Educated by Anxiety = Educated by Possibility

“Whoever is educated by anxiety is educated by possibility.” —Soren Kierkegaard

---

A white, speckly light flashes across my line of vision. Soon, I can only make out part of the computer screen and the talking points I’m writing up. A migraine I don’t have time for.

I go for a walk. After a mile, the aura fades and is replaced by what feels like a dense plate in the center of my chest, making it hard to breathe. Bikers speed by me too fast. The trucks on the street are too loud. The dense grey plate in my chest expands and shifts, making it feel like a shard of glass is cutting my chest.

I’ve been invited on National Public Radio to discuss my memoir Pathological. Two people will be joining me: Thomas Insel, former director of the National Institute of Mental Health (NIMH) and Paul Appelbaum, director of the Steering Committee of The Diagnostic and Statistical Manual of Mental Disorders (DSM). While preparing for the interview, I assume Appelbaum will respond to me and my book negatively, given that I heavily criticize the DSM.

For days, migraines with auras and panic attacks the intensity of which I’ve never known come and go. Tom Insel and I did another interview together, and he’s been very supportive of my work; I’ve never met Paul Appelbaum and my mind paints him as an enemy. He isn’t, of course. I have great respect for him. His specialty is ethics in psychiatry. He’s about as upstanding a psychiatrist as one can find.

The cut-glass feeling turns into an unsettling vibration. This is an emotion: anxiety. Or panic.

I thought mental health recovery would mean being immune to painful emotions, especially anxiety. Mental health is actually the ability to fully feel those emotions and keep going.

---

Researchers and mental health professionals refer to state versus trait anxiety. State anxiety is passing anxiety in response to a situation. Trait anxiety stays with you, always under the surface. For some, trait anxiety can be debilitating. It leads forty million Americans to get professional help and a diagnosis of anxiety disorder each year.

The etymology is telling. Anxiety stems from the Latin verb angor, meaning to constrict. Some languages equate it with anguish while others see the two—anxiety, anguish—as different: anxiety is a mental state like worry whereas anguish is a physical feeling that results from such worry. The American Psychological Association defines it as “characterized by feelings of tension, worried thoughts, and physical changes like increased blood pressure”—which makes it sound tame.

Many have written powerfully about living with debilitating anxiety, like Scott Stossel in My Age of Anxiety, describing it as an all-encompassing physiological, mental, and emotional torment.

We try to avoid anxiety—eat, drink alcohol, numb out with drugs, shop online, binge on Netflix—but historically, it’s been seen as a normal, human, even beneficial emotion. To the existentialists, it was an essential part of our humanness. The philosopher Soren Kierkegaard thought it was crucial for success in life: “Whoever is educated by anxiety is educated by possibility.” Studies have since shown this to be true. Anxiety actually makes us perform better. It motivates us.

Evolutionarily speaking, it’s vital. As leading anxiety researcher David Barlow puts it, without it, “[t]he performance of athletes, entertainers, executives, artisans, and students would suffer; creativity would diminish; crops might not be planted. And we would all achieve that idyllic state long sought after in our fast-paced society of whiling away our lives under a shade tree. This would be as deadly for the species as nuclear war.”

For decades, scientists and researchers have tried to determine what anxiety is and how it’s produced in the brain. Although we tend to talk about “anxiety” as a single entity, the New York University neuroscientist Joseph LeDoux explains that there are two mechanisms at play: survival circuit activity and the feeling of anxiety. One is unconsciously enacted by what he calls our defensive brains; the other is consciously thought by our mental processes. Many position anxiety in the amygdala—a mass about the size of an almond in the temporal lobe, the area just behind your ear—but we now know it’s more complex than that. The amygdala alone isn’t responsible. Anxiety arises because of the constant conversation going on among different areas of the brain. Neurotransmitters form an anxiety network.

Much of our understanding of anxiety as a bad thing comes from Freud. He invented pathological anxiety and made it the centerpiece of mental disorders. For Freud (and the Ancient Greeks), anxiety differed from fear in that it was about expecting and dreading danger that may or may not come, whereas fear was in response to an actual threat. (LeDoux says that anxiety and fear are inextricably intertwined.)

Freud is just one part of the short history of why we think of anxiety as a mental illness. In antiquity, some thought it was a sickness, others simply an annoyance. The Epicureans and Stoics offered a simple cure for it: stop regretting the past and fearing the future. In the sixteenth, seventeenth, and eighteenth centuries, it was seen as a symptom of other mental conditions. In the nineteenth and early twentieth centuries, it was the core feature of “nervous disorder” (neurasthenia), manic-depressive illness, and Freudian neurosis. In the DSMs I and II, anxiety, phobias, and obsessive-compulsive thoughts and responses were considered neurotic conditions. The DSM-III defined two types of anxiety: generalized anxiety disorder (GAD), which cognitively manifests as worry, and panic disorder (PD), which produces physical responses.

Over the various editions of the DSM, it’s become easier to diagnose. The DSM-III stipulated that to be considered “disordered,” your worries had to be “unrealistic.” This meant that worrying excessively, even to the point of excruciating anguish, about losing your job after making significant errors on a year-end report, for instance, wouldn’t qualify for a diagnosis. The DSM-IV loosened the criteria by removing the term “unrealistic,” which meant any worry was fair game. As diagnostic criteria loosened, the number of people diagnosed increased. Generalized anxiety disorder (GAD) went up by almost 20 percent. The DSM-5 has also helped make it the most common mental health diagnosis. The DSM-5 decreased the amount of time a person had to experience anxiety to qualify for a diagnosis from six months to three months.

Today, anxiety disorders are the most common mental health diagnosis, and the “anxiety product economy” is a multi-million-dollar empire.

There are days when anxiety doesn’t harrowingly vibrate in my chest and create in me a sense of being dislocated and of being so inside my head that I feel like I’m trapped, but those days are rare. Yes, anxiety interferes with my quality of life. But I’ve healed from mental illness and know real disability; this is more along the lines of something I’d much, much, much rather not experience.

---

The interview won’t take place in the studio. I’ll be doing it from home. That morning, I’m shaky and nauseated. My uneasiness is accompanied by diarrhea and then heartburn.

I go through my morning gratitude routine, which helps. While actively grateful, it’s impossible to be simultaneously sad, upset, angry, anxious, etc. But this morning I can’t concentrate.

I get on the Zoom call early and study my key points again. What if I get another migraine? What if I can’t breathe?

The Zoom app spins to life. Three boxes line the top of the screen. One is black with the radio station’s letters: WMAU. In another, a woman sits behind a soundboard. The other window is black with just the engineer’s name.

I’m not ready. I can’t do this.

The engineer welcomes me and asks me to test my sound. I do. He says it’s good and instructs me to get as close to the microphone as possible. He says I can turn off my camera. I do.

Sarah, this is happening. Let’s go.

Paul Appelbaum comes on. His face is the epitome of kindness. His beard and glasses make him seem avuncular. Should I say hello to him, my adversary who’s not my adversary?

I sweat. My mouth is dry. I want this to be over with. I want this not to start.

You’re anxious. You can be anxious and do this anyway. These thoughts seem impossible and stupid. Naïve. Are you kidding? My heart pounds.

The engineer says Paul Applebaum can turn off his camera, and he does. I focus on the screen, on Paul Appelbaum’s name. P-a-u-l. We wait. Tom Insel comes on with his camera off too. It’s just his photo along with his name. In his photo, he’s smiling. I stare at his image—smiling, calm. We’re all here for the same reason: to help those with psychiatric conditions and their loved ones.

The woman behind the soundboard raises her hand, cueing us that the show is about to begin. Tom Insel’s smiling picture stares back at me. My book will help people. It will give them the information they need about psychiatric diagnoses, so they and their children don’t make the mistakes I did.

During the interview, I make my points. The interviewer asks Paul Appelbaum if the public deserves to know what psychiatry knows about the invalidity and unreliability of diagnoses. In a turn I don’t expect, Paul Appelbaum agrees: Yes, patients deserve to know the truth.

I fist-pump the air. It’s a triumphant moment—not for me but for all patients.

Afterward, people I haven’t spoken to in years text and email to say they heard the interview and how illuminating it was. Never have I felt so strong, so purposeful, so able to feel the anxiety I feared for years, the anxiety that’s part of my recovery and my life.

---

Thank you for reading!

The best way to support my work is to purchase a copy of my national bestselling memoir Pathological, hailed by The New York Times as “a fiery manifesto of a memoir.” Pathological traces how we’ve come to believe that ordinary emotions are mental disorders and the twenty-five years I spent in the mental health system believing that psychiatric diagnoses are valid and reliable, which they’re not.

If you’ve already purchased a copy, thank you! You can gift a copy to a friend, your local library, or your favorite used bookstore.