of the anxiety—then I’m probably doing okay up here: nervous but not miserable; a little fuzzy but still able to convey clarity; the anxiogenic effects of this situation (me, speaking in front of people) counteracted by the anxiolytic effects of what I’ve consumed.* But if I’ve overshot on the medication—too much Xanax or liquor—I may seem loopy or slurring or otherwise impaired. And if I didn’t self-medicate enough? Well, then, either I’m miserable and probably sweating profusely, with my voice quavering weakly and my attention folding in upon itself, or, more likely, I ran offstage before I got this far.

  I know. My method of dealing with my public speaking anxiety is not healthy. It’s evidence of alcoholism; it’s dangerous. But it works. Only when I am sedated to near stupefaction by a combination of benzodiazepines and alcohol do I feel (relatively) confident in my ability to speak in public effectively and without misery. As long as I know that I’ll have access to my Xanax and liquor, I’ll suffer only moderate anxiety for days before a speech, rather than miserable, sleepless dread for months.

  Self-medicating, sometimes dangerously so, is a time-honored way of warding off performance anxiety. Starting when he was thirty, William Gladstone, the long-serving British prime minister, would drink laudanum—opium dissolved in alcohol—with his coffee before speeches in Parliament. (Once, he accidentally overdosed and had to go to a sanatorium to recover.) William Wilberforce, the famous eighteenth-century British antislavery politician, took opium as a “calmer of nerves” before all his speeches in Parliament. “To that,” Wilberforce said of his prespeech opium regimen, “I owe my success as a public speaker.”† Laurence Olivier, convinced that he was about to be driven to what he was sure would be reported as a “mystifying and scandalously sudden retirement” by his stage fright, finally confided his distress to the actress Dame Sybil Thorndike and her husband.

  “Take drugs, darling,” Thorndike told him. “We do.”‡

  I try to draw solace from what I have learned about Gladstone, Olivier, and other successful and exalted people who have been debilitated by their stage fright.

  Demosthenes, a Greek statesman renowned for his oratorical skills, was, early in his career, jeered for his anxious, stammering performances. Cicero, the great Roman statesman and philosopher, once froze while speaking during an important trial in the Forum and ran offstage. “I turn pale at the outset of a speech and quake in every limb and in all my soul,” he wrote. Moses, according to various interpretations of Exodus 4:10, had a fear of public speaking or was a stutterer; he overcame this to become the voice of his people.

  Every era of history seems to offer up examples of prominent, accomplished figures who managed—or didn’t manage—to overcome crippling public speaking anxiety. On the morning before William Cowper, the eighteenth-century British poet, was to appear before the House of Lords to discuss his qualifications for a government position, he tried to hang himself, preferring to die rather than endure a public appearance. (The suicide attempt failed, and the interview was postponed.) “They … to whom a public examination of themselves on any occasion is mortal poison may have some idea of the horrors of my situation,” Cowper wrote. “Others can have none.”

  In 1889, a young Indian lawyer froze during his first case before a judge and ran from the courtroom in humiliation. “My head was reeling and I felt as though the whole court was doing likewise,” the lawyer would write later, after he had become known as Mahatma Gandhi. “I could think of no question to ask.” Another time, when Gandhi stood up to read remarks he had prepared for a small gathering of a local vegetarian society, he found he could not speak. “My vision became blurred and I trembled, though the speech hardly covered a sheet of foolscap,” he recounted. What Gandhi called “the awful strain of public speaking” prevented him for years from speaking up even at friendly dinner parties and nearly deterred him from developing into the spiritual leader he ultimately became. Thomas Jefferson, too, had his law career disrupted by a fear of public speaking. One of his biographers notes that if he tried to declaim loudly, his voice would “sink in his throat.” He never spoke during the deliberations of the Second Continental Congress and, remarkably, he gave only two public speeches—his inaugural addresses—during his years as President. After reviewing Jefferson’s biographies, psychiatrists at Duke University, writing in the Journal of Nervous and Mental Disease, diagnosed him posthumously with social phobia.

  The novelist Henry James dropped out of law school after giving what he felt was an embarrassing performance in a moot court competition in which he “quavered and collapsed into silence”; thereafter, he avoided making formal public presentations, despite being known for his witty dinner party repartee. Vladimir Horowitz, perhaps the most talented concert pianist of the twentieth century, developed stage fright so acute that for fifteen years he refused to perform in public. When he finally returned to the stage, he did so only on the condition that he could clearly see his personal physician sitting in the front row of the audience at all times.

  Barbra Streisand developed overwhelming performance anxiety at the height of her career; for twenty-seven years she refused to perform for money, appearing live only at charity events, where she believed the pressure on her was less intense. Carly Simon abandoned the stage for seven years after collapsing from nerves before a concert in front of ten thousand people in Pittsburgh in 1981. When she resumed performing, she would sometimes drive needles into her skin or ask her band to spank her before going onstage to distract her from her anxiety. The singer Donny Osmond quit performing for a number of years because of panic attacks. (He is now a spokesman for the Anxiety and Depression Association of America.) The comedian Jay Mohr tells a story about frantically trying to pop a Klonopin on live television to stave off what he feared would be a career-ending panic attack while performing a skit on Saturday Night Live. (What saved Mohr on that occasion was not the Klonopin but the distracting hilarity of his sketch mate Chris Farley.) A few years ago, Hugh Grant announced his semiretirement from acting because of the panic attacks he’d get when the cameras started rolling. He survived one film only by filling himself “full of lorazepam,” the short-acting benzodiazepine with the trade name Ativan. “I had all these panic attacks,” he said. “They’re awful. I freeze like a rabbit. Can’t speak, can’t think, sweating like a bull. When I got home from doing that job, I said to myself, ‘No more acting. End of films.’ ” Ricky Williams, who won the Heisman Trophy in 1998, retired from the National Football League for several years because of his anxiety; social interactions made him so nervous that he would give interviews only while wearing his football helmet.§ Elfriede Jelinek, the Austrian novelist who won the Nobel Prize in Literature in 2004, refused to accept her award in person because her acute social phobia made it impossible to bear being looked at in public.

  Cicero, Demosthenes, Gladstone. Olivier, Streisand, W
ilberforce. Physicians and scientists and statesmen. Oscar winners and Heisman winners and Nobel laureates. Gandhi and Jefferson and Moses. Shouldn’t I draw consolation from the knowledge that so many people so much greater than I am have been, at times, undone by their stage fright? And shouldn’t their ability to persevere and, in some cases, to overcome their anxiety give me hope and inspiration?

  Why should the thought that others are thinking about us affect our capillary circulation?

  —CHARLES DARWIN, The Expression of the Emotions in Man and Animals (1872)

  The symptoms of performance anxiety can sometimes take the form of what seems to be a terrible joke custom-designed to humiliate.

  —JOHN MARSHALL, Social Phobia (1994)

  The DSM officially divides social anxiety disorder into two subtypes: specific and general. Those patients diagnosed with specific social anxiety disorder have anxiety attached to very particular circumstances, almost always relating to some form of public performance. By far the most common specific social phobia is the fear of public speaking, but others include the fear of eating in public, the fear of writing in public, and the fear of urinating in a public restroom. A startlingly large number of people arrange their lives around not eating in front of people, or are filled with dread at the prospect of having to sign a check in front of other people, or suffer what’s known as paruresis when standing at a urinal.

  Patients suffering from the general subtype of social anxiety disorder feel distress in any social context. Routine events such as cocktail parties, business meetings, job interviews, and dinner dates can be occasion for significant emotional anguish and physical symptoms. For the more severely afflicted, life can be an unremitting misery. The most mundane social interaction—talking to a store clerk or engaging in watercooler chitchat—induces a kind of terror. Many social phobics endure lives of terrible loneliness and professional impairment. Studies find strong links between social phobia and both depression and suicide. Social phobics are also, unsurprisingly, highly prone to alcoholism and drug abuse.‖