A Q&A with Scott Stossel, author of My Age of Anxiety: Fear, Hope, Dread and the Search for Peace of Mind
Q: Was there a particular event or moment that made you decide to write this book or have you been thinking for some time about writing a book about anxiety?
A: Both. The idea had been gestating for years, since anxiety was a topic that had interested me for a long time. But the particular moment was when, during the months leading up to the publication of my first book in 2004, I became overwhelmed by anxiety about the book tour the publisher had planned for me, which included a few live TV shows and some public-speaking events in front of rather large numbers of people. I was terrified - convinced I was destined for terrible humiliation. I was already medicated and in psychotherapy, but in desperation I sought additional help from Boston University's Center for Anxiety and Related Disorders. As I recall, the Center's website advertised that it could cure some patients of public speaking anxiety in just a few sessions of Cognitive-Behavioral Therapy. Perfect! I thought. That's just what I need! But the site also warned that four to six weeks might elapse before a new patient could get evaluated and then set up with a therapist for treatment. I didn't have that kind of time! So I wrote an e-mail to Professor David Barlow, who was then the director of the Center, laying out my predicament and saying that I knew that because time was short the Center might not have any treatment slots available, but that I really needed help fast - and that, by the way, I was considering writing about my anxiety. I thought admitting this fact might draw attention and accelerate the process of my gett ing in for an appointment. Someone from the Center called the next day to set me up with an expedited evaluation and treatment. That was the moment I fully latched onto the book idea: I've always been interested in psychology and intellectual history - and, as my book tour began that spring, I clung tightly to the idea that if I did have a nervous breakdown in public, well, then at least that could be material for my next book, a rationalization that probably in some small way helped me to avoid such a meltdown.
Q: My Age of Anxiety is in part a memoir but is also an exploration of the history of anxiety and how it has been diagnosed, treated, understood, and misunderstood over time. Why did you decide to take this parallel approach to the subject?
A: I never had any intention of writing a straight memoir. My life isn't that interesting to me, so I couldn't imagine it would be terribly interesting to other people. But I realized that my personal experience with anxiety gave me a kind of writerly authority - not the authority of the academic expert or the clinician but of the anxiety sufferer. By writing a firsthand account of the phenomenology of anxiety, I thought I could provide something that might be interesting and/or useful to general readers, to anxiety sufferers - and perhaps even to those academic experts and clinicians. Also, what attracted me to writing about anxiety was the intellectual richness of the topic. It encompasses science, philosophy, culture, intellectual history - and it relates, in varying degrees, to religion, politics, sports, and myriad other things. But I worried that treating the subject as pure intellectual history could end up feeling dry and abstract. Putt ing myself into the book allowed me to provide a character that - I hope! - readers can relate to, and also to inject some levity into a dark subject. I ended up putt ing way more of myself into the book than I originally imagined - but that became necessary because my own struggles with anxiety ended up providing the main narrative engine of the book. My personal history became the glue for all the disparate material I wanted to cover - the history of psychiatric medication, performance anxiety, choking in sports, the genetics of anxiety, Freud, Kierkegaard, Hippocrates, Plato, the connection between anxiety and authoritarianism, the science of nervous stomachs, etc etc etc. My hope is that my subjective experience adds dimension and texture to the science and history - just as the science and history have provided depth and context to my experience.
Q: You are incredibly frank about your own experiences (and those of your family) and treatments, both in childhood and adulthood. As a journalist and editor who has written a lot about other people, how was it to open up about your own life?
A: Kind of excruciating - but my hope is that it will ultimately prove somewhat liberating. Actually, the writing about my own experience was not so bad - but that's because while I was writing the book I was able more or less to pretend that it would never come out. Which wasn't hard, actually, because I feared it would never come out. Now that it is coming out, I'm a litt le bit terrifi ed and a litt le bit mortified. The notion that certain specific individuals might read this - colleagues and former colleagues, long-ago acquaintances, my mother - makes me cringe. But the early responses have been reassuring. Several people who have read the proofs have told me they alternated between being able to relate to my experiences and feeling relieved that, as they put it, "Boy, I sure am glad I'm not as messed up as that guy!" I do hope that reading about my (sometimes prett y embarrassing) experiences will be useful to readers - both to those who suff er from severe anxiety, in allowing them to discover that they are part of a rather large tribe that extends back through history, and to those who don't, because in describing my anxious misadventures I'm also talking about ideas and scientific concepts that have relevance to all of our lives.
Q: You delve into so much science and pharmacology as well as philosophy, art and literature. How did you go about your research?
A: I spent a good part of last eight years trying to read everything I could get my hands on - not only the relevant historical material and works of philosophy and literature, but also a lot of the research that's published in scientific journals every month, and also the self-help books. I interviewed researchers and clinicians, and I att ended many academic conferences. At times, I worried I'd end up spending forty years researching anxiety and never get around to actually writing about it. Each summer when I'd see my uncle on vacation, he'd note the stack of books and articles I was toting around with me and then shake his head and ask me why I didn't just stop reading and start writing. But I was worried I'd fail to master all the material before I wrote the book. And of course I did fail. But I tried. And if anyone ever wants to visit a vast museum of anxiety-related material, just come up to my attic.
Q: You struggle to come up with a usable definition of anxiety (that say differentiates it from depression or other conditions), how would you defi ne it? Also, when did anxiety officially become a clinical category?
A: The "anxiety disorders" did not officially became a clinical category until 1980, with the publication of the third edition of the Diagnostic and Statistical Manual, which is the bible of the mental health field. Between, say, 1900 and 1980 - the heyday of Freudianism - what we would today call clinical "anxiety"was for the most part subsumed by categories like "neurosis" or "psychoneurosis." Before Freud, anxiety tended to be diagnosed clinically as "neurasthenia," or "melancholia," or "the vapors" - or as any number of a wide range of other diagnoses that tended to lump together both anxiety and depression. In my research, I came across hundreds, if not thousands of diff erent defi nitions of "anxiety," many of which contradicted one another. But the simple definition of anxiety I ended up using - borrowing from one of my therapists, Dr. W., who in turn was borrowing from Charles Darwin - is "apprehension about future sufferingthe fearful anticipation of an unbearable catastrophe one is hopeless to prevent." Echoing Freud, Dr. W also makes a distinction between fear (which is produced by "real" threats from the world) and anxiety (which is produced by threats from within ourselves). In this view, anxiety is "a signal that the usual defenses against unbearably painful views of the self are failing." If you want a more official & technical definition, the current edition of the DSM defines anxiety as "The apprehensive anticipation of future danger of misfortune accompanied by a feeling of dysphoria or somatic feelings of tension. The focus of anticipated danger may be internal or external."
Q: The statistics are bracing. Rates of anxiety are rising along with the rates of those on medications to treat it. Some forty million Americans, or about eighteen percent of the population, now suff er from a clinical anxiety disorder. Are we gett ing more anxious? Or as you say might every age consider itself the most anxious?
A: Almost every age considers itself the most anxious. If you read back through history, you discover how almost every generation - going back to ancient times - laments how anxiety-wracked it is, claiming unprecedented levels of anxiety for itself. In some periods, claiming to be anxious - or "stressed," as we say today, or "neurasthenic" as we would have said in the 1890shas been a self-flattering diagnosis, because it was thought to reflect a refined sensibility or good breeding or that you are hardworking and important. But some evidence suggests that certain eras truly are more anxious than others, and I think a pretty strong case can be made that the present era is one of them. Until the last few hundred years, your place in life - your job, your position in the economic system, your social role - as fixed from the moment of birth; you were born into the role you would inhabit. The unleashing of capitalism and individualism produced wondrous advances in standards of living and in freedom of opportunity - but this also produced a great deal of anxiety, by destabilizing old rules and social structures. The combination of abundant freedom to choose - not only about which of 387 breakfast cereals to buy but about what personal style to adopt, what career to pursue - with abiding economic uncertainty is powerfully "anxiogenic," as the experts say. Some argue that uncertainty is actually rewiring our brains to become more anxious. Plenty of statistics suggest high and rising levels of anxiety in the U.S and around the world. For instance, a majority of Americans say they are chronically stressed, many of them "highly" stressed. Far more people report being on the verge of nervous breakdown that a few decades ago. Some survey data suggests that the average high school student today has the same level of anxiety as the average psychiatric patient in the 1950s.
Q: You can't write a book about anxiety without talking about drugs. And your chronicle of this arena is at once fascinating and overwhelming. The debate seems endless on this front. Do they work? Are they dangerous? And as you have struggled with, from a real philosophical point, even if they help do they change the nature of you are (I think the way you put it is do they "diminish the soul")? After all the research and your own personal experiences, where do you stand on this issue?
A: Boiled down, here are five things I believe:
1. Psychiatric medication can be extremely effective for some anxiety-ridden people some of the time, and it is a necessary and valuable part of the therapeutic arsenal. For some people, it can be the difference between living in housebound misery and having a semblance of a normal life.
2. For some people, medication doesn't work at all - or works a little but with side effects that are too severe to be worthwhile. Some medications, in certain circumstances, can make patients worse - and it can prevent people from addressing underlying psychological or existential issues.
3. Medication can be dangerous, because of dependency and addiction issues; overdose potential; and impaired functioning.
4. Many more people than is necessary may be taking psychiatric medication, leading to a society thatis astonishingly drug-saturated. The drug companies - which I think on balance have done enormous good for the world, and for the clinically anxious - have succeeded, in cahoots with the psychiatric establishment, in vastly enlarging the disease categories for which drugs are prescribed. This is a real problem.
5. I do believe that psychiatric medication can "diminish the self," or alter it in ways that raise thorny philosophical questions. Yes, I realize some of these points seem to contradict one another. But this is a complicated set of issues, so I think that feeling a bit conflicted and confused is better than having a black-and-white ideological position about drugs. I wish I did not have to take these medications myself - but for now I sure am grateful they exist.
Q: You chronicle so many different schools of thought and every method of treatment. Is it our mother? Our environment? Our genes? Our mind v. our body? Is the most current research leaning in any one direction?
A: In some ways, current research is leading toward synthesis of these various schools of thought and methods. For instance, cognitive-behavioral therapists, who are more or less of behavior-and environment theory of anxiety, have begun experimenting with using drugs normally associated with the body-is-the-cause-of-anxiety school to augment the power of cognitive-behavioral therapy. To cite one specific example: research has shown that a drug called D-cyloserine can enhance the formation of new memories during exposure therapy for phobias. Another example: The academic research of one cognitive-behavioral therapist I worked with ("Dr M" in the book) focused on the respiration physiology of anxiety, looking at how breathing rates and CO2 levels relate to panic att acks. In other words, this was someone who used a "mind"-based approach to treatment, but whose understanding of anxiety clearly encompassed the body. Similarly, current research is finding out how meditation, another "mind"-based approach to anxiety reduction, has observable effects on the physical structure of the brain. Meditation has tangible effects on the body. But the areas where anxiety research seems to be advancing most rapidly are in neuroscience and molecular genetics - often in conjunction with one another. Scientists are learning which genes lead to which temperamental traits, and also which genes encode which brain functions, like serotonin or dopamine processing, and beginning to figure out how all this fi ts together. This holds the potential for transformative advances in our understanding of anxiety and in the development of better treatments for it.
Q: You actually underwent some of this genetic testing. Was it instructive? Do you think genetics could unlock some potential in terms of treatments?
A: I think the answer to the latter question is pretty clearly yes. Already, genetic research has shown some efficacy in predicting which genotypes will respond most favorably to which antidepressant andanti-anxiety medications. And some of the genetic research is helping scientists to grasp the underpinnings of "resilience," a trait that has been shown to be tied to resistance to and recovery from anxiety disorders and trauma. One danger lurking amidst all these new findings in behavioral genetics is the temptation to reduce everything to genes. While working on the book, I flirted with succumbing to this temptation myself, especially after I'd had myself tested for various gene variations. While it's clear that much of one's temperament and personality - and one's propensity to be anxious - derives from hereditary predispositions passed along via the genes, culture and nurture and life experience play a strong role in determining whether a genotype for, say, an inhibited temperament will turn into an anxiety disorder or depression. If one half of an identical-twin set has an anxiety disorder the other half is very likely also to have the disorder, which suggests anxiety is highly heritable - but this isn't true one hundred percent of the time, so factors other than genetics play roles in determining your levels of anxiety.
Q: Where are we now in terms of what's coming to the forefront of scientific thinking on anxiety?
You write about emerging research on resilience (and in fact that is title of the book's final chapter), what does resilience mean in this context?
A: Historically, in seeking the causes of and best treatments for psychopathology, researchers have tended to focus on what's wrong with the people who suff er from it: what abnormalities in thinking or behavior or brain systems or genes have produced a vulnerability to, say, anxiety or depression. But in recent years we've been looking also at what makes mentally healthy people resistant to anxiety and depression and asking what are the personal characteristics and thought processes and brain structures of people who are able to withstand stress and even severe trauma without breaking down? Modern researchers group many of these resistance-conferring traits under the umbrella of "resilience," which as a psychological term of art means roughly what it does colloquially: the ability to resist, or to rebound quickly from, the effects of stress or trauma, and to persist in the face of setbacks. Some recent neuroscience studies have been fi nding that having abundant quantities of a neurotransmitt er called Neuropeptide Y is highly predictive of resilience. For instance Navy SEALs and Army Rangers, who are selected in part based their psychological and physical resilience, tend to have exceptionally high levels of Neuropeptide Y. Emerging genetic research suggests that your baseline level of Neuropeptide Y is encoded by your genes - which suggests, in turn that how resilient you are is determined by your genes before birth. But other research is revealing that resilience can clearly be learned, and can be developed through training. The military is investing in research to determine how best to cultivate resilience. Dennis Charney, a professor of neuroscience at Mt. Sinai Medical School and one of the world's leading experts on the neurobiology of clinical anxiety, has done groundbreaking work in laying out the kinds of habits and traits - such as optimism, altruism, faith or spirituality, strong social support networks, a sense of purpose, a sense of humor etc - that bolster resilience. Crucially, resilience can be learned, and can be improved through practice - this was a hopeful fact that I, who sometimes tends not to feel terribly resilient, gleaned while writing this book. In the stressful, uncertain times we live in, cultivating resilience may be a valuable goal for all of us.
Q: You write, "It has occurred to me that writing this book might be a terrible idea." You even write about discussing the idea with your therapist. Yet early on in the process of writing this book you ask the question: "In all the insight into history and culture that a study of anxiety might produce, is there anything that can help the individual anxiety suff erer? Can we - can I - reduce anxiety, or come to terms with it by understanding the value and meaning of it." So, terrible idea or ?
A: The jury's still out. The process of writing it was stressful and anxiety-producing and often miserable but also, at times, rewarding. There were many moments when I felt like I'd be crushed under the weight of it. But I persisted - showing, I suppose, some modicum of resilience that I didn't know I had - and completed the book, which probably was good for my mental health. Now, of course, my greatest anxiety is about what actually publishing this book, and revealing my neurotic brain to the world, will be like. That may indeed be a bad idea. Is it too late for me to back out now? (NOTE FROM PUBLISHER: YES)
Unless otherwise stated, this interview was conducted at the time the book was first published, and is reproduced with permission of the publisher. This interview may not be reproduced or reprinted without permission in writing from the copyright holder.
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