Taming the Anxious Brain

The temptation to condemn modern society (and psychology) as "obsessed with medicating all our problems" is strong, but I am never exactly sure how compelling it is.  It is true that medication of first-worlders for psychiatric illness has expanded greatly in the last few decades.  It is also true that many of the drugs most commonly prescribed - antidepressants, anxiolytics, sleeping pills - can cause a lot of problems and fail to treat the illness they are prescribed for.  Anxiolytic drugs are among the worst culprits, carrying a litany of dependency issues, producing excessive sedation, and potentially disrupting important enzymatic activity and promoting cognitive decline.  Despite all this, it is hard for me to say with any confidence that some worst case patient - say, an individual misdiagnosed with anxiety disorder and dependent upon benzodiazepenes with little impact on the condition that brought them to seek attention - would be better off a century ago.  Would they have adopted some coping mechanism, such as smoking or drinking, that would be more deleterous?  Would they have lived reasonably well as a ditch-digger somewhere?  Who can say?  I also feel that while overmedication still happens, it is nothing compared to the psychiatric practices of the 60s, 70s, and 80s.  We do not see Lenny Bruce, God rest him, coming back from the doctor with IV methamphetamine for "fatigue".  Quaaludes and other barbituates were successfully phased out because of their sharp dosage curve and severe dependency issues.  Etc.

I don't say this to be dismissive, but I do sometimes worry that the sentiment of concern over medication may produce poor outcomes in needy patients.  For example, the Waco clinic I worked in this summer was hesitant to distribute benzodiazepenes for anxiety, opting for one of a few antidepressants or buspar as a substitution.  From my understanding, these drugs do not work as well in many patients.  Benzodiazepenes are the best remedy available for a lot of people, even if they are dangerous.  Is it medically preferable to try a different drug first?  I would be very interested to see a study tracking anxiety patients across treatment 'roadmaps', because it could well be that substantial populations recover or are found to have another condition if treated with an alternative first.

I think that Vidya’s question about an acceptable level of anxiety is important.  There is a very fine line between constructive and detrimental anxiety.  For example, I had a friend that was extremely anxious during one finals period and began suffering minor panic attacks.  She went to the doctor and they offered to give her anti-anxiety medication; however, she decided not to take the medication because she feared that without stress as a motivator, she would not produce high quality work.  I am still conflicted about whether or not this was the correct decision.  It is possible that she did better on her finals because of her anxiety, but was this healthy?  On the other hand, at a certain point people become nonfunctional when they are under too much stress.  Additionally, would she have made the same decision if she were under less stress?  I feel that this brings up a flaw in David’s suggestion to allow people to make the decision whether or not they should be treated for anxiety: people in a very anxious state may not have the capacity to make a rational decision about what is best for their health.

I completely agree that anxiety has an adaptive role in human nature. Anxiety, like depression, may actually be helpful in certain circumstances. If anxiety were not somewhat advantageous I doubt it would still be universally ingrained in all of us. It is not surprising then that anxiety and depression are highly comorbid because both emotions can be used as helpful coping mechanisms albeit in many but not all situations. Depression allows you to grieve and reevaluate life in a slower self-reflective manner while anxiety jump starts the mind and body to pay more attention to something and react in an appropriate manner. It's a shock to the heart and brain. Moderate anxiety helps us act in stressful or important situations. The mind shocks the body into form and vice versa. This reaction makes us more conscientious, careful, and self-aware. However, when anxiety goes into overdrive it consumes the mind and body to only pay attention to the anxiety rather than being a mere catalyst for greater awareness of self and the complete situation at hand. I also agree that each person's neural signature may affect their interpretation of an intense emotion such as anxiety. Yes, society, especially fast-paced societies may exaggerate anxiety in many. Perhaps extreme anxiety was not a problem among cavemen. However, every person's consciousness creates their own reality. So what does it really matter if one person gets overly anxious in certain situations while another person doesn't? If a person's conscious reality seems harmfully anxious then that is all that really matters. If they sense that their emotions are traumatizing and a clinician agrees then what use is it to argue that if some people can handle it then all of us can? We each have our own pain-thresholds but those who can tolerate less should not be deemed weaker. Perhaps the overly anxious person is just better equipped for a different reality than the one they are in. In terms of treatment I wonder, does a medication that eases anxiety change a fundamental component of their reality? Are the medicated less in touch with their conscious nature than are those solely in therapy?

I like the idea that some people may be more likely to struggle with anixety than others, but that some of those people will be better able to control it than others.  Personal situation may have a lot to do with it.  Some people genuinely do have more to worry about than others, and this may affect a person's ability to cope with abnormal anxiety levels.  The Harvard student, originally labeled as a high-reactive type, overcame her problems with anxiety.  Part of this may be due to the fact that she is the kind of person who can get into Harvard.  She is obviously intelligent and hard-working, and probably found academic success in high school relatively easy to come by.  According to the NYT article, she is also a talented dancer, which is something else that would set her apart from other people in a positive way.  Baby 19, on the other hand, may be more of an average person.  She may have found it harder to be an A student and to really excel at something.  She may have felt she had less control over her success as a student than the Harvard student did.  I think a sense of control may be a key factor in handling abnormal anxiety.  This may explain why nursing homes make so much use of medications for anxiety.  That may be partly due to overprescribing, but anxiety may actually be more prevalent in nursing homes, simply because the residents have lost some of the control they once had over their own lives.

Lots of intriguing parallels between this conversation on anxiety and our earlier ones on depression, culture, consciousness, and the brain's role in experiencing.

As with depression, the "experiencing it" seems to be a significant factor in anxiety, one that can make things worse or better.  And as with depression, there are connections to culture, both in generating the problem and, potentially in alleviating it.  And, as with depression, there are issues of adaptive value (rather than simply of "illness").

I'm intrigued by the conversation about the James-Lang theory of emotion in connection with anxiety, the idea that anxiety may originate in bodily sensations themselves originating either in responses to threatening inputs or in threatening thoughts/ideas of one's own (or originating in genetic propensities).  My guess is that there's a nice parallel here with depression as well: bodily sensations that may be endogenous and/or be triggered by external input and/or by thoughts/ideas. 

I'm also intrigued, in the discussion here, by the concern without "anxiety" or "stress", one wouldn't be "oneself" or would lose "their motivation."  There are cultures without "intense productivity goals" and the individuals in them seem to do pretty well.  More generally, I suspect we overestimate the need for "outside forces" to cause motion (cf Making sense of the world: the need to entertain the inconceivable).  My guess is that there's enough going on in the nervous system to assure that people would act without strong external motivational factors.

Perhaps this all relates as well to the problem of "two behavioral outcomes from the same brain state"?  I don't actually see this as so problematic, as long as one bears in mind that "the same brain state" refers not to the entire brain but rather to a particular part of it (whatever part is being imaged, or inferred, or whatever).  One part of one's brain can be generating signals that result in bodily sensations of anxiety and another part can be experiencing those sensations and deciding how to act. One's behavior, "for the same brain state" of the first part, differs depending on what the second part does. To put it differently, one's interaction is always the resultant of lots of different "brain states" inclining one's actions in a variety of different directions.  And this is probably enough to keep one going even in the absence of external motivational factors.

As we were discussing anxiety in class this week, we ended up focusing on treatment of anxiety disorders, and even more specifically on the question of the effectiveness of drugs vs. the effectiveness of CBT and other non-medication therapies.  One of the readings mentioned that highly anxious people may experience the same "brain states" as people who are not anxious but interpret them differently, as excitement or arousal instead of anxiousness.  This seems to indicate that CBT could be an effective treatment for anxiety: if a therapist could help a patient train themselves to recognize these brain states and learn to re-interpret them without relying on catastrophic thinking, the anxiety could be ameliorated or at least reduced.  However, if these types of treatments prove to be ineffective for patients, drug therapy could be attempted.  I also think it's important to consider the source of the anxiety.  Anxiety with an easily recognizable cause (a recent move to a nursing home, an upcoming exam or job interview) and overly anxious responses to an anxiety-causing event (throwing up before an exam) might be more easily treated with CBT than generalized anxiety with no discernable cause. 
Over-prescription of psychotropic medications is becoming a problem in modern times, giving people the tendency to medicate all of their emotions and increasing the false belief that a person must feel happy all the time, or there is something wrong.  Anxiety certainly has its benefits - anxiety is what forces us to study for a test that is coming up, what causes us to check to make sure our stove wasn't left on at the end of the night or that or door is locked.  Of course, any of these behaviors can be done in excess, but there is no use in treating everyday anxiety, just as it might be better not to treat sadness as depression.

 I wonder to what extent we overcomplicate things by asking where we should draw the line in severity of anxiety before we decide to treat it. Why can't it be an issue of which people want to be treated? As one of the readings suggested, one person can "interpret" an overactive brain as exciting, while another can "interpret the same brain state" as anxiety-inducing. With the glaring problems of this description aside (i.e., the ability to have two behavioral outcomes from the same brain state), I think that this point at least illustrates the nuances in diagnosing anxiety given the technology currently available to us. It seems to be extremely difficult, if not impossible, to pinpoint a single dimension by which to assess anxiety severity (e.g., brain activation, verbal report, subconscious behavior, etc.), let alone to choose some arbitrary cut-off point after which we should treat it. So it seems like a great way to determine who to treat is to determine who wants to be treated! Sure, there might be some problems with this approach. As Vidya mentioned, everyone has some degree of anxiety: will people start flocking to anti-anxiety medications before a big test? I'm not sure that that would actually happen. Also as Vidya mentioned, stress helps us in many situations by preparing us for a difficult situation ahead. Someone completely void of stress would likely lose their motivation to tackle those situations, and may thus miss out on the excitement of those accomplishments which, although once nervewracking, seem more fulfilling.