Anxiety Read online

  After these theoretical explorations, we hope Chapter 4 will come as an engaging – but illuminating – diversion. In it, we present interviews specially conducted for this book with the actor, writer, and director Michael Palin and the former England football manager Graham Taylor. Each of them describes their experience of anxiety in their working lives and sets out the steps they have taken to combat it.

  In the second half of the book, we switch our focus to what happens when anxiety is sufficiently severe to be considered a clinical problem. We devote a chapter to each of the six main anxiety disorders covered in psychiatric classification systems: phobia; social phobia; panic disorder; generalized anxiety disorder; obsessive-compulsive disorder; and post-traumatic stress disorder. We conclude the book by assessing the various treatment options for anxiety problems. Here the advent of highly effective cognitive behavioural therapies means that there are real grounds for optimism.

  Anxiety is both absolutely normal and fascinatingly complex. It is also the focus of much cutting-edge contemporary psychological research and clinical practice. We draw on that research and practice throughout this book, but have sought to present it as clearly as possible. So we hope you’ll find that this isn’t just an authoritative guide to the nature of anxiety, it’s an accessible and entertaining one too.

  List of illustrations

  1 An illustration of ‘terror’ from Charles Darwin’s The Expression of the Emotions in Man and Animals

  Public domain

  2 Aaron T. Beck

  3 Joseph LeDoux

  4 The brain, showing the location of the amygdala

  5 Michael Palin

  © Basil Pao

  6 Graham Taylor

  © Provided courtesy of Watford Football Club David Clark

  Chapter 1

  What is anxiety?

  You know those days when you’ve got the mean reds … the blues are because you’re getting fat or maybe it’s been raining too long. You’re sad, that’s all. But the mean reds are horrible. You’re afraid and you sweat like hell, but you don’t know what you’re afraid of. Except something bad is going to happen, only you don’t know what it is.

  Holly Golightly in Truman Capote’s Breakfast at Tiffany’s

  Anxiety doesn’t ever go away. There’s not suddenly a sun-lit plateau where you’re never anxious about anything – it just takes different shapes and forms.

  Michael Palin

  Holly Golightly’s ‘mean reds’ may be horrible, but they are also absolutely normal. No one goes through life without experiencing anxiety from time to time – perhaps before taking a flight, giving a speech, or meeting new people. And though that anxiety-free sun-lit plateau may sound appealing, it’s probably just as well that we won’t reach it. As we’ll see, anxiety isn’t merely normal, it is often essential.

  On the other hand, for large – and perhaps increasing – numbers of people, anxiety is a major problem. The poet W. H. Auden published The Age of Anxiety in 1947. That now looks more like a remarkable feat of prophecy than the comment on post-war society Auden intended. The main mental health survey in the United States, for example, indicated that 18% of adults had experienced an anxiety disorder of some type in the previous 12 months. This figure refers only to anxiety that is sufficiently severe to warrant a medical diagnosis. Even so, it suggests that approximately 40 million adults in the US alone are suffering from clinical levels of anxiety – an extraordinary statistic.

  A still greater number of people are struggling with levels of anxiety that don’t meet the criteria for a full-blown disorder. The UK’s Mental Health Foundation reported that 37% of adults felt more frightened and anxious than they had in the past. More than three-quarters of those surveyed stated that the world had become a more frightening place over the previous ten years. And almost one-third (29%) admitted that anxiety and fear had driven them to change the way they behaved, preventing them from doing things they wished they could have done.

  At the other end of the scale, everyday anxiety is as natural – and beneficial – as any other emotion. We all know what it means to feel anxious; we have first-hand experience, sometimes on a regular basis. If we asked you to jot down five words to describe anxiety, doubtless you wouldn’t need long to ponder.

  A (very) brief history of anxiety

  The English word ‘anxiety’ has venerable roots. Like its European cognates angoisse (French), Angst (German), angoscia (Italian), and angustia (Spanish), anxiety originates from the ancient Greek angh, which can be found in the ancient Greek words meaning ‘to press tight’, ‘to strangle’, ‘to be weighed down with grief’, and ‘load’, ‘burden’, and ‘trouble’. It’s easy to detect the echoes of these feelings in the generally unpleasant experience we call anxiety. Angh subsequently made its way into Latin terms such as angustus, ango, and anxietas, all of which carry connotations of narrowness, constriction, and discomfort – much like another Latin term that has become part of modern medical terminology: angina.

  Ancient though the word ‘anxiety’ may be, it was rarely employed as a psychological or psychiatric concept before the late 19th century, and only became widespread over the course of the 20th century. Aubrey Lewis has noted that 3 academic articles on ‘anxiety’ were listed in Psychological Abstracts in 1927; 14 in 1931; 37 in 1950; and 220 in 1960.

  Not that there’s any evidence to suggest that the experience of anxiety (as opposed to the use of the term) was any less normal and widespread than it is today; it would be astounding if it were. Feelings of panic and fear, and the physical changes that often accompany them such as trembling, palpitations, and faster breathing, are regularly described in literary, religious, and medical writings throughout the centuries.

  However, these sensations were seldom referred to as ‘anxiety’. Moreover, they were usually explained as the product of moral or religious failings, or of organic physical defects or illness. The 18th and 19th centuries saw a huge rise in interest in ‘nervous illnesses’, but the symptoms of what we would today describe as anxiety were regarded as essentially physical in origin. Scientific debate focused on the question of which particular physical problem was responsible.

  For example, the eminent mid-19th-century French psychiatrist Bénédict Morel (1809–73) argued that symptoms of anxiety were triggered by disease in the nervous system. The influential Hungarian ear, nose, and throat specialist Maurice Krishaber (1836–83), on the other hand, believed that anxiety was caused by cardiovascular irregularities, a problem that could be rectified by the consumption of caffeine. (Given that caffeine is now known to increase feelings of anxiety, Krishaber’s recommended remedy is rather ironic.) And Moritz Benedikt (1835–1920), a professor of neurology at the University of Vienna, attributed the dizziness often experienced in panic attacks to problems in the inner ear.

  The meteoric ascent of the term ‘anxiety’ began only with the publication in 1895 of a ground-breaking paper by Sigmund Freud (1856–1939), the founder of psychoanalysis. Under the pithy title ‘On the Grounds for Detaching a Particular Syndrome from Neurasthenia under the Description “Anxiety Neurosis”’, Freud argued that anxiety should be distinguished from other forms of nervous illness (or neurasthenia).

  Freud, of course, wrote in German. James Strachey, who translated Freud’s works into English, was acutely aware of the problems caused by rendering the German Angst as ‘anxiety’: ‘[Angst may] be translated by any one of half a dozen similarly common English words – fear, fright, alarm, and so on – and it is therefore quite unpractical to fix on some simple English term as its sole translation.’ The usage, however, stuck.

  The central position that the term ‘anxiety’ holds in psychological and psychiatric thinking today is largely a legacy of Freud’s work on the topic, though Freud’s theories on the matter are now largely discredited, as we’ll see in Chapter 2. But other influences were at work too. One of these was the revival of interest in the mid-20th century in the work of the Danish philosoph
er Søren Kierkegaard (1813–55), and specifically his concept of Angst, an anguished dread triggered by the awareness both of our freedom to act and of our responsibility for those actions. Kierkegaard, and his thinking on Angst, was an important influence on prominent existentialist philosophers such as Jean-Paul Sartre (1905–80) and Martin Heidegger (1889–1976), though their idea of Angst was far removed from what psychologists today would define as anxiety.

  Then there was the very visible epidemic of shell-shock caused by the First World War. Few indeed must have been the communities in the UK that did not include someone clearly suffering from severe psychological problems as a result of horrors endured during the conflict. (Today, these men would be diagnosed not with shell-shock but with post-traumatic stress disorder, which you can read more about in Chapter 10.)

  Anxiety is an emotion

  Theories concerning anxiety abound, but scientists agree that it is an emotion. Indeed, fear is usually regarded as one of the five basic emotions, alongside sadness, happiness, anger, and disgust. (As we’ll see in a moment, the terms ‘anxiety’ and ‘fear’ are generally used synonymously.) By basic, we mean the first to develop in humans, usually within the first six months after birth.

  This is all well and good, but what exactly do we mean by the term ‘emotion’? The concept is a contested one, but there is general agreement that emotions are complex phenomena, typically affecting our thoughts, our bodies, and our behaviour. There is evidence that each of the basic emotions involves a distinct facial expression, and to some degree a different bodily (or physiological) reaction. When we become aware of one or more of these changes, we are feeling an emotion.

  Current psychological thinking has coalesced around the idea that emotions are strong, conscious feelings triggered by our assessment – or appraisal – of a particular event or situation. That appraisal, which may be conscious or unconscious, determines which emotion we feel. For instance, if we sense success, we are happy. If we detect that we have been wronged or thwarted, we experience anger. And if we think that we’re in danger, we feel fear.

  But why do we need emotions? Wouldn’t life be much more pleasant if we weren’t susceptible to fear, or sadness, or disgust? In fact, without them, our lives would almost certainly be a great deal shorter. Emotions help us survive, thrive, and pass on our genes. As Paul Ekman, a leading psychologist of emotions, puts it, they have ‘evolved through their adaptive value in dealing with fundamental life-tasks’. So, for example, the happiness our ancestors felt after developing a useful tool encouraged them to repeat the experience; their sadness when separated from friends and loved ones helped them preserve crucial social ties; and their anxiety helped ensure they didn’t end up as some wild animal’s meal.

  Psychologists define emotional states in terms of how long they last. Research suggests that initial physiological reactions – which include facial expressions – generally last just a few seconds. An emotion lasts anywhere from seconds to hours. If it goes on for longer, it’s referred to as mood; and if we have a tendency to react in this way, it’s part of our personality.

  Emotions are so important to us that it’s unsurprising that we are often extremely successful at decoding other people’s feelings. For example, research by Rainer Banse and Klaus Scherer has shown that people are adept at recognizing emotions simply by listening to someone’s tone of voice rather than what is actually said. (Banse and Scherer instructed actors to pronounce a nonsensical phrase, thus preventing participants from guessing the emotion from the meaning of the words used.)

  Other studies have revealed that individuals are often able to decode emotions on the basis of touch. A team of researchers in the US separated participants into pairs, and seated each pair at a table divided by a black curtain. One of the pair then attempted to convey a series of emotions – anger, disgust, fear, happiness, sadness, surprise, sympathy, embarrassment, love, envy, pride, and gratitude – purely by touching the other’s arm. Those doing the touching tended to use similar techniques to communicate particular emotions: stroking to suggest love, for example, or trembling to indicate fear. And the participants guessing which emotions were being communicated were often remarkably successful in their judgements. So, if we don’t know how the people around us are feeling, we may simply need to pay a little more attention to the signals they are almost inevitably sending out.

  Anxiety and evolution: fight or flight

  If you’ve detected the theories of Charles Darwin in the account of emotion we’ve just given, you are right. Indeed, emotions are the subject of a fascinating study by Darwin, The Expression of the Emotions in Man and Animals. Published in 1872, this book has long been overshadowed by Darwin’s revolutionary On the Origins of Species (1859). But after decades of neglect, The Expression of Emotions has come to exert a powerful influence on scientific thinking.

  Darwin sees emotions as primarily expressive behaviours: automatic, unconscious, and largely innate (rather than learned) physiological changes, facial expressions, and behaviours. What interests Darwin in particular is the range of actions and visible bodily changes that characterize each emotion. These actions and expressions both help the person experiencing the emotion and send signals to those around him or her. In the case of fear, Darwin notes:

  the eyes and mouth are widely opened, and the eyebrows raised. The frightened man at first stands like a statue motionless and breathless, or crouches down as if instinctively to escape observation. The heart beats quickly and violently … The skin instantly becomes pale … [and cold] perspiration exudes from it … The hairs on the skin stand erect … the mouth becomes dry …

  As the title of Darwin’s book makes clear, he doesn’t regard emotions as a distinctly human attribute. Indeed, Darwin devotes considerable effort to highlighting the continuities (as well as differences) between the animal and human experience and expression of emotion. For example, he writes:

  1. An illustration of ‘terror’ from Charles Darwin’s The Expression of the Emotions in Man and Animals

  With all or almost all animals, even with birds, terror causes the body to tremble…. With respect to the involuntary bristling of the hair [typically caused by fear], we have good reason to believe that in the case of animals, this action … serves, together with certain voluntary movements, to make them appear terrible to their enemies; and as the same involuntary and voluntary actions are performed by animals nearly related to man, we are led to believe that man has retained through inheritance a relic system, now become useless.

  Equally controversially for the time, Darwin insisted that the way in which human beings expressed emotions was almost always the same, regardless of ethnicity.

  So much for the expression of fear. What about anxiety’s adaptive function? How exactly does it help us? The classic account was formulated in 1915 by a professor of physiology at Harvard, Walter Cannon (1871–1945). He coined the phrase ‘fight or flight’ to describe an animal’s typical reaction to danger. Anxiety’s purpose is to alert us to potential threat and to prepare us to react appropriately. And to send a signal to others that they should be on guard.

  The three-systems theory of anxiety

  Anxiety sets in motion a series of physiological changes, all designed to help us focus entirely on dealing with the sudden threat to our existence. These changes are associated with what is known as the autonomic nervous system (ANS), whose job is to oversee basic physiological processes – for example, breathing, temperature regulation, and blood pressure. The ANS comprises two complementary subsystems: the sympathetic nervous system (SNS), which prepares the body to respond to danger; and the parasympathetic nervous system (PNS), which controls and counterbalances the frenzied activity of the SNS.

  So, for example, the sympathetic nervous system elevates our heart rate, allowing blood to reach our muscles faster (by as much as 1,200% in some instances). Our pupils dilate, relaxing the lens and allowing more light to reach the eye. The digestive system is put on ho
ld, resulting in reduced production of saliva – hence the dry mouth we often experience when we’re afraid. And new research suggests that the facial expression people typically assume when frightened – eyes wide open, nostrils flared, eyebrows raised – actually helps us see better and detect scents more efficiently: attributes that could make all the difference in dangerous situations. Without fear and anxiety, humans would surely have disappeared long ago. After all, creatures that cannot recognize danger and respond accordingly are well suited only to being someone else’s prey, as the dodo would doubtless attest.

  As we’ve seen, Darwin emphasized the way in which we express our emotions. But though this is clearly a crucial component, it doesn’t tell the whole story. There is more to emotions than the configuration our facial features assume, or the way we hold our body. This is what the psychologist Peter Lang was getting at when he formulated the ‘three-systems’ model of anxiety. According to Lang, anxiety manifests itself in three ways:

  1. What we say and how we think: for example, worrying about a problem, or voicing fear or concern.

  2. How we behave: avoiding certain situations, for instance, or being constantly on guard against trouble.

  3. Physical changes: for example, elevated heart beat or faster breathing, and facial expression.

  These three systems are only loosely interrelated. If we want to know whether someone is anxious, we can’t base our judgement simply on what they tell us about how they’re feeling; they may cover up their true emotions, or even be unaware of them. Similarly, the fact that someone engages in an activity doesn’t mean they’re not anxious about it (just as a person might avoid doing something for any number of reasons other than fear). And it’s quite possible to be anxious without feeling as if your stomach is tied in knots or that your heart is about to pound its way through your chest.