Health: 'The Irony of Fear'

Marc Siegel, special to The Washington Post, reports Tuesday on how irrational health anxieties boost the risk of conditions that should be feared the most. His article "The Irony of Fear" is adapted with permission of the publisher John Wiley and Sons, Inc. from Siegel's "False Alarm: The Truth About the Epidemic of Fear," copyright 2005.

Siegel, an associate professor of medicine at the New York University Medical School, was online Tuesday, Aug. 30, at 3 p.m. ET to answer your questions.

Siegel writes:

"America has its killer bugs, but Americans don't, as a rule, express great concern about them: Pneumonia, which killed 63,000 Americans in 2000, draws little public comment. Until 2003, when the flu deaths of 20 U.S. children early in the season were widely publicized, Americans didn't worry much about influenza either, despite the tens of thousands of deaths attributed to that disease each year.

"In comparison, relatively minor threats are widely feared. First publicized in 2002, West Nile virus was perceived as a great threat, though it killed only 284 people in the United States. In 2003, when severe acute respiratory syndrome, or SARS, emerged in Asia, there were only 7,000 cases in the world and fewer than 100 in the United States. No one in the United States died of SARS, but a lot of people worried. Many patients called my internal medicine practice in New York convinced that the slightest cough was SARS. People were afraid to sit next to an Asian person or to eat in a Chinese restaurant."

Read the Full Story: The Irony of Fear (Post, Aug. 30)

More From The Post: Stressed to Excess: Fear's Links to Disease (Post, Aug. 30)

A transcript follows.

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Marc Siegel: I am Marc Siegel MD. I am a practicing internist and an associate professor of medicine at NYU School of Medicine. I contribute regularly to the Washington Post. I became interested in fear in the post-9-11 period of vulnerability, where we all seemed to become afraid more easily. Fear is intended to be a protective mechanism, but if we trigger it unnecessarily it leads to a build up of stress hormones that can affect our health. My book focuses on triggers of this fear, from fear of illness to fear of what we hear and see in the news.

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Washington, D.C.: Dr. Siegel, in your article you seem to draw an implicit link between acute fear or anxiety (events that provoke a "fight or flight" response) and more generalized fear or anxiety (such as fear of disease). Individuals who suffer from abnormal levels of acute anxiety are sometimes treated with medication. Could, or should, we also treat irrational, exaggerated fears of a more generalized nature that way, in light of the potential deleterious health effects of harboring those fears?

Marc Siegel: it's a good question, and medication does have a potential role in breaking our cycles of worry. But as I point out in the book, better to look at what's provoking the unnecessary fear in the first place and to redirect ourselves away from it. Easier said than done, I know, but it involves a slow process.

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Fairfax, Va.: I'd like to ask Dr Siegel if he thinks someone could actually suppress the reactions of their hormone system so as to physiologically interfere with the 'fight - flight' - reaction as a result of being in a chronic anxiety-inducing atmosphere for many years when very young? If so, is there any way to contact any PET (or other electronic imaging) research being done on this question. I will not be available during the 3 p.m. period, but would very much appreciate any info or contact info on this question. The person I'm referring to has been on SSDI for 28 yrs due to a condition which has never been denied, but has never been scientifically/objectively verified either.

Marc Siegel: a study I refer to in the article, published in 1998, shows that this effect in childhood may cause serious medical illness later on. it has not been proven, but many of us believe that early intervention with therapy, corrective environments, possibly though not automatically medication, may help too. What works best? Love. Replacing the negative emotions of fear with positive powerful emotions works best - all go through the same pathway in the brain.

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Dayton, Ohio: Marc, I work in a gourmet grocery, and I see the flip side of this. We get a lot of customers who are basically saying "If I don't get my (almonds/cinnamon/pomegranate juice/whatever), I'm going to DIE TOMORROW!". We're afraid of some disease that's going to kill us with 100 percent certainty, and we also think there's some magic bullet out there that will let us live forever.

Marc Siegel: I call it going from panacea to panic. we become dependent on things to offset fear. Manufactures may falsely create this need so that we are afraid to do without their products. I don't think this is healthy.

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Silver Spring, Md.: Do you think we prefer to worry about things that we can't do anything about, over things that might require hard work?

For instance, worrying about cancer when you are 100 pounds overweight. But not losing any weight.

Marc Siegel: great point. This is exactly the way mad cow or bird flu works. Worrying about the wrong things is an excuse not to worry about the right things. And in fact, in many cases, the build up of stress hormones leads directly to obesity, which increases the risk of heart disease, stroke, and some kinds of cancer.

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Bethesda, Md.: Hello. For years, I've had a problem in which I fear getting sick while traveling or away from home. It can be paralyzing at times in that I often shy away from traveling and I really don't like spending a few days away from home. And when I do have to go, I always feel physically sick.

I think it stems from a fear of actually being sick somewhere far from home, without family and friends nearby, however irrational that sounds.

Do you have any comments or suggestions on how I can better deal with this?

Marc Siegel: I think you said it yourself, it's mainly that you don't like being away from home, away from the familiar. Uncertainty breeds fear, as I say in False Alarm, because it is connected directly to our ultimate fear of death. The solution for you might be to make sure your trips involve more familiar objects from your life, either people and things. I think the fear of illness part of the equation may improve the more comfortable you become traveling.

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Arlington, Va.: What do you recommend for people who have a tendency to experience fear and anxiety? How can a person become a good judge of what is a reasonable worry or fear?

Marc Siegel: a reasonable worry is one that is directly tied to a real danger or impending threat. Look at the statistical probability of what you are afraid of actually happening. if you are worried about something that is very unlikely, then you may need the help of a go-to person to help you put your fear in perspective. Also, since fear is such a powerful emotion, then obsessing less helps and keeping to your usual patterns of life that don't involve worry. If you can't break the cycle of worry with lifestyle changes, then consult with your physician.

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Anonymous: Can a person develop a fear about being too fearful? I mean, experience anxiety from worrying about worrying too much? How can a person just stop worrying without worrying about it first? Thank you.

Marc Siegel: this is a major problem. We worry about getting into a situation where we can't stop worrying. Performance anxiety is one example. Fear of the subway is another. One thing that works is a gradual immersion in situations that wrongly worry you, gently, a little at a time. it doesn't work for everyone, but strict avoidance often generates more fear.

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Washington, D.C.: What is a good way to find statistics re: a reasonable worry, that you mention?

Marc Siegel: this is a tough question to answer. I spend my book trying to sandpaper away the "potential" or overblown worries like mad cow, west nile, bird flu, hurricanes, excess fear of medications, fear of being without medications; what is left?

Nuclear fear for one. Difficult to assess, difficult to minimize, because a small object can hurt many. It's the elephant in the room.

But in America, we need to be worried about obesity and stress, poor eating, sleeping, and living habits. More and more studies link this to cancer, heart disease, stroke, and depression.

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Chicago, Ill.: I am medical professional and I have had lots of years of hypochondiasis. I think it comes with the territory to some degree. I overcame it when I moved to a 3rd world country for 4 years and had limited access to medically invasive testing or even routine diagnostics. I find my patients to believe that they need to be hyper-aware of every symptom they experience. We are inundated with messages to "talk to your doctor" and have forgotten the adage that tincture of time cures many things. MRI and CAT scan and total body scans are all the rage but ultimately, it's just being body aware (but not too aware!) and being happy. In a practical sense, what advice did you give to help people to get over these medical fears?

Marc Siegel: you've just given it. We are too spoiled sometimes. We should enjoy our technological advantages, and not obsess on the worst case scenario that each test brings. also, it is in the way we give news to patients. part of the excess worry is because increasingly we have our nurses dump answers onto answering machines. we need to return to the era of more direct involvement. (though I agree with you that their comes a point when excess catering to overblown concerns can cause more harm than good).

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Virginia: You mention obesity. Is it true that stress can cause weight gain? Is this more true for women than men?

Marc Siegel: this has been well shown. it is true for both groups, though as you might imagine, the distribution of weight isn't exactly the same. and some subgroups lose weight when they are stressed. Either way, it isn't healthy.

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Arlington, Va.: If a person is experiencing too much anxiety, would that person see a MD, a psychiatrist or a counselor first?

Marc Siegel: I think if that person is already in therapy, they should see their therapist first. but since some anxiety can be handled by a primary care doctor without referral, if you only have an internist or primary care practitioner, see that person first. Many of my anxious patients can be treated without referral.

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Albany, N.Y.: My wife has what I perceive as severe health anxiety. What can I say to her when, without any real evidence, she perceives that either she or our son has some rare ailment?

Marc Siegel: two things.

you can try to get her to look at the underlying problem - ex: that she loves her son so much that she is afraid of losing him.

you can also get the right statistics to show that the chances of the disease are very rare. If this doesn't work, she should involve a concerned physician.

P.S. I don't think Internet answers always work in this situation because they are often partial, and hard to interpret out of context.

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Kensington, Md.: Correct me if I'm wrong, but I think the general perception among Americans is we are such a 'medical superpower' that no one dies from ... say, pneumonia anymore. We can usually get our antibiotics or pop a pill for what ails us. So, the thought of a strain of virus for which we have no known cure is something we don't know how to deal with. Also, I think our society, which is so focused on staying/looking young forever has a good grip on mortality, which causes tremendous anxiety. They say the fear of death is at the root of -all- anxieties...that fear would certainly apply, here.

Marc Siegel: I agree completely. We are causing many of these problems by trying to attain a position of pure control over our lives that is of course at odds with our ultimate mortality. Better if we introduce doses of realism earlier on.

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Anonymous: I've heard it said that Washington, D.C., is one of the most 'anxiety ridden' cities in the country. I'm slowly recovering from a panic disorder (thanks to cognitive behavioral therapy, without medication), and since becoming more open about my anxiety issues, it seems like every other person I talk to here is either 'on' or has previously been on anti-anxiety meds. Do you have a sense of the statistics for our area? And if true, do you have any theories about why that is?

Marc Siegel: I don't know the exact statistics, but the reason is because D.C. is a primary target and you live amidst the stress of the federal government and the associated buzz. Plus, it is a little more difficult to place yourself geographically as a D.Cer an identification that relieves stress in other cities. Therapy may help as well as learning to see risks in real perspective. (low to the individual in many cases).

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Central Virginia: Dr. Siegel,

So much of popular culture is designed to attract attention by preying on people's fears. Headlines on television and in newspapers, politicians, 30-second sound bites, advertisements, and so many other forms of media constantly bring up new things to frighten people. If you change your cat's litterbox, you'll die! If you take this drug, you'll die! If you don't take this drug, you'll die! This new germ is lurking -- that food additive is toxic -- the climate is being dangerously damaged -- XX number of species are going extinct --

How in the world can one person make sense of all this? How can one sort through all the shouting and banging and come to terms with what needs immediate attention and what is not an emergency? No wonder people are stressed!

Marc Siegel: my book is about this problem. We need to learn to see the news in perspective, and the news needs to differentiate better between potential and actual threats. There needs to be a greater sense of what is a real danger versus a hyped one. This is a gradual process, which is aided when corrective information is added. People are stressed in part when they take doom and gloom messages too seriously and too personally.

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Washington, D.C.: Hi, I appreciate you answering my questions. I developed a fear of flying in college, 7 years ago. I still fly, but my heart speeds up and I start to sweat and get very nervous. I also have a fear of other people driving and being the passenger. I am fine to drive, but when I am a passenger, I feel afraid and nervous, even when their driving safely. Do you think that I have a control problem, for example, when I drive, I am slightly aggressive and not afraid, but if a friend is driving and I perceive they are not breaking when they should, I feel scared. Sometimes I wonder if it is an issue of not being in control and that is my fear of flying, no control of the plane. Does that make sense, or are my fears just considered "irrational."

Marc Siegel: Fear is often about loss of control, as the ultimate loss of control is death. I think your response is quite normal, though ironically, plane flight, even with all the negative publicity, is actually safer than driving. your risk of dying in a car is far greater (more than double each year than all the plane accidents over the past 50)

in terms of allowing other people to drive, it's the same thing. You trust your own driving more. You can learn to relinquish driving to others bit by bit. This would probably be a good idea over time.

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Washington, D.C.: I have little or no fear of illnesses as they may pertain to me, however, I do harbor enormous anxiety regarding my children. In a way, I know this to be irrational, they are vaccinated, we practice sensible hygiene, our lifestyle is geared toward benign health. But, I can't shake the fear that they will fall off the slide at the park, or find a way to guzzle drano, or something like that.

Marc Siegel: this is an expression of your love for them, which is a good thing as long as you channel it towards their care and not turning them into worriers too. I think children do better when we make them believe they are safe, which means understanding that statistically, they are

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Southern Maryland: My grandmothers were of the opinion that to control children, you scare them to death. "Don't go upstairs, the bogey man will get you!" "Don't run, you'll fall down and crack your head open." "Playing with matches will make you wet the bed." "Be careful with the scissors, you'll poke an eye out." Many of my generation are on meds. for depression and general anxieties. I don't think the problem is new -- our family grew up with fears, phobias, and anxieties. Before PMS was recognized as a condition, my mother acted every day of her life like she had PMS! I found Zoloft and Effexor eliminated the physical symptoms of anxieties, like sweaty hands, heart palpitations, fluttering stomach, fear of driving across the Bay Bridge.

Marc Siegel: the problem is not new. But what is new, is the information age - we are bombarded by partial information, alienated from its sources, and in the post-9-11 era, we feel more susceptible to remote dangers than we actually are.

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Washington, D.C.: Good afternoon,

I consider myself a stable, fairly well adjusted (older) adult. But for the past year I have been going through a kitchen remodel. We're now almost through, and I'm trying to understand why I have been so thoroughly discombobulated by the process. I've decided that it is all the little things, which I have no control over, plus the cost, that has created my sense of unease. I have tried to cope by talking to others who have dealt with the same thing; as well as, creating a paper trail in case I have to resort to legal means. Are there other ways of coping with upheaval in our daily lives that might be useful? Thank you for this interesting discussion.

Marc Siegel: the "paper trail" makes me smile, I went through the same thing myself. (not to worry you, but my contractor ultimately locked me out of my own apartment).

think organizing details helps to alleviate anxiety up until the point when it becomes an obsession on these details. another way to work is to include people in the process you can trust - which may be difficult with your contractor. Also, the next time you do a remodel you will be more prepared which will mean less fear.

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Anonymous: So, what golden nugget of advice would you give to combat this anxiety epidemic? Slow down? Turn off our TV? Get in touch with our mortality? Move to the mountains and live off the grid??

Marc Siegel: reordering our priorities - yes.

running away - no, though for anyone who wants a slower life in a less intense part of the world, I have no objection.

But I think the main thing we need is a new way to process information so we don't panic all the time. For starters, we need to acknowledge that we are dealing with a part of the brain that is emotional, but that can be triggered (sometimes wrongly) with information. Once turned on, fear is hard to turn off, and it can wear us down over time. Turning it on less often would seem to be a good idea.

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Marc Siegel: thank you all very much.

I really enjoyed it.

Drive safe.

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