My Age of Anxiety: Fear, Hope, Dread, and the Search for Peace of Mind

by Scott Stossel

  Cognitive-behavioral therapists argue that social anxiety disorder is a problem of disordered logic, or faulty thinking. If we can correct our false beliefs and maladaptive attitudes—our “cognitions” or “schema,” as they say—we can cure the anxiety. Epictetus, a Greek slave and Stoic philosopher living in Rome in the first century A.D., was the prototype of the cognitive-behavioral therapist. His essay “On Anxiety,” in addition to being one of the earliest contributions to the literature of self-help, seems to be the first attempt to connect performance anxiety to what we would today call issues of self-esteem.

  “When I see anyone anxious, I say, ‘what does this man want?’ ” Epictetus writes. “Unless he wanted something or other not in his own power, how could he still be anxious? A musician, for instance, feels no anxiety while he is singing by himself; but when he appears upon the stage he does, even if his voice be ever so good, or he plays ever so well. For what he wishes is not only to sing well but likewise to gain applause. But this is not in his own power. In short, where his skill lies, there is his courage.” In other words, you can’t ultimately control whether the audience applauds or not, so what use is there in worrying about it? For Epictetus, anxiety was a disorder of desire and emotion to be overcome by logic. If you can train your mind to perform the same way whether you’re alone or being observed, you’ll not get derailed by stage fright.

  Two influential twentieth-century psychotherapists, Albert Ellis and Aaron Beck, the founders of rational emotive behavioral therapy (REBT) and cognitive-behavioral therapy (CBT) respectively, each argued that the treatment of social anxiety boils down to overcoming fear of disapproval. To overcome social anxiety, they say, you need to inure yourself to needless shame.

  To this end, when Dr. M., a practitioner in the CBT mold, was treating me at Boston University’s Center for Anxiety and Related Disorders, she aimed, as a therapeutic exercise, to intentionally embarrass me. She would escort me to the university bookstore next door to the Center and lurk discreetly nearby while I asked purposely dumb questions of the clerks or told them I needed a bathroom because I was going to throw up. I found this excruciatingly awkward and embarrassing (which was the whole point), and it didn’t really help. But this is standard exposure therapy for social phobics; a growing body of controlled studies support its effectiveness. The idea, in part, is to demonstrate to the patient that revealing imperfection, or doing something stupid, need not mean the end of the world or the unraveling of the self.i

  Therapists of a more psychoanalytic bent tend to focus on the social phobic’s firmly held view of himself as a deeply flawed or disgusting human being devoid of intrinsic value. Kathryn Zerbe, a psychiatrist in Portland, Oregon, has written that the social phobic’s biggest fear is that other people will perceive his true—and inadequate—self. For the social phobic, any kind of performance—musical, sporting, public speaking—can be terrifying because failure will reveal the weakness and inadequacy within. This in turn means constantly projecting an image that feels false—an image of confidence, competence, even perfection. Dr. W. calls this impression management, and he observes that while it can be a symptom of social anxiety, it’s an even bigger cause. Once you’ve invested in the perpetuation of a public image that feels untrue to your core self, you feel always in danger of being exposed as a fraud: one mistake, one revelation of anxiety or weakness, and the façade of competence and accomplishment is exposed for what it is—an artificial persona designed to hide the vulnerable self that lies within. Thus the stakes for any given performance become excruciatingly high: success means preserving the perception of value and esteem; failure means exposure of the shameful self one is trying so hard to hide. Impression management is exhausting and stressful—you live in constant fear that, as Dr. W. puts it, the house of cards that is your projected self will come crashing down around you.

  A stammering man is never a worthless one. Physiology can tell you why. It is an excess of sensibility to the presence of his fellow creature, that makes him stammer.

  —THOMAS CARLYLE, FROM A LETTER TO RALPH WALDO EMERSON (NOVEMBER 17, 1843)

  As early as 1901, Paul Hartenberg anticipated one of the key findings of modern research on social phobics. While social phobics are unusually attentive to other people’s feelings, he wrote in Les timides et la timidité, scrutinizing the verbal intonations, facial expressions, and body language of their interlocutors for signs of how people are reacting to them, they are also unduly confident about the conclusions they draw based on those observations—and specifically about the negative conclusions they draw. That is, social phobics are better at picking up on subtle social cues than other people are—but they tend to overinterpret anything that could be construed as a negative reaction. Since they are predisposed to believe that people won’t like them or will react badly to them (they tend to have obsessive thoughts like I’m boring or I’m going to make a fool of myself by saying something stupid), they’re always seeking confirmation of this belief by interpreting, say, a suppressed yawn or a slight twitch of the mouth as disapproval. “Highly anxious people read facial expressions faster than less anxious people,” says R. Chris Fraley, a professor of psychology at the University of Illinois, Urbana-Champaign, “but they are also more likely to misread them.” Alexander Bystritsky, the director of the Anxiety Disorders Program at UCLA, says that while anxious people do have “a sensitive emotional barometer” that allows them to detect subtle changes in emotion, “this barometer can cause them to read too much into an expression.”

  Social phobics are, in at least this one respect, gifted—faster and better at picking up behavioral cues from other people, with social antennae so sensitive that they receive transmissions that “normal” people can’t. Put the other way around, the perception of healthy people may be adaptively blunted; they may not pick up on the negative cues—that yawn of boredom or twitch of disdain—that are in fact present.

  Arne Öhman, a Swedish neuroscientist at Uppsala University who has written extensively about the evolutionary biology of phobic behavior, believes that oversensitive emotional barometers are genetically hardwired into social phobics, causing them to be acutely aware of social status in interpersonal interactions. Consider the case of Ned, a fifty-six-year-old dentist who had been in practice for three decades. To outward appearances, Ned was successful. But when he showed up in a psychiatrist’s office, Ned said his career had been destroyed by his fear of “doing something foolish.”j Anxiety about doing something wrong that will lead to social humiliation is quite common. But Ned’s fear was interestingly specific: his performance anxiety was only acute when working on patients whom he perceived—based on the kind of insurance they carried—to have social status greater than he did. While he worked on Medicaid patients or those without insurance, his anxiety was negligible. But while treating patients with fancy insurance indicative of a high-status job, Ned was terrified that his hands would shake visibly or that he would sweat excessively, revealing his anxiety to his patients, who he believed were immune to anxiety and (as he put it) “completely at home in the world” and therefore prone to judge and even to ridicule him for his weakness.

  Symptoms of this kind of status-based social anxiety—and particularly the fear of being exposed as “weak” relative to one’s peers—appear regularly in the psychiatric literature going back a century. And lots of evidence supports Öhman’s proposition that people like Ned have an awareness of social status, and of social slights, that is too finely calibrated. A National Institute of Mental Health study published in 2008 found that the brains of people with generalized social phobia responded differently to criticism than the brains of other people. When social phobics and healthy control subjects read neutral comments about themselves, their brain activity looked the same. But when the two groups read negative comments about themselves, those diagnosed with social anxiety disorder had markedly increased blood flow to the amygdala and the medial prefrontal cortex—two parts of the brain asso
ciated with anxiety and the stress response. The brains of social phobics appear physiologically primed to be hyperresponsive to negative comments.

  This finding aligns with the many studies showing that social phobics demonstrate a more hyperreactive amygdala response to negative facial expressions. When social phobics see faces that appear angry, frightened, or disapproving, the neurons in their amygdalae fire faster and more intensively than those of healthy control subjects. As the NIMH researchers put it, “Generalized-social-phobia-related dysfunction may at least partly reflect a negative attitude toward the self, particularly in response to social stimuli, as instantiated in the medial prefrontal cortex.” What this means, in plain English, is that shame and low self-esteem have a biological address: they reside, evidently, in the interconnections between the amygdala and the medial prefrontal cortex.

  There’s now a whole subgenre of fMRI studies that demonstrate that the amygdala reacts vividly to social stimuli not perceived by the conscious mind. When individuals are placed in an fMRI machine and shown images of faces displaying fear or anger, their amygdalae flare with activity. This is not surprising: we know that the amygdala is the seat of the fear response. It’s also not surprising that neurons in the amygdalae of diagnosed social phobics tend to fire more frequently and intensively than those of other people in response to frightened or angry faces. What is surprising is that all people—social phobics and healthy control subjects alike—show a marked amygdala response to photos they are not consciously aware of seeing. That is, if you watch a slide show of innocuous images of flowers interspersed with pictures of scared or angry faces flashed so quickly you are not consciously aware of seeing them, your amygdala will flare in response to the emotional faces—even though you don’t know you saw them. Ask the test subjects in these experiments whether they saw the scared or angry faces and they will say they did not; the images flashed by too quickly for the conscious brain to register them. But the amygdala, operating with lightning-fast acuity beneath the level of conscious awareness, perceives the distressing faces and flares in the fMRI. Some subjects report feeling anxiety at these moments—but they can’t identify its source. This would seem to be neuroscientific evidence that Freud was right about the existence of the unconscious: the brain reacts powerfully to stimuli that we are not explicitly aware of.

  Hundreds of studies reveal an unconscious neurobiological stress response to social stimuli. To cite just one, a 2008 study published in the Journal of Cognitive Neuroscience found that people shown images of emotional faces for thirty milliseconds—faster than the conscious mind can perceive them—demonstrated “marked” brain responses. (The socially anxious had the strongest brain responses.) Fascinatingly, when test subjects were asked to judge whether images of surprised faces were positive or negative, their judgments were powerfully affected by the subliminal images flashed just beforehand: when the image of the surprised face was preceded by a subliminal image of an angry or scared face, subjects were much more likely to say that the surprised face they were looking at was negative, expressing fear or anger; when the image of the same surprised face was preceded by a flashed happy face, the test subjects were more likely to say the same surprised face was expressing joy. As one of the researchers put it, “Unconsciously perceived signals of threat … bubble up and unwittingly influence social judgments.”

  What’s the point of having such finely tuned social perception equipment? Why do our brains make judgments we’re not consciously aware of?

  One theory is that such “quick social judging” historically enhanced our odds of survival. In a baboon troop or a tribe of hunter-gatherers, you don’t want to make social impressions that will invite attacks from your peers or cause you to be banished. For baboons, being kicked out of the troop is often tantamount to death: a lone monkey found by another group is likely to be set upon and killed. To be an early human banished from the tribe was to be both denied access to communal food supplies and rendered vulnerable to animal predators. Thus a certain social sensitivity—a keen attunement to what group norms demand, an awareness of social threats, a sense of how to signal the deference that will keep you from getting pummeled by a higher-status member of your troop or banished from your tribe—is adaptive. (This is where blushing can be helpful as an automatic signal of deference to others.) Being aware of how your social behavior—your “performance”—is being perceived by others can help you stay alive. Calling attention to yourself and being judged negatively is always risky: you’re in danger of having your status challenged or of being kicked out of the tribe for making a bad impression.k

  Murray Stein, a psychiatrist at the University of California, San Diego, has observed that social submissiveness in baboons and other primates has striking parallels with social phobia in humans. The stress that social phobics feel in anticipation of normal human interactions, and especially of public performances, Stein says, produces the same hypercortisolism—an elevation in the levels of stress hormones and an activation of the hypothalamic-pituitary-adrenal (HPA) axis—that subordinate status does in baboons. Hypercortisolism, in turn, kindles the amygdala, which has the effect of both intensifying anxiety in the moment and tying social interactions more deeply to a stress response in the future.l

  Stein’s research builds on the work of Robert Sapolsky, a neurobiologist at Stanford who has done fascinating research showing a direct correlation between a baboon’s status in his troop and the quantity of stress hormones in his blood. Baboon populations have strictly ordered male hierarchies: there is the alpha male, who is usually the biggest and strongest and has the most access to food and females and is deferred to by all the other male monkeys, then there is the second-highest-ranking monkey, who is deferred to by all the other monkeys except for the alpha male—and so on, all the way down to the lowest-ranking male at the bottom of the social ladder. If a fight breaks out between two baboons and the higher-ranking one wins, the social order is preserved; if the lower-ranking one wins, there is a re-sorting, with the victorious baboon moving up the social ladder. Through careful observation, Sapolsky’s team has been able to determine the social hierarchies of particular baboon populations. Using blood tests from these primates, Sapolsky has found that testosterone levels correlate directly with social standing: the higher ranking the baboon, the more testosterone he’ll have. Moreover, when a baboon rises in the social hierarchy, the amount of testosterone he produces increases; when a baboon declines in status, his testosterone levels fall. (The causation seems to work in both directions: testosterone produces dominance, and dominance produces testosterone.)

  But just as higher rank is associated with testosterone, lower rank is associated with stress hormones like cortisol: the lower a baboon’s standing in the hierarchy, the greater the concentration of stress hormones in his blood. A subordinate male not only has to work harder to procure food and access to females but also has to tread carefully so as not to get beaten up by a dominant animal. It’s unclear whether high levels of cortisol cause a baboon to become submissive or whether the stress of being low status causes cortisol levels to rise. Most likely it’s both—the physical and psychological pressures of being a subordinate baboon lead to elevated levels of stress hormones, which produce more anxiety, which produces more stress hormones, which produce more submissiveness and general ill health.

  While findings from animal studies can be applied to our understanding of human nature only indirectly (we can reason in ways other primates cannot), Ned’s anxious response to practicing dentistry on “higher-status” patients may well have its roots in primitive concerns about overstepping bounds in the status hierarchy. Low-ranking baboons and orangutans that fail to lower their eyes—to signal their submissiveness—in the presence of higher-ranking ones risk inviting attack. A baboon’s status in the social hierarchy—and, beyond that, his skillfulness at behaving in accord with his rank, whatever that may be—does a lot to determine his physical well-being.m

  Both
low-ranking baboons and humans with social anxiety disorder resort easily to submissive behavior. Like low-ranking animals, people with the general subtype of social anxiety disorder tend to look downward, avoid eye contact, blush, and engage in behaviors that advertise their submissiveness, eagerly seeking to please their peers and superiors and actively deferring to others to avoid conflict. For low-ranking baboons, this behavior is a protective adaptation. It can be adaptive in humans, too—but in social phobics it is more often self-defeating.

  Low-status monkeys and socially phobic humans also tend to have notable irregularities in the processing of certain neurotransmitters. Studies have found that monkeys with enhanced serotonergic function (in essence, higher levels of serotonin in their brain synapses) tend to be more dominant, more friendly, and more likely than those with normal serotonin levels to bond with their peers. In contrast, monkeys with unusually low serotonin levels are more likely to display avoidant behavior: they keep to themselves and avoid social interactions. Recent studies of humans have found altered serotonin function in certain brain regions of patients diagnosed with social anxiety disorder. These findings help explain why selective serotonin reuptake inhibitors like Prozac and Paxil can be effective in treating social anxiety. (Studies have also found that when nonanxious, nondepressed people take SSRIs, they become more friendly.)

  Dopamine has also been implicated in shaping social behavior. When monkeys who have been housed alone are taken from their cages and placed into a group setting, the monkeys that rise the highest in the dominance hierarchy tend to have more dopamine in their brains—which is interesting in light of studies finding that people diagnosed with social anxiety disorder tend to have lower-than-average dopamine levels. Some studies have found striking correlations between social anxiety and Parkinson’s disease, a neurological condition associated with a deficit of dopamine in the brain. One 2008 study found that half of Parkinson’s patients scored high enough on the Liebowitz Social Anxiety Scale to be diagnosed with social phobia. Multiple recent studies have found “altered dopamine binding potential” in the brains of the socially anxious.n Murray Stein, among others, has hypothesized that the awkwardness and interpersonal clumsiness of social phobics are directly connected to problems in dopamine functioning; the dopamine “reinforcement/reward” pathways that help guide correct social behavior in healthy people may somehow be askew in the brains of social phobics.