According to one of the most reputable surveys of its kind, the National Comorbidity Study Replication (NCS-R), almost one in five Americans has met the criteria for an anxiety disorder over the past year, and an estimated one in three people will experience an anxiety disorder in their lives. Bearing in mind that in 1980, the Diagnostic and Statistical Manual of Mental Disorders (DSM) estimated lifetime prevalence rates of anxiety disorders in the 2 to 4% range, it is safe to say that the diagnosing of anxiety disorders has spiked in recent decades. On college campuses, anxiety has even surpassed depression as the central mental health issue identified by students. Several years ago a large Pennsylvania State University study revealed that more than half of students seeking services through campus health clinics named anxiety as a significant concern. Is it possible that rising rates of anxiety disorders speak to a widespread lack of appreciation for expectable levels of anxiety that are part of human variation, or a pathologizing of innate and normal anxious traits?
Moreover, in the mental health field have we moved too far away from presupposing that anxiety signifies repressed emotions in need of acknowledgement and fuller expression, as well as ignored needs for greater meaning, purpose, and personal fulfillment, instead favoring a medical model approach that simply categorizes anxiety as a symptom of a disorder, which drives the diagnostic numbers upwards?
Homo sapiens is an anxious species, for good reason. We are wired to be “better safe than sorry”—to be biologically primed to expect danger where it probably doesn’t exist so as to preemptively act protectively on those more rare occasions where danger does exist. Many common phobias and obsessions probably would have had prehistoric survival value, but in our modern technological society are more of a nuisance. Fears of snakes, spiders, insects, germs, strangers, heights, unfamiliar foods, and dark enclosed spaces once kept more humans alive to pass on their genes. Fear of flying affects anywhere between six and twenty-five percent of people. It’s understandable that so many people would dread stepping on an airplane given that the experience taps several core perennial human anxieties: being situated at an extreme height where falling would result in certain death, and entrapment in an enclosed space where movement is restricted and escape impossible.
To call fear of flying “aviophobia” and categorize it as the product of a disordered brain, or an irrational mind (given how safe flying actually is), devalues the distal fears that our brains were effectively wired to cope with. A meaningful approach to fears of flying—one that is brain-based, from an evolutionary standpoint—would accept that it is unnatural for us to step onto an airplane to begin with, and that those who dread and avoid the experience will need to avail themselves of whatever coping mechanisms and psychoactive substances that have proven useful, through personal experimentation, to override their natural anxiety.
Similarly, take social anxiety. In ancient environments there would have been survival value in avoiding talking with strangers and reserving one’s trust for close intimates. Dread of public speaking in front of others poised to exploit your weaknesses for gains in social status and group hierarchy would have been reasonable. Extrapolating from this, it is arguable that we humans are genetically pre-programmed to prefer socializing with known intimates rather than unknown strangers, and, unless absolutely necessary, to avoid speaking in front of a crowd where one’s social status, desirability, and attractiveness are being scrutinized. Some of us, more than others, have dispositional traits that leave us feeling exposed to judgment and negative evaluation in unfamiliar social situations. This is an ancient fear. This realization should help govern an approach to mild-to-moderate cases of social anxiety where, for pragmatic and social justice reasons, coping skills are provided to individuals whose traits disadvantage them in situations that are unavoidable for occupational, educational, or relationship-preserving reasons. This is altogether different from medicalizing social anxiety as the product of a disordered brain or mind, and shunting the person into treatment for a disorder.
When anxiety is reduced to a symptom to be medicated away, or an aberrant emotion based on cognitive distortions in need of correction though cognitive behavior therapy (CBT), the all-important representational value of that anxiety can be lost. From an existential-humanistic standpoint, anxiety can signal an urgency to heed unfulfilled personal longings, untapped creative ventures, needs for clearer meaning and purpose in one’s professional life, and desires for greater compatibility in one’s love life. Anxiety can be a clarion call from the client’s better self, a nagging inner tension that will persist until real-life changes are made that attend to deeper needs for meaning, purpose, creativity, and relational emotional depth and connection.
There is also poignancy and practicality to Freud’s original conceptualization of anxiety as the global emotional outgrowth of thwarted sexual and aggressive urges. All too often in my clinical practice over the years, when I explore the underlying concerns of clients suffering panic attacks, something of a sexual or aggressive nature is being overlooked or denied. For instance, a 26-year-old male client of mine, whose social anxiety had been so debilitating that he dropped out of medical school, recently looked up his old girlfriend. He was coming out of a period of extreme social isolation and avoidance of any romantic involvement. For the first time in his life he began experiencing recurring panic attacks. Once we started to look at his fear of becoming sexually involved with and emotionally attached to his ex-girlfriend, put in a dependent position and engulfed and trapped by his possible sexual and emotional reliance on her (as well as the reverse), his panic attacks abated. Another client had a full-on panic attack in my office in the context of his ex-wife berating him over child support payments. During the subsequent session it became clear that his panic attack was really a stifled rage attack. He was furious at what he perceived as his ex-wife’s mischaracterization of him as greedy, when he had been, in actuality, generous in his child support payments, but feared giving voice to his fury in her presence.
In short, from an existential-humanistic and psychodynamic point of view, a healthy approach to anxiety would be to view it as signifying something of significance that is being emotionally disavowed, or that life-enhancing sources of self-fulfillment are not being attended to.
Another often-overlooked source of anxiety pertains to the tension, uneasiness, and self-doubt stemming from the mismatch between a person’s temperament, or predominant personality traits, and contrary evaluative expectations in their work and love lives. Perhaps the most classic case is that of the introvert who internalizes an extroverted standard of self-evaluation. This would be the person who under-appreciates his or her needs for solitude, introspection, learning through immersion experiences, communication through writing rather than speaking, deep conversations rather than small talk, and swallows whole the extroversion bias that exists in our culture—that people should ideally be gregarious, outgoing, fast talking, spotlight seeking, action-oriented, work best in teams and in freely accessible office spaces, and welcoming of strangers and novel stimuli. An introvert forced to exist in an extroverted world is a recipe for high anxiety. The antidote is to listen to the remedial significance of that anxiety—self-acceptance as an introvert and implementation of life habits that square with one’s needs for solitude, introspection, and socialization mostly with close intimates.
It’s in vogue these days to take a mindfulness approach to anxiety; to not indulge troubling thoughts, to see them as meaningless, to let them just be. Obviously, there’s a place for not engaging and concretizing anxious thoughts that are unanchored to realistic dangers. But perhaps we have gone too far. When the representational and functional significance of anxiety are viewed as irrelevant and ignored, people are deprived of self-knowledge sources that are inroads to lasting solutions to anxiety.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.