3.2 Key issues in understanding anxiety

Claudia Hammond:

I’m Claudia Hammond and today we’re focusing on a single condition, a condition that can take over a person’s life preventing them from going out, from working, even from sleeping. The condition I’m talking about is anxiety, thought to affect around one in 14 people around the world in any given moment. The effects can be profound.

Female voice [Claire]:

Rather than thinking 'Oh I’m nervous', you think 'I don’t want to have a panic attack'. And for me I usually start thinking 'I can’t do this. What if somebody notices? What if I make a fool of myself? What if I end up in hospital? What if I end up on the streets?' It escalates into something catastrophic which isn’t the reality, but those are the thoughts that go through my head rather than 'Oh I might have a nice time', or, 'This might be tricky but it will be OK'. I’m thinking 'I’m going to die'.

Claudia Hammond:

Today we’ll be looking at the causes of anxiety and the cures and asking whether it’s on the increase. My guest today is clinical psychologist, Nick Grey, from the Centre for Anxiety Disorders and Trauma at the Maudsley Hospital in London. So, Nick, you see a lot of clients experiencing anxiety. Is it possible to define what it is?

Nick Grey:

I guess a reasonable definition would be that this is a kind of feeling of worry, fear, nervousness that people would have about something that’s got an uncertain outcome. That’s a very sort of lay definition I think.

Claudia Hammond:

Now, some people experiencing anxiety, like Scott Stossel the Editor of the American magazine The Atlantic, managed to keep it secret from their friends and colleagues but in the end his anxiety became so serious that he nearly missed his own wedding. As an author he found publicity tours for his books so stressful that he decided to make anxiety the topic of his next, The Age of Anxiety, which of course has unfortunately resulted in another book tour. I asked him what anxiety feels like for him.

Scott Stossel:

It can be more generalised − that feeling of worry, feeling of churning in the back of my mind worrying about every conceivable negative outcome. And sort of pessimistically anticipating the worst. That in some ways is the milder form of anxiety. The most acute form comes in two different genres. I would say one is just the sort of acute-onset panic attack, you would lose the ability to just think straight. And you start sweating, and you’re hyperventilating and you feel like you can’t get enough breath. And you feel as though your chest is constricting and you feel various forms of gastric distress. It can be quite terrifying and uncomfortable. You can have the same, similar sort of reaction in response to a phobic stimulus. So I have a number of specific phobias and, for instance, flying, heights. And if I’m, you know, in an airplane you can experience symptoms that are basically akin to a panic attack. But in those cases it’s triggered directly by the thing that you fear.

Claudia Hammond:

Now Nick, he mentions there the thing that you fear and for him there seem to be quite a range of triggers. Is that unusual for people to have so many different phobias at one time?

Nick Grey:

No, I mean, what we find with people with anxiety problems is that there might be a kind of a range of fears that they have but there’s usually kind of one or two which are kind of most prominent and kind of like the worst fears that they would have.

Claudia Hammond:

So is that different from, say, somebody having a phobia just of spiders? Would that count as anxiety still?

Nick Grey:

It definitely counts as anxiety. Anxiety is a normal process. It’s something that I think we all have at one time or another and it’s important for us to, you know, kind of help keep us safe and help keep, you know, our loved ones safe as well. If we see our kids running in to the road and there’s a car coming we’d feel anxious and that’s a good job that we do. I think what is less commonly the case is that people have this sort of disabling and chronic anxiety problem. I think that’s what Scott’s talking about. The good news is that there are effective treatments for these now.

Claudia Hammond:

We will talk about those later. And anxiety is something we seem to hear a lot about these days. We like to talk about the stresses and strains of modern life and how much harder it all is now. But as part of his research Scott Stossel has looked back in history and he’s concluded that anxiety is nothing new.

Scott Stossel:

Reading back through the historical literature, going back literally thousands of years is that it seems like every age, whether that’s each successive generation of the 20^th century, or going back to the Renaissance or going back to the late Roman Empire or even the 4^th century BC in Greece, every age presumes to think that it is the most anxious age ever.

You’ll find physicians in the 2^nd century AD Rome saying, never have there been so many anxious, miserable, melancholic people. And you look through British history, the Victorian era, the Georgian era. And so you start to realise that clearly some quotient of anxiety is relatively fixed throughout the human population and endures and is part of the human condition. So some percentage of people are going to be anxious all the time.

But I do think, all that said, that certain eras are more productive of anxiety than others and those tend to be eras like the Industrial Revolution or the Gilded Age or now where you have rapid technological change. Where the economy is uncertain, where you have rapid social transformation and changing ideas of gender identity. And the feeling of uncertainty produces anxiety that can actually rewire your brain to be more anxious.

Claudia Hammond:

So Nick, do we have any idea how many people do have anxiety disorders today and would it be fair to say that they’re on the rise or not?

Nick Grey:

I think the evidence is that actually they’re not on the rise. Maybe we’re talking about them more and there’s perhaps a little less stigma in talking about them. I think the best evidence is the quote that you gave earlier on, which is about one in 14 people worldwide would meet the criteria for an anxiety disorder.

Claudia Hammond:

And is it fair to argue that it’s something of a Western concept and do anxiety disorders and the levels of those go up in countries as they become more ‘westernised’? Is it a Western construct in a way?

Nick Grey:

Well, that’s a really interesting question and unfortunately there’s not been, kind of, really enough research outside of, kind of, America, Western Europe and Australasia. The evidence that there is, is actually, kind of, those, kind of, like Western Europe, Anglophone countries have about a 20 to 50% more greater likelihood of meeting the criteria for this kind of chronic anxiety than people from, kind of, sort of other cultures, kind of, African cultures, kind of, Indian, Asian cultures. But that might be to do with the way in which we’re measuring anxiety, the questions that we’re asking. What I don’t know, and what I don’t think the evidence is currently showing, is that as countries become perhaps more westernised in that way, or perhaps more kind of affluent more generally, whether that leads to any increase in anxiety.

Claudia Hammond:

And then I suppose you don’t know whether it would just be that more people are getting diagnosed? May be that anxiety is there but doesn’t get diagnosed because people don’t have the opportunity to have it diagnosed, or maybe it isn’t there?

Nick Grey:

Perhaps. But certainly in the kind of the studies that have got the, kind of, the best kind of evidence, at the moment they’re not looking at people who have almost, like, the opportunity to be diagnosed. They are looking at, kind of, community studies. So they’re, kind of, having researchers, kind of, ask people whether they’re seeking treatment or not. So this isn’t anything to do with the treatment seeking rates per se.

Claudia Hammond:

So what’s interesting is, what causes one person to experience extreme anxiety while another doesn’t. Scott has noticed a phobia of vomiting running in his family.

Scott Stossel:

My mother had that phobia fairly severely and I’d always thought that I’d acquired my phobia, they call it emetophobia, from seeing her worries. So I took particular care, at least tried to, to conceal my phobia from my daughter. And then a few years ago when she was seven years old, which as it happens was the exact same age when I developed my phobia, give or take a few months, she started expressing it in very similar ways. Which was both heart-breaking and fascinating to me because it wouldn’t seem that something as idiosyncratic as emetophobia could be transmitted through the genes.

So I mean my own conclusion based on, you know, the work of experts who study this regularly said there is a very strong inheritable component to one’s predisposition to have an anxious temperament. But all that said, anxiety is not wholly reducible to genetics, you know, I think that lays the basis for your propensity to be anxious. But then on top of that there is your upbringing, your life circumstances, your life, whether you were subjected to trauma and a certain component of luck.

Claudia Hammond:

So it’s that age-old question that we always face in psychology of how much is it down to the environment and how much is it down to genetic factors? Is there evidence that anxiety can be heritable or is it just that we copy what we see in other people. So, you know, Scott sees his mother and sees that she doesn’t like vomiting.

Nick Grey:

I think Scott summarised it really nicely. There is a genetic propensity to have, say, an anxious temperament. And then it’s the life experiences and traumatic events and the things that you observe but then determine how that kind of plays out or not.

Claudia Hammond:

And there do seem to be certain things that we’re more likely to have phobias of aren’t there, like snakes and spiders? Not everyone’s afraid of them but more people are and monkeys, for example, are afraid of, say, snakes as well.

Nick Grey:

Yeah. This sort of hypothesis from basic psychology around preparedness that there are some things that we’re, kind of, perhaps in an evolution return. We’re more prepared to develop phobias to such things which can immediately, kind of, cause us harm, dangerous animals. Things like vomit phobia, about, kind of, disgust, making sure the germs aren’t inside us. But then other phobias can develop really, kind of ,following traumatic events. So we can develop an anxiety response to almost any stimulus if it’s associated with a, kind of, traumatic experience that we’ve had.

Claudia Hammond:

And you mentioned evolution there. And Scott points out that we have all evolved to feel a degree of anxiety.

Scott Stossel:

Darwin talked how species that fear rightly enhance their chances of survival. And if nobody felt fear, if you didn’t have the 'fight or flight' response, we as a species, if that hadn’t been bequeathed to us by evolution, we probably would have gone extinct long ago. So some quotient of anxiety is highly adaptive. But I think for many people, and particularly people with anxiety disorders, there can be a gap between the public presentation of competence and confidence in the internal sense of, you know, imposter syndrome, you know, feeling like you’re inadequate. So everybody struggles with a little bit of anxiety but people have acute anxiety disorders and many people are quite good at hiding it. And that leads to, you know, what one therapist I talked to calls ‘impression management’ where you’re always in mortal terror of the vulnerable, anxious self-within being revealed, which in itself becomes kind of a contributory anxiety because you’re trying so hard to keep that inner, vulnerable, anxious imposturous self from being revealed that you have to put all this work in to maintaining your external impression or your brand. And that’s the symptom and a cause of additional anxiety.

Claudia Hammond:

Nick, I wonder whether there’s something you recognise in your clients? Do you see this sort of desperation to maintain a public face and to not have people know about it and to keep that anxiety a secret?

Nick Grey:

I think it’s very true of many of the people that we see, and I think it’s particularly true of those people who have, kind of, problems with, sort of, social anxiety. A social anxiety disorder where their worst fears are about showing signs of anxiety or saying or doing something that would be embarrassing or humiliating. And then other people thinking badly of them.

Claudia Hammond:

Well, our reporter Lin Lin Ginzberg has been to meet Claire, who has social anxiety disorder which she thinks was brought on by her job.

Lin Lin Ginzberg:

So I’m in the park with Claire who’s agreed to meet me just outside of work and this is a situation that may be a couple of years ago would not have been so pleasant. So can you tell us why that might be?

Claire:

Well, 18 months ago I was dealing with a very bad period of anxiety, well, severe anxiety, and panic attacks. And I’m right outside my office which is where most of it takes place. So, yeah, a couple of years ago this wouldn’t have been a particularly nice place for me to be. I’d want to be as far away as possible.

Lin Lin Ginzberg:

And what kind of events in your office would make you feel anxious?

Claire:

Well, I work in an office with very strong characters which doesn’t necessarily mean they’re bad people, it just means they’re a lot louder than me, more expressive than I am. And I put a lot of pressure on myself to, sort of, compete and confirm. It actually relates back to school in many ways for me because I felt the same way in classrooms. I need to be like these people, I can’t be like myself, I need to be like this. And the pressure to be like that eventually made me ill unfortunately.

Lin Lin Ginzberg:

And when did you realise that that was the case, that you were reacting to these situations that are distressful for everyone in a different way, and in a way that needed to be managed?

Claire:

It was starting to keep me up at night, I noticed. It was little things at first, sort of meetings, or presentations where I had to say something and eventually it spiralled in to I wasn’t sleeping at all because I was so worried about it. And I was worried about speaking to certain people at the office. And certain things, like I developed quite a bad tremor and heart palpitations. I had difficulty breathing. All the sort of common side effects of anxiety really.

Claudia Hammond:

Now Nick, I thought it was interesting there that Claire compares her competitive work environment today with being at school and says it feels a bit like that. When you’re talking to clients about their anxiety how much would you talk to them about their past as well?

Nick Grey:

Certainly that’s, kind of, where the evidence is in treating anxiety disorders. It’s trying to work on what’s keeping the problem going now. As part then of, as we go on in treatment, think about how we can try and prevent the anxiety, kind of, recurring. And I think that’s probably when we talk much more about perhaps the kind of the origins of it and how it may be that people are reacting to situations in the adult world now which are actually just an echo or ghost of, kind of, like the earlier experiences such as at school.

Claudia Hammond:

Do you ever find that clients sometimes can see this upside even though it can be so disabling for them?

Nick Grey:

I’m going to say I think in the kind of the health clinics in which I’m working there are very few upsides to experiencing, kind of, chronic anxiety, although I consider, maybe, see upsides to the, kind of, the normal process of, kind of, worry or fear. I think the one area perhaps where people can have some kind of form, of almost like personal growth from overcoming adversity or seeing that they can have perhaps, kind of, greater levels of empathy and compassion for others who are also, kind of, experiencing difficulties. But certainly most of the people that we’re seeing would say that their kind of chronic anxiety disorder is really a negative thing, and they want to be, kind of, be rid of it as far as is possible.

Claudia Hammond:

Yes, because I guess actually experiencing a chronic anxiety disorder is different from just a touch of perfectionism, say?

Nick Grey:

I’d think so, yeah.