In the Arcadian Woods

By GEORGE MAKARI

Anxiety: We worry. A gallery of contributors count the ways.

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Anxiety, psychiatry

Often I sense its electric energy during the initial phone call. Anxiety is like that. It leaps from you to me then back again like some unruly spirit. But that faint buzz reveals surprisingly little else about the being on the other end of the line. Who is not at times worried, nervous, troubled, frantic or even panicked? Anxiety may be an omen of vast import, or not much at all. Like the robot in the television series “Lost in Space” who proclaims “Danger, Will Robinson,” this primal alarm sends out its warning, but of what? As a psychiatrist, it is part of my job to find out.

After scheduling an appointment, my prospective patient has something new to worry about: me. For years, the press has been filled with stories of doctors who whip out their prescription pads after but a few minutes, or conversely, psychotherapists who turn up their noses at any “quick fix” that doesn’t plumb the deepest meanings of dread. Am I one of those caregivers who consider anxiety to be one thing only, always requiring my favorite remedy, be it based on neurotransmitters, attachment theory, or exposure and response prevention?

If so, my caller should be afraid. For the possible causes and meanings of anxiety are so varied that any one predetermined answer is sure to be often wrong.

Consider the many histories stuffed inside this little word. In pre-modern, Western Christendom, the Latin anxietas signified unease that often took its shape within a framework of sin, redemption and eternal judgment. Many who paced about with darkened brows had a fiery future flashing before them. Treatment for those anxious ones was available from physicians of the soul, Catholic priests who offered confession, among other consolations. The Reformation tore at this fabric and emphasized a Protestant’s private communion with the Lord. Thus, individuals were left to manage their own bad consciences. Even those endowed with an iron will like Oliver Cromwell nearly collapsed from the gnawing, unshakeable terror that they might forever burn. Kierkegaard and then the existentialists would riff on this theme of a dread that attends individual freedom and responsibility.

Henning Wagenbreth

Modern medical descriptions of anxiety developed in the 17th century. The Anglican divine, Robert Burton, in his 1621 compendium “The Anatomy of Melancholia,” worried about the burdens of the soul, but he mostly concentrated on describing natural varieties of alarm and unhappiness. He observed that those sick with anxiety simmered for long periods, then suddenly the “foul fiend of fear” caused them to turn “red, pale, tremble, sweat, it makes sudden cold and heat come over the body, palpitation of the heart, syncope, etc.” Thus, a man or woman could become “astonished and amazed” with fright. For Burton, these signs betrayed the presence of another disorder. His view — transposed nearly four centuries in time — still may hold: guilty ruminations and panic attacks can be symptoms of an underlying depression.

After 1800, anxious experiences began to be considered in and of themselves. And now our grisly parade truly commences. A series of descriptive medical terms emerged within different cultures. The French wrote of “angoisse,” a species of tortured misery that bordered on anguish. Germans adopted the term “Angst,” which referred to a terrible foreboding, a grave fear of some future event. The Spanish spoke of a freaked-out breathlessness they called “Angustia.” And in 1879, a British doctor distinguished worry from “panic,” a term derived from the story of the Arcadian god Pan, who was said to make noises in the woodlands that inspired unbridled terror.

This menacing menagerie may be of little interest to my patient, who will urgently desire some understanding of why he or she suffers. In 1866, the Frenchman Bénédict-Augustin Morel suggested severe anxiety was due to a dysfunction in the autonomic nervous system; others followed his lead and set out to examine problems in the brain, heart and lungs. From this perspective, Will Robinson’s robot was on the blink, and sometimes that is surely so.

A few decades later, Sigmund Freud, who first considered anxiety purely physiological, revised himself and put forward the theory of “signal anxiety,” in which small doses of anticipatory discomfort generated a cascade of self-protective responses. Later psychoanalysts like John Bowlby pursued odd or unceasing distress that emerged from experiences like abandonment or trauma. For these doctors, a troubled mind had grown quick, too quick, to misread benign stimuli as threats. Rather than being something to simply pacify, that worry became a thread that led back to psychic burdens, long accommodated but, in a flinch or a startled reaction, not fully forgotten.

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As I step into my waiting room, I prepare to grapple with these knotty issues and more. Anxiety disorders are now associated with complex epigenetic models, the transgenerational transmission of trauma, a neuroscience for fear conditioning, and even a pediatric infectious illness that triggers auto-immune mechanisms and results in obsessive compulsive disorder. To be open to all of this, I must be willing to enter a realm where most dare not tread. For anxious troubles are quintessential mind-body phenomena. They implicate a possible symphonic interaction of DNA, hormones, neurons, anticipatory fantasies, memories and thoughts, as well as the constraints and opportunities of our culture.

And so, in the end, there may be no one answer for my expectant patient, for not surprisingly, our diagnostic system can not accommodate such complexity. Instead, present medical classifications offer up a smorgasbord of disorders variously defined by the quality of nervousness, the object of terror, or its source. It is a broad, messy, forgiving schema, in which a number of anxious states remain difficult to cram inside only one box.

Given our state of knowledge, that’s as it should be. In my experience, these generalities provide important guidance, but often, critical particularities must be discovered with each individual. And so, I start by assuming only this. A signal of danger has arrived in consciousness. This ominous messenger, as in some Samuel Beckett play, takes the stage and says nothing. Who is he, what does he want? It is the stuff of epics, mysteries and horror stories, for the news may alter lives irrevocably, or it may signify nothing more than a branch snapping in the Arcadian woods.

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George Makari, M.D., is professor of psychiatry and director of the DeWitt Wallace Institute for the History of Psychiatry at Weill Cornell Medical College. He is the author of “Revolution in Mind: The Creation of Psychoanalysis.”

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