Dr. W. and I talk about the way academic conferences on anxiety have been placing increasing emphasis on how the psychological traits of resilience and acceptance can be crucial bulwarks against both anxiety and depression; much of the cutting-edge research and treatment focuses in particular on the importance of cultivating resilience.
“Yes!” Dr. W. says. “We need to work on making you more resilient.”
When I tell him what I’ve learned about the serotonin transporter gene, and about how people with certain genotypes are far more likely to live anxious, unhappy, and unresilient lives, Dr. W. reminds me how much he dislikes the modern emphasis on the genetics and neurobiology of mental illness because it hardens the notion that the mind is a fixed and immutable structure, when in fact it can change throughout a lifetime.
“I know,” I say. I’ve read about the recent findings on neuroplasticity—about the way the human brain can keep forming new neuronal connections into old age. I tell him that I understand the importance of resilience in combating anxiety. But how, I ask, do I gain that quality?
“You’re already more resilient than you know,” he said.
* * *
* In 2011, Giovanni Salum, a Brazilian psychiatrist, released the results of one of the largest-scale studies of the heritability of anxiety disorders ever conducted. Surveying data on ten thousand people, Salum found that a child who has no relatives with an anxiety disorder has only a one-in-ten chance of developing one himself. If that same child has one relative with an anxiety disorder in his family, his odds of developing an anxiety disorder rise to three in ten. And if a large majority of members have an anxiety disorder, the child’s odds rise to eight in ten.
† This squares with what studies have found about the relatively fixed percentage of soldiers who are especially prone to break down when exposed to combat stress.
‡ To be sure, genetic researchers grant that anxious emotion, or a talent for dancing, must have multiple genetic (and environmental) causes. But the trend toward reducing emotions to their underlying neurochemical correlates, and to the genes that underwrote them, can seem inexorable.
§ Let me stipulate here that I am not a genetic scientist, and that I am oversimplifying a vast and complex body of research. For an easy-to-understand book about psychiatric genetics by an expert, I recommend The Other Side of Normal: How Biology Is Providing the Clues to Unlock the Secrets of Normal and Abnormal Behavior by Jordan Smoller.
‖ Many studies have supported the connection between the met/met variant of the COMT gene and unusually high levels of anxiety—though, interestingly, mainly in women. One study, conducted by investigators at the National Institute on Alcohol Abuse and Alcoholism, looked at two disparate groups of women—Caucasians from suburban Maryland and Plains Indians from rural Oklahoma—and found that in both populations women with the met/met variant reported much higher levels of anxiety than did women with the other variants. (The met/met variant also correlated with having only a quarter to a third of the typical quantity of the catechol-O-methyltranferase enzyme in the brain.) When women with the met/met variant were placed in an EEG machine, they exhibited a “low-voltage alpha brain-wave pattern,” which has been found to be associated with both anxiety disorders and alcoholism. In short, the study revealed a connection not only between the gene and enzyme levels, and between enzyme levels and brain activity, but also between brain activity and subjectively experienced levels of anxiety. Another study, conducted among both German and American populations in 2009, found that people with the met/met version of the gene exhibited higher-than-average physiological startle responses when shown a series of unpleasant pictures and were, according to standard personality tests, higher in general anxiety.
a These different evolutionary strategies seem to apply even in fish. Lee Dugatkin is a professor of biology at the University of Louisville who studies guppy behavior. Some guppies are bold; some are timid. Bold male guppies, Dugatkin observes, are more likely than timid male guppies to attract females to mate with. But the bold guppies, in their brazenness, are also more likely to swim near predators and get eaten. The timid guppies thus tend to live longer—and therefore to prolong the time during which they have opportunities to mate. Both types of guppies, the bold and the timid, represent a viable evolutionary strategy: Be bold and mate more but be more likely to die young—or be timid, mate less, and be more likely to live longer. There’s an adaptive value to being a bold guppy—but there’s also an adaptive value to being a timid one. It’s not hard to see the same evolutionary strategies at work among human populations. Some people live boldly, mate promiscuously, take risks, and tend to die young (think of the bold and tragic Kennedy clan); others live timidly, mate less, are risk averse, and tend to be less likely to die prematurely in accidents.
b Not every study has borne out the initial hypothesis that having a short version of the SERT allele makes you more susceptible to anxiety or depression. For instance, while epidemiological studies consistently find that rates of clinical anxiety and depression are lower in Asia than in Europe and North America, genetic testing has found that the prevalence of the s/s SERT allele is markedly higher among East Asian populations than among Western ones—which raises intriguing questions about how culture and social structure interact with genetics to affect the rates and intensity of anxiety among individuals in different societies.
c I asked my brother-in-law, a medical student and former biochemistry major, to take the raw genomic data that 23andMe provided and plug it into open-source genome databases to figure out what variant I have of the COMT gene. And though 23andMe does not currently provide clients with even the raw data on SERT variants, I prevailed upon some neuroscientist friends of mine to test me for it, on the condition that I not reveal their names since they receive federal grant funding and are not supposed to perform the test on anyone who is not officially part of a study.
d Interestingly, different phobias seem to trigger different parts of our neurocircuitry and to have different genetic roots. This is true to my own experience. As phobic as I am of flying and of heights and of vomiting and of cheese, I have no inordinate fear of snakes or rats or other animals; in fact, the animal kingdom may be one of the few areas where I’m actually less fearful than I ought to be. I have been badly bitten by a dog (which resulted in a trip to the emergency room when I was eight), by a snake (I once had a pet bull snake named Kim), and was once viciously attacked by, of all things, a kangaroo, which I’d mistakenly thought wanted a hug. (Long story.) I’d be much happier covered in a pile of (nonpoisonous) snakes and rats than flying through even the mildest turbulence.
e I should say here that perhaps because both my children have received early psychotherapy for their anxiety—to help them take control of what we call their “worry brains”—they both seem to be less anxious than they were a few years ago. Maren is still emetophobic, but she’s developed techniques for managing her fear, and she’s less anxious—and in fact quite self-confident—in most areas of her life. Nathaniel remains an imaginative catastrophizer, but his separation anxiety has become a little less severe. Temperamentally, they will probably remain prone to anxiety for their entire lives—but my hope is that they will be able to manage their fear, and even harness it in productive ways, in such a fashion that they will be able to thrive despite it.
f From a 1948 “diagnostic impressions” report: “He was overconscientious and overly self-critical, a person of high energy and work output, but a procrastinator.”
g From a report by his principal psychiatrist during his sojourn at McLean in May 1953: “It has been noted that he is developing an increasing hand-washing ritual. This has not been taken up in psychotherapy sessions since I feel it is important not to give him the impression that we are unduly critical of his personal activities.”
h From a handwritten physician’s note from the spring of 1948: “The patient has had an irritable large bowel … for years.” From another note some y
ears later: “Patient chronically worried about his bowels.”
i “Patient is very pleasant,” a nurse noted, observing Chester as he ambled around the ward during his second stint at McLean. “Gives the impression that nothing could upset him.”
j “He has also been quite a burden on his wife.” That’s from a psychiatrist’s notes during Chester’s third stay at McLean.
k “Mr. Hanford remarked that he had once visited one of his students in the [neuropsychiatric] ward at the Mass General and was quite impressed with the way the doors, etc., were kept locked,” his psychiatrist noted. “He said, ‘I never expected that I would find myself under the same circumstances; I always felt that I could take care of myself.’ ”
l He took methyltestosterone, an anabolic steroid given to him by injection, which at midcentury was considered a standard treatment for depression in men; Oreton, a synthetic testosterone that today seems to be prescribed only to boys suffering delayed puberty; chloral hydrate, the old-fashioned nineteenth-century ethanol-chlorine derivative that remained popular as a sedative and sleep aid until the arrival of benzodiazepines; and Donatal, a potent combination of phenobarbital (the barbiturate in Luminal) and hyoscyamine and atropine (which are both plant derivatives from the deadly nightshade family), which was prescribed for his agitated bowels and nerves.
m As his principal psychiatrist writes, “In talking with him I have laid a good deal of stress on his previous value as an individual in his work for the college. I have led him to take more satisfaction in his executive and teaching accomplishments. Thus it has been possible to somewhat relax his self-critical attitude.”
n On April 29, 1949, Chester was returned to the care of his wife and his personal physician, Dr. Lee, his file noting, “There are some evidences of tension and depression still present, but it has been possible for him to be discharged home as improved.”
o “His colleagues recently have given him support during his illness these past five years, and actually he is not carrying the workload he should, and he knows it,” one psychiatrist noted. “He has also been quite a burden on his wife who has found it necessary to prepare some of his lectures for him.”
p During this same period, Dr. Tillotson also administered electroshock treatment to the poet Sylvia Plath, who recorded the experience in her novel, The Bell Jar.
CHAPTER 10
Ages of Anxiety
The philosophic study of the several branches of sociology, politics, charities, history, education, shall never be even in the direction of scientific precision or completeness until it shall have absorbed some, at least, of the suggestions of this problem of American nervousness.
—GEORGE MILLER BEARD, American Nervousness (1881)
In April 1869, a young doctor in New York named George Miller Beard, writing in the Boston Medical and Surgical Journal, coined a term for what he believed to be a new and distinctively American affliction, one he had seen in thirty of his patients: “neurasthenia” (from neuro for “nerve” and asthenia for “weakness”). Referring to it sometimes as “nervous exhaustion,” Beard argued that neurasthenia afflicted primarily ambitious, upwardly mobile members of the urban middle and upper classes—especially “the brain-workers in almost every household of the Northern and Eastern States”—whose nervous systems were overtaxed by a rapidly modernizing American civilization. Beard believed that he himself had suffered from neurasthenia but had overcome it in his early twenties.
Born in a small Connecticut village in 1839, Beard was the son of a Congregational minister and the grandson of a physician. After attending prep school at Phillips Academy in Andover, Massachusetts, he went on to Yale, where he began to suffer from the array of nervous symptoms that would afflict him for the next six years and that he would later observe in his patients: ringing in the ears, pains in the side, dyspepsia, nervousness, morbid fears, and “lack of vitality.” By his own account, Beard’s anxious suffering was prompted largely by his uncertainty about what career to pursue—though there is also evidence that he anguished over his lack of religious commitment. (Two of Beard’s older brothers had followed his father into the ministry; in his diary, he chastises himself for his indifference to spiritual concerns.) Once he decided to become a physician, however, his doubts left him and his anxiety dissipated. He entered medical school at Yale in 1862, determined to help others plagued by the anxious suffering that had once afflicted him.
Influenced by Darwin’s recent work on natural selection, Beard came to believe that cultural and technological evolution had outstripped biological evolution, putting enormous stress on the human animal—particularly those in the business and professional classes, who were most driven by status competition and the burgeoning pressures of capitalism. Even as technological development and economic growth were improving material well-being, the pressure of market competition—along with the uncertainty that took hold as the familiar verities fell away under the assault of modernity and industrialization—produced great emotional stress, draining American workers’ stock of “nerve force” and leading to acute anxiety and nervous prostration. “In the older countries, men plod along in the footsteps of their fathers, generation after generation, with little possibility and therefore little thought of entering a higher social grade,” Beard’s colleague A. D. Rockwell wrote in the New York Medical Journal in 1893. “Here, on the contrary, no one is content to rest with the possibility ever before him of stepping higher, and the race of life is all haste and unrest. It is thus readily seen that the primary cause of neurasthenia in this country is civilization itself, with all that term implies, with its railway, telegraph, telephone, and periodical press intensifying in ten thousand ways cerebral activity and worry.”*
Beard believed that constant change, combined with the relentless striving for achievement, money, and status that characterized American life, produced rampant nervous weakness.† “American nervousness is the product of American civilization,” he wrote. The United States had invented nervousness as a cultural condition: “The Greeks were certainly civilized, but they were not nervous, and in the Greek language there is no word for that term.”‡ Ancient cultures could not have experienced nervousness, he argued, because they didn’t have steam power, the periodical press, the telegraph, the sciences, and the mental activity of women: “When civilization, plus these five factors, invades any nation, it must carry nervousness and nervous disease along with it.” Beard also argued that neurasthenia affected only the more “advanced” races—especially the Anglo-Saxon—and religious persuasions; he observed that “no Catholic country is very nervous.” (On its face, this is a dubious proposition, and Beard had no real evidence to buttress it. On the other hand, rates of anxiety in modern Mexico, a primarily Catholic country, are much lower than in the United States. A 2002 World Health Organization study found that Americans are four times more likely to suffer from generalized anxiety disorder than Mexicans—and some research has found that Mexicans recover from anxiety attacks twice as quickly as Americans. Interestingly, when Mexicans immigrate to the United States, their rates of anxiety and depression soar.)
Neurasthenia was a self-flattering diagnosis, since it was thought to affect primarily the most competitive capitalists and those with the most refined sensibilities. It was a disease of the elites; in Beard’s estimation, 10 percent of his own patient load was made up of other physicians, and by 1900 “nervousness” had definitively become a mark of distinction—a signifier of both high class and cultural refinement.§
Beard’s books contain case studies and elaborate symptomatologies that sound strikingly contemporary to the modern ear. In A Practical Treatise on Nervous Exhaustion, published in 1880, he expatiates for hundreds of pages on the symptoms of nervous exhaustion. “I begin with the head and brain,” he writes, “and go downwards.” The list includes tenderness of the scalp; dilated pupils; headache; “Muscoe Volitantes, or floating specks before the eyes”; dizziness; ringing in the ears; softness of voi
ce (a voice “wanting in clearness and courage of tone”); irritability; numbness and pain in the back of the head; indigestion; nausea; vomiting; diarrhea; flatulence (“with annoying rumbling in the bowels these patients complain of very frequently”); frequent blushing (“I have seen very strong, vigorous men, who have large muscular power and great capacity for physical labor, who, while in a neurasthenic state, would blush like young girls”); insomnia; tenderness of the teeth and gums; alcoholism and drug addiction; abnormal dryness of the skin; sweating of the hands and feet (“A young man under my care is so distressed [by his sweating] that he threatens suicide unless he is permanently cured”); excess salivation (or, alternatively, dry mouth); back pain; “heaviness of the loins and limbs”; heart palpitations; muscle spasms; dysphagia (difficulty swallowing); cramps; tendency to get hay fever; sensitivity to changes in the weather; “profound exhaustion”; ticklishness; itching; hot flashes; cold chills; cold hands and feet; temporary paralysis; and gaping and yawning. On the one hand, this panoply of symptoms is so broad as to be meaningless; these are the symptoms, more or less, of being alive. On the other hand, this litany resonates with the twenty-first-century neurotic’s—it sounds, in fact, not unlike my weekly catalog of hypochondriacal complaint.
Neurasthenia also encompassed what we would today call phobia. Beard’s case studies range from the lightning phobic (“One of my patients tells me she is always watching the clouds in summer, fearing that a storm may come. She knows this is absurd and ridiculous, but she declares she cannot help it. In this case the symptom was inherited from her grandmother; and even in her cradle, as she is informed by her mother, she suffered in the same way”) to the agoraphobic (“One of my cases, a gentleman of middle life, could walk up Broadway without difficulty, because shops and stores, he said, offered him an opportunity of retreat, in case of peril. He could not, however, walk up Fifth Avenue, where there are no stores, nor in side streets, unless they were very short. He could not pay a visit to the country in any direction, but was hopelessly shut up in the city during the hot weather. One time, in riding in the stage up Broadway, on turning onto Madison Square, he shrieked with terror, to the astonishment of the passengers. The man who possessed this interesting symptom was tall, vigorous, full-faced, and mentally capable of endurance”); from the claustrophobic (who fear enclosed spaces) to the monophobic (who fear being alone; “One man was so afraid to leave the house alone he paid a man $20,000 to be his constant companion”); from the mysophobic (who fears contamination and must wash her hands two hundred times a day) to the panophobic (who fears everything). One of Beard’s patients had a morbid fear of drunken men.
My Age of Anxiety: Fear, Hope, Dread, and the Search for Peace of Mind Page 36
