In Medical Decisions, Dread Is Worse Than Fear

Procrastination, on the other hand, may not be so bad.
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Anxiety, like pain, is one of those amorphous symptom categories that are about as precise, taxonomically, as the two-letter state code on an envelope.

Psychiatric diagnoses help get us a little closer—perhaps to the zip code level—by separating out behavioral clusters like panic, anorexia, or obsessive-compulsive disorder. But there’s still a dearth of precision in the language used to describe the emotional states—fear vs. worry vs. dread—that these conditions entail.

In the spring of 2007, I was privileged to work with Martin Goldstein, a neurologist at Mount Sinai, on a functional MRI study of anticipatory anxiety, also known as dread. To understand how dread differs from fear, consider the difference between waiting in the lounge for a painful dental procedure and actually watching the drill coming at your mouth. Goldstein and his team were among the first to identify the activation of a collar-shaped brain region called the anterior cingulate cortex (ACC) in dread. They have studied this region in both healthy and pathological states.

More recent work on the topic made news when, this past fall, a group of British researchers demonstrated that people will electively endure extra pain just to avoid dread. Giles Story and his London team offered study participants the choice between less pain in the form of an electrical shock later, and more pain now. People consistently chose to experience electric shocks rated a 6 out of 10 immediately rather than to wait for a 4 of 10 in 15 minutes.

“When faced with the choice of whether to have a painful medical or dental procedure right now or in the future, many people opt to ‘get it out of the way now,’” Story and his colleagues wrote.

In other words: We would rather suffer more now than wait for less suffering down the line. The finding has implication for decisions we make in every aspect of our lives, but perhaps most obviously in healthcare. To what lengths will patients go in terms of present suffering in order to avoid dread?

A series of recent studies on prophylactic mastectomies, for example, has demonstrated the role of anxiety in leading women to opt for unnecessary breast removal. When women are diagnosed with cancer in one breast, some opt to have the contralateral breast removed as well. In many cases, these women are fully aware of the actual, numerical risk (or lack thereof) involved in these decisions.

“Despite knowing that CPM [contralateral prophylactic mastectomy] does not clearly improve survival, women who have the procedure do so, in part, to extend their lives,” Rosenberg and colleagues wrote in a September study in the Annals of Internal Medicine. These procedures are expensive and the recovery, even without complications, is long and painful.

One of the solutions Rosenberg proposed was “interventions aimed at improving risk communication.” Meaning that, perhaps if healthcare providers can help patients more rationally assess the risks for now versus later, they can help them avoid unnecessary suffering. To do so, providers will have to help patients address the assumptions that enable get-it-out-of-the-way decision-making.

What, for example, is the "it" in "get-it-out-of-the-way" thinking? The pain or consequence one wishes to avoid are often moving, even unknowable, targets. In pathological anxiety states, estimations of what “it” is are part of what goes awry. Patients with phobias consistently overestimate the degree of unpleasantness of a particular exposure.

Timing is also an important contributor to dread. As Story has explained, in the week before a painful dentist appointment, the dread builds exponentially. Outside of that week, dread is less of a factor. Helping patients see that time pressure for what it is is an important piece of “risk communication.”

Another part of dread is coping with uncertainty. Patients who avoid dread may not be appropriately assessing their own coping skills. Obsessive-compulsive patients pathologically underestimate their own capacity for tolerating uncertainty, and access compulsions as protection from uncertainty.

Reframing these assumptions is not simple. Cognitive therapy, a core aspect of most forms of psychotherapy, helps patients advance toward such clarity over the course of many weeks, and many hours of repeated exercises. Anxiolytic medications like Xanax act more crudely, by helping to quiet the most terrified parts of the brain so they don’t dominate the patient’s decision-making process.

In this regard, it will be interesting to see how patients taking prescriptions for anxiety weigh the recent findings about increased mortality associated with anxiolytics. How will anxiety patients weigh their need for immediate relief against the longer-term negative outcomes now associated with such drugs?

Even for those without an anxiety disorder, it can take time and training in order to diminish undue influence of anxiety on thinking about something like cancer risk. All of us stand to gain from a more objective understanding of how dread leads us to elect to endure more suffering than we otherwise might.

I was recently at a loss, for example, when my mother underwent several rounds of expensive and invasive testing to investigate an incidental medical finding. Her physician had indicated that these tests were necessary. I tried to reframe the decision for her based on the medical literature. In my view, there was no clear indication that she needed these tests and, in fact, the screening procedure used by her doctor to find the initial abnormality has been broadly condemned by various professional societies.

Over and over again she repeated, before each test, “I just want to get it done with.” The testing revealed no abnormalities. I have spent much time in the weeks since trying to figure out how I might have intervened differently in order to spare her the cost, the stress, and the radiologic exposure.

Get-it-out-of-the-way thinking is probably inversely related to our capacity for procrastination. I am a horrible procrastinator, but I have learned over the years that sometimes—occasionally—if you procrastinate long enough, the problem really does go away.

But it’s not the kind of outcome you want to bank on. But neither is the elective, preemptive, 6 out of 10 electric shock. There is room for all of us, as patients, to learn how to better weigh risks, and to identify dread as the product of often-flawed calculations. There’s already enough inevitable suffering; let's start looking for the pain we can avoid.

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Gabriella Rosen Kellerman, MD, is a physician and writer based in Berkeley, California. She has written for The Discovery ChannelScientific American, and In Our Own Hands, a forthcoming documentary about technology democratizing health care.

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