Fear ambushes me.
It is early on the morning of December 5, 1989. At least early for a college student, which is what I am. A sophomore at the University of Michigan in Ann Arbor, a bucolic campus of creaky A-frame houses, earnest politics, fraternity sweatshirts, and dollar pitchers of beer.
I am in the basement of a 1940s academic building staring at a wall covered in long sheets of dot-matrix printer paper detailing which classes have slots for the upcoming semester: Economics 101, Introduction to Buddhism, a Jane Austen seminar. Other sleepy students, jeans-clad and tousle-headed, are scribbling in notebooks nearby.
I feel fine. Groggy from a late night of studying, yes. Touched by a bit of that midwestern late-fall dread, anticipating another long winter of fierce winds and sleeping-bag-shaped coats. But I’m fine.
And then, a second later, I’m not.
A knot of fear erupts at the base of my spine and travels upward. My stomach flips, and I break out in a thin film of sweat. My heart rate shoots up—I feel the erratic thump thump banging against my ears, my stomach, my eyes. My breathing turns shallow and fast. Fuzzy gray blotches appear before my eyes. The letters before me warp, words dip and buckle.
There is no warning, no prodrome. The onset is as sudden as a car crash. Something in my body or brain has gone dramatically and irrevocably wrong. My noisy internal monologue—usually flitting from school to boys to a laundry list of insecurities—coalesces around one certain refrain: I’m dying. I’m dying. I’m dying.
I flee the building and somehow make it home, crawling into my bottom bunk in the room I share with two other girls. I hug my knees into my chest and huddle against the cinder-block wall—my breathing still shallow, my heart still racing, the hot terror still there. Remarkably, it seems, I am alive. Any relief that gives me, however, is short-lived: If I’m not dying, I must be going crazy.
Crazy like my grandmother.
Like the woman who clutched knives and thought Catholics were trying to kill her. Like the woman who spent three years in a mental institution, had electroshock therapy, and tried to burn the house down with my nine-year-old father and his brother and sister in it. Like the woman who died in my grandfather’s arms when I was two years old. She had suffered a heart attack but was too terrified to go with paramedics to the hospital.
Crazy like that.
I lie still. Perhaps if I cease all movement, even the tiniest shudder, become frozen, waxlike, I can quiet the torment. My insides feel noisy, in flux. Everything is revved up—as if the blood in my veins were running faster and the synapses in my brain were firing, or misfiring, at warp speed. I can feel the loud, frantic presence of every organ—liver, intestines, spleen. The cells in my body are vibrating, it seems, knocking awkwardly against one another. If I move at all, I will shatter, scattering bits of blood and bone all across the salmon-hued sorority house. I am sure of that.
Later that afternoon my boyfriend drives me to my parents’ house, all windows and suburban beige, about ninety minutes away. Over the next five weeks, I barely move from the living room sofa. I spend the days with my fingers pressed against my neck, feeling my pulse, counting the beats, reassuring myself at any given second that I’m alive. I keep still, trying to will my frenzied molecules to quiet. At night I have vivid, violent dreams. I develop weird new symptoms: tingling in my face and feet, chest pain, constant vertigo. The world is flat and out of focus, as if I’m wearing someone else’s glasses. My thoughts careen toward heart attacks, stroke, insanity.
I see a doctor. He listens to my story of how I’ve been transformed from a slightly silly sorority girl to a terrorized shut-in in just a few weeks’ time. He examines me, takes blood, does an EKG, and orders an echocardiogram, which details the chambers of my heart. His diagnosis: mitral valve prolapse, an anomaly of the heart that can cause palpitations but is generally benign. He prescribes a beta blocker, which he says will stop my heart from racing.
Except that it doesn’t.
This doctor is only the first of more than a dozen I will see over the next year. During that time, I will have several more EKGs, countless blood tests, another echocardiogram, a CAT scan and an MRI of my brain, and an EEG to check my brain’s electrical activity. I will take multiple trips to the emergency room, each time leaving without a diagnosis. This medical odyssey will cost my parents thousands of dollars. Doctors will suspect multiple sclerosis, a brain tumor, Epstein-Barr virus, and chronic fatigue syndrome. I will be told that I am fine. One doctor will fire me. I will drop most of my classes and barely leave my room. I will peer over the banister of a rooftop parking garage and think of jumping. I will go to a psychiatric emergency room and be sent home. I will have six sessions of psychotherapy, in which I’m asked whether I’m angry with my father. I’ll largely stop eating.
And still no one will know what is wrong with me.
Fast-forward to the beginning of the next school year. I am sitting in a psychiatrist’s office at the campus health center, telling the doctor that I won’t—I can’t—leave until she does something. She says she can prescribe Prozac, an antidepressant, or she can refer me to the anxiety disorders program at the University of Michigan hospital.
Anxiety disorder. It is the first time anyone has spoken the words.
The Anticipation of Pain
Eleven different anxiety disorders are listed in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, commonly referred to as the diagnostic bible. I had symptoms of four. I was having panic attacks—sudden, intense periods of blinding terror, rapid breathing, and chest pain—several times a day (diagnosis: panic disorder). The rest of the time I worried, living with the nervous expectation of imminent disaster (diagnosis: generalized anxiety disorder, or GAD). I had developed a long list of particular fears, too: dentists, flying, driving on highways, taking medication, touching dirt, using a new tube of toothpaste, and licking envelopes. I did my best to avoid them all (diagnosis: specific phobia). My world was becoming smaller and smaller as more places became no-go zones: movie theaters, stadiums, lines. The potential for panic attacks—and the difficulty of escape—was too great (diagnosis: agoraphobia).
I had symptoms of a couple of cousin disorders, too. A twisted perfectionism turned the smallest decision into a colossal obstacle; I felt a sense of sinister foreboding if I didn’t choose the “right” dress to wear, the “right” water glass (diagnosis: obsessive-compulsive disorder). I agonized over every odd sensation or twinge of physical pain. A headache was clearly an aneurysm; a bruise, leukemia (diagnosis: illness anxiety disorder, previously called hypochondriasis).
The estimated number of people who will have at least one anxiety disorder during the course of their lives is staggering: one in three Americans ages thirteen or older. If we look only at women, the number is even higher—about 40 percent. In any given year, about 40 million American adults have an anxiety disorder. And those numbers do not include the millions of garden-variety worriers and insomniacs whose anxiety, though not debilitating, leaches joy and steals peace of mind.
A certain amount of anxiety is good. It motivates us to study for tests, prepare for presentations, and save for retirement. It spurs us to get a physical or check the gas gauge. Too much anxiety, however, can be incapacitating and costly. In a 1999 study, the most recent estimate available, anxiety disorders cost the United States about $63 billion a year, more than half of it attributed to doctor and hospital visits. Other costs included psychiatric treatment, prescription drugs, and the value of lost productivity at work. There’s also mounting evidence that out-of-control anxiety wreaks havoc on the body, increasing the risk of heart disease and weakening the immune system. Ironically, being a hypochondriac may actually make you sick.
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It is tempting to think of our era—with its wars, terrorist attacks, rising sea levels, and economic insecurity—as, to borrow the poet W. H. Auden’s phrase, “the age of anxiety.” But cultural commentators throughout history have viewed their own times as equally fraught. In the 1880s, the telegraph, the steam engine, and even women’s intellectual pursuits were blamed for the nation’s unease. In the 1950s, it was the atomic bomb. Our world, it seems, always provides ample fodder for fear.
What is disconcerting is that rates of anxiety disorders—and depression—seem to be increasing among young people, particularly college students. According to a spring 2016 survey by the American College Health Association, 17 percent of students were diagnosed with or treated for anxiety problems during the previous year, and nearly 14 percent were diagnosed with or treated for depression. That is up from about 10 percent each for anxiety and depression in the fall 2008 survey. Parents and professionals are perplexed. While some of the rise may be because of increased prevalence, it could also be that more people are comfortable asking for help and admitting their troubles to researchers.
Depression may get most of the headlines and the research dollars, but anxiety is more prevalent. In people with a history of both an anxiety and a mood disorder, anxiety usually makes an appearance first. Anxiety disorders strike young, too: They have a median age of onset of fifteen, compared with twenty-six for mood disorders. And while anxiety disorders are pretty miserable in and of themselves, they are increasingly being thought of as gateway illnesses that can lead to a host of other problems, such as depression, substance use, and even suicide.
In fact, anxiety can be deadly. Depression is the mental illness most strongly associated with suicidal thoughts, but it doesn’t often lead to suicidal acts. Recent research has found that it is anxiety disorders and other illnesses, like problems with impulse control and addiction, that are more likely to lead to suicide attempts.
In most cases, the consequences aren’t fatal. Still, anxiety disorders can derail lives. Someone who develops an anxiety disorder at a young age is less likely to attend college. Anxious people who work have lower incomes. They are less likely to marry and, if they do, more likely to divorce. Anxious women face a greater risk of getting into unhealthy relationships and being the victim of domestic abuse.
That, thankfully, is not my story. If you met me now, you probably wouldn’t even notice my anxiety. (When I began telling acquaintances the topic of this book, they almost uniformly said, “I would never have guessed you’re anxious.”) I have a career I love, as a reporter writing stories for the Wall Street Journal. I’m happily married, with an adorable seven-year-old daughter. I have friends, laugh a lot, go to parties, and bake pies. My affliction is often invisible.
I have had many advantages. I grew up in a loving home, lived in safe neighborhoods, and went to good schools. I have almost always had health insurance and the ability to pay for therapy and medication. While these privileges didn’t prevent me from falling apart, I know they were critical in putting me back together.
But it has been a struggle. In tough years, I take medication and cycle through new therapies. In easy years, I still have to be diligent: Sleep eight hours. Do yoga. Take it easy on the wine. Pare down my responsibilities. And still I grapple with worry-induced insomnia. I tend to procrastinate, terrified of making the wrong choices. I have odd, unexplained physical symptoms—a tingling arm, chest pain. I can’t drive on highways. Anxiety affects how I work, how I love, and how I parent.
So what is anxiety?
The DSM calls it “anticipation of future threat.” Søren Kierkegaard, the nineteenth-century Danish philosopher, called it “the dizziness of freedom.” But the most cogent definition I’ve heard comes from Christian Grillon, a neuroscientist at the National Institute of Mental Health (NIMH). “Anxiety is the anticipation of pain,” he told me. “It could be physical pain or emotional pain.”
Anxiety is related to fear but is distinct. Whereas fear is concrete and imminent, anxiety is, as Grillon says, “sustained uncertainty.” It’s a chronic sense of uneasiness about a vague future, a gnawing worry about what may or may not happen.
Anxiety is universal, but the language we use to talk about it varies by culture, and so do its symptoms. The word anxiety comes from the Latin angere, which means “to choke or throttle.” In Cambodia, khyâl (“wind”) attacks involve neck pain, dizziness, and ringing in the ears. In Vietnam, trúng gió (“wind-related”) attacks are characterized by headaches. In Latin America, ataques de nervios (“attacks of nerves”) can include uncontrollable screaming and crying.
Differing cultural perceptions of anxiety make it difficult to accurately compare rates of anxiety disorders in countries around the world. Yes, studies show that, in Japan, only about 4 percent of the population has an anxiety disorder in a given year, and that the French have a rate (13.7 percent) more than double that of the Spanish (6.6 percent). But these statistics are influenced by everything from how researchers define the word worry to who responds to surveys. (You could argue that the most anxious people are the least likely to answer a stranger’s probing questions.)
Anxiety also exists on a continuum. There is no sharp boundary between mental health and mental illness, and no doubt other cultures draw the boundary differently than we do. When I asked Ron Kessler of Harvard Medical School, the country’s leading mental health epidemiologist, why so many people have anxiety problems, he said it was because “we have decided it is a disorder.” Still, even if we have become alert to the idea that everyday anxieties can be symptoms of a disorder, a formal psychiatric diagnosis requires that the person suffer from “clinically significant distress or impairment” in functioning. No matter the symptoms or the name you give it, anxiety is a problem if it keeps you from living—and enjoying—your life the way you want to.
. . .
I’ve tangled with severe anxiety for more than twenty-five years. Looking back, my troubles didn’t actually begin that December day in college, though it wasn’t until then that it spiraled out of control. I had been having strange “spells” for months. They started when I was living at home the summer after my freshman year. During the day, I was working as a receptionist at a company that made steel forgings, the kind of place where the women were called by their first names while the men were all Mister So-and-so. At night, I waitressed at an Irish bar in East Lansing, where I checked fake IDs, dodged the advances of horny Michi- gan State guys, and learned to perfect the head on a pint of Miller Light. Between jobs, I took step aerobics classes.
One night I was at the apartment of my boyfriend, Scott, a Michigan State student and Christopher Reeve doppelgänger I had begun dating in high school. The evening’s goal was, to paraphrase him, to get me high. I had tried smoking pot once or twice before but very tentatively. (I, seriously, tried not to inhale.) Frankly, I was afraid of it. I had been around enough of the stuff when I was a kid at my parents’ and my friends’ parents’ parties, the blue sheen of bongs glinting off Pledge-buffed coffee tables. Pot always seemed to make people silly and stupid. But Scott, an enthusiastic stoner, had been touting its effects for months. I was in.
We started smoking a joint and waited. Nothing.
“Take another hit,” Scott said.
I did. And when Scott took one, he grabbed me and kissed me, blowing smoke into my mouth.
Several more minutes went by. Then it hit me.
My heart beat faster. My mouth went dry. I felt breathless. My equilibrium and vision contorted; it was as if I were on a roller coaster the moment before the big plummet. I lay down on Scott’s bed, trying to take deep breaths and calm down. My legs felt like they were stretching, Alice in Wonderland style. I looked down and could have sworn I saw my feet on the other side of the room.
Desperate for distraction and wanting to feel grounded in some way, I reached for Scott and we started having sex. But I could barely feel him. My body was numb, deadened. I panicked.
“I can’t breathe,” I cried, sitting bolt upright.
“Sure you can,” Scott said, taking my hand. “Just relax.”
“I can’t. And my heart is beating so fast, too fast,” I said. “Something must have been in that pot. It must have been laced with something.”
I darted around the room, pacing and gulping air. “Or maybe I’m having an allergic reaction. Something is really wrong. I think I need to go to a hospital.” I threw on sandals, a T-shirt, and a pair of Scott’s boxer shorts. He scrambled to get dressed, too. I was already turning the doorknob to leave. Scott grabbed his car keys and followed.
At the ER, the bright lights, shiny linoleum, and bureaucratic questions sobered me up fairly quickly. I was not the only college student whose visit was spurred by chemical overindulgence. One drunken kid threw up on the waiting room floor. Another sobbed incoherently. In the exam room, a technician hooked me up to a heart monitor. A few hours later I was told I could go. A doctor scribbled my discharge instructions: “Avoid THC,” he wrote of the active chemical in marijuana.
I did that easily. That one episode was more effective than an entire adolescence of antidrug After School Specials. But the spells of breathlessness, racing heart, and, increasingly, fear, recurred every month or so. They seemed to come from nowhere. I had one while eating fried cheese sticks at Bennigan’s. I had another in the middle of a women’s studies class. I feigned a bathroom emergency and spent the rest of the class crouched in a ladies’ room stall. The attacks subsided after twenty or thirty minutes but left me jelly-legged and shaky for hours.
I don’t remember thinking much about the episodes during the intervals between them. I brushed them off, telling no one but Scott and hoping they’d vanish as abruptly as they’d begun.
According to the DSM, a panic attack is “an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes.” After that, it usually subsides. But when I landed on my parents’ sofa that December, it felt as though I were having a monthlong panic attack. Sure, my fear had peaks and valleys, but it was always there. Soon I was nearly immobile, a pajama-clad heap with greasy hair, one hand checking my galloping pulse, the other on the TV remote control, switching from MTV videos to Love Boat reruns and back again. I couldn’t read. I wasn’t actually watching the TV either. The noise was just a soundtrack for my fear.
My parents were bewildered and scared. My fourteen-year-old sister, Dana, would sometimes sit next to me, but mostly she tried to stay out of the way. “Nobody really told me what was going on,” she said recently. “I just knew that you were sick and needed some time off from school to get better. Everybody was tiptoeing around. I felt like I should not be trouble because Mom and Dad were clearly worried about you.”
It was only a few weeks before final exams, but I didn’t make it back to school. I took incompletes in my classes and planned to take my tests after winter break, when, I hoped, I’d feel better. My dad was alarmed to see me transform overnight from an energetic young adult into a listless lump. “It scared the shit out of us,” he recently recalled. “The next thing you know you’re rolled up in a fricking ball in bed.”
My parents took me to a doctor. I was terrified that something was wrong with my heart. “You thought it was going to explode,” my dad says. I started having strange neurological symptoms, too. Once, when I’d gathered the courage to venture to the mall with my mother, my peripheral vision vanished next to an Orange Julius. I had vertigo, too. The floor would rise up and the walls would tilt at odd angles. But the only diagnosis I was given was a fluttery heart valve, the mitral valve prolapse.
Nights were increasingly difficult. I was exhausted but had a tough time falling asleep. When I did, I had terrifying nightmares that became increasingly gory. Sometimes I was being chased by an unknown assailant. I dreamed I was shot in the head. Other times my face was being torn apart by an electric drill. The violence had a Tarantino vividness, but without the humor and gloss. I’d wake up shaking, with tears running down my face.
Rules crumbled. My boyfriend started spending the night with me in my high school bed, an almost life-size poster of Morrissey and his pompadour looking over us. Nothing sexual happened. Scott was more of a nocturnal life raft. I’d clutch his arm, hoping the warmth of his healthy twenty-year-old body would somehow heal me.
After a couple of weeks of infirmity, and with no real answers from the doctor, my parents began losing patience. It was right before Christmas, and we had plans to drive to the small southern Illinois town where my grandparents, aunts and uncles, and a mess of cousins lived, but I couldn’t imagine moving from my sofa. I begged them to let me stay home. They refused. I said I wouldn’t leave. They could go without me.
I didn’t win that fight. Instead, I ended up in the backseat of our blue Ford Thunderbird for the seven-hour drive to Salem, Illinois, a town of dried-up industry and oil wells, chain fast-food joints, and vast starlit skies. I don’t recall much from that trip. Did I eat my grandmother’s famous divinity—white sugary blobs topped with a single half walnut? Did I make small talk with cousins? Could anyone tell how scared and screwed up I was? Terror has a way of blacking out the details.
I do know that I took my pulse a lot, trying to will it back down to double-digit-per-minute territory. The vertigo and a growing exhaustion made it difficult for me to stay upright. I leaned against walls and car doors. And I soon found a spot on another sofa, this one in my grandparents’ house, and spent most of the time quaking under the orange and brown afghan my grandmother had crocheted. I spoke little and smiled wanly at the parade of relatives.
Back at home in Michigan, winter break was coming to an end. The new semester would be starting soon. The arguing with my parents intensified. I didn’t see how I could go back to school. I was too fragile. I still didn’t know what was wrong with me. I wanted to stay on that ridiculous beige-striped sofa (who knew there were so many shades of beige?) until I was better.
“You have to go back,” my parents said, unified in their decision.
“This is tough love,” said my father.
I was furious with them. I felt tossed out. Abandoned.
“We were concerned that if you stayed in your bedroom much longer, you would never go back to school,” my mom recalled recently.
“We wanted to get you off the couch. We wanted you to be normal,” my dad said. “Maybe it was a sink-or-swim move on our part.”
It took me years to forgive them. Now, after all my research, I know that they did the right thing. If I had stayed on that sofa, I would probably never have risen from it. Avoiding experiences that make you anxious just reinforces your anxiety.
. . .
I had to move rooms when I returned to school. I had been living with two other women, but now I would be living with three in a single room, a so-called quad. There were two sets of bunk beds, four dressers, four desks, a hodgepodge of sweatshirt-filled milk crates, and all the drama that four nineteen-year-old women can conjure.
It is awfully difficult to fall apart with no privacy, and I was almost never alone. The four of us lived in a stately, white-columned sorority house with close to a hundred other young women. We ate meals together, cooked by a surly, spice-averse man. We had weekly meetings where we’d debate which fraternities to party with and honor women who’d been “lavaliered,” given necklaces graced with the Greek letters of their boyfriends’ fraternities, a “going steady” move that was only one step away from engagement. It was hard for me to feign the required gushing.
I wasn’t alone even in the shower. The house had communal bathrooms, and the shower was a three-person affair, a white-ceramic-tile-covered stall with three metal showerheads. Fear had stolen my appetite, and I had lost fifteen pounds over the previous month. I had started to become afraid of food itself, worrying about unknown allergies or food poisoning. In that shower, I felt so fragile and ashamed as I compared my skeletal nakedness to the spirited curves of my sorority sisters. I did my best to shower at off-peak times—in the very early morning or during happy hour. Trying to hide my terror and appear “normal” was exhausting, so I came up with a cover story. I told my roommates and others I was recovering from mono, the quintessential college “kissing” disease. That was meant to explain why I skipped parties, stayed in bed a lot, and escaped to my parents’ house on weekends. And to a certain extent, I faked it.
In pictures from that semester, I don’t look haunted or timorous. In fact, apart from the awkwardly layered bangs, I look surprisingly okay. The extra-large men’s sweatshirts that were in fashion then hide my skinniness. I pose perched on bunk beds and smile widely with my arms flung around other girls. Flipping through the photos, I’m reminded of something Ned Kalin, a psychiatrist at the University of Wisconsin, told me, that patients with anxiety fascinated him because they often seemed so together, even when they were plagued by intense worry and fear. I had seemingly normal conversations with friends about boys they liked, about the fall of the Berlin Wall. I attended classes and did some schoolwork. (But only a minimal amount. I completed only two courses that semester.) Yet these efforts were undertaken, it seemed, by no more than a tiny sliver of my brain. The rest was stuffed with a litany of fears: my heart, my breathing, never being well again.
I had always been a quick, voracious reader, but ever since my spell on the couch, I found that I read pages, then had no recollection of their contents. My eyes skipped around, missing entire paragraphs. I’d finish a passage feeling inadequate and confused.
I still had to make up my final exams from the previous semester. I met with the dean in his office, and he explained the process of taking the exams, when and where they would happen. I nodded my head. After we had wrapped up, almost as an afterthought, he asked, “So what do you have?”
“Mitral valve prolapse,” I said. It was the only diagnosis I had been given, and I didn’t want to trot out my mono lie to an authority figure.
“Really? My wife has that,” he said, clearly unimpressed.
“It makes my heart race,” I mumbled weakly as I left, cheeks burning with shame.
Getting through each day was becoming harder and harder. My heart raced, my fear spiked, and I had difficulty breathing (these were clearly panic attacks, though I still didn’t know it at the time) when I stood in a line or went to a movie theater. So I stopped standing in line. Stopped going to see movies. Even more nonsensical things started to scare me, too. I became terrified of contamination, of dirt, of being infected by some ferocious bacterium. Using something new—a bottle of shampoo, a toothbrush—took major effort. (Perhaps it had been tampered with, my paranoia whispered.) I’d panic for a good hour or so afterward, waiting for some dire physical reaction. Choosing a plate or glass at dinner turned into a ten-minute struggle. I’d check carefully for dried food, lipstick marks, chips. Even if I found a pristine cup, it still might not “feel right.” Sometimes the easiest thing was not to drink or eat at all.
New fears cropped up everywhere. I licked an envelope, then recalled reading that LSD was sometimes delivered via paper. Was there LSD on that envelope? I thought. I knew the thought was ridiculous, yet I couldn’t shake it. (I haven’t licked an envelope since. I heartily thank the inventor of self-sticking ones.) I didn’t know it, but I had turned a corner in my anxiety disorder. No lon- ger was anxiety merely rattling around my brain and body; I was now exhibiting multiple “avoidance behaviors.” I could no longer do the things I wanted to do when I wanted to do them.
Avoidance behaviors are associated with more serious, harder-to-treat illnesses. Avoidance fuels anxiety in a vicious cycle. By steering clear of the things I was afraid of, I never got a chance to learn that what I feared most—dying, going crazy—wouldn’t actually happen. The not knowing made me even more anxious.
I saw many more doctors in the ensuing months in search of a real diagnosis, my mother often making the hour-long drive to Ann Arbor to accompany me to assorted specialists. I also ended up at the ER several times—driven by my ever-patient college friend Susie—when my symptoms became particularly intense. I was convinced I was having a heart attack. My heart beat like an avant-garde jazz number, cacophonous and herky-jerky. It would speed up, slow down, skip. In the waiting room, Susie would try to make me laugh. She had asthma and knew what it was like to feel fragile and breathless. But after each visit, I was sent home without any answers. I think a doctor or nurse or two might have said something about avoiding stress.
I continued to have neurological issues, too: tunnel vision, vertigo, freaky depth perception. My hands and feet were often numb and tingly. A neurologist suspected multiple sclerosis, and I had an MRI of my brain. In the middle of it, I began having trouble breathing, and my heart beat so rapidly and loudly, it seemed to strain my ribs. Spots danced in front of my eyes, and I thought I would pass out. Crying, I had to be pulled out of the clanking, vibrating tube.
They did a CAT scan instead. The machine was less tomblike so I gave it a go. My mother held my hand, her body shrouded in a lead apron to protect her from the radiation bathing my brain. That scan was “inconclusive,” with some vague shadow possibly suggesting a brain tumor. After a completely sleepless night picturing my slow and awful death from brain cancer, back into the MRI machine I went, this time with several milligrams of Valium in my bloodstream. The MRI was fine. My brain, I was told, was normal.
My dad now says that the scariest thing about that time was that nobody had a clue as to what was wrong with me. With no definitive diagnosis, the expanse of possibilities and prognoses was terrifying.
I was tired all the time, a bone-deep torpor. For a few weeks, I was actually excited to think that I might have chronic fatigue syndrome, a disorder that had suddenly emerged in the zeitgeist. Sure, it didn’t sound like fun, there weren’t really any effective treatments, and some doctors didn’t believe it existed. But at least it had a name.
I like to think that none of this would happen now. Today there’s a much better chance that a doctor would properly diagnose me, that the school would refer me to the counseling center, or that I would look up my symptoms online and figure it out on my own. But all this happened in an era before large-scale mental health awareness campaigns, when there was greater stigma around psychiatric disorders. In the 1980s, organizations like the National Alliance on Mental Illness and the Anxiety Disorders Association of America (now the Anxiety and Depression Association of America) mailed out their newsletters in plain envelopes. Active Minds, a robust advocacy and support organization with chapters at more than four hundred college campuses, wasn’t founded until 2003. I didn’t know anyone who had been to a therapist or was taking psychotropic medication.
Anxiety disorders didn’t even exist as a category in the DSM until 1980, and it wasn’t until 1987 that Prozac was released in the United States. Then in 1989 the World Wide Web was born. The internet and Prozac would dramatically change the diagnosis and treatment of mental illness. Prozac, a new selective serotonin reuptake inhibitor, had far fewer and less onerous side effects than earlier medications. And the internet made a torrent of health information available to anyone with a keyboard and made it possible to anonymously join online support groups. In 1990, the Americans with Disabilities Act spurred colleges to open disability offices that now field requests for academic accommodations like quiet rooms for test taking and extra time for assignments for students with all types of disabilities, including psychiatric ones.
Without these new supports, I had to tough it out. I did my best to play the role of the free-spirited college student, even heading to Cancún for spring break with my roommates. Although I was barely hanging on to my student status, my parents were happy to fund the trip. Maybe doing something fun and frivolous would bring me back to health.
It was a disaster.
The days were all right. We spent them sunbathing and swimming. But at night my friends headed out to bars, and despite having been an enthusiastic binge drinker my freshman year, I hadn’t had a drink since I got sick. My body and brain already felt so haywire, I couldn’t imagine doing anything to make it more so. (My reaction was not typical. Many people with anxiety disorders drink to relax, a way of self-medicating.) But I wasn’t open about my abstinence. So there I was at Señor Frogs, a bar crammed with sunburned spring breakers, with a tequila shot in one hand, desperately trying to figure out how to surreptitiously ditch it. I lowered my hand and poured it down the leg of my chair, figuring it would blend in with the sticky sludge already on the floor.
I managed to dance a little that night, but later on, back at our hotel, I felt a pain in my neck, and my hands and feet went numb. What if I somehow had broken my neck? It was an absurd thought. I hadn’t fallen. I could walk. I knew my fear was ridiculous, but I couldn’t get logic to prevail. On some primitive, emotional level, I was convinced I must have fractured a vertebra. I called the front desk and asked for a doctor. They sent someone up. The doctor examined me and said I needed an X-ray. So I got into a taxi with him and rode through the chaotic Cancún streets to an all-night medical clinic. (Why this didn’t freak me out more than a completely hypothetical injury, I have no idea.)
Several X-rays revealed—surprise—that I was fine. For a second I was relieved. Then I started worrying about the thyroid cancer I would most likely get because of the radiation from the X-rays.
The next day I stayed at the hotel while my friends went to the beach. I furtively called my mother, begging her to buy me a plane ticket so I could come home early. As in, that day. She did. Then I left my friends a weird, rambling note, packed my bags, and left. I was back in my parents’ house by late evening.
As the weeks wore on, I became lonelier and increasingly hopeless. Upon waking, I’d have a moment of sunny optimism—this would be the day I’d feel normal again. But then I’d prop myself up on an elbow, and the heart palpitations and vertigo would return, and the fears would gnaw at me again.
I began to think it would be easier to not wake up at all. I didn’t want to die. I’d spent months terrified of dying. But I couldn’t see any other way to escape how I felt. The doctors couldn’t help me. Nor could my parents or friends. And I increasingly didn’t feel strong enough to continue to slog through the days and nights.
Finally, when these dark, desperate thoughts scared the hell out of me enough to share them, I called my father and asked him to come to Ann Arbor and take me to the hospital. This time he didn’t tell me to buck up or that things would be better if I got some sleep. He came and got me right away.
We parked the car in a high-rise parking garage. As we walked to the stairwell, I glanced over the railing to the ground far below and had a sudden, strong impulse to jump. To erase everything. But self-preservation and a slim hope won out. I grabbed my father’s hand.
At the hospital, we bypassed the regular ER and instead went to the psychiatric emergency room. It was a small, quiet waiting room, and I was the only patient in it. I remember giving someone, a psychiatrist or psychologist, a short synopsis of the last three months and my new despondency. The doctors considered admitting me but decided that I wasn’t at acute risk of harming myself. (I had no actual suicide plan.) What I needed, they said, was outpatient counseling. The therapist handed me a small card with the words psychiatric emergency services in all caps and my appointment time written in black pen. A twenty-four-hour emergency phone number was on the back.
I had several therapy sessions, but the treatment seemed irrelevant. The therapist asked me about my childhood and how I felt about my parents, but I wanted to know why my heart raced and why I was always terrified. Scratch that. I had stopped caring why. I only wanted it to stop.
For centuries, excessive anxiety was considered more of a moral failing than a medical problem. The stories of the ancient Greeks and Romans are filled with negative depictions of people who don’t cope well with fear. “The skin of the coward changes color all the time, he can’t get a grip on himself, he can’t sit still,” writes Homer in the Iliad, about an anxious man preparing for battle. “He squats and rocks, shifting his weight from foot to foot, his heart racing, pounding inside the fellow’s ribs, his teeth chattering—he dreads some grisly death.”
Specific phobias pop up in ancient writings, too. In the third century B.C., Andreas of Charystos described aerophobia, a fear of open spaces. He also defined the apex of all phobias: pantophobia, the fear of everything. In the Classical period, anxiety was considered a component of melancholia, a mental state marked by fear and despondency. The Hippocratic physicians of ancient Greece thought all illness was caused by an imbalance among the four “humors,” or bodily liquids: phlegm, blood, yellow bile, and black bile. Melancholy was thought to arise from a surfeit of black bile. Practitioners treated melancholy with everything from special diets and exercise to enemas and bloodletting. The belief in humors persisted for centuries.
Religion tackled anxiety, too. Faith in God was the cure. “It was as if a light of relief from all anxiety flooded into my heart. All the shadows of doubt were dispelled,” wrote Saint Augustine in the fourth century A.D. of his experience reading the teachings of Jesus Christ.
By the seventeenth century, the belief in humors as the cause of melancholia and its attendant anxiety was supplanted by the emerging concept of nervous disorders. Dysfunction in the brain and nerves was now thought to be the cause of a host of mental and physical symptoms. The nervous disorders were generally treated by neurologists and general physicians. In 1869, George Miller Beard, a neurologist from New York, coined the word neurasthenia, literally “tired nerves,” to describe a constellation of physical and emotional symptoms, including headaches, rashes, fatigue, insomnia, and phobias. This weakness of the nervous system was caused, Beard thought, by the fast-paced lifestyle of nineteenth-century America. In particular, he blamed the stress of technological advances like the telegraph and steam power, as well as the “mental activity of women.”
Anxious women who weren’t diagnosed with neurasthenia were likely to be slapped with the label of hysteria. The Greek physician Hippocrates named the disease in the fifth century B.C.; he believed it was caused by the uterus wandering around the body. In Victorian-era women, hysteria was characterized by nervousness, insomnia, “excessive” sexual desire (or the complete lack of it), and a panoply of psychosomatic symptoms from headaches to fainting. It was commonly treated with “pelvic massage,” with orgasm as the goal. (The development of the vibrator was heralded as a major treatment advance.)
Just two years after Beard introduced the idea of neurasthenia, Jacob Da Costa wrote about a peculiar syndrome he had seen while working as an army doctor during the Civil War. He relayed the story of WWH, a young Union soldier who had survived the bloody battle of Fredericksburg. After the battle, WWH “was seized with lancinating pains in the cardiac region, so intense that he was obliged to throw himself down upon the ground, and with palpitation. The symptoms frequently returned while on the march, were attended with dimness of vision and giddiness, and obliged him to fall out of his company and ride in the ambulance.” Da Costa saw similar symptoms in hundreds of other soldiers, too. The young men complained of chest pain and heart palpitation, difficulty sleeping, dizziness, shortness of breath, and upset stomachs. Finding the soldiers otherwise healthy, Da Costa chalked up their symptoms to an overactive heart. He called the illness “irritable heart syndrome.” Today we might call it panic disorder or post-traumatic stress disorder (PTSD). Da Costa treated irritable heart with various drugs, including opium, digitalis (derived from the foxglove plant and not dissimilar to medicines used to treat heart failure today), and lead acetate.
It’s impossible to talk about the history of anxiety without mentioning Sigmund Freud. In 1894, he wrote a groundbreaking paper with a cumbersome name, “The Justification for Detaching from Neurasthenia a Particular Syndrome: The Anxiety-Neurosis.” Out of the broad bucket of neurasthenia, Freud adroitly defined what we now know as the anxiety disorders. His descriptions of panic attacks (which he called anxiety attacks), generalized anxiety, phobias, and even obsessive-compulsive disorder are vivid and sound incredibly modern. Freud, then working as a neurologist in Vienna, grouped all these symptoms under the diagnosis of “anxiety neurosis,” a disorder that existed in the DSM until 1980.
Here’s Freud’s pitch-perfect characterization of generalized anxiety, or what he calls “anxious expectation”: “A woman who suffers from anxious expectation will imagine every time her husband coughs, when he has a cold, that he is going to have influenzal pneumonia, and will at once see his funeral in her mind’s eye. If when she is coming towards the house she sees two people standing by her front door, she cannot avoid the thought that one of her children has fallen out of the window; if the bell rings, then someone is bringing news of a death, and so on; whereas on all these occasions there is no particular ground for exaggerating a mere possibility.”
Freud goes off the rails, however, when he describes the cause of anxiety neurosis. It arises, he asserts, from an accumulation of sexual energy that is inadequately released. Abstinence, premature ejaculation, and coitus interruptus are primarily to blame for anxiety neurosis in both men and women, Freud says. In later works, he abandoned this theory. Eventually, he came to believe that anxiety arose from unconscious threats and conflicts. This view would hold sway for decades.
We’ve come a long way from bloodletting and opium. Advances in brain imaging and genetics are yielding new insights into the origins of anxiety disorders and what can go awry in the brain. Groundbreaking treatments are on the horizon. Pioneering scientists are experimenting with programs intended to prevent anxiety disorders in children as young as three.
We now know that the foundation of anxiety is the defense system that nearly every organism has to detect and react to threats.
That’s what trips off the racing heart, the shallow breathing, and the urge to escape—a response that makes clear sense if you’re being chased by a bear. The fight-or-flight response is critical to survival.
When that response is initiated, the adrenal glands release the hormone epinephrine. Blood pressure rises and senses become sharper. The hypothalamus, a part of the brain that acts as the control center for the autonomic nervous system, releases corticotropin-releasing hormone (CRH), which in turn tells the pituitary gland and the adrenal glands to release the stress hormones adrenocorticotropic hormone (ACTH) and cortisol. This activation of the so-called HPA axis works together with the sympathetic nervous system to keep the body on high alert for danger. (Some studies have found a range of HPA axis abnormalities in people with anxiety disorders.)
At the root of this threat detection system is the amygdala, an almond-shaped structure in the brain that has been called its fear center. Probably no one knows more about the amygdala than Joseph LeDoux, a sixty-six-year-old neuroscientist at New York University and a genuine rock star in the world of anxiety disorders. (He fronts a band called the Amygdaloids.) In the 1980s, he successfully mapped the neurocircuitry of the defensive mechanism in rats.
People had speculated before that the amygdala was involved with fear. In the 1930s, Heinrich Klüver, a German-American psychologist, and Paul Bucy, an American neurosurgeon, conducted a series of experiments on monkeys. They found that removing both temporal lobes (which include the amygdala) caused monkeys to exhibit bizarre behaviors, including eating anomalies, hypersexuality, and fearlessness. Later scientists noticed similar behavior in people who had sustained damage to the amygdala and nearby brain structures due to strokes, infections, or other ailments. This came to be known as Klüver-Bucy syndrome.
Building on this work, LeDoux used a common experimental model called fear conditioning to teach his rats to react to an audible tone. When rats are threatened, say by a predator or by an electrical shock to the feet, they freeze, their hair stands on end, and their blood pressure and heart rate shoot up. In his experiments, LeDoux played a tone to the rats and followed it with a shock. After several rounds of this, the animals began to freeze as soon as they heard the tone. They had been conditioned to perceive the sound itself as a threat.
LeDoux’s goal was to trace the path in the rats’ brains from tone to rodent freak-out. To do this, he damaged different regions of the brain and then fear-conditioned the animals, noting what effect the various lesions had on the rats’ behavior. He started with the auditory cortex, which directly receives sensory information, and worked downward to more primitive brain structures. Lesions to the auditory cortex didn’t do much; the rats still froze to the tone. Lesions to the caudate-putamen, which is involved in movement and learning, also didn’t affect freezing behavior. But when LeDoux made lesions in the amygdala, the rats stopped freezing. No amygdala, no threat response. The locus of fear, it seemed, had been found.
The tone takes one of two routes to the amygdala, LeDoux found. The more direct route, which he dubs the “low road,” sends the stimulus right from the sensory thalamus, which relays sensory and motor information, to the amygdala, a journey that takes 10 to 12 milliseconds. The “high road,” by contrast, where the stimulus travels from the sensory thalamus to the sensory cortex and then to the amygdala, takes about twice as long. The low road is a “quick and dirty processing system,” LeDoux says. It unleashes the defense system almost instantly, even before a threat is consciously registered. He gives an example of a prairie dog spotting a bobcat. “The sight or sound of the bobcat goes straight to your amygdala and out comes the freezing response. If you had to make a deliberate decision about what to do . . . you could get so bogged down in decision making that you might be eaten before you made a choice.”
The amygdala itself has different regions that serve different functions. The lateral nucleus, for example, is the part that receives the information. The central nucleus sends that information to the parts of the brain that control the physical responses associated with fear—freezing, respiration, heart rate, and the release of stress hormones. The hippocampus is the region that processes the context of the threat experience. This cage is where you got the shock, it tells the rat.
LeDoux then tackled the question of how animals can shake fear. Rats that have been fear-conditioned by the pairing of a tone with a shock can override that learning when the tone is repeatedly presented without the shock. Eventually, they cease to freeze. This process is called extinction. In experiments in the 1990s, LeDoux found that another part of the brain, the medial prefrontal cortex, is critical to extinction. It acts, he says, by dampening the amygdala’s action. “The medial prefrontal cortex is clamping down the amygdala, sort of like the brakes. The amygdala is the accelerator.” Stress, however, can undo extinction. “The brake comes off,” he says.
LeDoux says that in people, anxiety happens when thoughts interact with this threat-defense mechanism. While our body is going into fight-or-flight mode, our mind conjures catastrophe and dredges up memories of prior peril. The result, LeDoux says, is the conscious experience of anxiety.
On an October afternoon, I visited LeDoux at his office on the eleventh floor of the Center for Neural Science at NYU, a block from Washington Square Park in Greenwich Village. His office has a view of the Empire State Building. His desk is cluttered with books, unopened mail, and a baseball cap adorned with the image of a brain. LeDoux is the hippest-looking neuroscientist I’ve met, sporting dark jeans, a checked shirt, and a gray-blond soul patch. He speaks slowly, with a bit of a Louisiana drawl; he grew up in Eunice, the son of a butcher. (The part of the cow that most intrigued him? “The slimy, wiggly, wrinkled brain,” of course.) He played in rock bands throughout high school and college, including one presciently named Cerebellum and the Medullas.
LeDoux takes me on a tour of his lab. We stop in a room lined with shelves, each piled with stacks of slim white boxes. “Here we have thirty years of rat brains,” he says, gesturing with an arm. He takes a box down, opening it to reveal dozens of slides, each with a thin slice of brain stained a brilliant cerulean blue.
In another room, we see an apparatus designed for rodent neurosurgery, a silver bracelike contraption with various arms, knobs, and grooves indicating measurements. Brain lesions, he tells me, are usually made with an electric current. The rats themselves (two hundred or so) are out of sight, in a room that is off-limits to visitors. (After several more interviews with scientists who work with animals, I discover that it’s standard policy not to let visitors see their subjects. Scientists are afraid of becoming the targets of animal rights activists.)
At one point, LeDoux confesses that he has a phobia of snakes. He traces the fear back to a traumatic childhood experience. “I remember as a kid being taken craw fishing on the bank of a bayou,” he recalls. “It seemed like there were thousands of slithering black snakes everywhere. It was so disgusting.” After that, he did everything he could to avoid them—a challenge given that he was an avid water-skier. “I would never get in the water ever. I’d be able to jump off the pier as the rope tightened and ski and then ski back up onto the landing.”
After I visited LeDoux, I watched a video of one of his band’s songs, “Fearing,” based on a poem by Emily Dickinson. The Amygdaloids, which LeDoux formed with other NYU scientists, write and perform songs about emotions and the mind. In the video, LeDoux appears in the dark, ominous attic of a ruined house, wearing opaque black sunglasses and singing these words:
But recollecting is not forgetting It’s vivid rehearsal of pain
It reminds me of that day It keeps fear in my brain
Studies have found that the amygdala and prefrontal cortex are involved in fear conditioning and extinction in people, too. Our fear response can be measured in a variety of ways, including skin conductance (a method of measuring sweating using electrodes) and fear-potentiated startle, an eyeblink reflex. Tiny sensors are placed under the eye to record the magnitude and intensity of the eye-blink. Researchers have found that people with anxiety disorders have a larger startle response than healthy people to conditioned stimuli—the colored light or tone that precedes an unconditioned stimulus, like an electric shock. And during extinction, the startle response tends to remain elevated. Simply put, anxious people catch fear easily and have a hard time letting go of it, even when there’s mounting evidence they’re safe. The amygdalae of anxious subjects also tend to be hyperactive even when they are not facing a potential threat. It is as if the anxious brain were always scanning the horizon for danger.
Anxious people aren’t just constantly on guard; they actually see more peril in the world. If a situation is ambiguous, they are more likely to perceive it as negative or threatening. That’s why when I have a headache, I think of brain tumors. And if my husband, Sean, is being quiet, I don’t consider that he might be tired—I think he’s mad at me. (Okay. Sometimes he is.) Scientists call this “attention bias to threat,” and they think that, like lightning-quick fear conditioning, the bias is linked to a hyperactive amygdala and dampened prefrontal cortex activity.
Scientists often use the dot probe task to measure attention bias. It generally works like this: Subjects are shown photos of two human faces side by side, one angry or fearful, the other neutral. The faces disappear, and a small dot or cross (the probe) is shown in place of one of the faces. Subjects need to respond as quickly as possible (often by pushing a button) to the probe. A subject is considered to have an attention bias toward threat if they respond more quickly to the probes that replace the threatening faces versus the neutral ones. In many studies, those with anxiety disorders are shown to have this bias. This is true even when the faces are flashed so quickly that they can’t be processed consciously. Non-anxious people, however, don’t show this bias.
Besides being constantly ready for crisis, anxious people have a hard time with uncertainty. What if? What if? What if? is the endless refrain of the anxious mind. Uncertainty far too easily morphs into inescapable catastrophe. Scientists call this “intolerance of uncertainty,” and it actually makes parts of the brain light up on a functional magnetic resonance imaging (fMRI) scan. Researchers at the University of California, San Diego, found that intolerance of uncertainty was linked to activity in the insula, part of the cerebral cortex that plays a role in emotion processing and body awareness. In a small experiment published in 2008, the scientists gave fourteen young adults a task called the Wall of Faces. The study subjects saw a series of pictures of thirty-two faces against a black background. Some faces had ambiguous expressions. Others were clearly happy or sad. The subjects who scored higher on a measure of intolerance of uncertainty had greater activity in the insula when they saw more faces with ambiguous expressions. Other studies have found that people with PTSD, social phobia, and GAD have increased activity in the insula when they anticipate seeing negative pictures.
Interestingly, scientists are finding that fear and anxiety may originate in different parts of the brain. The amygdala, it seems, is more closely tied to fear. It generates the raw, immediate response to an imminent threat. Anxiety, however—longer-lasting, amorphous uneasiness—may be rooted in an adjacent structure with an ungainly name: the bed nucleus of the stria terminalis, or BNST. Michael Davis, a neuroscientist who recently retired from Emory University, has been exploring the BNST for decades. During the 1980s, he and LeDoux were in something of a race to map the neurocircuitry of fear conditioning in rats. At that time, he noticed that the BNST was connected to the same structures as the amygdala: the parts of the brain stem that control blood pressure, heart rate, and freezing. Why, he wondered, would there be a second area of the brain that appeared to serve the same function as the amygdala? Nature didn’t usually duplicate itself like that.
While LeDoux was measuring fear conditioning by looking at freezing behavior, Davis began studying the startle reflex—specifically, fear-potentiated startle. Rats have a whole-body response when startled: Electrical activity can be detected in the rodent’s neck muscles 5 milliseconds after a loud sound. In Davis’s lab, first at Yale and then at Emory, rats were fear-conditioned by being exposed to a light followed by a shock. Then researchers elicited the startle response with a series of loud noises. Sometimes sounds followed the light that predicted the shock; other times there was no light, only sound. Not surprisingly, the startle response to the loud noise was bigger when the rats were also exposed to the light. This amplified response is known as fear-potentiated startle.
It was during these experiments that Davis stumbled on a potential role of the BNST. Over the years, he and his colleagues tested a host of compounds to see how they worked on fear-potentiated startle and, by extension, anxiety disorders. But there is a problem with fear conditioning. It involves learning: The rats have to learn that the light precedes the shock. So if a substance reduces fear-potentiated startle, you don’t know whether it is because the substance is actually reducing the fear response or whether it is simply causing amnesia. It’s possible, in other words, that the substance caused the rats to forget the link between the light and the shock. With that in mind, the lab searched for a way to elicit an amplified startle without learning. Davis’s colleague David Walker discovered that exposing rats to bright light for twenty minutes also enhanced startle. No learning was required. (Rats naturally avoid bright light and open spaces, which to a rodent signal danger.) “When the bright light is on for a long time, you don’t know when something bad is going to happen,” Davis says. Davis and Walker assumed that the amygdala was key for this extended fear conditioning, but it turned out that inactivating the amygdala didn’t block the increase in startle after the twenty minutes of light. Deactivating the BNST, however, did.
The amygdala, it seemed, controlled the lightning-quick response. The BNST was switched on by longer-lasting apprehension—the expectation of pain without any certainty as to when it would occur. Scientists aren’t certain when the shift from amygdala to BNST activity occurs in the face of danger, but it seems to be somewhere between four seconds and a minute.
In the 1990s, Christian Grillon, who was collaborating with Davis at Yale, began doing similar experiments in people. Humans have a whole-body startle reflex, too, but the eyeblink part of it is the most consistent and easiest to measure. Sustained uncertainty, Grillon found, makes people jumpy for a sustained period of time. In one critical experiment, Grillon and Davis recruited fifty-eight Yale students. Most of the subjects underwent repeated rounds where they saw a blue light and received a shock to the left wrist. The students were divided into three groups. In the first group, the shock was predictably delivered a few seconds after the light. In the second, shocks were delivered randomly, with no relation to when the light was shown. (A third group saw the blue light but didn’t receive any shocks.) Startle was elicited with a loud sound. Four days later the students underwent the same experiment. After being fear-conditioned, the first group startled more after hearing the sound—despite the four-day break. That wasn’t surprising. But the second group had a bigger so-called baseline startle, the startle scientists elicited even before the subjects began this round of the experiment. The unpredictability of the shocks had made them on guard and ready to jump as soon as they were back in the same environment.
“In a way, anxiety is the opposite of fear. Fear is about something that is in front of you that is predictable and imminent. Anxiety is the opposite. It is worrying about something that is in the future that may or may not happen,” Grillon says.
Based on the animal data, Grillon is pretty sure that the BNST is behind uncertainty-driven apprehension. One challenge for researchers is that the structure is small and hard to see on an fMRI scan. Grillon is excited about a powerful new scanner that his lab, now at NIMH, has procured. Using the new equipment, Grillon and colleagues have recently mapped the human BNST and its connections to other brain structures. It is a step toward understanding the area and its role in human anxiety. “Where is the anxious thought of a shock?” he says. “It may not be at the same place as the anxious thought of my kid not going to college or losing my job or fear of God.” Perhaps the BNST will prove to be a fruitful target for new drugs or psychotherapies.
Neuroscientists caution that this kind of imaging work is still in its infancy. Other brain regions are being explored, too, and it’s unlikely that there’s any single route to an anxiety disorder. Also, developing anxiety is likely a dynamic process, with anxious thoughts and behaviors reinforcing the underlying neurobiology. As researchers Dan Grupe and Jack Nitschke write, “A patient with an anxiety disorder probably builds up neural pathways of anxiety just as a concert pianist strengthens neural pathways of musicianship—though hours of daily practice.”
I wonder when things started to go awry in my brain. When did my amygdala go into overdrive? When did my prefrontal cortex cease to keep my body’s fight-or-flight response in check? Neuroscientists are starting to see anxiety disorders as disorders of brain development that begin in childhood. And as with other neurological diseases—such as Alzheimer’s disease with its telltale plaques and tangles—the brain likely shows signs of the illness long before the first panic attack or paralyzing bout of worry. The trick will be to locate those signs.
Reprinted with permission from On Edge: A Journey Through Anxiety © 2017 by Andrea Petersen. Published by Crown, an imprint of Penguin Random House LLC.
Author Photo: © marcgoldbergphotography.com