2013 : WHAT *SHOULD* WE BE WORRIED ABOUT?

Worry in and of itself can be extremely corrosive to our lives. The things we worry about tend to be distinct from those problems that grab our attention, stimulate us and mobilize us to action. It is of utility to recognize a potential or imminent danger and then do something about it. It is quite anther to ruminate in a state of paralysis. Taking scientific, political or personal action to address climate change is progressive. Lying sleepless in bed thinking about the melting polar caps does nothing but take a mental and physical toll on the insomniac.

The very word worry connotes passivity and helplessness. We worry about some event in the future and hope that it works out. And the very nature of the question we are posed this year implies that much of how we worry is irrational. I'm confident that many of the responses addressing what we shouldn't be worrying about will reassure readers because they will be specific and supported by the evidence. Columbus ultimately revealed that people need not fear falling off of a flat earth. General and weak 'don't worry, be happy' bromides are of no use. Notice that people who are told to 'relax' rarely do.

Moreover, there is a large segment of the population for whom the serenity prayer really doesn't cut it. They cannot distinguish between the obstacles in life that they might actively address, thereby diminishing worry, and those for which there is no salutary behavior and would therefore be best put out of mind. In fact, these people worry not only about problems for which there are no solutions, but about circumstances that to others may not appear to be problems at all. For this group irrational worry becomes pathological anxiety. I am writing about the tens of millions of Americans who suffer from anxiety disorders.

I currently treat people in my psychiatric practice who are often derisively called 'the worried well'. They are most certainly worried, but not at all well No one would question the morbidity associated with the irrational fears of the psychotic patients I once treated at Bellevue Hospital: the fear that they were being poisoned; that thoughts were inserted in their minds; that they had damned the earth to hell. Yet, trying to rationally explain away someone's phobia—aside from the use of structured cognitive behavioral therapy—is no more useful than trying to talk someone out of his delusion.

People with anxiety disorders suffer terribly: The young man with OCD, tormented by disturbing imagery forced to wash his hands for hours, until they bleed; the veteran, haunted by flashbacks of combat, literally re-experiencing horrors physically survived; the professional who must drive hundreds of miles for fear of flying; the former star athlete, now trapped, unable to leave her home, fearing she might have another panic attack at the mall or while driving over a bridge. And the numbers are staggering: anxiety disorders are the most commonly diagnosed psychiatric disorders, afflicting nearly 20% of all adult Americans each year and almost 30% over the course of their lives. Those suffering from phobias, panic, generalized anxiety disorder, PTSD and the rest are more likely to be depressed, more likely to abuse substances and are more likely to die younger. And before death arrives, whether sooner or later, enjoyment of life is vitiated by their anxiety. Pleasure and anxiety do not co-occcur.

And while we all want to avoid the biological and social risk factors for anxiety, for tens of millions of Americans and hundreds of millions worldwide, it is too late. Once morbid anxiety takes hold, only psychotherapy and/or psychopharmacotherapy will suffice. Worry descends upon the worrier like a fever. Without appropriate treatment, that febrile anxiety burns away at the soul. With it, the fever may break. Only then can the worried become well.