Can We Cure Fear?
We naturally view any risk we witness as a personal threat--even when it is
on the opposite side of the globe and we see it only on TV. Is popping a
pill the answer?
By Marc Siegel
Excerpted with permission of John Wiley & Sons, Inc. (www.wiley.com), from
False Alarm: The Truth about the Epidemic of Fear. Copyright ?2005 by Marc
Siegel.
In early 2004 my daughter, Rebecca, was taking a bath. She was almost three
years old. When the tub's Jacuzzi device turned on, she became petried. I
raced to her side, to find her standing straight up, bright red from crying.
For months afterward, she abhorred baths. As a physician who has studied the
neurobiology of fear, I knew that the prefrontal cortex of her young brain
had just finished wiring its "safety center," where analytical reasoning can
overcome primitive emotions. I tried to appeal to her newly working brain
center to suppress the worry that this tub would always bring the scary
bubbles, but her body's innate response was too strong. By starting with
showers and diverting the focus of her attention from the tub, I was
gradually able to return her to baths. But to this day she is wary of
bubbles.
Why is fear so intractable? And what can we do about it? Therapy has
provided succor for many people; others have relied on the strength they get
from their faith or other support networks. But in a world where we
regularly witness hair-raising events--such as the aftermath of suicide
bomber attacks in full color on our living-room televisions, on Web sites
and on newspapers' front pages--is such verbal support enough? Answering a
perceived need, fear-blunting medications are coming onto the scene. Could
we--should we--all simply pop pills to ease our anxieties?
Fear is more than a state of mind; it is chemical. The feeling of alarm
arises from the circuitry of our brains, in the neurochemical exchanges
between nerve cells. Fear is a physical reaction to a hazard. As long as the
danger is direct and real, fear is normal and helps to protect us. Fear also
has a genetic component. A rat will recoil from the odor of a fox, even if
that rodent has spent its whole life in a laboratory. Likewise, we humans
are automatically apprehensive about situations that once threatened our
ancestors.
When one feels threatened, the metabolism revs up in anticipation of an
imminent need to defend oneself or flee. "Fight or flight," or the acute
stress response, was first described in the 1920s by Walter B. Cannon, a
physiologist at Harvard University. Cannon observed that animals, including
humans, react to dangers with a hormonal discharge of the nervous system.
The body unleashes an outpouring of vessel-constricting, heart-thumping
hormones, including epinephrine, norepinephrine and the steroid cortisol.
The heart speeds up and pumps harder, the nerves fire more quickly, the skin
cools and gets goose bumps, the eyes dilate to see better, and the areas of
the brain involved in decision making receive a message that it is time to
act.
_____
Once a person has learned to feel apprehensive about something, he or she
may always dread it.
_____
At the center of these processes is the amygdala, an almond-shaped region of
the brain. Neuroscientist Joseph E. LeDoux of New York University, a pioneer
in the study of the fear cycle, describes the amygdala as "the hub in the
brain's wheel of fear." The amygdala processes the primitive emotions of
fear, hate, love and anger--all neighbors in the deep limbic brain we
inherited from animals that evolved earlier. The amygdala works together
with other brain centers that feed it or respond to it. This fear hub senses
through the thalamus (the brain's receiver), analyzes with the cortex (the
seat of reasoning) and remembers via the hippocampus (the memory-input
device).
It takes only 12 milliseconds, according to LeDoux, for the thalamus to
process sensory input and to signal the amygdala. He calls this emotional
brain the "low road." The "high road," or thinking brain, takes 30 to 40
milliseconds to process what is happening. "People have fear they don't
understand or can't control because it is processed by the low road," LeDoux
says.
Fear Factor
Once a person has learned to feel apprehensive about something, he or she
may always feel dread associated with that experience. And unlike mice, we
humans can be alarmed by events we have only read or heard about, so we may
worry about disasters we may never experience. If we are unable to respond
for lack of an appropriate target, we become anxious.
Adding to the problem--according to studies of how humans evaluate risks by
University of Hawaii at Manoa psychologists Robert J. Blanchard and D.
Caroline Blanchard--is that people often fail to assess the level of threat
accurately. We tend to overpersonalize risk and to experience an unrealistic
sense of peril when we hear or read of a bad event occurring to someone
else.
For example, my mother-in-law has a severe case of multiple sclerosis and
has been confined to a wheelchair for almost 20 years. Six years ago my
brother-in-law developed a mild case of MS, and my wife, a neurologist, then
confided in me her fear, practically a conviction, that she would be next.
Every time she brings up her perception that MS is her destiny, I try to
counter it with the bald statistic that only 4 percent of close relatives
are at risk for the disease. "There is a 96 percent chance that you won't
get it," I say. But for my wife, as for many others, the perception rests
with the 4 percent. Empathy for her mother and a natural tendency to
personalize her experience create the fear and the conviction, despite her
neurologist's knowledge of the disease.
Recurrent or unremitting fear has the same deleterious effects on the human
body that running persistently at 80 to 100 miles per hour has on a car.
Many illnesses are more likely to occur as a result, including heart
disease, stroke and depression. Thus, we should focus our efforts on
avoiding the ordinary killers such as heart attacks that develop as a result
of our unremitting worries rather than extraordinary occurrences or exotic
diseases. Consider: in 2001 terrorists killed 2,978 people in the U.S.,
including five from anthrax attacks. That same year, according to the
Centers for Disease Control and Prevention, heart disease killed 700,142;
cancer, 553,768; accidents, 101,537; and suicide, 30,622. Murders (not
including 9/11) accounted for only 17,330 deaths.
Liquid Courage
So what can be done about irrational fear? There is no one standard
treatment in part because symptoms vary from one individual to the next. A
person may feel destined to a given bad outcome and have a greater sense of
foreboding because of a certain family tendency. Some people's bodies more
easily release the ght-or-ight hormones than others. Time-consuming therapy
and the resulting reeducation, to avoid triggering our fears, have been the
chief solution to date. Now research also suggests therapy could be
supplemented by a simple pill that blocks the reception or production of
fear signals or even by a fear "vaccine." The fear research does not seek a
traditional vaccine--in which the immune system develops protective
capabilities in response to the presence of an injected (inert) disease
agent. Rather the immune system might be chemically primed with a shot so
that it is as healthy as possible--making the body less susceptible to
hyperreacting to threats.
One of the first clues that an avenue to treating fear could be to stop
certain signals from being received or transmitted by neurons came from work
by neuroscientist Larry Cahill of the University of California, Irvine. In
1994 Cahill tested on humans the effects of the drug propranolol, a beta
blocker that stops the reception of stress hormones called catecholamines.
He found that the drug prevented people from recalling a gory story better
than a bland one. Ordinarily, the mild stressfulness of hearing an exciting
story makes it more memorable than an uneventful tale. Propranolol is
routinely prescribed for anxiety relief and to treat high blood pressure and
related ailments, but Cahill's research suggests it has a greater potential
for treating fear.
Along these lines, Roger K. Pitman, a professor of psychiatry at Harvard
University, theorized that administering propranolol can both prevent the
laying down of fear memories and blunt the ght-or-ight response. In 2002
Pitman and his group looked at the effects of giving propranolol to 41
people in the emergency room, starting within six hours of a traumatic event
(mostly car accidents). The study participants received the drug for 10
days. Three months after the trauma, Pitman found a signicantly lower
incidence of post-traumatic stress disorder in those who received the drug
than in the control group, which had not received the drug.
_____
Could medical remedies keep us impassive in the face of things that ought to
sadden, outrage or inspire us?
_____
Another way to hinder the fear response is by disrupting signal production.
LeDoux and Karim Nader of McGill University reported in the August 17, 2000,
issue of Nature that when rats received a shot of anisomycin, an antibiotic
that inhibits protein synthesis, their fear memory was blocked. They could
not recall a previous fright and could not trigger a new fight-or-flight
response, because the amygdala could not make the signaling molecules.
Reducing neural overreaction is another approach. In a study by
neurobiologist Jonathan Kipnis, now at the University of Nebraska Medical
Center, and his colleagues published in the May 25, 2004, issue of
Proceedings of the National Academy of Sciences USA, the authors found
evidence that immunological "vaccines" could prevent excess fear. They
injected normal mice with amphetaminelike drugs that caused psychotic
symptoms. Some of the mice received the protective vaccine, a chemical
cocktail known as glatiramer acetate, or copolymer-1 (Cop-1); a control
group got no vaccine. Cop-1 stimulates production of immune system T cells,
which protect nerve cells from "irritability," or hair-trigger firing. The
mice that received Cop-1 were able to learn to swim through a maze in
recognizable patterns, whereas the control mice could not do so. The Cop-1
mice exhibited normal calm behavior, showing that they avoided a state of
panic. This kind of immune modulation has yet to be studied in humans, but
such experiments are anticipated.
Blunting fearful memories with pills or vaccines is, however, not the same
as retraining the brain so that it is better equipped to handle future
situations. Regardless of the development of such medicines, therapy will
continue to play an important role in treatment for fear. As the President's
Council on Bioethics put it in the 2003 book Beyond Therapy, "Use of
memory-blunters at the time of traumatic events could interfere with the
normal psychic work.... There is a danger that our new pharmacological
remedies will keep us 'bright' or impassive in the face of things that ought
to trouble, sadden, outrage, or inspire us--that our medicated souls will
stay at no matter what happens to us or around us."
For years, I have tried to help my patients handle their disease fears
without knowing if I am succeeding or not. In studying the fear circuitry of
the brain, I have come to appreciate that teaching might not automatically
lead to learning. Fear is a deep-rooted emotion, difficult for the brain to
control. Sometimes it cannot be avoided. My daughter's experience with the
bubbles taught me that if fear is unlearned, it is because a new emotion
replaces it. (She developed courage about returning to the bath.) This
healing occurs at its own speed, and a parent, or a doctor, often has little
control over it.
To conquer fear we must return it to its primitive place as an instinct
reserved for protecting us from true physical dangers. We must stop
overpersonalizing it. We must resist those in the media and elsewhere who
highlight the wrong dangers and hype the need to respond--making the threat
seem even more real. We must regain our footing by exerting order over
controllable aspects of our lives [see box on opposite page]. We must
replace our unreal fears with real courage.
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