Actively anxiousby The Listener
Anxiety disorders are the most commonly diagnosed mental illness. Atlantic editor Scott Stossel suggests they're both a curse and a blessing.
This article was first published April 24, 2014.
Scott Stossel, future editor of the Atlantic, spent his childhood crying on sidelines and trembling in corners. Most days after school, this prodigious catastrophiser’s “worry brain” would convince him his parents had died in a car crash. During his wedding ceremony, he shook and sweated and focused entirely on not vomiting. A panic attack at his desk once sent him barrelling into a door so hard he bounced to the floor and an exit sign fell off the wall onto his head.
He was formally diagnosed with an anxiety disorder at age 10 and that was later divvied up into a mix of panic disorder, agoraphobia, social phobia and an array of specific fears.
Throughout his career, Stossel, 44, carefully hid all these anxieties. But now he has “come out” in a bestselling book, My Age of Anxiety: Fear, Hope, Dread and the Search for Peace of Mind.
Most of the book is devoted to the history and science of anxiety. Stossel reckons he has probably read more on the topic than any other non-expert alive. He started with Hippocrates and Freud and moved on to thousands of modern scientific papers. He interviewed hundreds of psychotherapists, and drew on the dozens of treatments he has personally tried in his quest to be well.
It gets messy in places. As Stossel explains, researchers are finding strong links between anxiety disorders and digestive function: many highly strung people also have highly reactive bodies and roiling insides.
So Stossel writes of soiling himself on the plane during his first romantic getaway with his future wife and blocking a toilet in the Kennedys’ Hamptons mansion during a visit to research his 2004 biography on John F Kennedy Jr’s brother-in-law Sarge Shriver.
Stossel used every towel in the bathroom mopping up, ditched his pants, wrapped a dirty towel around himself, and made a dash for his room. He was nearly there, running full tilt, when John Jr appeared in the hallway in front of him.
“Hi, Scott,” Kennedy said, seemingly unfazed. “Uh, hi,” replied our hero.
It sounds like a bad Ben Stiller movie. On the phone from his Atlantic office in Washington, Stossel laughs. “Yeah. Exactly.”
But professionally the book is a risk. Stossel tells the Listener his bosses had no control over the copy and no idea of the extent of his problems – or the fact he seeks out “the sweet spot” before public events using a precise mix of beta-blockers, benzos and booze. The reaction? Well, he says, he hasn’t been fired yet. He even got a nice note from the boss’s wife.
Stossel has also been hit by an “avalanche of anxiety”. Friends, colleagues, strangers and celebrities have all told him of their own struggles.
It’s no wonder. Anxiety disorders are now the most commonly diagnosed mental illness in the world. A 2009 World Health Organisation (WHO) analysis puts the United States in front in terms of prevalence: nearly a third of Americans will be diagnosed with an anxiety disorder.
According to the WHO figures, New Zealand comes in third – just behind Colombia – with 25% of our population diagnosed during their lifetime.
Our national Mental Health Survey, last run eight years ago, found 15% of New Zealanders were actively anxious. They met the diagnostic criteria for an anxiety disorder and had had an episode in the previous 12 months. Those younger than 44 were worst afflicted, with women outnumbering men by nearly two to one. After adjusting for age, gender, education and income, there was no difference in anxiety by ethnicity.
It’s not just adults who are anxious. More recent figures, from the 2011-12 children’s National Health Survey, found 2% of Kiwi children are diagnosed with an anxiety disorder before age 14. These anxious kids make up two-thirds of all children diagnosed with any emotional or behavioural problems, including ADHD and depression.
And although the numbers are small, the rate of diagnosis is climbing, even for preschoolers. The proportion of children diagnosed with emotional or behavioural problems rose from 1.8% in 2006-07 to 3.2% in 2011-12, with anxiety disorders accounting for most of that gain. The increase in anxiety was statistically significant across the board: for boys and girls, older children and those aged two to four.
WHAT'S MAKING US ANXIOUS?
In the WHO analysis, “anxiety disorder” covers specific phobias, social phobia, post-traumatic stress disorder, adult separation anxiety disorder, panic disorder and generalised anxiety disorder. Our health surveys also include obsessive compulsive disorder in the mix.
As Stossel highlights in his book, these anxiety disorders are all closely connected, and tend to “compound and metastasise”: once you get one, you’re much more likely to get another. (They are also closely linked to depression, to the point that some experts believe anxiety and depression are one and the same.)
And we now know they tend to show up young. In 2008 researchers at Harvard Medical School published an analysis of data from interviews with a quarter of a million people with anxiety disorders. Startlingly, they found the first presenting symptom for 85% of these adults was a phobia that emerged in childhood.
They found that a six-year-old with a phobia – of water, say, or the dark – is about five times as likely to develop social phobia as a teenager, and that teen is then more than twice as likely to develop major depression as an adult.
The nature of the link between childhood phobias and adult anxiety and depression is not entirely clear. But, writes Stossel, “the fact of it is”.
But where does that phobia come from in the first place? Stossel has traced serious anxiety disorders through six generations of his family and he is now – part heartbroken, part fascinated – watching his children deal with similar anxieties to his own.
He pictures one’s propensity for anxiety like a pyramid, with genetics at the base. Modern science is solidly behind this notion.
Anxiety certainly seems to be an inbuilt trait, rather than purely a learnt behaviour; it is well established that a proportion of infants, about 10-20%, are fussier and twitchier than their peers.
And it’s likely those children have an anxiety disorder lurking in their family tree. Stossel cites a 2011 study of 10,000 people that found anxiety “density” in families predicts whether or not children will develop disorders.
Children with no anxious relatives have a one in 10 chance of developing a disorder, the study found. One close relative with a disorder raises the odds to 30%, and if “a large majority” of the family is anxious, children have an 80% chance of developing a disorder.
Meta-analyses of such genetic studies have found similar patterns. And researchers are now zeroing in on the genes that drive them.
WARRIORS VS WORRIERS
The COMT gene, for example, oversees the production of an enzyme that breaks down dopamine in the prefrontal cortex. It has been called the “warrior-worrier” gene, because the variant a person is born with appears to dictate how they regulate their emotions. Those with the warrior variant produce plenty of the dopamine-dissolving enzyme and tend to be less inhibited, experience negative emotions less intensely and be less jumpy – they have a less reactive “startle reflex”.
Worriers, on the other hand, wind up with an excess of dopamine, which means they have a harder time controlling their emotions and fear reflexes. They also find it very difficult to relax after being frightened, even once they realise they’re safe – all traits, as Stossel diplomatically notes, that could help them avoid danger.
The SERT gene also seems to be a critical marker. For more than 20 years researchers have been finding two of the gene’s three variants are associated with disordered reactions to stress. Under normal conditions, the people whose SERT gene carries one or more short alleles truck on much like those born with only long alleles. But in the face of stresses such as relationship, health or employment problems, those with short alleles are more likely to develop an anxiety disorder or depression and to become suicidal.
Other genes seem to play a powerful role in insulating children against trauma. Stossel points to studies carried out by Kerry Ressler, a professor of psychiatry at Emory University in the US who oversees a lab devoted to unpicking the molecular and cellular mechanisms of fear. Ressler has found a variant of the CRHR1 gene seems to protect children against the long-term psychological fallout of child abuse, giving them “almost complete immunity to depression”. Similarly, children with a particular variant of the gene FKBP5 seem to be much less susceptible than others to post-traumatic stress disorder.
Ressler posits that such genes may explain a swathe of earlier studies that found strong correlations between the way a child is parented and whether they go on to develop an anxiety disorder. Perhaps what’s really going on, Ressler thinks, is “anxious genes” in the family are dictating both the parents’ behaviour and the child’s future tendencies.
Still, says Stossel, anxious parents should not despair.
“My basic conclusion is that there is a large genetic component to all of this, but your genes are not destiny. Everyone is born with an underlying physiological predisposition – with high reactivity to stress or low reactivity. Some people are born with a constellation of genes that make them very quick to crack under stress or to develop anxiety, and other people are highly resilient or resistant to it, and I think that’s the strongest determinant. But then overlaid on top of that, obviously, there is a powerful role for your upbringing and your parenting.”
In one 2011 study that Stossel clearly finds reassuring, researchers took young monkeys from their anxious mothers. Raised instead by non-anxious mothers, these monkeys grew up to be less anxious than their siblings who stayed with the biological parent. “They also, intriguingly, tended to become the alpha males of the troop.”
GENTLY DOES IT
So what can anxious parents do, short of handing their kids over to someone more chilled out?
“Basically it’s better not to be anxious parents. But to the degree that it’s possible, you want to gently but firmly push [your children] to do the things that make them anxious. You don’t want to be mean or do things that terrify them but you don’t want to enable the anxiety or allow it to grow by indulging it.” If a child is scared to go to school, for example, it’s very important to keep them going to school.
“Just be a sympathetic parent. Listen to their anxieties but help them to understand that anxiety is an emotion, they can handle their anxiety better than they think they can, and teach them techniques for soothing themselves, which is something I probably didn’t get enough of as a child.”
He’s being charitable. In the book Stossel quotes his father admitting to being verbally and physically abusive with his children. He was emotionally distant, a heavy drinker and dismissed the many psychiatric sessions that both Scott and his sister Sage regularly attended as “wacko lessons”.
Stossel’s mother, meanwhile, was extremely anxious, at times emitting “a nervous hum that is practically audible”. She recently told her son she “consciously withheld affection” from him because her own mother was affectionate and yet she grew up to be anxious. She was overprotective, too, dressing her son every day until he was nine or 10, picking out his clothes until he was 15 and running his baths until he was in high school.
“My parents tried to do the best they could and in many ways they were very good parents,” Stossel says. “But it was a bad combination.”
Stossel and his wife – who has no problems with anxiety – got their own kids into talk therapy as soon as their phobias appeared.
Maren was six when she developed “very, very acute” emetophobia, or fear of vomiting. Stossel has the same phobia, which underpins many of his other anxieties: he’s phobic about flying, for instance, because planes are a venue for vomiting, as signalled by the sick bags. Likewise public speaking – Stossel’s great fear is that he will vomit on stage. He was careful not to let on to his children that he has such a phobia.
After a six-month course of cognitive behavioural therapy, Maren is doing much better, Stossel says. “We keep an eye on her because she clearly has that anxious temperament, the way I do, and we worry about that recurring, especially as she gets into adolescence.” For now, though, Stossel looks at his daughter, remembers what he was like at her age, and marvels.
Nathaniel, now seven, is another story. “He has acute separation anxiety,” Stossel says. “We call it his ‘worry brain’; he has the same gift for catastrophising that I do, that many sufferers of general anxiety disorder do … We’re going to take him back to the psychotherapist and see if we can correct some of the maladaptive thought patterns he has.”
A compelling finding of new studies using brain scanning is that such talk therapies, and meditation, can bring about concrete structural changes in the brain. In other words, they work.
Stossel is a particular fan of cognitive behavioural therapy (CBT). “More and more studies every year show CBT to be very effective – to be as effective or more effective as medication for many people, but without the side effects and dependency problems and maybe more long-lasting.” There is evidence to suggest even a short course of CBT – a few sessions – can be effective, he says.
But it’s much easier to develop anxieties than to extinguish them. “They can get rekindled and come back pretty easily – it’s almost like those grooves have been worn in … they can flare up again and you have to go back for a tune-up. But it is possible.”
He seems in awe of certain Buddhist monks: master meditators whose brains show greater activity in the frontal cortices and less in the fear centre – the amygdalae – than normal people. Some monks seem to have completely suppressed their instinctive startle reflex, the strength of which closely correlates with a person’s anxiety levels.
MEDITATE AND MEDICATE
Further, within weeks of beginning meditation, it seems to bring about biological change in the brain. Stossel points to a 2011 study in which researchers at Massachusetts General Hospital had subjects meditate for 27 minutes a day for eight weeks. Their amygdalae, too, were changed by meditation: becoming less dense, in line with drops in the subjects’ self-reported stress levels.
The irony, Stossel points out, is that very anxious people – who might benefit most from calming techniques such as yoga and meditation – find them most difficult. Relaxation could be even more important than we thought: researchers are now drawing links between women’s stress levels and fertility.
So what else works? Stossel boiled down his years of research into a list (see 'Advice to anxious readers' below) which did not, in the end, make it into the book. He strongly advocates the classic self-care strategies – sleep, diet, exercise – as well as mental techniques, particularly resilience and acceptance, that one might learn in therapy.
Then, of course, there’s medication. Stossel has been on a cocktail of psychiatric drugs since he was 12 or 13, knocking back his round-the-clock doses of Thorazine with orange juice because he couldn’t bear the taste. He calls himself “a living repository of the pharmacological trends in anxiety treatment of the last half-century”.
Although he knew public speaking is by far the most common phobia, and that throughout history people have been using opium, booze or anything they could find to mitigate such performance anxiety, Stossel was taken aback during his book tour at the number of public figures who confided that they rely on beta blockers or benzodiazepines to do their jobs.
“The number of performers who have told me they medicate before doing their radio show or their TV show stunned me. I would never have guessed – these are people I’ve heard on the radio and they sound so cool, calm and collected, like anxiety would be completely alien to them.”
His book outlines many of the controversies around the medication of anxiety: the fact that anxiety disorders were only included in the DSM psychiatric handbook in 1980, and only then because scientists had stumbled on drugs to treat them; the astonishing boom in prescription rates for anti-anxiety medications; and the major studies that are now questioning whether SSRI antidepressants are any more effective than placebos.
SOMETHING IN THE WATER
Stossel notes trace amounts of SSRI antidepressants are now showing up in frogs and fish in the US and in the lake that supplies drinking water to Las Vegas, Los Angeles, San Diego and Phoenix. Where does he stand on it all?
Stossel believes it is possible to be concerned about an overly medicated society and sceptical about the pathologising of what can often be “normal” anxiety without being opposed to careful use of the drugs themselves. He takes them reluctantly, he says, and believes that they work, “at least a little, at least some of the time”.
Still, he frets over studies that suggest long-term use of tranquillisers can actually shrink parts of the brain. He swears he feels more stupid than he used to.
But trumping those fears is the story of his great-grandfather Chester Hanford, who had many of the same problems as Stossel, finally cracking and ending up in an asylum. When Stossel considers how he holds it together while Hanford could not, he thinks the difference could be “some ingested chemical compounds that in whatever mysterious and imperfect way interact with my genotype to keep me suspended, tenuously, over the abyss”.
Unsurprisingly, anxiety hits the armed forces hard, both on the battlefield and subsequently. Reinforcing the research that suggests anxiety is in some way innate, many studies have found that in combat soldiers seem to succumb to panic in relatively fixed proportions. British psychologist John Leach writes that 10-15% will quickly descend into “uncontrolled weeping, confusion, screaming and paralysing anxiety”. Another 10-20% seem fairly composed, impervious to panic, while most people simply dither, becoming lethargic and confused.
Stossel points to two projects under way at the Pentagon to mitigate this. The first seems sensible: commanders are able to monitor in real time levels of the stress hormone cortisol in soldiers’ blood, so they can pull individuals out of combat if the concentration reaches post-traumatic stress disorder territory.
But Stossel has serious reservations about Pentagon moves to investigate how to stamp out soldiers’ fight-or-flight response. He believes that could compromise fighters’ ability to assess risk and could affect their sense of morality.
“You do worry a bit about what kind of Faustian deal you’d be striking there, to completely eliminate the fear response.”
Would he flick a switch on his own anxiety, given the opportunity? On this, Stossel says, he is torn. There are certainly upsides to being a nervous wreck. First and most obvious: anxious people are more likely than others to avoid risky situations like extreme sports or getting into fights, which might help keep them alive longer. People who are highly anxious also tend to be very adept at anticipating and preparing for bad outcomes in their everyday lives.
Further, anxious people’s vigilance seems to give them the ability to read others’ facial and behavioural cues faster: they can be more attentive, more socially sensitive, more tuned-in. Stossel’s wife has wondered whether he would become “a total jerk” without his anxiety disorders and he thinks there’s some truth in that.
BETTER WORKER BEES?
Professionally, too, anxiety can be a boon.
There is, Stossel writes, growing evidence that IQ and anxiety are linked – and that people who tick both boxes have real advantages. He cites a 2005 University of Wales paper that scrutinised financial managers and found the best performers were anxious and had high IQs. The researchers wrote: “Anxiety is an important component of motivated cognition, essential for efficient functioning in situations that require caution, self-discipline and the general anticipation of threat.”
University of California psychologist Dean Simonton believes the cognitive or neurological mechanisms at play in anxiety may also boost the sort of creative thinking that can lead to scientific breakthroughs. Simonton, who studies the psychology of genius, estimates that “a third of all eminent scientists suffer from anxiety or depression or both”.
Other studies are showing people with neurotic tendencies can make better employees.
Stossel cites Harvard psychology professor Jerome Kagan, who is so convinced of this he will only hire research assistants with highly reactive temperaments. Kagan, interviewed by the New York Times, explained: “They’re compulsive, they don’t make errors, they’re careful when they’re coding data … [They] are generally conscientious and almost obsessively well prepared.”
The University of Rochester Medical Centre expanded on this in a 2012 study, concluding that neurotic people tended to be better at planning and organising, more goal-oriented and were generally effective, high-functioning employees.
Another study, published last year, Stossel writes, “found that neurotics contribute more than managers predicted to group projects, while extroverts contribute less, with the contributions of the neurotics becoming even more valuable over time”. The director of that study, associate professor Corinne Bendersky, says in future she would hire “more neurotics and fewer extroverts than my initial instinct would lead me to do”.
Even if the anxious person feels little benefit, having them around may help the rest of us. Stossel says one of his therapists, whom he calls Dr W, has noticed that “a lot of his most miserable patients, his most unhappy patients, are anxious lawyers – but if you want a really good lawyer you should hire these guys, because they’re extremely gifted at imagining every worst-case thing that could befall you but then preparing for it. So there are ways in which it can be quite constructive.”
And Jeremy Coplan, a psychiatry professor who in 2012 published a study finding correlations between high levels of worry and high IQ scores in people with generalised anxiety disorder, believes a lack of anxiety can actually be dangerous. Such people can be incapable of picking up on threats, Coplan says, and if they happen to be leaders, “they are going to indicate to the general populace that there’s no need to worry”.
But will the growing weight of research drive employers to seek out anxious people, rather than consign them to the scrap heap after the first round of psych tests?
Stossel: “I would like to think, for my own sake and [that of] people like me, that you will see that start to happen, where companies will value the positive qualities that come with being anxious.”
IF ALL ELSE FAILS, WRITE A BOOK
Yet Stossel seems unconvinced. He keeps the chapter on the redemptive qualities of anxiety very short. Is that because, after a life spent twitching and catastrophising and overflowing the Kennedys’ loo, he’s not really sure there’s an upside?
“Yeah,” he says. “I was trying to convince myself … I had this hope that I could come to terms with it and find redeeming qualities in it.” He says in small ways writing and publishing the book has helped ease his anxiety, but despite his years of research and trying every treatment under the sun, he is still a long way from a cure. He is trying to accept that perhaps there isn’t one.
He has higher hopes for his children. The book is dedicated to Maren and Nathaniel, with the single line: “May you be spared.”
“Freud suffered from fairly severe anxiety and depression with the specific symptoms of fear of dying and travel phobia, both concerned with the traumatic losses of his early years.” – Louis Breger in the 2000 biography Freud.
Phobic actor Richard Burton, writes Scott Stossel, “could not bear to be in a room with honey; even if it was sealed in a jar, even if the jar was closed in a drawer”.
After his famous 1886 voyage on the Beagle, Charles Darwin spent most of the next three decades debilitated and housebound by horrendous digestive problems. Some now believe – as Darwin seems to have done – that his symptoms were linked to anxiety. Darwin was so sick, writes Stossel, it is a miracle that he managed to write On the Origin of Species.
In 2009, Hugh Grant told the Mirror he had “four or five terrible panic disorders” while filming 2007’s Music and Lyrics. “I did the whole film full of [anti-anxiety drug] lorazepam,” he said. He vowed to quit acting, but managed a comeback after visiting “every shrink in London”.
Performance anxiety often hits sports people. Golfer Greg Norman famously choked at the 1996 US Masters, his nerves seeing him lose a huge early lead. Afterwards Norman wound up sobbing in the winner’s arms.
In 1967, singing in front of 135,000 people, Barbra Streisand forgot the words to a song. So began 27 years of crippling stage fright: she did not return to the stage until the early 1990s.
Scholars are divided over whether poet Emily Dickinson was reclusive because of a devotion to her work or on account of an anxiety disorder: she would startle when the doorbell rang, increasingly withdrew from her friends and would speak with her select visitors only from behind a darkened door.
Seemingly out of nowhere, after a performance of Othello, Laurence Olivier developed such bad stage fright he had to quit acting for five years. He made a triumphant return in 1971 in the play Long Day’s Journey Into Night.
Mahatma Gandhi had an awful fear of public speaking. As a young lawyer, he froze during his first appearance before a judge and ran from the court.
Woody Allen has been open about his battle with what he calls “the bluebird of anxiety”. “I make films because if I don’t make them then I don’t have anything to distract me,” he said in 2005. “My whole life I am constantly fighting all kinds of depression and terror and anxiety.”
Advice to anxious readers
by Scott Stossel (abridged)
If I were to distil the collected wisdom of the ages – from Hippocrates to the latest cutting-edge studies – into a few simple rules, those would be these:
• Want less
• Relax more
• Cultivate an optimistic outlook (smile and you will be happy)
• Help others (look outward, not inward)
• Simplify – declutter your life
• Train yourself to “under-react”
• Confront your fears and phobias – expose yourself to them, decondition the fear
• Resolve your inner conflicts – or at least acknowledge them, bring them into conscious awareness
• Change what you can, but accept the things you can’t
• Be inner-directed, not other-directed
• Develop a sense of self-efficacy. Believe that you can cope – because you probably can cope better than you think
• Escape the tyranny of “should”
• Meditate – cultivate mind-body awareness
• Eat healthily
• Drink less caffeine
• Accept yourself
• View life as an adventure, not as a trial
• Most important, cultivate emotional resilience
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