Is anxiety on the rise, or are we just better at talking about it?
Steve* was at the top of his game in the mid-2000s. A high achiever, he'd won the medal for law in his final year of university. After uni, he rose to become a partner in an establishment Sydney law firm. He recalls being an anxious child, racked by family expectations at school, university, sport – in all kinds of things. Then, he says, "In my final year at university, I could barely get out of bed in the morning, I was so crippled by nerves."
A thin, mild-mannered and articulate man whose spectacles give him a schoolmasterly look, Steve still managed to do what was expected professionally and socially. He advanced in his career, married, had two daughters, and lived in a nice house in a good suburb. As time passed, however, his mood darkened. He continued to experience feelings of dread, from butterflies in the stomach to full-on panic attacks.
Anxious patients often think they’re weak because they get anxious, but I always tell them it’s the complete reverse,” says psychiatrist Lisa Lampe. Credit:Getty Images
"As a lawyer in my 30s, I was confronted several times a day with new crises, and would react," he recalls. "Simply waking up in the morning triggered it, and realising I had another 10 or 12 hours ahead of decision-making, where people were relying on me, where I had to reach my own and others' expectations."
The final straw came after he worked as senior counsel on a highly contentious case in which the company he was representing was publicly excoriated. "Our conduct was questioned and all sorts of nasty allegations were made against us and the firm, as well as lots of other people. It was very ugly," he says. "Ultimately I personally was completely exonerated, but it was very stressful for months and months."
Steve went on holiday after the case. Instead of returning refreshed, however, he finally succumbed. An unexceptional email came in, requiring action, and he froze. He sat there for half an hour before ringing his then wife, also a high-powered lawyer, to come and get him. Another senior partner found him wandering outside the building while he waited for her, barely able to speak. His colleague brought him back inside, sat him down and told him he needed to see a doctor.
"I'd never imagined until that point that there was a health issue. The thought had never occurred to me," he says, still sounding a little nonplussed. "I thought it was just me, that it was just life."
The diagnosis? Severe depression. What Steve believes now is that only when the secondary diagnosis was made, of generalised anxiety disorder (GAD), did he begin to receive appropriate help. GAD was the more profound problem, triggering the depression. Intense treatment, including cognitive behavioural therapy, ensued, and he was put on medication. On medical advice, he left the law and is now a freelance writer, relying on prescription drugs and the support of a revivified Christian faith.
Medically diagnosed or not, anxiety has become the defining mental issue of our decade. Social and mainstream media is full of stories about it: what it is, whether it's on the upswing and if so why, and how we can overcome it. Search for the word on Pinterest and you could be there for days. Twitter even has a hashtag, #ThisIsWhatAnxietyFeelsLike.
We used to complain about nerves, or tension, or stress in a general way; now we can't stop talking about a medicalised concept of anxiety. It's typically attributed to the increasing pace and pressure of 21st-century life, under-supported and a long way away from permanent jobs and quiet weekends in the bosom of family, friends and neighbours. Teenagers caught up in the pitiless maw of social media. Adults facing extended working days, being on call 24/7, hustling precarious jobs on stagnant wages, perhaps living alone, maybe helicopter parenting, feeling concerned about everything from global warming to terrorism and the rise of political extremism … you don't have to look far to find reasons for disordered mental states.
It's no surprise, then, that a niche publishing wave is underway, from a slew of books released worldwide to magazines such as the three-year-old online site, Anxy. Sarah Wilson's 2017 book, First, We Make the Beast Beautiful, is a harrowing memoir of life-long anxiety by the successful journalist turned bestselling author and entrepreneur, who recently turned her sights towards encouraging greater philanthropy. Jill Stark's Happy Never After, out last July, is less gut-wrenching but equally exploratory and explanatory.
There are even events covering the topic, such as the Big Anxiety festival, billed as the country's largest mental health gathering. Hosted by the University of NSW and the Black Dog Institute, it's intended to create "opportunities for meaningful encounters that increase curiosity and empathy, decrease stigma, support neurodiversity and promote psychological and emotional well-being in our society". More than 160,000 people attended the inaugural event in 2017, which was successful enough to be repeated later this year. Director Jill Bennett's essay, Are we all anxious now?, was published as far afield as the Tate museum's magazine in the UK.
All this interest raises the question: is the type of anxiety that's serious enough to be medically diagnosed on the rise, or are we just renaming aspects of the human condition and talking about them more?
The figures, as is often the case, are unclear. Many medical researchers suggest the diagnosis of anxiety is fairly static, although the Australian Bureau of Statistics says the proportion of the population reporting anxiety-related problems has risen sharply over recent years to 11.2 per cent in 2014-15. Indeed, it's thought that one in three women and one in five men in Australia will experience anxiety at some point in their lives.
"I agree that the stats are pretty stable," says Lampe. "My theory is that awareness of mental health generally is growing. I think it developed for the more obvious disorders, like schizophrenia, first. Then, remember, there was a great rash of publicity around bipolar disorder in the 1990s, and a lot of people came out saying they had it. Then there was a focus on depression, which was around the time Beyondblue got up. Then other people put their hands up and said, 'I have terrible trouble with anxiety,' and the focus switched to that. I think it's anxiety's time and it's well overdue."
A lively conversationalist who has specialised in treating anxiety since leaving university, Lampe finds this a positive development. "I fell in love with treating anxiety disorders because people get better," she says. She emphasises the strength, rather than the weakness, of sufferers. "The thing that always strikes me about my anxious patients is that they've got this debilitative condition and yet they soldier on. The sad thing is, they often think they're weak because they get anxious, but I always tell them it's the complete reverse. Imagine if other people felt they had to cross a 12-lane freeway, with no help, to start every day, and then carry on. The strength that requires is actually amazing."
Imagine feeling you had to cross a 12-lane freeway, with no help, to start every day, then carry on. The strength that requires is amazing.
Psychiatrist Richard Wu, who is as considered as Lampe is vivacious, works in the calm of a Sydney CBD heritage-listed building. He also believes anxiety is increasing; it's certainly showing up more and more in his practice. Wu notes the academic truism that quantitative research lags behind qualitative experience. And why wouldn't anxiety be increasing, he points out – society puts people in an impossible bind these days, increasing pressure in tandem with isolation. He believes a diagnostic bias in favour of depression has eclipsed anxiety when patients like Steve present with symptoms that could fall into either category.
"There has always been an under-recognition of anxiety disorders and it's really hard to find true statistics on them," he says. "The commonly accepted figure is about 33 per cent of the population will fit the diagnostic criteria at some time in their lives for anxiety disorders. That's already very high. But what I'm seeing is something we could call a hidden, or an elusive, epidemic."
Not everyone who experiences anxiety consults a doctor, of course. Paul*, who lives in Canberra, has experienced the full blast of anxiety in the form of panic attacks. When his daughter was little, he took the morning preschool run, while his wife did afternoons. At the time, he was uncomfortably overweight, and he still remembers the sense of rising fear as he got out of breath trying to fit his daughter's shoes on, organise her lunch and pack her schoolbag. The thought that ricocheted around his brain as it was happening was, "Please don't let me die of a heart attack now, when she's alone with me and it will be hours until anyone finds us."
Like Steve, Paul woke every morning in a high state of anxiety, which would wear off as the day progressed. Unlike Steve, he never sought help, never received treatment; taking instead the old-school approach of self-medicating with alcohol. Eventually, as he lost weight, became fitter and drank less, and his daughter became less dependent, the intensity of his anxiety receded
So, what exactly is anxiety? The most authoritative medical definition, from the American Diagnostic and Statistical Manual of Mental Disorders (DSM-V), is a six-month period of uncontrollable worry accompanied by three or more persistent problems such as restlessness, fatigue, concentration issues, irritability, muscle tension or sleep disturbance. Anxiety disorders were only officially defined in 1980's DSM-III, but the most recent edition – the DSM-V, published in 2013 – already has a dozen sub-categories, from phobias to social anxiety to generalised anxiety disorder, with many refinements within each. As The New York Times reviewer, Nathan Heller, remarked in his review of Scott Stossel's 2014 bestseller, My Age of Anxiety, "Clusters of these symptoms probably describe the entire city of New York." One could say the same for Melbourne, Sydney, Hong Kong, London and other world cities.
Clusters of anxiety symptoms probably describe the entire city of New York.
Anxiety occurs on a long continuum, from horror stories to the butterfly flutter we've all experienced when checking exam results or struggling to meet difficult deadlines. David H. Barlow, founder of Boston University's Centre for Anxiety and Related Disorders, calls it "the common cold of mental disorders". Its most severe form has been recognised for millennia, if not isolated. In 1621, Robert Burton described a patient of the ancient Greek physician Hippocrates – the "father" of Western medicine – in this way: "He dare not come into company for fear he should be misused, disgraced, overshoot himself in gestures or speeches, or be sick; he thinks every man observeth him." Burton described these symptoms: "Many lamentable effects this fear causeth in man, as to be red, pale, tremble, sweat; it makes sudden cold and heat come over all the body, palpitation of the heart, syncope, etc. It amazeth many men that are to speak or show themselves in public."
One of the poet W.H. Auden's greatest works, published in 1947 in the aftermath of World War II, was called The Age of Anxiety. As Stossel puts it in My Age of Anxiety, "Every generation, going back to Periclean Greece, to second-century Rome, to the Enlightenment, to the Georgians and to the Victorians, believed itself to be the most anxious age ever."
Every generation, going back to Periclean Greece … believed itself to be the most anxious age ever.
Kate* has been anxious since childhood. At school, she says, tougher children often took her under their wing and looked after her, but that wasn't an option when she reached adulthood. (And anyway, she points out, such relationships are emotionally unbalanced, with the stronger person dominating.) Kate took a science degree at university, with her curiosity about her own experience leading her to major in psychology. Now a mother of three, she tries to help herself, but has also been formally diagnosed with generalised anxiety disorder by a psychiatrist. She has used Xanax and beta-blockers, the side effects of which she found to be worse than the original problem.
"The worst part for me is social phobia," she says. Painfully shy as a child, she still can't control her sweating and blushing and stammering when she finds herself in public. Parties are generally not on. The night before we speak, she'd been to an 18th birthday party and got through it in a haze. She couldn't speak at her own wedding.
"As I'm talking, I'm watching myself talk and judging whether that is going well or not, and how it might be judged from the other person's point of view," she explains. "An incredible amount of effort goes into trying to make sure I'm coming across okay, and it just ends up being this spiral. The more you are judging yourself, the worse it will become. And you're quite aware that it's visible, especially when you start blushing. I know it's impossible to work out what another person is thinking, but that doesn't stop me trying."
Her only reliable solution is to withdraw. "Immediately there's a sense of relief," she says. "You're out of it, you're away, and it's fine. And that effectively reinforces withdrawal. I've got years' worth of withdrawal behind me."
The nature-versus-nurture debate colours research into anxiety. Yes, it runs in families, but is that due to genetic inheritance or the anxious environment in which the children are raised, becoming their own anxious parents?
The influential Harvard professor of psychology Jerome Kagan spent two decades studying more than 450 healthy children, born without medical complications, to assess what combination of temperament and life history produces an "excessively fearful or anxious adolescent or adult". He reported that most babies with "high reactive" symptoms of anxiety – responding to external stimuli with agitated limb movement, muscle spasticity, and an occasional arching of the back, accompanied by fretting and crying – had become less fearful, and begun to resemble typical children, by the time they were four-and-a-half years old. None, however, became "consistently extroverted", he wrote. "The temperament of the high reactive infants constrained their development of an extremely extroverted personality rather than causing a fearful, anxious personality in most of these children."
By the time they were seven, half the high reactive had a serious fear of kidnapping and other dangers, compared with only 10 per cent of the low reactive kids. Interestingly, Kagan found guilt to play a large part in the most inhibited children. They "also displayed extreme sensitivity to criticism over violation of standards they believed were appropriate. That is, they seemed as prone to guilt as to fear and anxiety."
So what level of anxiety is an inevitable product of the times we live in, and when does that become a medical issue? A UN study of 15 different countries in 2017, looking at teleworking, found that 41 per cent of "highly mobile" employees (those who more often work from home) considered themselves highly stressed, compared to only 25 per cent of those who worked only on-site. The home workers' higher reliance on smartphones and laptops, as well as their comparative social isolation, contributed to higher stress levels and insomnia.
Mark Ryan, head psychiatrist at the Sydney neuroCare clinic, specialises in sleep disorders and the link between sleep and physical and psychological well-being. "The elephant in the room is sleep," he says simply. "Anything less than six hours a night is going to lead to significant cognitive impairment." And that, he says, bumps up a range of symptoms, including anxiety. He quotes Jerome Kagan on the nature/ nurture debate, pointing out that even if childhood testing suggests you're the kind of person who's more likely to react to things, it doesn't mean you're doomed to high anxiety if you can arrange your environment, or life, well.
We don't have psychological problems, we have problems in living. As a psychotherapist, what I do is help people have a life that will work.
"We use drugs and cognitive behaviour therapy to treat anxiety, but when you carve it all up, there's still a missing link," he says. "With a top-down approach, we're only treating the shadows. We only see one thing at a time and people end up taking a lot of drugs." He maintains there's a huge placebo effect in many patients relieved by taking medication, refers glancingly to the commercial interests of big pharmaceutical companies in treating anxiety, and says much of the anxiety he sees is learned.
Canadian academic Jordan Peterson was a psychology lecturer with a large student following before his recent notoriety. In one of his earlier online lectures, he quotes the Austrian psychiatrist Thomas Szazs on "the myth of mental illness". "We don't have psychological problems, we have problems in living," Peterson says, "and often what I'm doing as a psychotherapist is helping people have a life that will work."
In Sydney, Richard Wu emphasises life skills, too. "You know, if you put a bunch of rats together, their stress levels will go up," he says. "Well, we're living in increasingly dense urban areas … and people are worried about retrenchment and mortgages. There are things happening at a philosophical level as well. Nietzsche talks about "moral chaos": without the institutions and the beliefs we once had, we are chasing mediocrity in increasingly narcissistic ways."
Steve the lawyer knows his anxiety was heightened by a stressful period at work, though he emphasises how kind his firm was when the crunch came. "When I joined the firm in the mid-1980s, it was the tail-end of what I would call the 'golden era' of the law as a profession, where the lawyer's role was to give advice and his expertise was respected for that," he says. "Now law firms, for a start, are global conglomerates. In a sense, I was unlucky that the world was changing around me. All of a sudden, far from just being a lawyer, you're expected to be a businessman, with these targets for billing that were increasingly onerous.Although I more or less managed to do it, increasingly I realised it was too much pressure. I just didn't want to do it; it wasn't really where my talents lay."
He is happy with his current lot as a freelance writer. "I'm much poorer, but happier and considerably healthier."
* Names have been changed.
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