On April 13, 2004, at 2 o’clock in the afternoon, I, then 34 years old and working as a senior editor at The Atlantic and dreading the publication of my Sargent Shriver biography, presented myself at the nationally renowned Center for Anxiety and Related Disorders at Boston University. After meeting for several hours with a psychologist and two graduate students and filling out dozens of pages of questionnaires, I was given a principal diagnosis of “panic disorder with agoraphobia” and additional diagnoses of “specific phobia” and “social phobia.” The clinicians also noted in their report that my questionnaire answers indicated “mild levels of depression,” “strong levels of anxiety,” and “strong levels of worry.”
Why so many different diagnoses? And why were they different from the diagnoses of my youth (“phobic neurosis,” “overanxious reaction disorder of childhood”)? Had the nature of my anxiety changed so much? How can we make scientific or therapeutic progress if we can’t agree on what anxiety is?
Even Sigmund Freud, the inventor, more or less, of the modern idea of neurosis—a man for whom anxiety was a key, if not the key, foundational concept of his theory of psychopathology—contradicted himself over the course of his career. Early on, he said that anxiety arose from unexpressed sexual impulses (anxiety is to repressed libido, he wrote, “as vinegar is to wine”). Later in his career, he argued that anxiety primarily arose from unconscious psychic conflicts. Late in his life, in The Problem of Anxiety, Freud wrote: “It is almost disgraceful that after so much labor we should still find difficulty in conceiving of the most fundamental matters.”
Today, the American Psychiatric Association’s Diagnostic and Statistical Manual (now in its just-published fifth edition, DSM-5) defines hundreds of mental disorders, classifies them by type, and lists, in levels of detail that can seem both absurdly precise and completely random, the symptoms a patient must display (how many, how often, and with what severity) to receive any given psychiatric diagnosis. All of which lends the appearance of scientific validity to the diagnosing of an anxiety disorder. But the reality is that there is a large quotient of subjectivity here (both on the part of patients, in describing their symptoms, and of clinicians, in interpreting them). Studies in the 1950s found that when two psychiatrists evaluated the same patient, they gave the same DSM diagnosis only about 40 percent of the time. Rates of consistency have improved since then, but the diagnosis of many mental disorders remains, despite pretensions to the contrary, more art than science.
In the spring of 2004, such was my terror over the looming book tour that I sought help from multiple sources. I first went to a prominent Harvard psychopharmacologist. “You have an anxiety disorder,” he told me after taking my case history. “Fortunately, this is highly treatable. We just need to get you properly medicated.” When I gave him my standard objections to reliance on medication (worry about side effects, concerns about drug dependency, discomfort with the idea of taking pills that might affect my mind and change who I am), he resorted to the clichéd—but nonetheless potent—diabetes argument, which goes like this: “Your anxiety has a biological, physiological, and genetic basis; it is a medical illness, just like diabetes is. If you were a diabetic, you wouldn’t have such qualms about taking insulin, would you? And you wouldn’t see your diabetes as a moral failing, would you?” I’d had versions of this discussion with various psychiatrists many times over the years. I would try to resist whatever the latest drug was, feeling that this resistance was somehow noble or moral, that reliance on medication evinced weakness of character, that my anxiety was an integral and worthwhile component of who I am, and that there was redemption in suffering—until, inevitably, my anxiety would become so acute that I would be willing to try anything, including the new medication. So, as usual, I capitulated, and as the book tour drew closer, I began a course of benzodiazepines (Xanax during the day, Klonopin at night) and increased my dosage of Celexa, an antidepressant I was already taking.
But even drugged to the gills, I remained filled with dread about the book tour, so I went also to the Boston University center, and was ultimately referred to a young but highly regarded Stanford-trained psychologist who specialized in cognitive-behavioral therapy. “First thing we’ve got to do,” she said in one of my early sessions with her, “is to get you off these drugs.” A few sessions later, she offered to take my Xanax from me and lock it in a drawer in her desk. She opened the drawer to show me the bottles deposited there by some of her other patients, holding one up and shaking it for effect. The drugs, she said, were a crutch that prevented me from truly experiencing and thereby confronting my anxiety; if I didn’t expose myself to the raw experience of anxiety, I would never learn that I could cope with it on my own.
She had a point, I knew. But with the book tour approaching, my fear was that I might not, in fact, be able to cope with it.
I went back to the Harvard psychopharmacologist (let’s call him Dr. Harvard) and described the course of action the Stanford psychologist (let’s call her Dr. Stanford) had proposed. “You could try giving up the medication,” he said. “But your anxiety is clearly so deeply rooted in your biology that even mild stress provokes it. Only medication can control your biological reaction. And it may well be that your anxiety is so acute that the only way you’ll be able to get to the point where any kind of behavioral therapy can begin to be effective is by taking the edge off your physical symptoms with drugs.”
At my next session with Dr. Stanford, I told her I was afraid to give up my Xanax and related what Dr. Harvard had said to me. She looked betrayed. After that, I stopped telling her about my visits to Dr. Harvard. My continued consultations with him felt illicit.
Dr. Stanford was more pleasant to talk to than Dr. Harvard; she tried to understand what caused my anxiety and seemed to care about me as an individual. Dr. Harvard seemed to see me as more of a general type—an anxiety patient—to be treated with drugs. One day I read in the newspaper that he was administering antidepressants to gorillas at the local zoo. Dr. Harvard’s treatment of choice for the gorillas in question? SSRI antidepressants, the same class of medication he had prescribed for me.
I can’t say for certain whether the drugs worked for the gorillas. Reportedly, they did not. But could there be a more potent demonstration that Dr. Harvard’s approach to treatment was resolutely biological? For him, the content of any psychic distress—and certainly the meaning of it—mattered less than the fact of it: such distress, whether in a human or some other primate, was a medical-biological malfunction that could be fixed with drugs.
Not all therapists have such black-and-white views; many find room both for medication and for other kinds of therapy. Some cognitive-behavioral therapists, for instance, use certain drugs to enhance exposure therapy. And neuroscientists increasingly recognize the power of things like meditation and traditional talk therapy to render concrete structural changes in brain physiology that are every bit as “real” as the changes wrought by pills or electroshock therapy.