Image: Lola Dupre
For a condition that affects so many of us, there is very little agreement about what anxiety actually is. Is it a physiological condition, best treated with medication, or psychological – the product of repressed trauma, as a Freudian might suggest? Is it a cultural construct, a reaction to today’s anomic society, or a more fundamental spiritual and philosophical reflection of what it means to be human? For most sufferers, the most pressing concern is whether drugs work, and if therapy is a good idea.
Our modern, medical definition of anxiety could be traced back to 1980 and the publication of the third edition of the Diagnostic and Statistical Manual (DSM-III), the doctor’s and psychiatrist’s bible for identifying mental illness. The authors of DSM-III suggested that, according to their new criteria, between 2 and 4 per cent of the population would have an anxiety disorder. But three decades on, the America’s State of Mind Report showed that one in every six people in the United States suffers from anxiety.
The most recent nationwide survey, which took place in 2007, found that three million people in the UK have an anxiety disorder. About 7 per cent of UK adults are on antidepressants (often prescribed for anxiety, too) and one in seven will take benzodiazepines such as Xanax in any one year. Mental health charities warn that our anxiety levels are creeping even higher; they often blame our “switched-on” modern culture for this, or the financial crisis and the long recession that followed it.
And yet, it is difficult to quantify whether it is our feelings of anxiety that have changed, or whether it’s just our perception of those feelings that is different: are we increasingly viewing ordinary human emotions as marks of mental illness? “In theory, it’s possible that we’ve just watched too many Woody Allen films. That’s a very difficult argument to definitively disprove,” the clinical psychologist and author Oliver James told me.
If that seems like a slightly flippant way of framing the debate, that could be because James’s books, including The Selfish Capitalist and Britain on the Couch, are premised on the idea that rates of depression and anxiety have reached record highs in the affluent consumer societies of the English-speaking world.
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In January this year, Scott Stossel, who is the editor of the American magazine the Atlantic, published My Age of Anxiety, an account of his lifelong, debilitating battle with nerves. There has been a lot of interest in the book in both the US and Europe. Stossel, who is 44, is a successful journalist and yet he is deeply insecure. He has been in therapy for three decades and has taken a cocktail of antidepressants, anti-psychotic medications and sedatives (not to mention more conventional cocktail ingredients such as gin, Scotch and vodka) in an attempt to cope with any number of phobias, from the common (agoraphobia and fear of public speaking) to the more niche (turophobia: fear of cheese).
Stossel reveals in painful, intimate and sometimes comical detail the humiliations of living with high anxious tension and very loose bowels. Despite the severity of his problems, he successfully concealed them from most of his friends and colleagues until the book was published. He told me when we spoke that in recent months co-workers have given him lots of hugs (“which is sweet, but a little bit uncomfortable”) and thousands of strangers have approached him because they so identify with the experiences he describes in the book.
“I was very nervous about coming out as anxious,” Stossel says. “And now it’s too late and I can’t un-come out. It hasn’t been a cure, but it has been something of a relief. I now feel there are practical things I can help with, like trying to reduce the stigma around anxiety.”
He says we ought to view anxiety less as a “psychological problem” and more like a “medical condition, in the way gout or diabetes is. These are things that need to be managed and treated, and have an organic basis. It’s not necessarily that you are weak, but that you have an illness.”
Yet while we understand how our modern diet is making gout and diabetes more common, the causes of anxiety are more mysterious.
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Anxiety has long been associated with depression, and often the two were subsumed under the notion of “melancholia”: Robert Burton’s great book Anatomy of Melancholy (1621) was as much about anxiety as sadness. But the DSM-III classified anxiety and depression as separate conditions: the former is related to feelings of worry, the latter to low mood and loss of pleasure and interest. More often than not, however, the two occur together. The blurred lines between normality and illness, or depression and anxiety, make it very hard to grasp what it means to say that three million people in the UK suffer from anxiety.
If one in seven of us is taking pills to control or ward off anxiety, are we just medicalising an ordinary human emotion? Did the purveyors of the early anti-anxiety medicines such as Miltown – discovered in the 1940s, and the first in a line of blockbuster drugs including Prozac and Xanax – manage to create a new problem along with the solution they offered?
Stossel describes how in the 1950s a young psychiatrist called Donald Klein began randomly treating his patients with a new drug called imipramine. He noticed that patients on imipramine often remained very anxious but were less likely to suffer from acute paroxysms of anxiety. And so, having found a cure, he defined the problem – “panic attacks”.
Until imipramine, panic attacks didn’t “exist”. This process of working backwards from new drugs to new illnesses is known as pharmacological dissection, and it is not uncommon. Yet even if modern drugs shaped our understanding of mental illness, that doesn’t mean they made us sick.
Or maybe the UK’s epidemic of anxiety isn’t pathological at all but a product of historically unprecedented good health and affluence. Perhaps anxiety is a luxury that comes with wealth, freedom and the privilege of having nothing fundamental to fear in our modern society.
This isn’t an unpopular notion. A World Health Organisation survey in 2002 found that, while 18.2 per cent of Americans reported anxiety in any one year, south of the US border only 6.8 per cent of Mexicans did. Of the 14 countries surveyed by WHO, Nigeria reported the lowest levels of anxiety, with only 3.3 per cent of respondents experiencing anxiety in any year. Nigeria’s per capita GDP is $2,690, about 6 per cent that of the US, and in 2010 84.5 per cent of Nigerians were living on less than $2 a day, the international poverty line. Breaking out into a nervous sweat on the London Tube because you can’t remember if you unplugged your hair straighteners is the kind of indulgence you can’t afford if you’re struggling to feed yourself, or so the argument goes.
However, it’s not that simple. Again, it’s very hard to tell whether feelings of anxiety vary internationally or if people label them differently. In countries with a large stigma against mental illness, people are less likely to report disorders such as anxiety or depression. Yet the psychiatrist Vikram Patel, who recently featured on the BBC Radio 4 programme The Life Scientific, says his research in India and Zimbabwe has convinced him that rates of mental illness are the same all over the world.
The way we understand anxiety is cultural, says Beth Murphy, head of information at the mental health charity Mind. “If you’re living on the breadline in a hand-to-mouth existence you might not recognise what you are feeling as anxiety, but it’s quite probable that you’re going to be pretty worried about where your next meal is coming from.”
This raises another problem: if you are feeling anxious because it’s very likely you could go hungry tomorrow, are you in any meaningful way unwell?
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Just as sadness is natural but depression is an illness, most of the people I spoke to who suffered from anxiety instinctively drew a distinction between “good anxiety”, the nervous adrenalin that helps you get stuff done and meet deadlines, and “bad anxiety”, the destructive kind. Our common-sense interpretation of “bad anxiety” also suggests that the worries here should be disproportionate or irrational.
The Diagnostic and Statistical Manual used today identifies anxiety disorders according to how severe and persistent the feelings of worry are, and whether these feelings are accompanied by elements from a list of secondary symptoms, including sleep disturbance, muscle tension, poor concentration and fatigue.
Although the anxiety should be “excessive” the focus is solely on the feelings, and not what caused them. This might go some way towards explaining the boom in prescriptions for mental illnesses; doctors sometimes prescribe antidepressants to someone who has suffered bereavement, something Oliver James described as “ludicrous”. The counter-argument is: if a short course of drugs can make it easier to cope with the painful but completely healthy process of grieving, why not take them?
At its most extreme, anxiety is a debilitating, life-altering condition. I spoke to Jo, a volunteer at the charity Anxiety UK, and she told me that feelings of anxiety have “blighted” her life.
“It’s stopped me from doing so many things that I would have liked to have been able to do and it’s stopped me from living what I feel is a normal life, doing things like having relationships, perhaps getting married, having children, having a career. It’s put paid to all that,” she says bitterly.
Jo, who is in her fifties, has been overcome by anxiety since she was in her teens. She dropped out of school at 16, unable to cope with the pressure of exams, and when her anxiety peaks she is unable to work and is left isolated. Anti-anxiety drugs have helped ease the physical symptoms – such as headaches and irritable bowel syndrome – yet they’ve left her with “the same worries and fears”.
What does anxiety feel like when it’s at its worst? “It’s an overwhelming feeling of being out of control, and overwhelmed by everything.” Jo pauses, and then adds quietly, “It’s not nice.”
While researching this piece, I was struck by how many friends came forward with stories of anxiety-induced insomnia, phobias and stress, though mostly this didn’t prevent them from working or socialising. I spent one strange dinner with a friend who is a lawyer. I noticed when we met that her hands were raw and bleeding slightly, and while we ate she repeatedly reached into her bag and disinfected them. Under stress from work, she had developed a huge fear of germs.
Another friend, a corporate lawyer, recently collapsed while out shopping after she suffered a panic attack. There’s a recognisable stereotype of the neurotic, angst-filled high-flyer – and it has a historical precedent. In the 19th century nervousness was seen as a mark of social standing, because only the new leisured classes could afford such sensibility. But how closely related are these manifestations of unease and anxiety to those feelings experienced by people who are incapacitated by their nerves or phobias?
The triggers for people’s nervous complaints can be idiosyncratic. I chatted about this to Andy Burrows, a musician and the former drummer of the indie band Razorlight. He says he has never felt overly anxious about performing to huge crowds at Wembley or the O2 Arena in London – a prospect that might make most people break into a sweat – but he has suffered from anxiety since his teens and is so freaked out by lifts and tunnels that he can recite from memory the average time that a London overground train spends underground. It takes 16 seconds to travel through the tunnel from Hampstead Heath to Finchley Road and Frognal Station “at regular speed”, he says – and sometimes he just has to get off the train and walk between the two.
Of course, phobias can seem funny to an outsider. I can laugh with friends about the time I leapt up from my chair, tipped over my coffee and ran out of a café because I suddenly couldn’t cope with being in a confined space with a pigeon. And yet, for a brief few seconds, as someone with a fear of birds, I experienced a terror so profound that it overrode my usual instinct not to cause a scene.
In 2012, the National Health Service recorded 8,720 hospital admissions for acute anxiety. According to research for the Organisation for Economic Co-operation and Development, 40 per cent of new claimants for disability benefits in the UK are suffering from mental illnesses, of which anxiety and depression are the most common. The effect of this is that Britain has a higher proportion of people claiming unemployment benefit for mental health conditions than any other developed nation. The estimated cost to the UK of mental illness is roughly 4.4 per cent of GDP, through lost productivity and health-care costs.
What is going wrong? One problem is that we are not doing enough to support people with anxiety. The first port of call for most sufferers is their GP, and the response they get can vary. I know this because a few years ago, when I experienced a bereavement and a break-up in quick succession, I turned from a natural worrier into an unravelled bundle of nerves. I was unable to sleep, read or concentrate.
After a strange few months, spent mostly wandering aimlessly in London, as if somehow I might lose my panic down a backstreet, I burst into tears in front of my doctor. “Patient tearful but able to maintain eye contact,” the GP typed on the large screen in front of us, leaving me feeling like some zoo exhibit. She advised me to book an appointment with someone who knew more about mental health.
In the end, I was lucky. The second doctor prescribed me a low dose of antidepressants (against his advice, I decided not to take these). Then, although the NHS waiting list for counselling was months long, my university counsellor could see me and within two months I felt almost normal again.
Even when they are very much aware of mental illness, GPs can often be constrained in the solutions they can offer. One in every ten people in the UK has to wait more than a year for therapy and 54 per cent have to wait for more than three months (people from black and ethnic-minority communities often wait the longest).
Anxiety is a broad, confusing label and is a condition with multiple causes. We are not the first generation to believe we live in an exceptionally anxious age, and yet in some ways, thanks to the development of drugs and talking therapies, anxiety is a peculiarly modern experience. Perhaps at the very root of Britain’s struggle with nerves – whether viewed in terms of its economic effects or from the perspective of plain, simple suffering, or whether one merely wonders why three million of us appear to be afflicted by a disorder we still can’t quite define – is that we don’t often talk about it.
In an odd way, it might be easier to admit in modern Britain that you’re deeply sad than that you are anxious or scared. Collectively we might be freaking out but most of us are suffering in silence.
Sophie McBain is a staff writer for the New Statesman