What do we talk about when we talk about anxiety?

In this extract from his new history of anxiety, Scott Stossel attempts to pin down what exactly we mean by the word itself…

My Age of Anxiety

On February 16, 1948, at 3:45 in the afternoon, my great-grandfather Chester Hanford, who had recently stepped down after twenty years as the dean of Harvard College to concentrate full-time on his academic work as a professor of government (“with a focus on local and municipal government,” as he liked to say), was admitted to McLean Hospital with a provisional diagnosis of “psychoneurosis” and “reactive depression.” Fifty-six years old at the time of his admission, Chester reported that his primary complaints were insomnia, “feelings of anxiety and tension,” and “fears as to the future.” Described by the hospital director as a “conscientious and usually very effective man,” Chester had been in a state of “anxiety of a rather severe degree” for five months. The night before presenting himself at McLean, he had told his wife that he wanted to commit suicide.

Thirty-one years later, on October 3, 1979, at 8:30 in the morning, my parents—worried that I, ten years old and in the fifth grade, had of late been piling various alarming new tics and behavioral oddities on top of my already obsessive germ avoidance and acute separation anxiety and phobia of vomiting—took me to the same psychiatric hospital to be evaluated. A team of experts (a psychiatrist, a psychologist, a social worker, and several young psychiatric residents who sat hidden behind a two-way mirror and watched me get interviewed and take a Rorschach test) diagnosed me with “phobic neurosis” and “overanxious reaction disorder of childhood” and observed that I would be at significant risk of developing “anxiety neurosis” and “neurotic depression” as I got older if I wasn’t treated.

Twenty-five years after that, on April 13, 2004, at two o’clock in the afternoon, I, now thirty-four years old and working as a senior editor at The Atlantic magazine and dreading the publication of my first book, presented myself at the nationally renowned Center for Anxiety and Related Disorders at Boston University. After meeting for several hours with a psychologist and two graduate students and filling out dozens of pages of questionnaires (including, I later learned, the Depression Anxiety Stress Scales and the Social Interaction Anxiety Scale and the Penn State Worry Questionnaire and the Anxiety Sensitivity Index), I was given a principal diagnosis of “panic disorder with agoraphobia” and additional diagnoses of “specific phobia” and “social phobia.” The clinicians also noted in their report that my questionnaire scores indicated “mild levels of depression,” “strong levels of anxiety,” and “strong levels of worry.”

Why so many different diagnoses? Did the nature of my anxiety change so much between 1979 and 2004? And why didn’t my great-grandfather and I receive the same diagnoses? As described in his case files, the general scope of Chester Hanford’s syndrome was awfully similar to mine. Were my “strong levels of anxiety” really so different from the “feelings of anxiety and tension” and “fears as to the future” that afflicted my great-grandfather? And anyway, who, aside from the most well adjusted or sociopathic among us, doesn’t have “fears as to the future” or suffer “feelings of anxiety and tension”? What, if anything, separates the ostensibly “clinically” anxious, like my great-grandfather and me, from the “normally” anxious? Aren’t we all, consumed by the getting and striving of modern capitalist society—indeed, as a consequence of being alive, subject always to the caprice and violence of nature and each other and to the inevitability of death—at some level “psychoneurotic”?

Technically, no; in fact, no one is anymore. The diagnoses that Chester Hanford received in 1948 no longer existed by 1980. And the diagnoses that I received in 1979 no longer exist today.

In 1948, “psychoneurosis” was the American Psychiatric Association’s term for what that organization would, with the introduction in 1968 of the second edition of psychiatry’s bible, the Diagnostic and Statistical Manual (DSM-II), officially designate as simply “neurosis” and what it has, since the introduction of the third edition (DSM-III ) in 1980, called “anxiety disorder.”

This evolving terminology matters because the definitions—as well as the symptoms, the rates of incidence, the presumed causes, the cultural meanings, and the recommended treatments—associated with these diagnoses have changed along with their names over the years. The species of unpleasant emotion that twenty-five hundred years ago was associated with melaina chole (ancient Greek for “black bile”) has since also been described, in sometimes overlapping succession, as “melancholy,” “angst,” “hypochondria,” “hysteria,” “vapors,” “spleen,” “neurasthenia,” “neurosis,” “psychoneurosis,” “depression,” “phobia,” “anxiety,” and “anxiety disorder”—and that’s leaving aside such colloquial terms as “panic,” “worry,” “dread,” “fright,” “apprehension,” “nerves,” “nervousness,” “edginess,” “wariness,” “trepidation,” “jitters,” “willies,” “obsession,” “stress,” and plain old “fear.” And that’s just in English, where the word “anxiety” was rarely found in standard psychological or medical textbooks in English before the 1930s, when translators began rendering the German Angst (as deployed in the works of Sigmund Freud) as “anxiety.”

Which raises the question: What are we talking about when we talk about anxiety? The answer is not straightforward—or, rather, it depends on whom you ask. For Søren Kierkegaard, writing in the mid-nineteenth century, anxiety (angst in Danish) was a spiritual and philosophical problem, a vague yet inescapable uneasiness with no obvious direct cause. For Karl Jaspers, the German philosopher and psychiatrist who wrote the influential 1913 textbook General Psychopathology, it was “usually linked with a strong feeling of restlessness . . . a feeling that one has . . . not finished something; or . . . that one has to look for something or . . . come into the clear about something.” Harry Stack Sullivan, one of the most prominent American psychiatrists of the first half of the twentieth century, wrote that anxiety was “that which one experiences when one’s self-esteem is threatened”; Robert Jay Lifton, one of the most influential psychiatrists of the second half of the twentieth century, similarly defines anxiety as “a sense of foreboding stemming from a threat to the vitality of the self, or, more severely, from the anticipation of fragmentation of the self.” For Reinhold Niebuhr, the Cold War–era theologian, anxiety was a religious concept—“the internal precondition of sin . . . the internal description of the state of temptation.” For their part, many physicians—starting with Hippocrates (in the fourth century b.c.) and Galen (in the second century a.d.)—have argued that clinical anxiety is a straightforward medical condition, an organic disease with biological causes as clear, or nearly so, as those of strep throat or diabetes.

Then there are those who say that anxiety is useless as a scientific concept—that it is an imprecise metaphor straining to describe a spectrum of human experience too broad to be captured with a single word. In 1949, at the first-ever academic conference dedicated to anxiety, the president of the American Psychopathological Association opened the proceedings by conceding that although everyone knew that anxiety was “the most pervasive psychological phenomenon of our time,” nobody could agree on exactly what it was or how to measure it. Fifteen years later, at the annual conference of the American Psychiatric Association, Theodore Sarbin, an eminent psychologist, suggested that “anxiety” should be retired from clinical use. “The mentalistic and multi-referenced term ‘anxiety’ has outlived its usefulness,” he declared. (Since then, of course, the use of the term has only proliferated.) More recently, Jerome Kagan, a psychologist at Harvard who is perhaps the world’s leading expert on anxiety as a temperamental trait, has argued that applying the same word—“anxiety”—“to feelings (the sensation of a racing heart or tense muscles before entering a crowd of strangers), semantic descriptions (a report of worry over meeting strangers), behaviors (tense facial expressions in a social situation), brain states (activation of the amygdala to angry faces), or a chronic mood of worry (general anxiety disorder) is retarding progress.”

How can we make scientific, or therapeutic, progress if we can’t agree on what anxiety is?

Even Sigmund Freud, the inventor, more or less, of the modern idea of neurosis—a man for whom anxiety was a key, if not the key, foundational concept of his theory of psychopathology—contradicted himself repeatedly over the course of his career. Early on, he said that anxiety arose from sublimated sexual impulses (repressed libido, he wrote, was transformed into anxiety “as wine to vinegar”). Later in his career, he argued that anxiety arose from unconscious psychic conflicts.† Late in his life, in The Problem of Anxiety, Freud wrote: “It is almost disgraceful that after so much labor we should still find difficulty in conceiving of the most fundamental matters.”

If Freud himself, anxiety’s patron saint, couldn’t define the concept, how am I supposed to?

Continue reading this extract from My Age of Anxiety

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