Our Bodies, Our Fears

Anthony Lepre started feeling awful almost as soon as Tom Ridge put the nation on high alert for a terrorist attack last week. The normally well-adjusted Los Angeles chiropractor started tossing and turning instead of drifting off to sleep at night. He awoke in the middle of the night short of breath, his heart pounding. And the sound of his telephone seemed a sure sign of bad news. By midweek, he was rushing off to Costco to stock up on fruit juice, bottled water, peanut butter, canned tuna "and extra food for my cats Monster, Monkey and Spike." He also picked up a first-aid kit, six rolls of duct tape and a bulk package of plastic wrap to seal his windows. "The biggest problem was that I felt helpless," he says, "completely powerless over the situation." The health-conscious 46-year-old even found himself chomping pizza and sweets, figuring a few treats would help him "forget about the situation for a while."

And so it went for millions of Americans. The recent barrage of bad news--nukes in North Korea, snipers in Maryland, a failing economy, an imminent war, a threat of domestic terror--has left this privileged nation feeling unusually vulnerable and uncharacteristically anxious. Gas masks and biohazard suits are selling as briskly as duct tape and plastic sheeting. Winter vacations are on hold. Psychotherapists are working overtime. And even people who soldiered on after 9-11 are now blinking. Thirty-five-year-old Kateria Niambi, a lifelong Brooklynite who works as a marketing director in lower Manhattan, never thought of leaving New York during the grim fall of 2001. Yet she recently bought a house in suburban New Jersey and now plans to pack up her two daughters and move. "It was like, 'Where can I go that my kids will be safe?'" she says.

Iraqi civilians are no doubt asking the same question. Israelis and Palestinians have asked it for decades. And though America's current worries may seem unprecedented, the current situation has nothing on the 1918 flu pandemic or the Cuban missile crisis. Yet none of that makes living with fear any easier. As Drs. Afton Hassett and Leonard Sigal of New Jersey's Robert Wood Johnson Medical School wrote recently, we're living in a "chronic heightened state of alertness and... helplessness," prompted by a "poorly defined... danger that could strike at any time in any form without warning." Such feelings can be as unhealthy as they are unpleasant, impairing immunity, interrupting sleep and exacerbating everything from acne to ulcers. "The psychological state of fear affects us biologically," says Los Angeles psychiatrist Carole Lieberman. "People who are anxious drink and eat more. They have more accidents. They're more likely to get colds or suffer heart attacks." In short, as University of Michigan neuroscientist Stephen Maren puts it, a brain system designed to keep us from getting eaten is now "eating away at us."

Such is the paradox of fear. It is, as Saddam might say, the mother of all emotions--a response so fundamental to survival that we share it with rodents, fishes and fruit flies. Yet fear and anxiety can shackle us, diminish our lives, even kill us. Until recently, no one knew how the brain generated such feelings or why they were so hard to will away. When New York University neuroscientist Joseph LeDoux started studying fear as a graduate student in the late 1970s, most experts believed it was beyond the reach of neuroscience. Since then, it has been elucidated more clearly than almost any aspect of the psyche. Besides sussing out the function and dynamics of the fear response, researchers have started to pinpoint its underlying mechanisms, and even manipulate them. When you consider that 19 million Americans suffer from fear-related disorders even in the best of times, the value of such insights is hard to exaggerate.

The feelings inspired by vague threats are of course different from the ones you'd experience in a burning building or a hijacked airplane. But they're not entire-ly separate. Fear and anxiety exist on a continuum. They're rooted in the same physiology and can have similar consequences. To get at the essence of anxiety, you have to start with the anatomy of fear. The brain is not just a thinking machine. It's a biological adaptation, designed to promote survival in the environments where it evolved. As neuroscientist Steven Hyman of the National Institutes of Mental Health observes, "Survival depends on the ability of an organism to respond to threat or reward, and predict the circumstances under which they are likely to occur." The brain structures that handle that job evolved long before the neocortex (the seat of conscious awareness), and they easily override it. The "emotional brain," as LeDoux calls this web of ancient circuitry, is highly attuned to signs of potential danger. And through a process known as fear conditioning, it can readily learn to perceive a mundane stimulus as a warning sign. Expose a rat to a distinctive sound before administering a shock, and after a few repetitions the sound alone will trigger a paralyzing fear response. Subject a soldier to extreme trauma in a tropical setting, and moist summer breezes may later cause him white-knuckle panic attacks.

Twenty years ago no one knew how fear conditioning worked. But by surgically removing discrete parts of rodents' brains--and performing the same simple conditioning experiment--researchers have detailed the underlying mechanisms. The fear system's command center is the amygdala, a small, almond-shaped structure that rests near the center of the brain and is elaborately tied to other regions through nerve fibers. A rat lacking an amygdala won't freeze at the sound of a tone, no matter how often the tone is paired with a shock. And though human subjects can't be carved up or electrocuted for the sake of science, studies of patients with damaged amygdalas show that they have similar deficits. Unlike people with intact brains, they're no more attuned to emotionally charged words such as rape than to bland ones like handkerchief. And though they can recognize individual faces, they don't perceive threatening expressions as unfriendly. Even a split-second glance at a hostile face activates the amygdala in a normal brain.

An activated amygdala doesn't wait around for instructions from the conscious mind. Once it perceives a threat, it can trigger a body-wide emergency response within milliseconds. Jolted by impulses from the amygdala, the nearby hypothalamus produces a hormone called corticotropin releasing factor, or CRF, which signals the pituitary and adrenal glands to flood the bloodstream with epinephrine (adrenaline), norepinephrine and cortisol. Those stress hormones then shut down nonemergency services such as digestion and immunity, and direct the body's resources to fighting or fleeing. The heart pounds, the lungs pump and the muscles get an energizing blast of glucose. The stress hormones also act on the brain, creating a state of heightened alertness and supercharging the circuitry involved in memory formation. "The amygdala tells the rest of the brain, 'Hey, whatever happened, make a strong memory of it'," says James McGaugh, a neurobiologist at the University of California, Irvine. "It makes a strong --correlation between the significance of an event and the remembrance of it."

You wouldn't want it any other way. Yet as researchers learn more about the fear response, they're also learning more about the huge costs it imposes. Like any aggressive defense establishment, the amygdala and its army of stress hormones can divert resources from other critical uses. It can also cause extensive collateral damage. Consider the experience of Elizabeth Brace. She was 37 years old and living in Rancho Cucamonga, Calif., in 1994, when a powerful earthquake struck 100 miles away in Northridge. The temblor didn't knock her house down, or even break her dishes. But it jolted her out of bed and sent her running, terrified, to pluck her son from his crib. When she didn't come back, her husband went to the child's room to find her face down on the floor, bleeding from the nose and mouth, dead. By all indications, the quake had scared her to death.

Harvard neurologist Martin Samuels collects stories like Brace's to show just how dangerous the stress hormones can be. "Norepinephrine is toxic to tissues--probably all tissues, but in particular the heart," he says. Israel recorded nearly 100 excess deaths during Saddam's 1991 Scud missile attacks--not from bomb injuries but from heart attacks presumably triggered by fear and stress. And a recent study suggests that heart patients around New York City suffered life-threatening heart arrhythmias at more than twice the usual rate in the month following the World Trade Center attack. "Prolonged stress has physiological consequences," says Dr. Jonathan Steinberg, chief of cardiology at New York's St. Luke's-Roosevelt Hospital Center and the leader of the study. "These patients experienced potentially fatal events, even though many of them had trouble identifying themselves as unduly fearful."

In other words, acute fear is not the only kind that can hurt you. Constant, low-grade adrenaline baths may subtly damage the heart, raising the long-term risk of cardiovascular disease. Continuous exposure to cortisol can dampen the immune system, leaving stressed people more vulnerable to infections and possibly even cancer. Stress hormones can harm the brain, too, severing connections among neurons. In both hu--man and animal studies, researchers have found that prolonged stress also shrinks the hippocampus, a brain structure that plays critical roles in processing and storing information.

Even when it doesn't wreck the heart or the brain, prolonged stress can have countless subtler effects. And Lepre, the L.A. chiropractor, is not the only one feeling them. Pierluigi Mancini, the director of a community counseling clinic in Norcross, Ga., says his clinic's family and adolescent program has recently seen a sixfold increase in the number of people seeking help. "Kids are acting out, and adults don't know what to do or who to talk to about the terror alerts," Mancini says. "People are reporting head-aches, insomnia, back pain, neck pain, disorientation. But after a physical exam, we can't find a physical cause." Such complaints are common among worried people, and you don't have to be a hypochondriac to experience them. "Stress almost always comes out in a bodily symptom," says Afton Hassett, an expert in psychosomatic illness. Even at low levels, she says, anxiety causes muscle tension, which leads in turn to aches, pains and twitching eyes.

Children are especially vulnerable to fear and anxiety. "I'm seeing a lot of regressive behavior," says Lieberman, the Los Angeles psychiatrist. "Lots of parents are telling me their kids are afraid to sleep, or go to school, because they don't want to be separated if something catastrophic happens." Anxious children are even more likely than adults to experience their anxiety as a stomachache or a physical malaise, and emotional experiences have deeper effects on their still- developing brains. "Kids learn everything faster than adults," says Dr. Bruce Perry of the ChildTrauma Academy in Texas. "If they have the stress response turned on a lot, their bodies say, 'I'm in a world where I need to use these systems a lot'."

Genes and temperament make some kids less vulnerable than others. But when a susceptible child experiences too much fear, the consequences can extend beyond general anxiety to include phobias and posttraumatic stress disorder--conditions in which the amygdala hijacks the rest of the brain every time it encounters some cue. Like a rat in a conditioning experiment, the sufferer reacts as violently to a harmless stimulus as she would to a life-threatening emergency.

Some 11 million Americans (mostly women) suffer from phobias. Some phobias are general, others specific, but they're all tenacious--for unlike names, our fears are never forgotten. What keeps most people from being paralyzed by them is not erasure but a phenomenon known as extinction, in which neurons in the cortex create new memories to compete with the visceral ones managed by the amygdala. Researchers have recently traced this fear-busting capacity to a particular part of the prefrontal cortex. In a recent study, stimulating this brain structure helped rats extinguish their conditioned fear responses more rapidly. Experts now hope that electromagnetic devices will help phobic people down the same path.

But in truth, the path is already open. "We can take people with very severe phobias and treat them in a day or two," says Dr. David Barlow of Boston University's Center for Anxiety and Related Disorders. The treatment has several components, but at its heart is an exercise that Barlow calls "talking to the amygdala." Instead of simply telling people that high places can be safe, he takes them to high places. By surviving the experience, and surviving it again, they form the new memories needed to temper the oppressive ones. The technique is as old as fear itself, but neuroscience has begun to show us why it works--and why avoiding what scares you is so futile.

That's not to say that fear is never rational. Sixty-nine-year-old Doro Adelstein considers herself a gambler and, as such, likes to improve her odds. When the Queens, N.Y., widow heard the warnings of impending terror last week, she decided to use a free plane ticket she'd been saving to hide from Osama bin Laden among the white tigers and crap tables of Las Vegas. "I know I can't stay here forever," she says as she tugs a slot-machine arm at the MGM Grand Hotel & Casino, "but I was in Manhattan on 9-11 and it was the worst day of my life. Whenever they say there's going to be another attack, I remember what it was like that day. This time it seems really real, and I figured the terrorists are less likely to attack Las Vegas than New York, don't you think?'

Your guess is as good as hers. At least she's enjoying herself--no small accomplishment amid so much uncertainty. Anyone with a TV and an amygdala is sure to experience anxiety in the coming weeks and months. For those lacking tickets to Vegas, the best remedy may be to turn off the set, venture into the world and come home alive to remember it.

Steps to prepare for the worst:

STOCK UP: Put together a kit that includes a battery-operated radio, nonperishable food, water and disinfectant. And don't forget the duct tape--it could be used to seal windows and doors with precut plastic.
GET TOGETHER: To save time and minimize confusion, decide on a family meeting location.
COMMUNICATE: Pick an out-of-town contact to be a family liaison if there's no other way to stay in touch. This person could also keep important documents.
STAY SMART: Be familiar with work and school emergency plans; make sure contact info is up to date.

A number of nighmarish scenarios exist:

CHEMICAL: Agents could be sprayed from aircraft, released into the water supply or detonated as a bomb. They dissipate rapidly, however, and are difficult to produce.
BIOLOGICAL: Probably the easiest to bring into the country, but many bio agents are difficult to grow and break down quickly when exposed to the sun.
RADIOLOGICAL: A "dirty bomb" combines conventional explosives with low-level sources of radiation. Radioactive fallout is not widespread.

...Against The UNTHINKABLE
Experts say better warning and communication systems are needed to coordinate the most effective response. But what if you are exposed? How will you know--and what can you do?

Effects vary depending on the type--and amount--of toxic substance:

CHEMICAL: Immediate symptoms include blurred vision, difficulty breathing and nausea. Be aware of unexplained fruity or bitter smells, low-lying clouds and numerous dead animals, birds or fish.
BIOLOGICAL: Bio attacks are hard to detect. Stay on the lookout for unusual spraying activity and abandoned spray devices. Initial symptoms of smallpox include fever and malaise. Plague results in pneumonia. Symptoms of anthrax exposure resemble a cold.
RADIOLOGICAL: Early symptoms of radiation sickness will usually appear between one and six hours after exposure. They can include headache, nausea, vomiting and diarrhea.

It's critical to act quickly:

CHEMICAL: Remove clothing and put in plastic bag. Wash body and flush eyes with water. If inside, get out. Nerve agents sink to low-lying areas, so get to the highest ground possible.
BIOLOGICAL: Unfortunately, the first evidence of a bio attack may occur only when symptoms appear. At this point, it's important to seek medical attention ASAP. Treatments do exist for some bio agents, but time is of the essence.
NUCLEAR: Leave contaminated area immediately and get inside the nearest building. Remove clothing and shower. Potassium iodide can be taken if radioactive iodine is released in the attack.

Graphic: (graphics/illustrations/text) Tracking Fear In The Brain... ...And Through The Body: When threatened, the brain shoots first and asks questions later. Fear kicks in at the first signs of danger, then a complex system analyzes the real risk.

FIRST RESPONSE: The senses pick up a threatening sensation, like a loud noise, and send it directly from the thalamus to the amygdala, which initiates the body's fight-or-flight response
MISGUIDED FEAR: In people suffering from phobias, the prefrontal cortex may lose its ability to control the amygdala, allowing it to act unheeded and arouse fear in non-threatening situations.
HIGHER REASONING: Information also gets sent to the sensory cortex, which gives a more careful appraisal of the threat. If the loud noise turns out to be harmless, the prefrontal cortex will dampen the amygdala's fear reaction, calming the body.

THALAMUS: Routes information from the eyes and ears to other parts of the brain for processing.
SENSORY CORTEX: Separates threats from false alarms. Was that loud noise a gunshot or just a car backfiring?
HIPPOCAMPUS: Helps evaluate threats by placing them in context of previous experiences. A frightening noise heard in a place you consider safe is less likely to scare you.
PREFRONTAL CORTEX: Reins in the amygdala if an initial threat is deemed insignificant.
AMYGDALA: The brain's rapid-response system. Sends the body into high alert if triggered.

Fear sends the body into a hypervigilant state by honing the senses and allocating energy for quickened responses. A look at how defenses are mobilized.

SIGNALING THE BODY: The amygdala prompts the autonomic nervous system to increase heart rate and breathing. It also tells the adrenal glands to release hormones such as cortisol, which increase energy.

HEART beats faster
BREATHING quickens to take in more oxygen
PERSPIRATION increases to regulate body temperature
STOMACH vessels constrict to force blood elsewhere
ARMS AND LEGS receive extra blood for energy
LIVER releases sugar into blood for added energy

LONG-TERM EFFECTS: While well adapted for passing threats, fight-or-flight reactions can wear the body down after years of responding to constant stresses. Some symptoms:
· Impaired memory
· High blood pressure
· Weakened immune system
· Stomach ulcers

CHRONIC ANXIETY: Unlike fear, anxiety is not aroused by predictable threats. It also arises from a different part of the brain.

· Short-term
· Involves specific phobias
· Activated by central nucleus of amygdala

· Long-term
· Generalized
· Activated by the bed nucleus of stria terminalis