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

by Scott Stossel

  There seems to be remarkable consistency across human populations: a fixed percentage of individuals will crack under pressure, and another fixed percentage will remain largely immune to it. Comprehensive studies conducted during World War II found that in the typical combat unit, a fairly constant proportion of men will emotionally collapse early on, usually even before getting to the battlefield; another relatively fixed proportion (some of them sociopathic) will be able to withstand extraordinary amounts of stress without ill effect; and the majority of men will fall somewhere between these extremes.

  John Leach, a British psychologist who studies cognition under extreme stress, has observed that, on average, 10 to 20 percent of people will remain cool and composed in combat situations. “These people will be able to collect their thoughts quickly,” he writes in Survival Psychology. “Their awareness of the situation will be intact and their judgment and reasoning abilities will not be impaired to any significant extent.” At the other extreme, 10 to 15 percent of people will react with “uncontrolled weeping, confusion, screaming and paralyzing anxiety.” But most people, Leach says, up to 80 percent of them, will in high-stress lethal conditions become lethargic and confused, waiting for direction. (This perhaps helps account for why so many people submit so readily to authoritarianism in periods of extreme stress or disruption.)

  On the other hand, British psychiatrists observed that during World War II, as the Luftwaffe rained bombs on London, civilians with preexisting neurotic disorders found that their general levels of anxiety actually declined. As one historian has written, “Neurotics turned out to be remarkably calm about being threatened from the skies”—probably because they felt reassured to discover that “normal” people shared their fears during the Blitz. One psychiatrist speculated that neurotics felt reassured by the sight of other people “looking as worried as they have felt over the years.” When it’s acceptable to feel anxious, neurotics feel less anxious.

  One fascinating study of stress during wartime was conducted by V. A. Kral, a doctor who was held in the concentration camp Theresienstadt during World War II. In 1951, he published an article in The American Journal of Psychiatry reporting that although thirty-three thousand people died at Theresienstadt—and another eighty-seven thousand were transferred to other Nazi concentration camps to be killed—no new cases of phobia, neurosis, or pathological anxiety developed there. In fact, Kral, who worked at the camp hospital, noted that while most detainees became depressed, few experienced clinical anxiety. He wrote that those who had before the war suffered from “severe and long-lasting psychoneuroses such as phobias and compulsive obsessive neuroses” found that their ailments had gone into remission. “[Patients’] neuroses either disappeared completely in Theresienstadt or improved to such a degree that patients would work and did not have to seek medical aid.” Interestingly, those patients who survived the war relapsed into their old neurotic patterns afterward. It was as though real fear crowded out their neurotic anxiety; when the fear relented, the anxiety crept back.

  Military psychiatrists have collected a lot of data on what kinds of situations cause soldiers the greatest anxiety. Many studies have shown that the amount of control a soldier feels he has strongly determines how much anxiety he experiences. As Roy Grinker and his colleagues first described in Men Under Stress, the classic study of combat neuroses during World War II, while fighter pilots were terrified of flak shot from the ground, they found fighting with enemy planes to be exhilarating.u

  Combat trauma is a powerful psychic destroyer: many soldiers break down emotionally during war; still more break down afterward. Vietnam produced thousands of traumatized soldiers, many of whom ended up homeless and addicted to drugs. Some fifty-eight thousand U.S. soldiers died during active combat in Vietnam between 1965 and 1975—but an even greater number have committed suicide since then. Suicide is also rampant among veterans of our recent wars in Iraq and Afghanistan. According to numbers from the Army Behavioral Health Integrated Data Environment, the suicide rate among active-duty soldiers increased 80 percent between 2004 and 2008; a 2012 study published in Injury Prevention reported that the number of suicides is “unprecedented in over 30 years of U.S. Army records.” A study in The Journal of the American Medical Association concluded that more than 10 percent of Afghanistan veterans and nearly 20 percent of Iraq veterans suffer from anxiety or depression. Other studies have found massive rates of antidepressant and tranquilizer consumption among Iraq veterans; ABC News reports that one in three soldiers is now taking psychiatric medication. The mortality rates for those who break down under combat stress are much higher than for those who don’t: a recent study published in the Annals of Epidemiology showed that army veterans diagnosed with post-traumatic stress disorder have twice the premature death rate of their unafflicted peers. The rates of postcombat suicide have become so high in recent years that the U.S. military has made providing prophylactic treatment for post-traumatic stress disorder a high priority. In 2012, the suicide rate reached a ten-year high—a staggering eighteen current and former servicemen are killing themselves every day in the United States, according to Admiral Mike Mullen, the former chairman of the Joint Chiefs of Staff.

  Of course, until 1980, when the diagnosis was decreed into existence alongside the other anxiety disorders with the publication of the DSM-III, there was officially no such thing as PTSD.v As with social anxiety disorder, there remains some controversy over whether such a thing as post-traumatic stress disorder really exists in nature—and over whether, if it does, how broadly it should be defined. These debates inevitably get politicized because of the billions of dollars at stake in veterans’ medical benefits and drug company revenues and because of abiding tensions over the distinction between moral cowardice and a medical condition. For its part, the U.S. military today views PTSD as a real and serious problem and is dedicating considerable resources to researching its causes, treatment, and prevention. The Pentagon underwrites many studies of Navy SEALs, generally the toughest, most resilient soldiers in the military, to uncover what combination of genes, neurochemistry, and—especially—training makes them so mentally formidable. Experiments have consistently found that SEALs think more clearly, and make faster and better decisions, than other soldiers in chaotic or stressful situations.

  As important as the nature of the combat stress a soldier experiences is, recent findings in neuroscience and genetics suggest that the nature of the soldier may be more important in contributing to the likelihood of a nervous breakdown. Whether you are more likely to break down under modest combat stress or to remain implacable even under extreme wartime conditions may be largely attributable to the neuro-chemicals you bring to the battle, and these are partly a product of your genes.

  Andy Morgan, a psychiatrist at the Yale School of Medicine, has studied the Special Operations Forces trainees at Fort Bragg who undergo the famous SERE (Survival, Evasion, Resistance, and Escape) program. These aspiring Navy SEALs and Green Berets are exposed to three weeks of extreme physical and psychological hardship to determine whether they could withstand the stress of being a prisoner of war. They endure pain, sleep deprivation, isolation, and interrogation—including “advanced techniques” such as waterboarding. The trainees selected for the program have already made it through a couple of years of training at places such as Fort Bragg’s John F. Kennedy Special Warfare Center and School. The physically and psychologically weak get weeded out long before SERE. But even for the elite troops who make it this far, SERE can be astonishingly stressful. In a 2001 paper, Morgan and his collaborators noted that recorded changes in the stress hormone cortisol during SERE “were some of the greatest ever documented in humans”—greater even than those associated with open-heart surgery.

  Morgan recently discovered that the Special Forces recruits who performed most effectively during SERE had significantly higher levels—as much as one-third higher—of a brain chemical called neuropeptide Y than the poorer-performing recruits did.
Discovered in 1982, neuropeptide Y (or NPY, as the researchers call it) is the most abundant peptide in the brain, involved in regulating diet and balance—and the stress response. Some individuals with high NPY levels seem completely immune to developing post-traumatic stress disorder—no amount of stress can break them. The correlation between NPY and stress resistance is so strong that Morgan has found he can predict with remarkable accuracy who will graduate from Special Forces training and who will not simply by performing a blood test. Those with high NPY levels will graduate; those with low levels will not. Somehow, NPY confers psychological resistance and resilience.w

  It’s possible that those in the Special Forces who thrive under pressure have learned to be resilient—that their high NPY levels are the product of their training or their upbringing. Resilience is a trait that can be taught; the Pentagon is spending millions trying to figure out how to do that better. But studies suggest that a person’s allotment of NPY is relatively fixed from birth, more a function of heredity than of learning. Researchers at the University of Michigan have found correlations not only between which variation of the NPY gene you have and how much of the neurotransmitter you produce but also between how much NPY you produce and how intensely you react to negative events. People with low levels of NPY showed more hyperreactivity in the “negative emotion circuits” of the brain (such as the right amygdala) than people with high NPY levels and were much slower to return to calm brain states after a stressful event. They were also more likely to have had episodes of major depression—and that was independent of anything having to do with their serotonin systems, which is where much of the neuroscience research over the last few decades has been concentrated. Conversely, having ample quantities of NPY seems to prepare you to thrive under stress.

  Other research has found that soldiers whose bodies are more reactive to stress hormones are more likely to crack under pressure. A 2010 study published in The American Journal of Psychiatry concluded that soldiers with more glucocorticoid receptors in their blood cells were at greater risk for developing PTSD after combat. Studies like this tend to validate the idea that how likely you are to break down under pressure is largely determined by the relative sensitivity of your hypothalamic-pituitary-adrenal axis: if you have a hypersensitive HPA axis, you’re much more likely to develop PTSD or some other anxiety disorder in the aftermath of a traumatic experience; if you have a low-reactive HPA axis, you will be much more resistant, if not largely immune, to developing PTSD. And while we know that lots of things condition the sensitivity of your HPA axis—from how much affection your parents gave you to your diet to the nature of the trauma itself—your genes are a major determinant. All of which suggests a strong correlation between your genetically conferred physiology and how likely you are to crack under stress.

  But if grace under pressure is largely a matter of the quantity of a certain peptide in the brain, or of your inborn level of HPA sensitivity, what kind of grace is that?

  The hero and the coward both feel the same thing, but the hero uses his fear, projects it onto his opponent, while the coward runs. It’s the same thing, fear, but it’s what you do with it that matters.

  —CUS D’AMATO, BOXING MANAGER WHO TRAINED FLOYD PATTERSON AND MIKE TYSON

  Are those of us with hypersensitive HPA axes, our bodies set to quivering like mice in response to the mildest perturbances, doomed to falter at the moments of greatest importance? Destined, like Aristodemus the Trembler and Roberto Durán, for shame and humiliation? Fated always to be victims of our twitchy bodies and unruly emotions?

  Not necessarily. Because when you begin to untangle the relationships between anxiety and performance, and between grace and courage, they turn out to be more complicated than they at first seem. Maybe it’s possible to be simultaneously anxious and effective, cowardly and strong, terrified and heroic.

  Bill Russell is a Hall of Fame basketball player who won eleven championships with the Boston Celtics (the most by anyone in any major American sport, ever), was selected to the NBA All-Star team twelve times, and was voted the league’s most valuable player five times. He is generally acknowledged to be the greatest defender and all-around winner of his era, if not of all time. He is the only athlete in history, in any sport, to win a national college championship, an Olympic gold medal, and a professional championship. No one would question Russell’s toughness or his championship qualities or his courage. And yet, to my amazement, this is a man who vomited from anxiety before the majority of the games he played in. According to one tabulation, Russell vomited before 1,128 of his games between 1956 and 1969, which would put him nearly in Charles Darwin territory. “[Russell] used to throw up all the time before a game, or at halftime,” his teammate John Havlicek told the writer George Plimpton in 1968. “It’s a welcome sound, too, because it means he’s keyed up for the game and around the locker room we grin and say, ‘Man, we’re going to be all right tonight.’ ”

  Like someone with an anxiety disorder, Russell had to contend with nerves that wreaked havoc with his stomach. But a crucial difference between Russell and the typical anxiety patient (aside, of course, from Russell’s preternatural athleticism) was that there was a positive correlation between his anxiety and his performance—and therefore between his upset stomach and his performance. Once, in 1960, when the Celtics’ coach noted with concern that Russell hadn’t vomited yet, he ordered that the pregame warm-up be suspended until Russell could regurgitate. When Russell stopped throwing up for a stretch at the end of the 1963 season, he suffered through one of the worst slumps of his career. Fortunately, when the play-offs started that year and he saw the crowd gathering before the opening game, he felt his nerves jangling, and he resumed his nervous vomiting—and then went out and gave his best performance of the season. For Russell, a nervous stomach correlated with effective, even enhanced, performance.x

  Nor is cowardice always necessarily an impediment to greatness. In 1956, Floyd Patterson, at the age of twenty-one, became the youngest world heavyweight boxing champion. Then, in a series of classic bouts with Ingemar Johansson between 1959 and 1961, he became the first boxer in history to regain the title after losing it. The following year he lost the title for good in a match against Sonny Liston, but he remained an intermittent contender for another decade, fighting against Liston, Jimmy Ellis, and Muhammad Ali.

  Patterson was tough and fierce and strong—for several years, by dint of being heavyweight champion, probably among the toughest and fiercest and strongest men in the world. Yet he was also, by his own account, a coward. After his first defeat by Liston, he took to bringing disguises—fake beards and mustaches, hats—to his fights, in case he lost his nerve and wanted to slip out of the dressing room before the bout or to hide afterward if he lost. In 1964, the writer Gay Talese, who was profiling Patterson for Esquire, asked him about his penchant for carrying disguises.

  “You must wonder what makes a man do things like this,” Patterson said. “Well, I wonder too. And the answer is, I don’t know … but I think that within me, within every human being, there is a certain weakness. It is a weakness that exposes itself more when you’re alone. And I have figured out that part of the reason I do the things I do, and cannot seem to conquer that one word—myself—is because … is because … I am a coward.”

  Of course, Patterson’s definition of cowardice might be different from yours or mine; it’s hardly conventional.y But it nevertheless suggests that inner anxiety can be coupled with the outer appearance of physical bravery, that weakness is not incompatible with strength.

  In rare instances, anxiety can even be the source of heroism. During the 1940s, Giuseppe Pardo Roques was the leader of the Jewish community in Pisa, Italy. He was widely respected as a spiritual guide—but he was also impaired by crippling anxiety, in particular by an overwhelming phobia of animals. Hoping to conquer his anxiety, he tried everything: sedatives, “tonics” (neurophosphates meant to strengthen the nervous system), psychoanalysis with one
of Freud’s protégés, and—in an endeavor I can relate to—reading everything he could get his hands on, from Hippocrates to Freud, about the theory and science of phobias. Nothing worked; his phobia dominated his life. He was unable to travel—was barely able to leave his house—because of the irrational fear that he would be set upon by dogs. When he did muster the courage to walk the streets, he would swing a cane wildly around himself at all times to fend off the animals he feared might attack. After neighbors acquired a pet dog, he contrived a reason to get them evicted because he couldn’t bear to have an animal so close by. He spent hours every day completing elaborate rituals meant to assure him there were no animals in his house. (Today, he would be diagnosed with OCD.)

  Roques recognized the irrationality of his fear but was powerless to overcome it. “Its intensity is just as great as its absurdity,” he once said. “I am lost. My heart beats fast; my face no doubt changes expression. I am no longer myself. The panic increases, and the fear of the fear increases the fear. A crescendo of suffering engulfs me. I believe I will not be able to hold my own. I search for help; I don’t know where to find it. I am ashamed to ask for help, and yet I am afraid the fear will make me die. I do die, like a coward, a thousand deaths.”

  Silvano Arieti, a young man who lived in the community, was fascinated by Roques. How was it, Arieti asked himself, that a man as brilliant and wise as Roques could allow his life to be circumscribed by so irrational a fear? Roques was afraid to travel—he had never left Pisa in all his sixty years—and there were days when his anxiety was so bad that he couldn’t even leave his bedroom. But—and here’s what was so fascinating to Arieti—Roques showed himself in other ways “to be an utterly fearless man, courageously prepared to defend the underprivileged, the underdog, the distressed in any way.… His almost constant fear was accompanied by a constantly available courage.” He could handle “real” fears and, in fact, would bravely help others beset by them. But his own phobias, “in their fully tragic intensity,” he was helpless to do anything about. Was there a link, Arieti wondered, between Roques’s moral strength and his mental illness?