Poe's Heart and the Mountain Climber: Exploring the Effect of Anxiety on Our Brains and Our Culture

“Pulls seamlessly from psychology, medicine, history, and popular culture to explore anxiety from all angles and offer advice on managing it.” —O, The Oprah Magazine

Richard Restak, M.D., is a neurologist, neuropsychiatrist, and clinical professor of neurology at George Washington University Medical Center in Washington, D.C. He is the bestselling author of thirteen acclaimed books about the brain, including Mozart’s Brain and the Fighter Pilot.

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Our Anxious Culture

Triggers for Anxiety

Unfortunately, our brain isn't very proficient at probability estimation. Take an airplane phobia, for instance. Untold numbers of people suffer from a fear of flying, an anxiety condition that can range from the mildly discomfiting to the totally incapacitating. Most of us can bring to mind one or more acquaintances who refuse to step onto an airplane under any circumstances. More numerous are anxious flyers like myself who travel by air on a regular basis, but only in the absence of any reasonable or convenient alternative. Yet if you look into the statistics of air travel, behind all this you come up with a fairly astounding figure that logically should greatly reduce airline jitters.

Statistically, a specific air traveler would have to get on a commercial airplane daily for more than eight thousand years before falling victim to a multiple-fatality airplane crash. Death is much more likely to occur in the car used to travel to and from the airport. Car accident fatalities happen with a frequency of 1 in 18,800, with a significantly decreased risk if the traveler leaves the driving to a professional: Bus and train accident fatality statistics are 1 in 4,400,000 and 1 in 5,050,000, respectively. Motorcycles are associated with a 1 in 118,000 risk of death. Nor is walking the streets risk free (you have a 1 in 45,200 risk of being struck by a car).

While most of us experience some mild anxiety about travel risks, we tend to forget about the greater statistical risks involved if we confine our lives to the place where we feel the safest: our own homes. On lists of the world's most dangerous places, the home ranks second (the highway takes top honors).

In addition, we tend to be most anxious about grisly or horrific--albeit unlikely--possibilities. Think back a few summers ago when vacationers along East Coast beaches spent precious afternoon hours anxiously scanning the ocean waters for sharks. Death from a shark attack occurs at a rate of only about 1 in 94,900,000, a paltry number compared to death from drowning (1 in 225,000), skin cancer due to prolonged unprotected sun exposure (1 in 37,900), or even injuries from being struck by lightning (1 in 4,260,000). Despite these figures, many vacationers opted to play it safe by abandoning the beaches in favor of a few hours of boating--apparently oblivious of the fact that fatal boating accidents occur with a frequency of 1 in 402,000.

Even the most publicized of recent anxiety-provoking events involved more moderate risks than is commonly believed. While 2,801 people died in the World Trade Center attacks, about 15,000 people escaped the buildings; while 12 people died in 1995 after cultists released sarin nerve agent on three Tokyo subway lines, only 5,500 passengers out of the hundreds of thousands riding the trains that day required medical treatment; while 5 people died during the anthrax scare in the fall of 2001, infectious-disease experts estimate that many more people were exposed to the organism but failed to come down with the disease.

Here is a test (which I failed, incidentally) that can serve as a reality check on your own ability to accurately measure risk assessment. Please answer the following question about the likelihood of your becoming a victim of a terrorist attack: "If you won a free trip to one of the following places, which trip would you most likely pass up because of anxiety about personal safety: Israel, Istanbul, Bali, or New York City?"

Writer Wendy Perrin asked that question in late 2002 of 13,857 Conde Nast Traveler subscribers. Eighty-five percent felt Israel was too risky; 29 percent would avoid Istanbul, 56 percent wouldn't go to Bali because of the number of people killed there in the bomb blast earlier that year; but only 1 percent said they would pass on a free trip to New York.

While Israel scores highest in terms of perceived danger (only 15 percent of respondents would accept a no-obligation, no-strings-attached free trip) and New York seems quintessentially safe and universally desirable (99 percent of the respondents were ready to start packing their bags), statistics provide reasons for perhaps a more nuanced approach.

In the recent past, New York has seen more casualties from terrorism than anyplace in the world. In addition, most experts on terrorism place New York at the top of any list of potential terrorist attacks (Washington, D.C., comes in second, which, as a Washingtonian, I don't personally find reassuring). But despite the far more numerous casualties that accompanied the collapse of the Twin Towers, and the heightened risk of more attacks in New York in the future, almost all of Wendy Perrin's respondents said they would accept a free trip to New York.

Despite the meager 15 percent acceptance rate for a free trip to Israel, an argument can be made that even that conflicted and fragmented country is safer than New York--at least it was in 2002, when 202 Israelis had died at the hands of terrorists, compared to ten times that number of deaths in New York the previous year. Indeed, Israel's terrorism death toll--measured in fatalities per hundred thousand residents--is much lower than the annual homicide rate in New York and dozens of other U.S. cities.

What can explain these poll results? I suspect most people find New York less threatening than anywhere in Israel, Indonesia, or Turkey simply because New York is more familiar. As a rule, we tend to be most anxious when dealing with the novel or the unknown. This was true even before the emergence of terrorism; upcoming trips to new places creates in most people a mix of pleasurable anticipation coupled with a dollop of anxiety about whether events would proceed without a hitch.

In our more threatening world, it's only natural for us to envision something bad happening in unfamiliar rather than familiar places (one of the reasons videos of the fall of the Twin Towers still seem so nightmarish). The same thing holds true in regard to illnesses. We fear smallpox, anthrax, and SARS not only because they are so deadly, but also because we have no experience with such diseases. And the anxiety resulting from such uncertainty skews our thinking toward illogical conclusions.

Two factors determine the risks we're willing to take. The first is our risk perception--our estimation of the likelihood of a bad outcome. Access to information can influence risk perception, but only up to a point. For example, a year or so ago each of us was asked to decide this question: Should I take the smallpox vaccine? Experts on vaccines and public health weren't much help in deciding this question because of their disagreement about whether the remote threat of terrorist-initiated smallpox epidemic justified a mass inoculation.

As a result of this lack of expert agreement, each of us was left to decide on our own whether to find and take the vaccine. Most people didn't have a clue what to do and, as a result, felt anxious because they were being asked to make a potentially life or death decision about something they were professionally unqualified to evaluate or in many instances even understand. As a result, few American took the vaccine. Yet based on historical experience, such unwillingness doesn't make a lot of sense: The fatality rate from the vaccine can be expected to be no more than 1 in 750,000, a number that would be dwarfed by the fatalities and disabilities that would result from a terrorist-created smallpox epidemic.

Perhaps you consider a 1 in 750,000 chance of death unacceptable? If so, you should stop riding bicycles (1 in 341,000 chance of death) and stay out of swimming pools (1 in 225,000).

Risk tolerance, the second factor, is our willingness to accept foreseeable risks and move on. While two people may share a common risk perception (on many occasions a distorted one, as discussed above), one person may be willing to accept the risk, but the other won't.

For instance, several years ago I had an epileptic patient under my care who experienced frequent and life-threatening seizures despite trials on numerous anticonvulsants. Finally, I found a drug that worked. My patient's seizures stopped and, as a pleasing side effect of the new drug, she lost thirty pounds of excess weight. Everything was going swimmingly until six months after I started her on the drug.

While sorting through my mail one morning, I opened a letter from a pharmaceutical company sent to every neurologist in the nation warning of potentially fatal bone marrow and liver toxicity resulting from the use of my patient's drug. According to the letter, such complications were rare. Though troubling, the risk seemed acceptable to me; that is, if I were the patient, I would have continued with the drug. For one thing, regular checks on blood and liver function could detect these problems at an early stage. If the drug was then withdrawn, an affected patient would have a good chance for a complete recovery. But when I sat down with my patient and explained the situation to her, she opted to discontinue the drug because she considered the risks unacceptable. At her insistence, I switch her to another anticonvulsant. Over the next year, she experienced several seizures and regained the weight she'd lost.

What would you have done if you were in her situation? Would you have elected to remain seizure free and at an optimum weight for your age and height, but at a small risk for developing a serious side effect from the medication? Or would you have decided that the risk was simply too high? What would have been your risk tolerance in this situation?

In an attempt to gauge risk tolerance, Wendy Perrin asked the Conde Nast respondents a variation on her initial question: "How high a risk of a terrorist attack would you be willing to accept before canceling a pleasure trip?" More than half of them (53 percent) said they would not go if the odds were 1 in 100,000 or greater. Acting on the basis of such a low risk tolerance would preclude driving, walking the streets, or holding a job.

No, the human brain, it turns out, isn't very good at calculating odds. What's worse, it tends to overestimate the likelihood of rare, albeit painful or dangerous, experiences. And while this risk intolerance can provide a certain measure of security ("better safe than sorry"), it also deprives the anxious person of a great many of life's pleasures. Attempts to guarantee an unrealistic sense of security in an insecure world lead to many of the anxiety-driven behaviors we will discuss in more detail later in this book: phobias, obsessions, compulsions, panic attacks, and, most frequent, generalized anxiety disorder.

But the media is probably the greatest contributor to anxiety in our culture. In his book The Culture of Fear, sociologist Barry Glassner observed that "any analysis of the culture of fear that ignored the news media would be patently incomplete, and of the several institutions most culpable for creating and sustaining fears the news media are arguably first among equals." And while Glassner wrote about "fear," his observations are actually more descriptive of anxiety.

Certainly, on our local and national new programs, crime and disaster stories make up by far the greatest portion of the broadcasts. Nor are the newsmagazines any different. They adhere to the operating principle that we live in the midst of untold numbers of threats to our physical and mental health. As Glassner put it, "the guiding principle seems to be that no danger is too small to magnify into a national nightmare."

Television writers and commentators, it seems, have unwittingly adapted as their operating principle some advice once offered by Richard Nixon: "People react to fear, not love. They don't teach that in Sunday school, but it's true."

We have only to look around us to encounter applications of that philosophy: According to marketers, no home is safe without an elaborate burglar-alarm system; and increasingly sophisticated firewalls must be installed to keep out computer viruses and worms. While anxiety works as a great motivator, how much is too much?

Consider this question, asked in an editorial in the magazine Anxiety Culture, which advocates the maverick but nonetheless intriguing view that the anxiety level of the general population relates to the volume of sales of consumer goods: "Is there an optimum level of consumer anxiety (optimum from the point of view of the seller) at which the amount of sales of consumer goods is greatest?"

This "optimum level" would obviously land somewhere between two extremes. At one end of the scale, the consumer never buys anything because of being too scared to go outside or being too anxious to spend more money than absolutely necessary. At the other end of the scale, the person is so content already (i.e., he or she has a complete lack of anxiety) that there is no need to consume and no desire to purchase status symbols.

The editorial goes on to suggest that this optimum level of anxiety might be maintained by our constant exposure to the media's focus on crime and violence in news, current affairs, television drama, and films.

Nor is it just insurance and burglar-alarm sales that benefit from public anxiety. Some of us are willing to run up huge levels of debt to acquire those items we are led to believe might quell our social-comparison anxieties. Exactly how much we will go into debt before our financial anxiety overrides our social-status anxiety varies from person to person.

In short, in order to sell newspapers, boost TV ratings, or peddle commercial products, it helps to create anxiety in readers, viewers, and purchasers. Causes for that anxiety can range from comparatively trivial concerns such as whether you suffer from bad breath (and therefore should be popping "oral care" strips of Cool Mint Listerine throughout the day) to more weighty worries like whether this might be the day terrorists have chosen to carry out a deadly sarin attack during your daily subway ride to work.

And while anxiously mulling over these matters, you're likely to encounter on the morning news an advertisement encouraging you to undergo expensive laser surgery for the "correction" of the perfectly harmless condition of myopia (nearsightedness). Moments later you may encounter another advertisement suggesting that you can vastly enhance your appearance and sex appeal by buying a new pair of glasses. The hook here consists of the subtle suggestion that somehow your glasses are unbecoming. And although each of these two advertisements advocates an opposite course of action, they both share a common approach: arousing your anxiety that your present situation isn't acceptable, that you must either undergo corrective surgery or buy new glasses.


From the Hardcover edition.