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

by Scott Stossel

  Many years later, after he had moved to America and become one of the world’s foremost scholars on mental illness, Arieti would publish a book, The Parnas: A Scene from the Holocaust (1979), in which he recounted what happened in Pisa after the Germans occupied part of Italy. Throughout 1943 and 1944, as first the Italian Fascists and then the Nazis terrorized Pisa’s Jewish community, most Jews fled. But Roques, prevented by his anxiety from traveling, stayed in Pisa. “The idea of going far away from home, to another city, or to the country, increases my anxiety to the point of panic,” Roques told six friends who chose for various reasons to remain in the city with him. “I know that these fears are absurd to the point of being ridiculous, but it is useless to tell myself so. I cannot overcome them.” When his followers tried to attribute his willingness to brave bombs and Nazis to courage or spiritual grace, Roques demurred. His illness, he said, “has caused such a narrowing of my life, not to mention gossip and ridicule, and has shadowed my whole existence. I live, trembling, with a totally irrational fear of animals, especially of dogs. I also have a fear of the fear itself.… Had I not felt this sick fear constantly, I would not be here; I would be far away. What you call a special gift is illness.” But the fact that his fear of dogs was greater than his fear of bombs and Nazis made him appear brave.

  Early on the morning of August 1, 1944, the Nazis arrived at Roques’s home and demanded that he surrender the guests who were staying with him. He refused.

  “Aren’t you afraid of dying?” the Nazis demanded. “We will kill you, you filthy Jew.”

  “I am not afraid,” he told them.

  And according to those who survived and were later interviewed by Arieti, Roques manifestly was not afraid, even though he knew the Nazis were about to murder him. As real danger approached, he appeared to be free of fear.z

  Giuseppe Pardo Roques was not the only Pisan imprisoned by his anxiety during the war. When the bombs started falling, reducing parts of the city to rubble, most people left. But Pietro, a young man who lived not far from Roques, could not go more than a block from his house; his agoraphobia would not permit it. So he stayed home. Pietro would sooner have had a bomb dropped on his head than endure the terror that seized him when he walked too far from his house. “The fear caused by the neurosis was stronger than the fear of the dangers of the war,” Arieti observes.

  Pietro survived the war—and ended up decorated as a hero for his courage. After each bombing, he would run out into the ruins (so long as they were within a block of his house) and free people trapped in them. In this way, he saved several lives. Only because he was constrained by his phobia was he available to help the bombing victims. “His illness made him become a hero,” Arieti writes.

  To someone who suffers from anxiety, the stories of Roques and Pietro, and of Bill Russell and Floyd Patterson, hold obvious appeal; in their anxiety lies not just redemption but a source of moral heroism and even, perhaps, a strange sort of courage.

  * * *

  * Together, the alcohol and the benzodiazepines slow the firing of neurons in my amygdala, increase transmission of dopamine and gamma-aminobutyric acid, boost production of beta-endorphins in my hypothalamus, and decrease transmission of acetylcholine.

  † Of course, to opium Wilberforce likely owed many other things, too, among them his horrible depression and a host of physical problems. After initially being prescribed the drug for bowel troubles, he became addicted, taking it every day for forty-five years straight.

  ‡ Actually, Olivier seems not to have resorted to drugs. “There was no other treatment than the well-worn practice of wearing it—the terror—out,” he wrote in his autobiography, “and it was in that determined spirit that I got on with the job.” But he did quit the stage for five years to escape his anxiety.

  § For a time, Williams took Paxil for his anxiety, and he briefly became a pitchman for SmithKline Beechman—though he later told The Miami Herald that marijuana “worked 10 times better for me than Paxil.”

  ‖ Early in his career, Sigmund Freud took cocaine to medicate his social anxiety before salons at the home of one of his mentors.

  a The term “social phobia” first appeared in 1903, when Pierre Janet, an influential French psychiatrist who was a contemporary and rival of Freud, published a taxonomy of mental illnesses that classified erythrophobia among what he called phobies sociales or phobies de la société.

  b If nothing else, this demonstrates the complex ways in which culture and medicine interact: what’s normal, even valorized, in one culture is considered pathological in another.

  c Liebowitz also developed what became the standard psychological rating scale for measuring a patient’s degree of social anxiety.

  d Paxil had earlier been approved for the treatment of depression, obsessive-compulsive disorder, and generalized anxiety disorder.

  e Lane’s book is representative of a substantial and ever-growing literature that accuses the pharmaceutical-industrial complex of creating new disease categories for profit. I will have more to say about this in part 3.

  f Research has shown that being the object of another’s direct gaze is highly emotionally and physiologically arousing. One of the surest ways to cause the neurons in the amygdala of a human test subject to fire is simply to have someone stare at the subject. Many studies have demonstrated that the amygdalae of those diagnosed with social anxiety disorder tend to be consistently more reactive to the human gaze than those of healthy control subjects.

  g Peter, I can only assume, felt no such anxiety. He went on to become a member of President Barack Obama’s first-term cabinet.

  h It didn’t help that the choir director was a strange and tyrannical man who lived with his parents and had a horrific stutter. He’d start screaming at you during choir practice and would get stuck on a word, his face contorted into a paroxysm of anger and frustration, and you would have to wait many seconds for whatever expletive he was trying to direct at you to finally burst out.

  i On a number of occasions, I saw other therapists from the center putting their patients through similar exposures at the same store, forcing them to ask strange questions or to make obvious and embarrassing mistakes. The store employees must have wondered why they had so many weird interactions with apparently deranged customers every day.

  j Ned’s case is drawn from John Marshall’s book, Social Phobia.

  k Some social phobics find even positive attention to be aversive. Think of the young child who bursts into tears when guests sing “Happy Birthday” to her at a party—or of Elfriede Jelinek afraid to pick up her Nobel Prize. Social attention—even positive, supportive attention—activates the neurocircuitry of fear. This makes sense from an evolutionary perspective. Calling positive attention to yourself can incite jealousy or generate new rivalries.

  l The phobic response gets deeply consolidated in the neurons of the amygdala and the hippocampus—which is in part what makes it so hard to stamp out phobias. In this way, anxiety can be wretchedly self-reinforcing: stress activates the amygdala, which increases anxiety; increased anxiety stimulates the HPA axis, which makes the amygdala twitchier still—and all of this neural activity deepens the association of anxiety with the phobic stimulus, whether that’s social interaction or a turbulent plane flight. In short, being anxious conditions you to be more anxious in the future.

  m Interestingly, recent studies have found that the happiest-seeming and least stressed monkeys are what we might call the beta males—those monkeys near the top of the hierarchy, who tend to be easygoing and socially skillful. Being the highest-ranking male is a lot healthier and less stressful than being the lowest-ranking male—but being a high-ranking male who is not the highest-ranking male is even more healthy and less stressful, because you’re not always having to worry about the palace coup that threatens to topple you.

  n All drugs of abuse elevate dopamine levels in the basal ganglia—an area of the brain where dopamine is low in socially anxious patients. A chro
nic dopamine deficit may help account for why social phobics are more likely than others to struggle with addiction.

  o Although Asperger’s patients and social phobics in some ways suffer from a similar problem—a difficulty in managing social interactions that puts off others—they arrive at it from more or less opposite directions: whereas the Asperger’s patient is no good at imagining what’s in other people’s minds, the social phobic is too good at it.

  p I will discuss the relation between genes and anxiety in greater depth in chapter 9.

  q One of the hallmarks of modernity is an abiding uncertainty about status. Hunter-gatherer societies tended not to be very socially stratified; for most of human history, people lived in fairly egalitarian groups. That changed during the Middle Ages. From the twelfth century or so all the way through the American Revolution, society was highly stratified—but also largely fixed: people didn’t move between feudal castes. Modern society, in contrast, is both highly stratified (there’s a high degree of income inequality in many countries) and highly fluid. The notion that anyone can, with luck and pluck, rise from poverty to the middle class, or from the middle class to great wealth, is integral to our idea of success. But not all mobility is upward. Unlike in a society with more fixed socioeconomic strata, there is always the fear of falling—a fear that is heightened in economic times like these. The many forces bearing down on the American worker—the creative destruction of free-market capitalism; the disruptions to the labor force caused by technology; the changing and uncertain relations between the sexes and the accompanying confusion about gender roles—combine to produce constant uncertainty. People naturally worry: Am I being overtaken by other people with more relevant job skills? Will I lose my job and fall out of the middle class? Some have argued that this chronic uncertainty is physically rewiring our brains to be more anxious.

  r Even, and perhaps especially, psychotherapists are not immune. Because they feel patients and peers look to them to be in control of their emotions, the pressure psychotherapists put on themselves not to appear anxious or agitated can be great—and can perversely make them feel more anxious and out of control. I have on my shelf several books by therapists who have at times felt handicapped and humiliated by their own anxiety. The Anxiety Expert: A Psychiatrist’s Story of Panic (2004) was written by Marjorie Raskin, a psychiatrist specializing in anxiety who was tortured by panic attacks brought on by public speaking. She went to great lengths to hide her anxiety and, like me, medicated herself heavily with benzodiazepines. Painfully Shy: How to Overcome Social Anxiety and Reclaim your Life (2001) was cowritten by a psychologist, Barbara Markway, who concedes that she herself has not, in fact, ever fully “overcome her social anxiety or reclaimed her life.”

  s There have been elite athletes for whom this has been the case, too. Reno Bertoia, to name just one, was a young third baseman for the Detroit Tigers who once seemed to have a bright future in the major leagues—until, in 1957, he became so overwhelmed by anxiety that, as the Tigers’ trainer observed, he “couldn’t hit and sometimes bobbled fielding plays that should have been easy.” The more nervous Bertoia got, the worse he played; the worse he played, the more nervous he got—a classic vicious cycle of ever-increasing anxiety and ever-decreasing performance. Soon, his play had so deteriorated that Tigers management was on the verge of dropping him from the team. Desperate and unhappy, Bertoia resorted to taking Miltown, an early, pre-Valium tranquilizer. The transformation was astounding. Bertoia “stopped holding himself in,” the trainer reported. “He’s a different man on the bench—talking and joking—and much more relaxed.” On the field, meanwhile, he started “pounding the ball in tremendous fashion.” His batting average rose a hundred points.

  t This diagnosis had been applied informally since the French Revolution to men who broke down during combat, but it was only in 1871, when a physician named Jacob Mendes Da Costa wrote up a case study on Henry for The American Journal of the Medical Sciences, that the condition was formally inscribed in the scientific literature as soldier’s heart or irritable heart or Da Costa’s syndrome. Historians of psychiatry often identify this article as the first in the medical literature to describe the conditions we would today call panic disorder and post-traumatic stress disorder.

  u The relationship between lack of control and anxiety has been demonstrated many times over the years in noncombat situations, too. Researchers have produced ulcers in mice simply by depriving them of control over their environment, and a raft of studies have demonstrated that people in jobs where they don’t perceive themselves to have a lot of control are much more susceptible to developing clinical anxiety and depression, as well as stress-related medical conditions like ulcers and diabetes.

  v PTSD is the successor to soldier’s heart, shell shock, battle fatigue, and war neurosis, among other diagnoses.

  w Researchers are currently investigating whether administering NPY via a nasal spray could help block the development of post-traumatic stress disorder.

  x Of course, when a nervous stomach impairs performance, the complexion changes dramatically. Consider the difference between Bill Russell and Donovan McNabb, the quarterback for the Philadelphia Eagles during the 2005 Super Bowl. Like Russell, McNabb was an elite athlete. A six-time Pro Bowler and the holder of almost all the Eagles’ passing records, McNabb was one of the most successful college and pro quarterbacks of his generation. Yet despite many playoff victories, McNabb, unlike Russell, never won a championship—and ever since his team lost that 2005 Super Bowl game, he has been dogged by the claims of several teammates (which McNabb denies) that he was vomiting in the huddle and couldn’t call plays. (The debate over whether McNabb did or did not vomit in the huddle still continues eight years after the game, and has been called “one of the great mysteries in the history of sport.”) The implication is that McNabb, for all his athletic talent, was overwhelmed by the pressure of the occasion and succumbed to nerves, that he lacked the leadership qualities, the toughness—the literal intestinal fortitude—to keep his stomach in check and lead the Eagles to victory. McNabb has never been seen the same way since. (Augmenting his reputation as a choker: McNabb’s stats in crucial playoff games were markedly worse than his stats in ordinary regular-season games.)

  y “When did you first think you were a coward?” Talese asked him. “It was after the first Ingemar fight,” Patterson said. “It’s in defeat that a man reveals himself. In defeat, I can’t face people. I haven’t the strength to say to people, ‘I did my best, I’m sorry,’ and whatnot.”

  z In his book, Arieti elaborates a theory about why this should have been the case. His view was that Roques’s phobia of and disgust at animals was a displacement of his disgust at the evil inherent in man. As a young boy, Roques had been happy and optimistic. But during his studies as an adolescent, he discovered the facts of the Crusades, the Inquisition, and the myriad other horrors that man has visited upon man across history. He couldn’t bear this. To preserve a loving view of humankind, and a view of the world as a friendly place, Arieti theorizes, Roques projected onto animals the evil that is in man, preferring to fear animals rather than give up his view of mankind as essentially good. When Roques was confronted unavoidably with evil in the form of the Nazis, his animal phobia disappeared. This, Arieti argues, gives his phobic anxiety an almost spiritual quality, since it permitted him to displace revulsion and anxiety onto insentient creatures, allowing him to retain love for humankind.

  “When the sensitive youngster has made these unpleasant realizations [about the evil in man and the danger and hardship of existence],” Arieti writes, “he has difficulties in facing life. How can he trust, how can he love or retain a loving attitude towards fellow human beings? He might then become suspicious and paranoid; he might become a detached person unable to love. But this is not the case with the phobic. The phobic is a person who retains his ability to love. As a matter of fact, in my long psychiatric career I have never seen a phobic person who was
not a loving person.” We are born, it seems, into a Rousseauian state of innocence, but if we accurately observe life and human nature, we must adopt a Hobbesian defensive crouch against life’s depredations. Phobias sublimate our Hobbesian horror into neurotic and irrational fears, Arieti argues, allowing us to preserve a more innocent and loving stance toward the world.

  PART III

  Drugs

  CHAPTER 5

  “A Sack of Enzymes”

  From time immemorial, [drugs] have been making possible some degree of self-transcendence and a temporary release from tension.

  —ALDOUS HUXLEY, IN A MAY 9, 1957, PRESENTATION TO THE NEW YORK ACADEMY OF SCIENCE

  Wine drunk with an equal quantity of water puts away anxiety and terror.

  —HIPPOCRATES, APHORISMS (FOURTH CENTURY B.C.)

  In anticipation of the release of my first book, in the spring of 2004, my publisher arranged a modest publicity tour that entailed national television and radio appearances, as well as bookstore readings and public lectures around the country. This should have been a delightful prospect—the chance to promote my book, to travel on someone else’s nickel, to connect with readers, to achieve a kind of temporary, two-bit celebrity. But I can scarcely convey what powerful dread this book tour conjured in me.

  In desperation, I sought help from multiple sources. I first went to a prominent Harvard psychopharmacologist who had been recommended by my principal psychiatrist a year earlier. “You have an anxiety disorder,” the psychopharmacologist had told me after taking my case history at our initial consultation. “Fortunately, this is highly treatable. We just need to get you properly medicated.” When I gave him my standard objections to reliance on medication (worry about side effects, concerns about drug dependency, discomfort with the idea of taking pills that might affect my mind and change who I am), he resorted to the clichéd—but nonetheless potent—diabetes argument, which goes like this: “Your anxiety has a biological, physiological, and genetic basis; it is a medical illness, just like diabetes is. If you were a diabetic, you wouldn’t have such qualms about taking insulin, would you? And you wouldn’t see your diabetes as a moral failing, would you?” I’d had versions of this discussion with various psychiatrists many times over the years. I would try to resist whatever the latest drug was, feeling that this resistance was somehow noble or moral, that reliance on medication evinced weakness of character, that my anxiety was an integral and worthwhile component of who I am, and that there was redemption in suffering—until, inevitably, my anxiety would become so acute that I would be willing to try anything, including the new medication. So, as usual, I capitulated, and as the book tour loomed, I resumed a course of benzodiazepines (Xanax during the day, Klonopin at night) and increased my dosage of Celexa, the SSRI antidepressant I was already taking.