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Anxiety After 9/11

In the aftermath of 9/11, some 4 million Americans faced exaggerated fears or generalized anxiety disorder.

Americans have been jittery. As we cautiously open our mail, terror is ever present. Here, we take a look at fear itself.

The passengers boarding the Virgin Atlantic Airways flight from London to Los Angeles were wary, but everyone began to relax after takeoff. In midflight, over Canada, an attendant noticed a suspicious object behind a seat. Immediately, the cabin erupted in panic. The plane made an emergency landing in Edmonton, Canada, the passengers were evacuated, and a bomb squad was dispatched. The suspicious item? A cellphone.

We know nothing will be the same after September 11, 2001. Yes, policies will change: Airline security will tighten, mail service will be examined, and restrictions on civil liberties must be accepted. These are the sorts of changes politicians propose and men and women in uniforms will carry out; they are the unavoidable inconveniences of everyday life.

Such changes are coming to pass, but the altered American landscape includes more than security measures and ID cards. On September 11, terrorists did more than destroy buildings; they scarred the American psyche. The details are telling: Pharmacists report an increased demand for anti-anxiety drugs and the antibiotic Cipro, and some HMOs have seen a 25 percent increase in calls.

We are having difficulty grappling with our sudden loss of security. In the weeks immediately after the attacks, a survey of 668 Americans by the Institute of Social Research in Ann Arbor, Michigan, reported that 49 percent of participants felt their sense of safety and security had been shaken. And some 62 percent of respondents said they had difficulty sleeping. In another poll of 1,015 Americans conducted by the Harvard School of Public Health and the Robert Wood Johnson Foundation, 57 percent had taken steps to protect themselves—such as taking precautions when opening mail and avoiding public events.

In place of invulnerability, many people now harbor a small and disquieting fear—a fear of attack by unseen agents at unexpected times using unthinkable weapons. The most common objects or occurrences have now assumed horrific resonance. A plastic knife is no longer a utensil packed for a picnic, but a means to mass murder.

Psychologists study many kinds of fear. There are common phobias, such as the fear of spiders, and post-traumatic stress—the fears that spring from memories of dramatic, sometimes life-threatening events. But because most Americans are far removed from New York City and Washington, D.C., other sorts of fears are probably at work. In particular, psychologists will look for symptoms of generalized anxiety disorder, which creates an exaggerated fear response in people who have been emotionally scarred.

Over time, the general level of anxiety should ease. But some long-lasting effects will remain, and a few things will never be the same.

A man on a flight to San Jose, California, opens an envelope and a powdery substance spills out. A fellow passenger alerts the flight attendant, reporting that he had dispersed the powder into the ventilation system. Once the plane lands, it is held on the tarmac for three hours and the FBI is called to investigate. The "powdery substance" was confetti enclosed in a greeting card.

Such an overreaction shows just how fearful ordinary people are. But there is nothing wrong with feeling fear: We all do at some point. Fear is one of the most basic emotions and is not, in itself, dangerous; it is part of a natural alarm system designed to react to or anticipate danger. And though that system was first employed to avoid natural predators—a lion on the prowl, say—it has been adapted over time to deal with abstract threats or even social situations. For some, a letter filled with a powdery substance or the sight of a man wearing a gas mask would create a distinct sensation of fear, even panic, though it would be hard to explain the exact threat to someone who lived just one hundred years ago.

Although the reaction to fear is perfectly natural, it can be unpleasant. Fear begins in the amygdala, a cluster of cells deep in the most primitive part of the brain that weighs information for emotional content and possible threat. If a threat is sensed, the amygdala sends out immediate signals. Simple reflexes are set off: a jump or a shout. And the adrenal glands in the kidneys begin pumping adrenaline and noradrenaline, two chemicals that act as messengers to trigger reactions all over the body. A rush of adrenaline and noradrenaline causes the heart to race, breathing to quicken, pupils to widen and saliva to dry up. In the extreme, it is common to experience hyperventilation, dizziness, trembling and even nausea.

Another physical reaction is a change in the blood's circulation pattern—the vessels close to the skin constrict so that more blood is available to the large muscles. This redistribution is important because muscles in the arms and legs might be needed to run from or fight off an attacker. But it creates a distinct physical sensation—the blood running cold or a chill down the spine.

As an outgrowth of this ancient alarm system, fear also weakens the ability to concentrate. People who are anxious often complain that they are easily distracted from daily chores. That's a normal part of the fear response: One of the most important aspects of dealing with danger is finding out where it is coming from. Instead of focusing on small tasks, the brain cries out to scan the environment and find the threat. In the distant past, the threat might have been a predator in the bushes. With the current threats coming not from tigers but from terrorists, people most often study the newspaper looking for clues to potential danger.

The entire design of the body's alarm system is geared toward protecting the individual from threats. But people don't just react to threats—they anticipate them, as well. Again, this kind of fear is part of the normal strategy humans have evolved to avoid danger. Anticipatory fear has two distinct modes: anxiety, a preoccupation with an impending threat, and worry, the internal struggle to find a way to escape the danger.

It is probably safe to say that most of the fear experienced since September 11 has been worry and anxiety. Americans have been anxious about attacks from anthrax-laced mail, they have worried about the availability of antibiotics and the safety of the water supply. Such anticipation is not only normal, it is healthy—often the best way to protect oneself is to spot a threat before it is imminent and find ways to avoid it.

For decades, many people feared the threat of nuclear war. Indeed, after the Soviet Union demonstrated its nuclear weapons in 1949, many Americans were beset by the kinds of worries and anxieties that some people now feel about the possibility of terrorist attacks. In fact, many people were certain that civilization as we know it was about to end—a feeling made stronger by books and movies, such as "On the Beach" and "The Day After" set in postapocalyptic futures.

This worry about nuclear annihilation led to actions such as building bomb shelters and installing the so-called hotline between Moscow and Washington. Indeed, one can argue that taking such steps in response to cold-war hysteria kept nuclear war at bay.

Yet some fears persist in ways that are not advantageous to the fearful. Those sorts of fears create more problems than they solve, and paralyze rather than motivate. Anxiety disorders are a significant mental health problem in the United States—about one in four people experience one form at some point in their lives. Several variants have been identified, from social anxiety disorder, a fear based on social scrutiny, to panic disorder, in which a person is actually afraid of fear itself.

Sometimes, though, a person may develop anxiety or worry about potential catastrophes to an extent far beyond the normal fear response. Even though the individual may not think she is worrying too much, her anxieties, in fact, cause an enormous amount of stress and may even keep her from fully participating in everyday life. This sort of exaggerated worry is known as generalized anxiety disorder (GAD). Some 4 million American adults have GAD, and it afflicts women twice as often as it does men.

The development of GAD appears to involve a small genetic factor. In July 2001, researchers from the Medical College of Virginia in Richmond reported in the Journal of Nervous and Mental Disorders that a study of 3,100 twins suggests that inherited traits account for some 15 to 20 percent of the vulnerability to GAD; the other factors are environmental.

The National Institute of Mental Health describes the symptoms of GAD this way: People with GAD can't seem to shake their concerns, even though they usually realize that their anxiety is more intense than the situation warrants. Their worries are accompanied by physical symptoms, especially trembling, twitching, muscle tension, headaches, irritability, sweating or hot flashes.

The physical symptoms of GAD, then, mirror the body's reaction to fear. Indeed, GAD can be thought of as living in a state of constant, if low-level, fear. But unlike the normal causes of fear—real threats that require a serious response—generalized anxiety disorder exaggerates the amount of danger arising from a potential situation. People with GAD tend to overestimate the likelihood of harm coming from a given situation and view minor or ambiguous events as catastrophes. If normal fear is an alarm, GAD is a false alarm you can't turn off.

Normal worrying differs from excessive worrying in amount, not in kind. A study of 1,588 college students, published in the Journal of Abnormal Psychology by psychologists at Pennsylvania State University and Elizabethtown College in Pennsylvania, found that there was no clear way to separate levels of worry into two tidy groups. Instead, there seems to be a continuum of worry.

Research suggests that GAD is linked to the brain's storage of emotionally charged memories. The feelings one has at the time of an event appear to play an important role in the strength of later memories. Although all memories fade over time, the ones connected with the most passionate emotions remain the most indelible.

From the evolutionary perspective, that makes sense: Memories are stored so that we can gain information about the world; so remembering emotional events helps us duplicate our biggest triumphs and avoid repeating our most ignominious defeats. The best way to do that is to retain the memory with a mental tag that conveys an emotional message.

Sometimes, though, emotionally laden memories of a dangerous situation get stored in a confusing way. That's particularly true of threats that may be somewhat abstract in nature. If a snake has threatened you, you know what to look out for in the future. But for Americans who feel threatened by terrorism, the danger signs are not exactly clear. Indeed, in the weeks after September 11, the news was filled with details of the hijackings and reports of anthrax bacteria arriving in the mail. These images, as well as predictions that future attacks are 100 percent certainties, are all "tagged" with fearful emotions.

Once a memory has been tagged with fear, the brain is ready to respond when it senses something that triggers that memory. It is almost as if a person becomes scarred emotionally and will react anytime the wound is touched. To test this model, Schmidt conducted a study of some 1,300 men and women in their first year at the U.S. Air Force Academy. Cadets who had reported having a panic attack in the past were found to be more likely to believe that anxieties are harmful—which is itself a cause of panic attacks. After experiencing a panic attack, a person becomes more vulnerable to additional attacks. This suggests that traumatic events in a person's past may play a large part in creating anxiety disorders.

Psychologists believe such scarring is the result of a person experiencing an unexpected personal loss—some event that makes him feel the world is a threatening place. But there are many people with GAD who have not had such personal losses. Instead, seeing friends experience a tragedy or even receiving mistaken information about potential risks is enough to trigger exaggerated anxiety.

Whatever the cause, once the fear structure is in place, even the most everyday occurrences can instill deep anxieties. If the fear involves the health and safety of your children, for instance, then simply watching them board a school bus can be unsettling.

It's important to remember that, on balance, fear is a good thing. It warns us of imminent dangers and reminds us of past threats. Many ingenious solutions—from the Constitution to the Internet—have come from worrying about difficult problems.

The fears that resulted from the attacks on the World Trade Center have been paralyzing for some. For others, the anxiety has led to extreme overreactions—such as refusing to enter a post office.

In time, perhaps we can put these fears to constructive use. Rather than panic at the sight of a man in a turban, read up on other cultures. Instead of worrying about the supply of antibiotics, research how difficult it is to contract anthrax.

In the wake of the most horrendous attacks in American history, it is healthy to feel some fear. Just don't allow that fear to defeat you.

Read More About It

The Anxiety Epidemic Billie Sahley, Ph.D. (Pain & Stress, 1999)

Stop the Nightmares of Trauma Roger Callahan, Ph.D. (Professional Press, 2000)

Rapid Eye Technology Ranae Johnson, Ph.D. (Rain Tree Press, 1996)