Our new era of anxiety

Anxiety disorder rates have risen twentyfold in 30 years -- largely because psychiatry misunderstands human nature

Published June 2, 2012 10:00PM (EDT)

This article was adapted from the new book "All We Have to Fear", from Oxford University Press.

Fears, worries, and apprehensions are painful and ubiquitous aspects of human existence, whether they are common or idiosyncratic, specific or diffuse, rational or irrational. Studies of the U.S. population indicate that the most common forms of psychiatric disturbances by far are various fears that, when intense, psychiatry currently classifies as “anxiety disorders”: fear of public speaking, heights, or meeting new people; fear of snakes or rodents; and many other conditions where people experience intense anxiety.

Moreover, it might seem as if a startling increase in the number of anxiety disorders has occurred in recent years. Consider that in 1980, the third edition of the authoritative Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association stated: “It has been estimated that from 2 to 4% of the general population has at some time had a disorder that this manual would classify as an Anxiety Disorder.”

Then, the first large community study conducted after the publication of this manual, the Epidemiologic Catchment Area Study, found that about one out of ten people had an anxiety disorder in any given year and that roughly 15% of individuals experienced these conditions at some point in their lives. Just two decades later, a similar and equally rigorous study, the National Comorbidity Study Replication (NCS-R), yielded the shocking result that almost one out of five people had had an anxiety disorder over the past year, and more than a quarter of the population (28.8%) had had one at some point in their lives.

Even the NCS-R actually underestimates the frequency of anxiety disorders, as measured by psychiatry’s current criteria for diagnosing mental disorder. Because it asks people to remember years later what anxieties they had earlier in life, many respondents forget past episodes. A recent New Zealand study with substantially improved methodology that involved repeated interviews of participants established that in any given year between ages 18 and 32, nearly a quarter of all young adults (22.8%) experience an anxiety disorder and that virtually half (49.5%) report at least one such disorder during the entire period. Obviously, the study would have yielded even higher estimates if it had included disorders emerging after age 32 or before age 18.

How did rates of anxiety disorders rise by as much as twentyfold over the past 30 years to encompass as much as over half the population?

Philosophers have long emphasized that much anxiety results from pondering life’s mysteries and uncertainties, as in angst about the inevitability of death and the meaning of existence. For most people, however, far more mundane situations — and ones much less immediately threatening than, say, a car rapidly bearing down on one in the street — create anxiousness. They become worried when they might be late for a meeting, miss a plane, park in a no-parking zone, see a police car approaching, or give a public talk. Such everyday occurrences as leaving a middle-school child at home can lead to intense worry among parent and child alike: “All the while I was out, I kept looking at my watch and listening for my phone. He called me four times in an hour: ‘When are you coming home? Where are you? Are you on line yet? Did you leave the store yet?’ It made me so nervous, I just browsed and left." These worries are built into the structure of modern life, emerging daily or even hourly, especially among people with nervous temperaments.

Life-endangering contexts can generate a degree of normal anxiety that leads to extreme actions. One example (immortalized in a recent motion picture titled "127 Hours") is that of a hiker in a remote area whose arm got caught under a fallen rock — and who, fearing his eventual death, amputated the arm with his hunting knife in order to escape.  Unlike such responses to immediate — but brief — risks of death, many threatening situations are enduring. The resulting anxiety might also be chronic, yet still normal. For example, many survivors of the Hurricane Katrina disaster in New Orleans experienced anxiety symptoms that, unlike those following the 9/11 attacks, did not subside quickly because the effects of the disaster were not corrected. The lack of adequate housing, schooling, policing, and employment continued for substantial numbers of people long after the hurricane itself was gone. Six months after the disaster, nearly half the residents of the New Orleans metropolitan area still reported high levels of anxiety symptoms.

Many anxiety conditions do not seem to be related in any comprehensible way to external situations, to previous terrifying experiences, or to our biological nature as a species. Take the example of the poet Emily Dickinson who, by the time she was 40, would not leave her home and hid in her room, unwilling to see even her longtime friends. Nothing about Dickinson’s circumstances could account for her refusal to walk outside or to meet with people she had known for extended periods of time. A great number of people ranging from Isaac Newton — who spent several years inside his house — to actress Kim Basinger have shared the fear of going out in public.

But not all disordered states of anxiety involve fear of a particular action, event, or object. Sudden panic attacks when there is no obvious context or trigger, in which people not afraid of anything in particular experience heart palpitations and other symptoms that make them think they are having a heart attack and are going to die, can cripple a person’s life. Generalized anxiety of a lesser intensity, where one feels anxious or worries disproportionately about various not-very-threatening concerns in contexts that do not truly explain the level of anxiety, can also make an individual miserable.

Unlike natural fears, these unfathomable symptoms — sometimes relatively harmless affectations, sometimes devastatingly distressing and impairing — cannot be explained by consideration of their context or by understandable reactions to memories of past dangers. They seem to indicate that something has gone wrong in the way our fears are aroused and sustained.

There is also a third type of anxiety that doesn’t quite seem to fit either of these categories. These anxieties are out of proportion to the actual danger in the present environment yet seem understandable as reactions that came down to us as part of our biological inheritance of fears that did make sense in the prehistoric past.

Early hominids had much to fear. The most ancient stages of human evolution featured environments where people without powerful weaponry faced numerous predators, could do little to protect themselves from harsh climates and natural disasters, and were defenseless against disease. Food was often scarce and in many environments was impossible to preserve for long periods of time. Dangers were everywhere at the same time that security from threats was weak and often unavailable. Small bands of just one or two hundred people faced other hostile groups of humans and other predators, without any government to protect them. Although a range of strategies could be adaptive for dealing with some specific circumstances, on average, vigilance, caution, and readiness to flee at a moment’s notice would probably have had the greatest evolutionary payoff.

Many fears that do not seem helpful today were useful at the time that they became part of the biological nature of our species. A good example is snake phobia, a common and often intense fear. Charles Darwin recounted an incident that indicates the powerful instinctual nature of snake phobias:

I put my face close to the thick glass-plate in front of a puff-adder in the Zoological Gardens, with the firm determination of not starting back if the snake struck at me; but, as soon as the blow was struck, my resolution went for nothing and I jumped a yard or two backwards with astonishing rapidity. My will and reason were powerless against the imagination of a danger which had never been experienced.

Much evidence shows that snake fear is biologically programmed to be easily triggered in us, and the reason is not hard to see. Intense fear of snakes was valuable in the ancestral environments where snakes posed serious dangers.

Snake fear might seem outdated and useless to urban dwellers, but its value remains in those modern locations that still feature considerable numbers of snakes, such as the desert terrain of Arizona. One news story under the headline “Rattlesnakes Bite 4 Over Weekend; One Man Wanted to Pet Snake, Doctors Say,” reported that snakes bit eight people in the Phoenix area over the previous week.

One victim, Patrick Hotchkiss of Quartzsite, Ariz., “had just stepped off his porch Sunday afternoon when he was struck ... ‘I should’ve been more vigilant. Usually I am,’ said Hotchkiss ... Some of the other victims were gardening or hiking. One child was playing in a yard.” Some of the bites occurred under odd circumstances that vividly illustrate the danger of having no fear of snakes:

But others got closer than they should have. Doctors said one man was bitten on the hand after trying to pet a snake. They said the man had been drinking prior to the incident. “We’ve seen several people who’ve tried petting the snakes, and even on occasion people trying to kiss the snake. Any of those things usually result in the patient getting bitten,” said Dr. Michael Levine, a toxicologist at Banner Poison Control Center.

Obviously an innate tendency to develop a fear of snakes might be a good thing in those environments that snakes inhabit. No matter how inexplicable a fear of snakes might seem at first in an apartment dweller in Manhattan, the fear is quite understandable when placed within the context of our development as a species and the biological nature that our evolutionary shaping imparted to us. Some of these natural fears are rooted in immediately perceived real dangers, others in our memories of past dangers that influence our present expectations, and still others in our species’ history of natural selection that shaped our fear for dealing with dangers that existed in ancestral times but that no longer pose threats.

But some emotions that were adaptive during this evolutionary period were genetically transmitted to future generations for whom those emotions, rather than being protective, might instead be a constant source of needless distress, suffering, and impairment. Consider the anxiety of the popular former sports announcer John Madden, who, like many people, is terrified of air travel. Despite having to travel long distances almost every week, Madden would never fly but always used buses, which are far more inconvenient and time-consuming. Given that flying is many times safer than driving, Madden’s intense fear might seem to be as inexplicable as Emily Dickinson’s unwillingness to see her friends, but many people tend to be afraid of flying, and their fear seems to make a certain amount of sense in terms of human nature, though not in terms of what is currently rational.

Of course, air travel is an invention that did not exist at the time humans evolved, so fear of air travel in and of itself is not a biologically shaped fear. Rather, air travel happens to have several features that human beings were shaped to fear. Intense fear of being at extreme heights where falling would mean death and of entering enclosed spaces where escape is impossible might have been adaptive in ancient periods when such places were genuinely dangerous and to be avoided. Fear of being passive and out of control while facing such anxieties might additionally be naturally anxiety-provoking. People who had fears that motivated them to stay away from such situations might have avoided the occasional disaster and thus passed on to their descendants genes that made them more fearful of entering enclosed spaces, climbing to higher altitudes, and not being in control. Madden’s fear could thus reflect the natural, if no longer constructive, operation of such biologically designed psychological mechanisms. Its evolutionary origin would explain why a substantial percentage of the population shares this fear, even if many people manage to overcome it and, unlike Madden, continue to fly.

Air travel is extremely unlikely to pose the risk of falling from a height or finding oneself trapped by a predator in an enclosed space. Such fears are at the same time natural and yet no longer adaptive in most modern environments. They are an unfortunate mismatch between anachronistic but natural emotions that once were functional and our modern, technologically transformed environment.

The ubiquity of innate fears that are not necessarily adaptive in modern life provides one answer to the question of why anxiety disorders seem to be so common. When fears of crawling animals, flying, strangers, or public speaking are considered to be pathological, rates of anxiety disorders will soar because humans were naturally designed to have such fears. A second reason why so much fearful behavior can readily be classified as disordered is that individual tendencies to express anxiety vary continuously. People who are naturally at the high end of this temperamental continuum can be mistakenly classified as having anxiety disorders.

While evolution programmed anxious emotions to arise in threatening and uncertain situations, culture helps define what particular objects and situations people consider to be dangerous, what cues activate their fear responses, and what sorts of things they worry about as well as the degree of intensity or duration with which one should respond. For example, while witchcraft is a common source of anxiousness in many African societies, it is unlikely to be a source of fear in modern Western cultures. Witch fear is seen as reasonable in the former but not the latter. Fears of being buried alive dominated nineteenth century consciousness in the United Kingdom and United States but would be extremely rare at present; conversely, food allergies, a rare source of anxiousness in the past, are a dominant source of worry in the contemporary United States.

The basic challenge humans face is not to avoid acquiring fears — they are largely part of our nature — but rather to learn how to overcome the many currently useless innate fears that we experience. “It is less a matter of acquiring fears of the dark and of strangers,” according to psychologist Stanley Rachman, “than of developing the necessary competence and courage to deal effectively with the existing predispositions or actual fears.” Adequate criteria for anxiety disorders must take into account normal human variation in anxiousness and must separate genuine pathology from both high-end anxious temperaments and low-end skilled suppression or endurance of natural fears.

 Excerpted with permission from "All We Have to Fear: Psychiatry's Transformation of Natural Anxieties into Mental Disorders," from Oxford University Press. 

By Allan V. Horwitz

Allan V. Horwitz is Board of Governors Professor of Sociology at Rutgers University. He is the author of numerous articles and books on various aspects of the sociology of mental illness, including "The Social Control of Mental Illness," "Creating Mental Illness" and "The Loss of Sadness" with Jerome C. Wakefield.

MORE FROM Allan V. Horwitz

By Jerome C. Wakefield

Jerome C. Wakefield is University Professor, Professor of Social Work and Professor of the Conceptual Foundations of Psychiatry at New York University. He is also the author with Allan Horwitz of "The Loss of Sadness," named best psychology book of 2007 by the Association of American Publishers.

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