This is the latest in a series of essays seeking to demystify issues in mental health that affect all of us for a proportion, often a substantial proportion, of our lives. However it remains the case, even in 2023, that many of us do not like to discuss mental health issues, particularly as they may apply to ourselves, even though the greater majority of us will encounter mental health issues of one sort or another at some point or other or even throughout our lives. In many conservative societies, the idea of seeing a psychiatrist and taking psychiatric medications to address mental health issues remains quite taboo. Nevertheless it affects each and every one of us. Nobody can honestly say that they have never suffered from a mental health issue. Mental health problems are at least as ubiquitous as problems in physical health. People just don’t like to talk about them.
Anxiety is such an issue. Anxiety, or worry as it is more colloquially called, is something that the vast majority of us suffer from every day. Anxiety is a sense of fear, disquiet or concern arising out of uncertainty as to the future; or certainty as to an inevitable negative outcome. Unfortunately we all suffer from anxiety, because it is inevitable that at some point we are all going to die; and as a general rule none of us want that. Also it is inevitable for most of us that we will have financial ups and downs in our lives; and inevitable that our relationships with others will stronger and weaker moments; it is also inevitable for the vast majority of us that we will suffer from periods of poor physical health, no matter how self-disciplined we are in seeking to resist health decline or risky situations in which we might get hurt.
Moreover life is just replete with uncertainty, risk and sheer chance. Life is not fair. The reason why we might not get a job we are enthusiastic about may have nothing to do with the merits of an impeccable biography and everything to do with some secret prejudice on the part of the decision maker that we may never learn of. Or we may not be in the right place at the right time. Nor can we predict the drunk driver on the road we take home every evening and whose recklessness suddenly shatters our families’ or friends’ lives. Although we can be certain that we are going to die, we can very rarely be certain as to when; this is probably just as well, or we would all worry about death even more than in fact we all do. (Anyone who tells you they are not worried about death is engaging in an exercise in self-deception; we all worry about death, and the fact that we do so is the foundation of religious belief.) Hence we all have reasons to be anxious, and most of us spend large periods of time in our lives being anxious about a variety of different things.
Many of our anxieties are irrational, and it turns out to be impossible to rationalise them. Talking through a risk about which we have an irrational anxiety seldom helps; we may know the anxiety to be irrational and hence having the irrationality explained to us will not alleviate it. Those of us (and it is a substantial proportion of the population) who are afraid of flying fall into this category. Flying is universally acknowledged by statisticians to be by far the safest form of travel: much safer than walking in the street, for example. Nevertheless for some people the idea of getting in a densely packed metal tube and hurtling through the skies at speeds far higher than experienced on the ground remains extremely frightening. Others may be nervous not of the act of flying itself but of the interminable procedures associated with it, because they may suffer from a version of claustrophobia and in that context they may find long chaotic lines of people, having orders barked at them, and waiting in crowded rooms bereft of personality an ordeal in itself. In many or even most cases these irrational anxieties are the result of trauma: past events in one’s life that were deeply unpleasant and created lasting mental scars. The result is that associated types of event may trigger unpleasant emotional reactions, and those may be accompanied by physical reactions.
The physical and mental reactions accompanying anxiety can be extensive and severe. They may include the heart beating faster; a crawling sensation on the skin; an inability to focus one’s mind; reiterations of thoughts about the event(s) to which one’s anxiety relates (that is to say, having the same thoughts repeatedly); insomnia; clumsiness; a propensity to drink more alcohol, smoke, or even consume other recreational narcotics; short-temperedness; high blood pressure; and a variety of other unpleasant or harmful bodily reactions. In part this is because anxiety is associated with the release of adrenalin in response to fear. Where animals perceive a risk, they release adrenalin, a neurologically active bodily chemical, that creates all these reactions in order to trigger the so-called “fight or flight” mechanism in response to danger. Anxiety is part of the same neurological mechanism. The problem however is that many of the uncertainties about which the developed human mind is capable of contemplating are things we cannot easily escape from and that we cannot easily fight.
The human capacity for thinking into the future and contemplating a variety of different possible outcomes is the source of our enhanced condition of anxiety compared to animals. Goldfish are famously said to have a memory of only nine seconds. If that is right then they do not have substantial memories in the folds of which to harbour trauma and presumably they are not capable of looking very far into the future either, so they do not spend their times worrying whether they are going to die because their owners may neglect to clean out their water tanks. Humans suffer from anxiety because they have long memories and advanced faculties for cognition, and are capable of thinking about all sorts of things that may or may not happen in the future. They worry about these things, and this triggers fight-or-flight neurological reactions that generate anxiety. In one sense, humans have become over-developed. Perhaps this is why humans invented alcohol, a substance designed to numb the human capacity for over-contemplation through its sedative effects upon the brain.
Hence anxiety is a mental health issue that affects us all, and we should not be ashamed of it. Also we should all acknowledge that it is a neurological condition: that is to say, it is the result of chemical imbalances that affect the way the brain operates and interacts with the body, and it affects how we think. Sometimes anxiety can be a good thing, as when it motivates us to study for an important examination; most of the time, however, anxiety is not a good thing and it is better to remain calm in the face of uncertainty or adversity. This represents some of the essential teachings of the Buddha.
Anxiety becomes problematic when people are subjected to long-term uncertainties or harm outside the ordinary spectrum of daily human experience. While the human body and mind is capable of managing anxiety using its own natural methods when the causes of the anxiety are typical and fall within the categories of daily chores or woes, when a person is exposed to extreme or incessant risk or hardship then neurological imbalances may arise. Just a a bone may snap where subject to extreme force, the chemicals affecting the functioning of the brain and its interactions with the body may also become dysfunctional when the human mind is placed under pressure and stretched over extended periods of time or in response to high levels of danger or suffering. Where this occurs, it is important to recognise that there is a chemical problem in the operation of the human body that needs to be addressed.
There are a number of ways of resolving such issues. The most obvious is to remove the risk, danger or harm from which the person is suffering. If there is a continuing open uncertainty in their lives, then that uncertainty needs to be addressed, and the constant fear of risk or danger removed. Unfortunately life is not always that kind, and sometimes - as with long-term illness, or the anticipation of death - it is not possible permanently to expel from consciousness the thoughts that are maintaining the anxiety one is suffering from. Where the causes by contrast are human, it is possible to relieve the anxiety - if sympathetic and decent human beings, qualities we hope to find in all people, acknowledge that they are contributing to a person’s anxiety and take steps to mitigate it. Bosses should stop harassing their employees or making their lives at work uncomfortable, for example.
Where anxiety needs to be managed because the longer-term causes of the condition - the uncertainty or unpleasantness that the sufferer cannot take their mind off - cannot or will not be relieved, then medical approaches should be considered, just as they would be in the event of a broken limb or another sustained medical problem. There should be no shame or embarrassment in this. Chronic anxiety can be crippling, and it has a habit of feeding from a rational source to irrational ones. In other words, if a person is suffering from rational anxiety then he or she may become frightened of a number of other things that there is no due reason to harbour anxiety about. The victim (because by this stage, this is really what the sufferer has become) may acknowledge that his or her anxieties are irrational; but they continue nonetheless. At this stage pharmaceutical treatment may become appropriate, because no degree of talking through one’s problems is going to make them disappear.
There are a variety of different categories of medication that may be used to treat anxiety. Some are more appropriate in the short-term. Others may be more useful in the long-term. Benzodiazepines are a class of anxiolytic (anxiety-reducing medication) with a long history but currently a bad press amongst many international medical circles, and people are forever looking for alternatives to them. Ranging from diazepam (valium, a relatively mild benzodiazepine with a longer half-life in the blood stream) through alprazolam (known commonly as Xanax), which for reasons not entirely understood also acts as an anti-depressant; through to lorazepam, an acute anxiolytic often used to treat battlefield or medical trauma, and beyond, there are a range of these medicines. What psychiatrists prescribing these medications for anxiety over the decades have come to notice is that they are habit-forming and may create patterns of physical dependency. Moreover patients need taking these medications over any period need to exercise self-discipline not to increase the dosages.
The other problem with the benzodiazepine class of medications is that they are used by alcoholics, smokers and drug addicts to self-treat their own more damaging addictions. While benzodiazepines are indeed the correct treatment for these types of addiction in almost every case, treating these addictions - which may have anxiety as their cause - should be undertaken under medical supervision. The temptation is to self-medicate addiction problems with benzodiazepines, and this is generally not regarded as a good thing because the patient with the addiction problem may not understand all the relevant positive and negative qualities of these medications. The net result is that in some countries with severe substance abuse problems, a black market trade in benzodiazepines emerges. In other words, a patient legitimately consuming these medications may have them stolen by less scrupulous friends and then they may be illegally sold. Hence these medications need to be controlled; and in most jurisdictions, they are (albeit in some cases rather belatedly).
Nevertheless they may be over-controlled. Xanax, an American invention and a tremendously effective anxiolytic, recently fell out of fashion in much of Europe and has found itself on various countries’ pharmaceutical black lists on the ground that it is too addictive. Another way of making the same point is that it might be regarded as too effective. It is in fact an extraordinarily good anxiolytic medication, assisting with poor sleeping patterns and depression (two common side-effects of anxiety) as well as the principal symptoms of anxiety itself. That may be why it remains so widely prescribed in the United States, where Xanax does not attract the same level of medical stigma as it has recently endured in parts of Europe.
The so-called Z drugs, including zoplicone, are highly rated for short-term sleep deprivation but they are not anxiolytics. They help a person sleep but they do not contribute to the alleviation of anxiety when that person is not asleep. Therefore they are not a suitable replacement for benzodiazepines, although that idea has been touted. Also it transpires that they are extremely physically addictive if taken for more than about a week. A patient loses all ability to sleep without them. Generally they are for use in acute circumstances only, such as a patient in acute pain who is otherwise unable to sleep.
Sometimes anxiety becomes so acute that it may be assessed as within the category of generalised anxiety disorder or “Bipolar II Disorder” (an inability of the body to control the levels of neurological chemicals controlling mood, so that a person becomes subject to rapid mood swings over short periods). In these cases the patient may be stabilised with a course of mild atypical anti-psychotics, although longer-term use of such medications does not obviously generate any benefits for patients suffering from prolonged anxiety. These medicines are also habit-forming; it is far from clear that providing them in lower doses to people with anxiety disorders is the appropriate course when they are ordinarily reserved for patients with more severe mental health issues in higher doses.
The statistical evidence that benzodiazepines have medically beneficial effects for people with anxiety problems, at lower dosages, is extremely limited. This course of enquiry by psychiatrists may just be a matter of trying any medication except for benzodiazepines, which are currently out of fashion. After a few high-profile cases in which benzodiazepines were used for suicide or mass murder, doctors are now nervous in parts of Europe about prescribing benzodiazepines and this irrational reaction on the part of psychiatrists may prove to be just a phase. It may ultimately not represent best medical practice.
It is also important to treat the physical symptoms of anxiety, because prolonged stress or tension can reduce not just the quality of one’s life but one’s longevity as well. In particular, hypertension, which is caused or exacerbated by anxiety, may take years off a person’s life. Hence hypertension medication such as propranolol (an essentially harmless pharmaceutical over-regulated in many western countries) may be considered for a person suffering from anxiety. Likewise, increased smoking or alcohol use (or, almost as bad, reduction in the consumption of alcohol from moderate usage to zero - something that tends to make the patient thoroughly miserable and thereby exacerbate anxiety and depression) must be monitored and treated. The physical consequences for the body of anxiety can often be the most destructive.
Finally, consider the possible benefits of psychotherapy. Psychotherapy is often over-emphasised as a cryptic science; in fact it is just the art of talking to somebody about their concerns. Often, people suffering from anxiety feel that they cannot discuss their worries with others, often because they feel ashamed, embarrassed or under some duty of professional confidentiality. Nevertheless it is very important to talk to another person about one’s fears and anxieties, because it helps put them in perspective. We should never restrict the important right of people suffering from anxieties to do so, either through informal norms or legal strictures. That can contribute to the mental damage a victim of anxiety may suffer. And, in law, anxiety is a sort of medical harm in respect of which a person owing a duty of care, whether in government, by virtue of private contract, or otherwise, may be responsible in law. We must not overlook the anxiety that our actions may cause in others, and we should give those suffering from anxiety every opportunity to release themselves from their angst through discussion with trusted friends and colleagues. We must be alert to the mental anguish anxiety causes as a result of our actions, in every course of life. Should we fail in this mandate, the law is likely to hold us accountable.