July 23, 2012 | 7
Daniel Smith has discovered the perfect cure for battling overwhelming sweat—the kind of sweat that soaks through the shirt, leaves nasty residue, and makes you want to avoid the company of fellow human beings for the foreseeable future. The kind, in other words, that is caused by a bout of anxiety (which can be provoked, naturally, by basically anything – typing at your computer, choosing a salad dressing, sitting on a bench in Boston Common).
The magical solution? Place pads on the underside of your shirt, under your armpits. As in, feminine menstrual pads. When Daniel’s wife comes home one day with a jumbo pack of Always Ultra Thins™, he has “one of those Archimedes-in-the-bathtub moments.” His very own epiphany. “From then on,” he writes, “whenever I have had to leave the house to meet someone it behooves me not to repulse, I have worn beneath my arms a product expertly designed by a multinational corporation to absorb eighty milliliters of menstrual blood at a wearing.”
And in that single image, the grown man with pads proudly under his arms, we see the scope of Smith’s new book, Monkey Mind: a balance of the devastating and the devastatingly hilarious. As Smith traces his ongoing battle with clinical anxiety, we learn just how disruptive and downright crippling the struggle can be—and how difficult it can be to acknowledge and diagnose, let alone begin to understand and treat.
Though anxiety disorders are currently the most prevalent psychiatric disease category, affecting, according to a 2011 Nature paper, 28% of people over their lifetime—and that’s not to mention their large contribution to major depression and substance abuse—the actual term, anxiety, is strangely absent from medical discussions until relatively recently. The Greeks may have coined many a label that is still in use today—melancholia, mania, hysteria, paranoia—but they had no word for that most basic psychiatric condition of anxiety. No word at all.
By the time the Romans arrived, it seemed the omission had been fixed. A new term entered the vocabulary: anxietas. Anxietas, however, was not anxiety as we know it today. It meant instead a lasting state of fearfulness. A partial description of anxiety, to be sure, but far from the full story.
As the centuries wore on, the Greek and Roman view held sway. Until the nineteenth century, there was little mention of what we’d now recognize as anxiety. Instead, each separately identifiable symptom had its own descriptor. There’d be the difficulty breathing. That was a pulmonary condition. There’d be the sick feeling in your stomach. That was a gastric condition. There’d be dizziness and light-headedness. That was a middle-ear problem. And so on.
But notice what all of these descriptions have in common: they are fundamentally physical explanations. No mention is made of any potential origins in the mental or the psychical. Everything has a direct cause in the physical body.
It’s a view that has proven to be remarkably sticky. In the first English psychiatric textbook, William Battie did in fact include anxiety—Anxiety, rather—in his list of disorders. But the description was a strange one. Anxiety, he wrote, was the result of an “excess of sensation.” Not exactly the phrasing that comes to mind today. In 1765, neurologist Robert Whutt called the condition a result of nerve coats that were “obstructed, or inflamed, compressed by hard swelling, or irritated by acrid humours.” An interesting theory, no doubt, but not quite what we think of when we think of a mental disorder.
By 1858, anxiety had taken on symptoms that the Romans had once relegated to angor, a separate term that means a state of intense fear—like our concept of panic. (It also means strangling, a condition that I’m sure anxiety sufferers would recognize as very much a part of anxietas itself.) In the new definition, it was accompanied by feelings of pressure, closeness, and inability to breathe. An elaboration of the symptoms—but still a very physical one.
Even as the twentieth century dawned, the resistance to treating anxiety as anything but a physical condition persisted. Though Freud had introduced the thoroughly mental concept of anxiety neurosis in 1895, encapsulating in his definition many of the current DSM-IV criteria for anxiety disorders, his view elicited pushback instead of a changing view of the disease. Panic, wrote physician Eduard Brissaud in 1890, was a phenomenon caused by the brain stem. Even as late as the mid-twentieth century, B. F. Skinner dismissed anxiety—not at all surprisingly—as a conditioned response to learned fear.
While the omission of the mental may seem extraordinary in retrospect, it’s actually not at all difficult to explain. After all, the physical symptoms of anxiety are a major part of the disorder—more so, perhaps, than is the case with many other psychiatric conditions. In Monkey Mind, Smith takes us not only through bouts of sweating (with and without pads), but through nausea, dizziness, clamminess, disorientation, sometimes near paralysis, as when he finds himself unable to walk toward the student behavioral-health center at Brandeis, heart palpitations and elevated pulse rates. As he writes, “The truly gripping thing about anxiety had always been how physical it was…. Like a fever it infused me.” The physical is very much a part of anxiety. Very much indeed.
What’s more, it’s awfully tempting to look for concrete causes. If you narrow anxiety down to its physical manifestations, you make it somehow seem more manageable. If it’s physical, it’s easy to control. You’re the one to blame if you can’t. If it’s mental, not quite so much. A physical disease makes it easier to assign blame. A mental one is not nearly as neat. Consider Smith’s own reaction, near the end of his journey of understanding, to his therapist, Brian (the therapist, incidentally, who ends up most able to help him understand and deal with his condition). Smith’s first instinct is to explore, “Who screwed me up? Through what actions? Out of what motivations? Was there blame to be assigned?… Let’s anatomize my psyche. Let’s build a narrative. Let’s make a catharsis.” He wants, in other words, nothing more than a linear story—and one where physical blame can be easily apportioned.
But you know what? Therapist Brian does something peculiar in response to Smith’s demands. He Does. Not. Care. He doesn’t want to talk about it—even if the it involves a pair of lesbians who are about to seduce the teenage Daniel. He seems altogether, well, bored. Why? Smith, it soon becomes clear, is starting with the wrong end forward. If the anxiety he is experiencing is like a “house on fire, and you have to escape right now or you’ll burn to death,” Brian tells him (and, “That’s exactly what it feels like,” Smith acknowledges), “explain to me the logic of sending in the marshal to figure out what caused the fire. Wouldn’t it make more sense to—oh, I don’t know—put it out first?”
The point hits home. Daniel realizes that the actual causes of his condition aren’t physical. Those physical trappings (like some nasty reviews that appear in response to one of his pieces in The Atlantic) are a trigger, yes, but the anxiety originates on the inside. In his own mind. Following Brian’s advice, he soon recognizes that it’s thoughts—thoughts inside his head, thoughts he’d previously ignored altogether—that initiate the anxious cascade. And you know what? Once he realizes that, he gains that very thing he’d been seeking in all of his physical searches: a way to address the problem, to control it, so to speak, before it spirals out of control. Even though attending to his thoughts seems to him “dangerously akin to, say, petting scorpions,” it ends up being the very thing that saves him.
What Brian knows and Daniel learns is that the ancients (and moderns, to a point) had it backwards. The physical isn’t the cause of anxiety. It’s the result. “First came the thoughts,” writes Smith, “then came the feeling. Fever dreams, then fever. A topsy turvy notion.” Such a view is much less clear and linear. It doesn’t mesh so neatly with causes and effects.
When Smith first begins to research his condition with the view of eventually writing a book, he wants nothing more than to determine a precise physical origin of this debilitating state. Was it his loss of virginity? Was it, as his mother suggests, the time when he nearly drowned as a child? It would be amazing if it were that simple. But, as he realizes, it never is. Sure there are causes—and genetic ones, too; anxiety runs in his family—but at the end, an understanding of anxiety must necessarily probe deeper. It’s not as easy as eliminating (or acknowledging) the physical origin of the condition. It’s much scarier—like petting scorpions. It’s all about your mind.
And when it comes to the mind, there’s no neat narrative arc. That’s as frightening a thought today as it was in the times of the Greeks. No wonder they decided to altogether avoid creating a word to describe anxiety. Maybe without a word to pin it down, it would cease to exist.
Tye KM, Prakash R, Kim SY, Fenno LE, Grosenick L, Zarabi H, Thompson KR, Gradinaru V, Ramakrishnan C, & Deisseroth K (2011). Amygdala circuitry mediating reversible and bidirectional control of anxiety. Nature, 471 (7338), 358-62 PMID: 21389985