CHAPTER 5
ANXIETY AND SMOKE DETECTORS
Whoever has learned to be anxious in the right way has learned the ultimate.
—Søren Kierkegaard, The Concept of Anxiety, 18441
I was standing on a boulder at the edge of the Pacific at Point Reyes, just north of San Francisco, reveling in glorious sun, wind, and salt spray from waves just a foot or two high. A sign read, “Danger! Sneaker waves. Do not go out on rocks,” but I saw no big waves headed toward my rock on that lovely day. Then, in an instant, frigid water was up to my thighs, dragging me off my suddenly slippery perch. I was lucky that my momentary fear deficiency wasn’t fatal. Seaside jaunts still arouse a vivid memory, with anxiety that motivates avoidance.
Those who experience only a thrill after a wave nearly sweeps them out to sea are likely, at some point, never to be seen again. Others have the opposite problem: they experience so much anxiety that they never go near the ocean. Playing on the beach is no fun if you think a tsunami could arrive any minute. For people with anxiety disorders, mere hints of danger arouse sweating, tension, fast pulse, pounding heart, panicky feelings, and flight.
When Martha came to our clinic, it was the first time she had left the house in years. Her husband did all the grocery shopping, and she bought her clothes by mail order, in increasingly large sizes.
Sam was a capable carpenter, but if he sat with other workers at lunch, he got too anxious to eat. They wondered if he thought he was too good for them, so when he did say something, they were ready with ridicule that amplified his anxiety.
Julie also could not eat with others, but her fear was of choking. So she ate alone at home, blending her food to a thick liquid.
Mel loved the out-of-doors. He jogged every day until he became preoccupied by the fear that he would contract West Nile fever from a mosquito bite. After that he rarely left the house, and he slathered his skin with insect repellent when he had to go out.
Bill feared he would catch HIV, not from having sex but from using a public restroom. He knew that could not actually happen, but he never drove more than an hour from home, and he hadn’t taken a vacation for years.
And then there was Marilyn, who was frightened of birds. She wanted treatment because her husband had invited her to go with him to London, but she was horrified by a mental image of being enveloped in a flock of pigeons.
I treated these patients and hundreds more with anxiety disorders. It is hard for many people to grasp just how devastating anxiety can be. Some people think that anxiety disorders are “just nervousness.” That’s a bit like saying that paraplegia is “difficulty walking.” Serious anxiety is much more common than it seems. Just as you don’t let others know about your fears, others conceal theirs, making many who suffer with anxiety think that they are the only ones. If only that were true.
Across a lifetime, approximately 30 percent of people have an anxiety disorder that qualifies for a formal diagnosis,2 and some people with less anxiety nonetheless need help. For instance, the criteria for social anxiety are set so that only about 12 percent of the population gets the diagnosis,3 but those criteria are arbitrary. The proportion of people who are afraid of giving public presentations, for example, is closer to 50 percent, and many are glad for help.
From Spiders and Snakes to the First Anxiety Clinic
As a medical student on my first research project, it was my job to get the snakes and spiders and to draw the blood. A new treatment for phobias called “exposure therapy” was just coming into its own in the late 1970s. It was a product of behavioral psychology studies that suggested that phobias could be extinguished if the patient stayed close to the snake or spider despite the terrible anxiety. My research mentor, George Curtis, had the inspired idea that this provided a remarkable opportunity to discover, with no ethical compromises, how intense anxiety influenced hormones.
Our volunteer phobia sufferers were eager at the start and grateful at the end, but in the middle, they were terrified. Each came for five sessions of three hours each. In order to study stress hormones at their peak, we started three hours after the midpoint of sleep, about 6 a.m. for most people.4,5 That meant I had to go to the pet shop the night before to borrow a snake, spider, mouse, or bird. Our overnight animal guests didn’t please my girlfriend, but she put up with them. The pet shop was hesitant until, to our surprise and their delight, a cured patient came in to buy a tarantula, the first of many such purchases. I got very good at drawing blood.
The project provoked anxiety in us as well as our patients. My psychoanalytic supervisors explained phobias as products of libido displaced from its original source because of unconscious defenses. They said behavioral treatment would cause new symptoms, the way popping one dent out of a Ping-Pong ball causes a new one. They got me worried, but it happened only once; a man with multiple phobias became more generally anxious after his bird phobia improved. Scores of others got fast relief from phobias that had crippled them for decades.
The treatment was simple. For the woman with a bird phobia, we brought a caged pigeon into the room and encouraged her to get as close to it as possible. After a few minutes of crying and trembling with the bird at the door of the room, she asked us to take it away. We did. We then asked if the anxiety was the same at the end of those minutes as it had been at the start. “No,” she said, “it went down from ninety-five to ninety.” We asked if she wanted to get better faster with more intense anxiety or get better slower with less. She chose fast, so we brought the pigeon back into the room without the cage and held it in front of her, moving it closer whenever she gave the okay.
Like many patients in the midst of exposure therapy, she demonstrated extraordinary courage. Her pulse was 130, she was sweating, trembling, and so frightened she could hardly talk, but she kept reaching out toward the pigeon. Her anxiety decreased to 80, then 70, then 50, at which point she suddenly relaxed and said, “I wonder why I didn’t do this a long time ago.” By the end of the session, she had her hand on the bird, which now was as anxious as she was. A month later, she was proud to report having had a happy lunch with the pigeons in Trafalgar Square. We were thrilled to see how effective treatment could be.
The experience of exposure therapy is intense for therapists as well as for patients. Doing it well takes a special combination of confidence, cajoling, sympathy, and patience. At first it seemed too stressful and even cruel to ask patients to endure such intense anxiety, but as we saw fast cures, our confidence grew and transferred to our patients. Many said the treatment was like surgery whose pain was worth it.
I was amazed not only by how well exposure treatment works but also by the patterns of improvement. Sometimes the anxiety gradually subsided, as you would expect if the treatment was reversing previous conditioning. Equally often, however, anxiety would plummet suddenly in the midst of an intense session. One minute a patient would be sweating and trying not to scream while looking at a boa constrictor. The next minute she would be saying, “I’m not sure why I’ve ever been afraid of these things. They’re actually kind of cute. My anxiety is down to forty. Can I hold it now?”
There were other surprises. One woman with a snake phobia was trying hard to reach out and touch the snake when she suddenly said, “Oh, my God, I just remembered how this all began.” She said that when she was six years old, her father had seen a snake on the road and stopped the car. He had chopped the snake into pieces with a shovel, put them in a jar, and given it to her to hold between her legs. The psychoanalysts who supervised my psychotherapy treatments were delighted to hear about a case that seemed to confirm Freud’s theories, but they refused to believe that she had overcome her fears in two hours of exposure therapy, instead of two years of psychotherapy.
Then there was the time we heard screams coming from a room where a woman was reading a magazine during a control session. She had seen a tiny insect, a silverfish, crawling up a wall in our not-perfectly-
hygienic laboratory. When she calmed down, she explained. When she was seven years old, she had been diagnosed with polio, whisked out the back door of the doctor’s office, and put into a hospital room alone, where she had lain for weeks, paralyzed and terrified by visions of insects crawling on the wall next to her face.
Treating phobias firsthand provides insights that just talking with patients doesn’t reveal. Behavior therapy is far more complicated and interesting than mechanically extinguishing a conditioned response. In some patients, it uncovered remarkable memories, and the patterns by which patients improved varied enormously.
Word about the availability of fast, effective treatment got out, and the phone started ringing. Far more people wanted help than we could treat. Many were desperate. We saw students who couldn’t finish high school because of fear of being called on in class. We treated a corporate vice president who had lost his job because of fear of flying. I made a house call for a woman who had not left her small trailer for years. A stockbroker with an elevator phobia had to leave early for work so he could walk up the twenty stories to his office. His aerobic condition was superb, but he was tired of climbing and of making excuses to clients about why he couldn’t ride the elevator.
Our research project soon expanded to become one of the first clinics specializing in anxiety disorders. It was gratifying to be able to provide relief for so many people who had not gotten help elsewhere. But what caused these disorders? And why did so many people have fears of snakes and spiders, while so few feared sneezes and unsafe sex? A big question gradually came into focus.
Why Does Anxiety Exist at All?
The general answer is obvious enough: individuals with a capacity for anxiety are more likely to escape from dangerous situations now and to avoid them in the future. After long conversations with the anxiety maven Isaac Marks, we recognized that there should be disorders of deficient as well as excess anxiety, as is the case for every other protective response.6,7 Excessive immune responses cause much disease, but immune deficiencies can be fatal. Scores of articles report the harm caused by anxiety, but hardly any describe its benefits. When I was on the circuit lecturing about anxiety disorders, I asked every audience if anyone knew of studies showing the benefits of anxiety. Many thought I was daft, but finally someone suggested I look at an article about fear of heights by the New Zealand researcher Richie Poulton.
The prevailing theory was that people develop a fear of heights after a bad fall. That seemed intuitively obvious, but no one had ever proved it. Poulton identified a group of children who had been injured in a fall between ages five and nine and compared them to those who had had no similar injury.8 At age eighteen, a severe fear of heights was present in 2 percent of those who had had a fall in childhood but 7 percent of those who had not. That was the opposite of the prediction! If mild as well as severe fears were included, the difference was even more dramatic. Fear of heights was seven times less common in eighteen-year-olds who had experienced a fall in childhood.9 In retrospect, the explanation is simple: children who had too little fear to protect them against falls in childhood still had too little fear at age eighteen.
I began looking for other cases of hypophobia. We all know reckless people who lack the usual fear of dangerous animals, social criticism, driving fast, taking drugs, and death-defying stunts. At California ski resorts, young daredevils ski down (actually, jump off) slopes (actually, cliffs) that others fear. These men—they are nearly all men—are admired for their skill and courage, especially by women. Every year, several die.
I vividly recall a professional motorcycle racer who asked for my help. The night before a big race, he would vomit everything he ate, and he couldn’t sleep. This began shortly after a friend had been killed in a race. Each year, he said, two or three other riders on the circuit were killed or severely injured. He had been in several wrecks but had no permanent damage so far. He denied feeling fear but reported that in addition to vomiting the day before each race, his heart rate went up, he sweated, he felt short of breath, and his muscles tightened up. He wanted a drug that would stop his symptoms. As a pro with many advertising endorsements, his income depended on it. When I told him I thought his anxiety was protecting him, he listened politely. When I told him it would be dangerous for him to take a drug to reduce his anxiety, he got angry and left. I don’t know if he is still alive.
Hypophobia is serious and potentially fatal but underrecognized and rarely treated. Hypophobics don’t come to anxiety clinics. Instead, they are found in experimental aircraft, on creative frontiers, and on the front lines of battlegrounds and political movements. They are also found in prisons, hospitals, unemployment lines, bankruptcy courts, and morgues. Pharmaceutical companies have not rushed to provide treatment for hypophobia, but several drugs would likely be effective. One might even be acceptable to a few people—yohimbine reportedly also causes intense orgasms. Starting a clinic for hypophobics could improve health and prevent injuries, but it doesn’t seem like a good business proposition.
As I got more serious about understanding why anxiety exists, I began to see more connections. The panic attacks described by my patients seemed essentially the same as the “fight-or-flight response,” a phenomenon first named by the great physiologist Walter Cannon in his seminal 1939 book, The Wisdom of the Body.10 He noted that high heart rate, shortness of breath, sweating, freezing, and flight are all useful responses in the face of life-threatening danger. That was exactly what I was seeing in my patients. But was it really the same thing?
One evening as I pulled into my driveway at dusk after a long day in clinic, a rabbit froze motionless in the headlight’s glare. It made me think. I had never heard my panic patients describe freezing, but then I had never asked them. The next day I did. My first patient said, “Oh, yes, sometimes I am so paralyzed that I wonder if I will ever move again.” I asked all my panic patients for the next few weeks; about half reported feeling paralyzed for a moment as their panic attacks began. An evolutionary perspective opened my eyes to something I should have seen years before.
Why Is Anxiety So Often Excessive?
The Smoke Detector Principle explains a lot of useless anxiety. As mentioned in chapter 3, systems that regulate protective responses such as vomiting and pain turn the response on whenever the benefits are greater than the costs, even if that means false alarms. The costs of such responses tend to be low compared to the benefits of avoiding danger. So when danger may or may not be present, the small cost of a response ensures protection against a much larger harm. That is why we put up with false alarms from smoke detectors. It is why we can safely use medications to block responses such as vomiting and pain. And it is why useless anxiety is so common.
The Smoke Detector Principle is based on signal detection theory, used by electrical engineers to decide whether a click on a telephone line is a genuine signal or just noise.11 The correct decision depends on the ratio of signals to noise, the costs of a false alarm, and the costs and benefits of an alarm when the danger is actually present. In a city where car theft is common, a sensitive car alarm system is worthwhile despite the false alarms, but in a safer locale it would be just a nuisance.
Panic disorder is caused by false alarms in the emergency response system. The system has been honed to speed escape when life-threatening danger may be present. You are thirsty on the ancient African savanna and a watering hole is just ahead, but you hear a noise in the grass. It could be a lion, or it might just be a monkey. Should you flee? It depends on the costs. Assume that fleeing in panic costs 100 calories. Not fleeing costs nothing if it is only a monkey, but if the noise was made by a lion, the cost is 100,000 calories—about how much energy a lion would get from having you for lunch!
Louder sounds are more likely to be caused by a lion. How loud does the sound need to be before you flee? Do the math. The cost of not fleeing if the lion is present is 1,000 times greater than the cost of a panic attack, so t
he optimal strategy is to run like hell whenever the sound is loud enough to indicate a lion is present with a probability greater than 1/1,000. This means that 999 times out of 1,000 you will flee unnecessarily. However, 1 time out of 1,000, fleeing will save your life.
Realizing that individual episodes of panic are often normal but useless helped both me and my patients to understand the problem better. The idea is not new. The philosopher Blaise Pascal used similar logic to argue that it is rational to believe in God; the cost is low, but failing to believe might result in burning in Hell for all eternity.12 Adding a little math and evolutionary theory to Pascal’s insight helps to explain why useless emotional suffering is so common. It can also help doctors to make good decisions about when it is safe to prescribe drugs that block normal responses such as pain, fever, cough, and anxiety, which are often not needed in the individual instance.13,14,15
Phobias
Snake and spider phobias are common. So are fears of bridges, heights, elevators, and airplanes. Fear of speaking in public is yet more common. Agoraphobia is characterized by fear of leaving the house and fear of open places. However, we never saw patients who complained about excess fear of books, trees, flowers, or butterflies. And we only rarely saw fears of many dangerous things, such as knives, electrical wires, bottles of pills, chemicals, or motorcycles. Why? This is an evolutionary question.
When Isaac Marks and I worked together for a summer on the question, we tried to figure out if different anxiety disorders corresponded to different kinds of dangerous situations. As the table below shows, they do.16
Good Reasons for Bad Feelings Page 9