Anxiety Read online

  Definitions of anxiety

  Bearing in mind that there is still no single definition of anxiety, let’s now look at a couple of helpful attempts. The first comes from the DSM (the Diagnostic and Statistical Manual of Mental Disorders), a standard resource for mental health professionals compiled by the American Psychiatric Association. According to the DSM, anxiety is:

  The apprehensive anticipation of future danger or misfortune accompanied by a feeling of dysphoria or somatic feelings of tension. The focus of anticipated danger may be internal or external.

  And here’s a slightly less technical definition of anxiety from the US psychologist David Barlow:

  Anxiety is a future-oriented mood state in which one is ready or prepared to attempt to cope with upcoming negative events…. If one were to put anxiety into words, one might say, ‘That terrible event could happen again and I might not be able to deal with it, but I’ve got to be ready to try.’

  Both definitions make the point that anxiety is an emotion (though the DSM uses the term ‘feeling’ and Barlow refers to it as a ‘mood state’). As we all know, anxiety is no fun; this is what the DSM means by ‘dysphoria’ (the psychological term for an unpleasant feeling). Our body may behave in unusual ways (stomach churning, eyes widening, heart racing) – hence the DSM’s reference to ‘somatic’ feelings. And at the root of it all is the perception that we may be facing serious trouble.

  A closely related but slightly different concept is stress. Stress is defined as what we feel when we believe we can’t cope with the demands facing us. It comprises two elements: a problem and a self-perception (specifically, that we’re not able to deal with the problem in question). Like anxiety, stress is rooted in the fight or flight system. It can trigger a range of emotional responses including, very often, anxiety.

  You may also be wondering how anxiety differs from fear. In fact, the two terms are often used interchangeably, and we do so in this book. That said, some researchers do make a differentiation, and typically it revolves around the object of our emotion. Fear usually has a clear object – seeing a shark’s fin while we’re swimming, perhaps, or a dangerous piece of driving from the car alongside us on the motorway – and it often functions as a sort of emergency reaction (being mildly frightened is almost a contradiction in terms). But things are generally much less clear-cut when it comes to anxiety. Instead of situations in which we know exactly what it is that’s scaring us – and when our fear will soon disappear once the threat has passed – we may not have a clue why we feel anxious. As Holly Golightly put it in Breakfast at Tiffany’s: ‘something bad is going to happen, only you don’t know what it is.’

  Anxiety can often be a less intense feeling than fear. It can seem vague and amorphous – and for that very reason difficult to rid ourselves of. After all, if we don’t know what is making us anxious, it’s difficult to know how to deal with the problem. Some experts have suggested that anxiety is the emotion we feel when we can’t, or don’t know how to, take action to deal with a threat. So a large dog charging towards us with its teeth bared is likely to prompt us to a fearful sprint; worries about dying are more likely to take the form of nagging anxiety than straightforward fear.

  If anxiety is normal, how can we tell whether it’s getting out of hand? At what point does ordinary, run-of-the-mill anxiety become a clinical problem that needs attention? Every case must be judged in its own context, but a mental health professional will consider:

  • whether the individual is becoming anxious inappropriately (their anxiety is like an overly sensitive car alarm);

  • whether the anxiety is based on an unrealistic or excessive perception of danger;

  • how long anxiety has been affecting the person;

  • how distressing it is for the individual;

  • and the degree to which anxiety is interfering with the person’s day-to-day life.

  They’ll then try to match the person’s experiences to the six types of anxiety disorder – the ones categorized as such by the main psychiatric diagnostic systems – that we describe in Chapters 5 to 10.

  If you’re concerned about your own levels of anxiety, you’ll find self-assessment questionnaires for many specific disorders in the Appendix on pp. 124–132.

  Chapter 2

  Theories of anxiety

  As we saw in Chapter 1, the term ‘anxiety’ was rarely used by doctors and scientists until the 20th century. As interest in anxiety has grown, however, an increasingly rich and varied body of theoretical work devoted to understanding it has developed. In this chapter, we look at four key perspectives on anxiety, progressing from ideas that date back to the end of the 19th century to the most recent developments:

  • psychoanalytic

  • behavioural

  • cognitive

  • neurobiological

  Psychoanalytic theories of anxiety

  The deeper we penetrate into the study of mental processes the more we recognize their abundance and complexity. A number of simple formulas which to begin with seemed to meet our needs have later turned out to be inadequate…. Here, where we are dealing with anxiety, you see everything in a state of flux and change.

  Sigmund Freud, ‘Anxiety and the Instinctual Life’

  An influential historical figure in the study of anxiety was the founder of psychoanalysis, Sigmund Freud (1856–1939). Freud trained as a medical doctor at the University of Vienna, specializing in neurology (the study and treatment of disorders of the nervous system). By the 1890s, Freud had come to believe that the symptoms displayed by many of his patients were the product, not of disease of the physical nervous system, but rather of their failure to deal with invisible, unconscious, and primarily sexual psychological drives. This insight became the cornerstone of psychoanalysis, which remained the predominant form of treatment for psychological problems in Europe and the United States until at least the 1970s.

  Freud’s interest in anxiety was marked by the publication in 1895 of his paper, ‘On the Grounds for Detaching a Particular Syndrome from Neurasthenia under the Description “Anxiety Neurosis”’. As the title indicates, the principal purpose of this paper was to distinguish what Freud called ‘anxiety neurosis’ (Angstneurose) from other forms of nervous illness (or neurasthenia).

  What were the symptoms of ‘anxiety neurosis’? Freud listed:

  • Irritability.

  • Deeply engrained and distressing pessimism; the belief that disaster is just around the corner. Freud called this trait ‘anxious expectation’.

  • Panic attacks, often involving physical symptoms such as difficulty breathing, pains in the chest, sweating, vertigo, and trembling.

  • Waking up at night in fear.

  • Vertigo, in which the individual experiences ‘sensations of the ground rocking, of the legs giving way and of its being impossible to stand up’.

  • Phobias.

  • Feelings of nausea, ravenous hunger, or diarrhoea.

  • Tingling of the skin (pins and needles) or numbness.

  Freud argued that, unlike other nervous illnesses, anxiety neurosis was caused by the failure to properly satisfy the build-up of sexual excitement. By way of example, Freud cited the cases of ‘intentionally abstinent’ men and women; men ‘in a state of unconsummated excitement’, for instance if they were engaged but not yet married; and women ‘whose husbands suffer from ejaculatio praecox or from markedly impaired potency … [or] whose husbands practise coitus interruptus or reservatus’.

  Rather ironically, given that psychoanalysis is all about the primacy of the mind, in 1895 Freud believed that anxiety was caused by physical factors. Sexual excitement certainly had a profound influence on the psyche, triggering the desire for sexual satisfaction, but its essence was physiological. In men, Freud argued, it consisted of ‘pressure on the walls of the seminal vessels’. Freud thought an analogous process took place in the case of women, though he didn’t know what this might be.

  Freud’s views o
n anxiety, however, evolved considerably over the decades. His later position is summarized in ‘Anxiety and Instinctual Life’, a lecture he gave in 1932. Neurotic anxiety still has its roots in sexual energy, but this energy is now seen as fundamentally psychological rather than physical.

  You may have noticed the use of the term ‘neurotic’ here. This is because by now Freud was distinguishing between anxiety as a justified response to real danger, and so-called neurotic anxiety, which is excessive and irrational. Realistic anxiety arises from threats in the external environment; neurotic anxiety arises from within, though we are unaware of its true cause. Realistic anxiety helps us; neurotic anxiety can make our life a misery.

  Key to Freud’s theory of anxiety is what he called the id, a wild and primitive psychic reservoir of instinctive desires. The job of managing and controlling these desires, which are buried deep in our unconscious, falls to a second part of the Freudian psyche, the ego. When the ego fails in this unenviable task, neurotic anxiety results, and the desire is thereby repressed. Freud also suggests that our episodes of anxiety recall our first encounter with danger: the trauma of birth. Each anxious fear we experience is an echo of this fundamental event.

  Freud’s mature theory of anxiety is illustrated by one of his most famous case studies: that of Little Hans. Hans was a five-year-old boy who developed a fear of horses. Freud, working principally from information communicated by Hans’ father, argued that Hans’ horse phobia was in reality a fear of his unconscious sexual desire for his mother and the retribution from his father that he unconsciously anticipated. The ‘unacceptable’ fear – unacceptable because resulting from an Oedipal infatuation with his mother – is transformed into a more acceptable phobia. The neat distinction between realistic and neurotic fears is thereby overturned: Freud shows that at the root of every neurotic anxiety is the fear of an external danger (in this case punishment, possibly by means of castration, at the hands of the father).

  Freud was undoubtedly one of the most influential thinkers of the 20th century, yet his ideas are now deemed more or less irrelevant by scientists. As the psychologist Stanley Rachman has written: ‘The entire enterprise, including the theory of anxiety, is rich in theorizing but lacking in methodological rigour and deficient in facts.’

  Behavioural theories of anxiety

  Anxiety is a learned response.

  O. H. Mowrer

  One of the most famous experiments in the history of psychology took place in London in 1920. Directing the experiment was the then-star of Anglo-American psychology, John Broadus Watson (1878–1958). Watson was the leader of behaviourism, an approach that would dominate academic psychology for much of the 20th century.

  Behaviourism constituted a vigorous rejection of the academic psychology pioneered by Wilhelm Wundt (1832–1920) and William James (1842–1910) and of psychoanalysis, which had rapidly become the dominant approach in Europe to understanding and treating the mind and its disorders.

  Behaviourism, as its name suggests, took as its subject the behaviour of humans and animals (it saw no fundamental difference between the two). Indeed, Watson argued that behaviour was the only appropriate subject for a genuinely scientific psychology to study. Thoughts, emotions, dreams – all were irrelevant. How could such phenomena be studied scientifically? In his ‘behaviourist manifesto’ of 1913, Watson had written:

  Psychology … is a purely objective experimental branch of natural science … Its theoretical goal is the prediction and control of behaviour.

  For Watson and his followers, all behaviour had a simple explanation: we learn it. And this brings us back to that celebrated 1920 experiment. Starring opposite Watson in 1920 was an infant immortalized by Watson (together with his assistant and future wife Rosalie Rayner) as ‘Albert B.’.

  Albert B. was nine months old, the son of a wet nurse at London’s Harriet Lane Home for Invalid Children. Watson and Rayner began by testing Albert’s reactions to a range of objects, including a white rat, a rabbit, a dog, cotton wool, and burning newspapers. Albert – who, according to the psychologists, was a happy, healthy, and stoical child – appeared perfectly content with them all.

  Some weeks later, Watson and Rayner showed Albert the white rat for a second time. On this occasion, as soon as Albert touched the rat, the psychologists slammed a hammer against a steel bar, producing a sudden and frighteningly loud noise. Over the next few weeks, they discovered that Albert was now afraid of the white rat, even when the steel bar wasn’t struck. And not only that: the child was also scared of objects that in some way resembled the white rat, such as a rabbit or even Watson’s hair.

  Watson and Rayner used the term ‘conditioning’ to describe this process of learning to fear an unthreatening neutral object or situation because of its pairing with another more obviously frightening event. In this, they were heavily influenced by the work of the Russian scientist Ivan Pavlov (1849–1936). Pavlov famously demonstrated that, once a given stimulus (for example, a metronome) is associated with food, dogs will learn to respond to that stimulus in the same way as they react to food – by salivating – even when no food is present.

  Watson and Rayner used the example of Albert B. as evidence for their theory that all fears are the result of conditioning: we learn them, usually in our childhood:

  the early home life of the child furnishes a laboratory situation for establishing conditioned emotional responses.

  It is conditioning, they argued, that explains how irrational fears and phobias develop:

  It is probable that many of the phobias in psychopathology are true conditioned emotional reactions …

  One baby is not, of course, a scientifically robust sample; on the other hand, most of Watson’s experiments were performed on rats.

  Behaviourist ideas regarding anxiety were subsequently developed by the American psychologist O. H. Mowrer (1907–82). In what has been termed the two-stage theory of anxiety, Mowrer argued that anxiety – and specifically the desire to avoid it – is a crucial driver of human behaviour:

  anxiety (fear) is the conditioned form of the pain reaction, which has the highly useful function of motivating and reinforcing behavior that tends to avoid or prevent the recurrence of the painproducing stimulus. [Mowrer’s emphasis]

  Mowrer’s emphasis on the motivating power of experience anticipates the operant conditioning theory of the Harvard psychologist Burrhus Skinner (1904–90). Skinner focused on the effect our behaviour has on the world around us. If the effect is positive, we learn to repeat the behaviour; a negative effect teaches us to try something different next time. So, for example, because we know how much pain an angry pitbull could inflict upon us, and the terror we’d feel as it rushed towards us, we’re careful not to make any sudden or threatening movements when we walk past one.

  Such behaviour is eminently sensible when it comes to genuine risks. But Mowrer’s theory also helps explain how irrational anxieties can take hold. A person who avoids flying because of the anxiety it triggers in them deprives themselves of the opportunity to discover that their fears are exaggerated: the chances of being killed or injured in a plane crash are minute and the fear that seems overwhelming eventually dissipates. By avoiding such situations, our anxiety merely tightens its grip.

  Behaviourist approaches to anxiety struggled to supply satisfactory answers to several important questions. For example, why is it that of the many people who experience a frightening experience – a car crash, for example – only some go on to develop a phobia that means they are fearful of travelling by car again? Why do many people develop phobias of situations in which they have never been? And if, according to classical conditioning theory, we can learn to be frightened of any neutral stimulus, why is it that some fears are much more common than others? Why are so many people afraid of heights and animals and so few scared of trees or chocolate?

  More recent research has suggested explanations for at least some of these conundrums. It’s clear, for example, that we do n
ot actually have to experience an event ourselves to become afraid of its repetition. We can learn to fear from how others behave and from what they tell us. So if a parent has a phobia, there is an above-average chance of their child developing it too. And some fears may have been hard-wired by evolution. Thus, although we may never have encountered a snake or a dangerous spider, our ancestors would have had ample experience of their potential danger. The very common fears of heights can be understood in the same way. These apparently vestigial fears, relics of human pre-history, are termed ‘prepared’ fears by psychologists.

  Behaviourism doesn’t provide a complete explanation of anxiety (it would be remarkable if it did!). But its contribution has been huge. Many fears are indeed learned, if not in the relatively crude fashion of classical conditioning. Indeed, the capacity to learn from experience and formulate plans to avoid future danger is surely part of the explanation for humanity’s success. As Mowrer wrote: