On Edge

A Conversation with
Andrea Petersen
Author of
ON EDGE
A Journey Through Anxiety
Crown; May 16, 2017
 
 
Q. First things first: How do you define anxiety?
A. The best definition I’ve heard is from a neuroscientist at the National Institute of Mental Health who told me that anxiety is the “anticipation of pain.” That pain can be physical or emotional. Anxiety is of course a common human emotion. It becomes a disorder when it is so severe and so constant that it impairs our lives and prevents us from doing the things we want to do. Of the eleven anxiety disorders that are listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM), specific phobia and social anxiety disorder are the most prevalent. Generalized anxiety disorder, panic disorder, and PTSD are also quite common. Many people who struggle with anxiety have more than one disorder, and anxiety disorders often also go hand-in-hand with depression.
 
Q. Which types of anxiety have you experienced?
A. My anxiety has primarily taken the form of panic attacks—abrupt surges of physical symptoms like shortness of breath and chest pain coupled with the overwhelming fear that I’m dying or going crazy—and crippling worry, often about my physical health and safety and that of my friends and family. When I have a headache, I think I have a brain tumor. When my husband is quiet, I don’t consider that he might just be tired—I’m convinced that he’s mad at me. (Of course, sometimes he actually is!) I can’t drive on highways, because I’m destined to have a panic attack when I do. When my anxiety was at its worst, I avoided movie theaters and standing in lines. (I was afraid of being trapped.) I also developed several bizarre fears, such as the fear of using new tubes of toothpaste and even licking envelopes. My anxiety can be incredibly physical. Besides panic attacks and the muscle tension that often goes along with worry, I’ve had neurological symptoms like tunnel vision, odd pains, and tingling in my arms and legs. Anxiety, for me at least, is a whole body state.

Q. In the book, you’re incredibly honest about how anxiety has affected you—even, at times, brought your life to a standstill. Did you have any hesitations about being so candid?
A. Definitely. I was very nervous about going public with my anxiety. I was worried about how it might affect my career as a journalist. Would my editors lose confidence in me or feel like I had to be coddled? Ultimately, I felt that anxiety was too important not to write about. In my reporting for the Wall Street Journal, I was hearing about how rates of anxiety disorders were rising among young people. And I was learning about new research revealing that anxiety is a serious risk factor for suicide; it is more closely linked to suicidal acts than depression is.
 
Q. You describe nearly every available therapy to combat anxiety, and you’ve tried most of them yourself. What are the most effective nondrug therapies for anxiety?
A. Cognitive behavioral therapy (CBT) is the most evidence-based nondrug treatment for anxiety disorders. CBT usually involves exposure, where you gradually face the situations that you fear, and cognitive restructuring, where you tackle catastrophic thoughts. CBT is what finally brought me relief in college. I’ve done several more rounds of it since then, and it has always been helpful for me: Research shows that about half of patients significantly improve after CBT. (People do often need booster sessions.) Acceptance and commitment therapy (ACT) takes a slightly different approach and is similarly effective. It includes exposure but also emphasizes mindfulness. There are also a growing number of studies looking at meditation and yoga, and results are encouraging. 
 
Q. What about medications for anxiety? Which ones have been proven to work?
A. The most commonly used medications for anxiety are antidepressants like Prozac and Lexapro and benzodiazepines like Xanax and Klonopin. Clinicians and many patients find that these kinds of antidepressants, selective serotonin reuptake inhibitors, ease anxiety. But in scientific studies, they often don’t work much better than placebos. There’s some evidence that they may be more effective at preventing relapse than treating acute illness. The benzos can relieve anxiety instantly. But they can also be addictive, particularly when combined with alcohol or other drugs. Overdose deaths involving benzos have risen alarmingly in recent years. So there’s clearly a need for new drug treatments. 

Q. You offer a fascinating—sometimes harrowing—history of treatments for anxiety. What are a few of the treatments that were tried and abandoned through the decades?
A. The nineteenth century was a heyday of eccentric treatments for so-called nervous disorders. Many people visited spas in the countryside or urban “hydros” where they were sprayed with water, alternately hot and cold, and then dunked into arctic swimming pools. The rest cure—which was most commonly prescribed to women—was also popular during this time: Patients were placed on a stringent regimen of bed rest, massage, and a high-fat diet rich in milk. Women diagnosed with hysteria—a condition with symptoms like nervousness, insomnia, and headaches—might be treated with “pelvic massage” with orgasm as the goal. (The vibrator was hailed as a huge treatment advance.) In the first half of the twentieth century, barbiturates were popular medications for anxiety and insomnia. But they were dangerous and addictive. The deaths of Judy Garland and Marilyn Monroe have been attributed to barbiturate overdoses. 
 
Q. On Edge is much more than your personal story—you also draw on your experience as a science and health writer at the Wall Street Journal to illuminate the science of anxiety. What is some of the most promising research happening now?
A. This is an incredibly exciting time in anxiety research. Because of advances in neuroimaging and genetics, scientists are developing biomarkers—such as certain patterns of brain activity or genetic profiles—that may soon be able to guide individual patients to the most effective treatments for them. There are also new treatments that target the particular brain dysfunctions that seem to underlie anxiety disorders. Anxious people often pay more attention to potentially threatening stimuli in their environment. Attention bias modification is a new therapy that often uses a simple computer game to combat this tendency and teach patients to pay more attention to benign stimuli. Other therapies show promise, too, like transcranial magnetic stimulation (TMS), where a device is placed above the scalp to generate a magnetic field and stimulate parts of the brain, and fMRI neurofeedback, where patients have their brains scanned and can see and modify brain activity in real time.
 
Scientists are also experimenting with medications, like D-cycloserine, that can boost the learning that takes place during CBT treatment. Some studies are finding that substances often used as party drugs, like ketamine (known as Special K) and MDMA (Ecstasy) can ease anxiety.
 
Q. How has anxiety affected your relationships?
A. Perhaps unexpectedly, anxiety has actually made many relationships—with close friends, my parents, and other family members—deeper and richer. Anxiety has made me more vulnerable and willing to ask for help and has made me more empathetic and able to relate to other people in pain. But anxiety has been hard on those who love me, too, especially when it has been at its worst.
 
Anxiety has been an occupying force in my romantic relationships, too. I’ve had boyfriends who were caretakers, as well as others who became bewildered and frustrated when I panicked or when anxiety prevented me from doing things. Eventually, I made it a policy to tell men about my anxiety by the second date. When I first told my husband, Sean, he wasn’t fazed. Then, early in our relationship, when we were on a hike in New England, I fell and broke my wrist—and had a massive panic attack. He called 911 and rode with me in the ambulance and, later, kept my apartment stocked with Tylenol and ice cream. I knew then that he was a keeper.
 
Q. Both when you were pregnant and as your daughter—now seven—has grown up, you’ve struggled with the fear that she might be predisposed to anxiety. Is there a genetic basis to anxiety disorders?
A. There is. Studies of twins have found that genes are responsible for 30 to 40 percent of the variation in the individual risk for anxiety disorders. Having a first-degree relative—a parent, sibling, or child—with an anxiety disorder bumps a person’s risk of developing one up to five times that of the general population. I can see how mental illness winds its way through my own family tree. My sister struggles with anxiety and several cousins deal with panic attacks. My father has been treated for depression. In the 1950s and 1960s, my grandmother spent several years in a mental institution. She was deeply paranoid, heard voices, and was diagnosed with schizophrenia: She once attempted to burn down her family’s home. Researchers have found that some of the same genes underlie many psychiatric illnesses, from schizophrenia to depression, and likely anxiety disorders, too.
 
Q. If a young child is at risk for developing an anxiety disorder—because of a family history or temperament—are there preventive treatments?
A. There are versions of CBT that are very effective at treating anxious kids. There are also new therapy programs designed for healthy children who have a genetic predisposition to anxiety disorders, like my daughter. Other programs are targeted at “behaviorally inhibited” children—shy, fearful kids who are at particular risk for developing social anxiety—and their parents. I visited a pioneering one at the University of Maryland where preschoolers learn social skills, such as making eye contact and negotiating conflict. Meanwhile, parents are taught to praise brave behavior (such as asking another child to play) and ignore anxious behavior (clinging to a parent during a playdate). Early results are pretty dramatic, and these programs have the potential to prevent a lot of misery.
 
Q. How has anxiety affected your career as a journalist?
A. This may sound strange, but in some ways, anxiety has actually helped my work. Reporters often have to learn new subjects quickly, synthesize the information, and make it understandable to readers. It is easy to make mistakes, and with social media, journalists’ screwups are very public. So insecurity and paranoia can actually be useful. Fear of messing up drives me to triple-check spellings and do extra interviews.
 
That said, anxiety is useful only up to a point. When my anxiety is at its worst, I can have a hard time concentrating and tasks can take longer to complete. Research has found that people with anxiety disorders can have difficulty making decisions and show deficits in spatial navigation and working memory. I felt this firsthand after September 11, when I was covering the anthrax attacks in New Jersey. My anxiety soared, and I ended up in the ER with a panic attack. And for the first time in my career, I couldn’t complete one of my stories: I let my editor down—and myself, too. Thankfully, that hasn’t happened since. I love being a journalist and have built a solid, rewarding career. Still, I sometimes wonder if I would have taken more risks in my career—maybe done more stints overseas, for example—if I didn’t struggle so much with anxiety.
 
Q. Rates of anxiety disorders and depression seem to be rising among young people, especially college students. Why do you think that is? 
A. Between 2008 and 2016, the number of college students diagnosed with or treated for anxiety problems jumped from 10 to 17 percent. For depression, the number rose from 10 to 14 percent. Educators and therapists don’t know exactly why this is happening, but they have some theories. Worries about the economy and the high cost of tuition, competition for grades and internships, and the influence of social media are a few. Some experts place some of the blame on parents who haven’t given their children enough autonomy or let them fail in middle school and high school, which means that when young adults face setbacks in college, they aren’t prepared. Also, college counseling centers do a lot more outreach now and there’s less stigma around having a mental illness among young people. So much of the rise may be because more students are comfortable enough to ask for help.
 
Many colleges now have student mental health organizations like Active Minds or peer support groups where young people struggling with mental health issues can get valuable support and understanding. When I visited the University of Michigan recently, several students told me that being involved in these groups was life changing.