Quantifying the cost to society of panic and anxiety

What's the price of panic? What economic costs does it impose on individuals, businesses, and society?

We can probably make a fair assessment of treatment costs directly attributable to panic disorder. Beyond that, the short answer is, It's hard to say. Certainly there are lots of folks receiving treatment for physical ailments -- acid reflux, for instance, or heart palpitations -- that are not directly attributable to but are unquestionably contributed to by panic.

And then there are the costs of un- and underemployment.

Consider my story. More than once in my life, I've been unemployable, or damn close to it, thanks to panic. These were the times when agoraphobia took over, pulling the geographical boundaries of my life closer and closer, shrinking the world to the point that I couldn't even make it to the corner store without being overwhelmed by inexplicable but searing terror.

The prospect of making it through the day in a cold, claustrophobic cubicle farm can become unbearable during these times. I've panicked a number of times in office settings, and spent more than a few hours staring at the clock and counting off the minutes until 4:45 or 4:50 p.m. would finally roll around and I might sneak away from my desk before the official 5 p.m. quitting time without putting my job in too much jeopardy. When panic and agoraphobia have entered the picture, work for me has been a challenge to endure, even when I've had jobs that were both interesting and high-paying.

The prospect of commuting to and from work makes periods of agoraphobia even worse. My first panic attack took place on a highway (I-95 in Connecticut; see here), and over the years I've developed a mighty fear of scenarios common to commuters everywhere. The derailed commuter train, stuck in the tunnel between stations. The sweltering subway car, AC disabled; the press of sticky bodies as the train rounds a bend; the end-of-day summertime commuter-train stink. The rush-hour highway traffic jam, where it takes a full hour to get to the next exit. The line of cars in the left-turn lane, only one or two making it through before each green light turns red. When it comes to causing dread at various categories of rush-hour transportation, my agoraphobia does not discriminate.

When the agoraphobia gets bad enough, un- or underemployment is sure to follow. Investment analyst, book editor, web writer, legal-document proofreader, short-order cook . . . I've left or been let go from a number of jobs because agoraphobia had rendered me unable to drive on rush-hour highways and bridges, or ride a rush-hour subway, or take a rush-hour bus. Sometimes, I've been able to manage my fear to the point that I could work part-time; other times, I've worked during off hours (on the overnight shift at Kinko's, for example) so I didn't have to brave the crowds during regular commuting hours, or restricted myself to temp jobs because I didn't trust my ability to commit to a position for the long term.

Knock on wood, things have been better for me in recent years, so I no longer experience the prospect of attending a business meeting in an office downtown as an existential challenge. But things have been worse in the past, and I there's always the threat that agoraphobia will make them worse again in the future. I've been around long enough to know that, and accept it. And there's no escaping the fact that the career I've built for myself, as a marketing consultant and copywriter, allows me to spend most of my time in my home, always the safest, easiest, most comfortable place for a would-be agoraphobic to be.

Obviously, I'm not the only person whose career path has been sidetracked by periods of shaky mental health. There are millions of us out there, most of us silent about what we've endured, whether out of shame or fear of being found out by employers. Mental illness has imposed that cost on us, in addition to what we pay as individuals and as a society for treatment.

But how much is that, exactly? According to one study published in the American Journal of Psychiatry, lost earnings related to serious mental illness approach $200 billion per year. On average, those with serious mental illness have an annual income that's 42% lower than the average income for the rest of us ($22,545, versus $38,851).

As the study makes clear, this is just part of the total economic cost imposed by mental illness:

...it is important to recognize that the NCS-R yields a conservative sample for estimating economic impact. As a door-to-door survey, NCS-R did not assess individuals hospitalized in institutions, incarcerated in prisons or jails, or who are homeless. Indeed, NCS-R had so few subjects with schizophrenia or autism that these diagnoses were not part of the original epidemiological analysis, even though both are associated with chronic disability and lifelong loss of income on a far greater per capita basis than mood or anxiety disorders. 

Accepting this conservative estimate of a loss of $193.2 billion in earnings each year from serious mental illness, can we estimate the total economic impact of serious mental illness? In Table 1 we begin to answer this question, adding the new estimates of income loss to data from 2002 on the direct costs of health care and disability benefits, including Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI) cash assistance, food stamps, and public housing financed by federal and state revenues. Missing are the costs of health care for comorbid conditions. Missing are estimates for the loss of productivity due to premature death and the loss of productivity of those with serious mental illness who are institutionalized, incarcerated, or homeless. Missing is the cost of incarceration, although as many as 22% of individuals in jails and prisons have been diagnosed with mental illness.... Missing is the cost of homelessness, although approximately one third of adult homelessness is associated with serious mental illness.... And, of course, missing from any such tabulation is the cost to family members who bear much of the emotional and financial burden of these illnesses. The $317 billion estimated economic burden of serious mental illness in Table 1 excludes costs associated with comorbid conditions, incarceration, homelessness, and early mortality.

This study focuses on the costs of serious mental illness in general; the cost of panic will be a fraction of this cost. The exact amount? Again, it's hard to say. But rest assured that it's in the tens of billions of dollars. Per year. If another study, this one from the Netherlands, is any indication at all, the cost is great indeed; there, the annual per capita economic cost of panic is estimated to exceed $20,000.

Fear panic and society part two

When you’re afraid, there are five basic steps to coping effectively.

First, you must identify the cause of your fear. In my case, as long as I believed that what threatened me was a heart attack or stroke, I would never identify nor begin to understand what was really causing the adrenaline to flood my system: panic.

Second, you must learn about the cause of your fear. In my case, with enough reading about panic, I finally began to believe that, despite what my body and mind were telling me during my panic attacks, I was not in mortal danger when one struck; that the places I associated with panic – the rush-hour subway, the crowded shopping mall – were not in fact dangerous; that panic is biological as well as psychological in nature, and not an indication of personal weakness or a deficient personality; and, perhaps most importantly, that millions of people experience panic – that I was not alone.

Third, you must analyze the way you process fear in your thoughts, identifying when fearful thinking is irrational and challenging that irrational thinking with logic and objective truth. Cognitive restructuring, it’s called in psychology-speak. we tend to focus on the negative, on what might go wrong; we think catastrophic thoughts, which prevent us from acknowledging that reality might not be quite so bleak as the world we’ve conjured in our head. When we listen the voice in our head that says we’re having a heart attack or a stroke, panic is terrifying. When, rather, we question that voice, offering a reality-based alternative to the story about the world it wants us to believe, panic becomes something not quite as severe – something not quite panic. “It’s not a heart attack, it’s a physiological response to adrenaline,” we tell ourselves, and panic has that much smaller a hold on us.

Fourth, you must learn to relax, to calm your body and give your mind a break from worry. Painting, reading, listening to music, hiking, working out, meditating…there’s a long list of activities people who panic can use to help keep their anxiety in check. Learning to relax and forget our fears for a while allows us to deal with those fears more realistically and effectively.

Fifth and finally, you must stop avoiding your fear, and face it head-on. You must expose yourself to the things you fear – the people, places, situations – so that you can learn that those things do not cause nearly as much existential threat as your panic has convinced you they do. After one debilitating bout of agoraphobia when I lived in Los Angeles, for instance, it was only by getting in my car and driving a bit farther from home each evening that I was able to reclaim the ability to move about that city without fear-imposed restrictions.

The weeks and months after 9/11 were a time of great fear. Unfortunately, the actions we took in response to that fear rarely mapped to these five steps; indeed, the actions we took as a result of 9/11 often ran completely counter to these proven prescriptions for dealing with fear.

Consider step one: identifying fear’s cause. The immediate cause, of course, was al Qaeda, the fundamentalist Islamic terrorist network headed by an elusive Saudi-born ideologue named Osama bin Laden, was the immediate cause of our fear. Immediately, though, we began to confuse the issue. In the weeks following 9/11, U.S. authorities rounded up some 1,200 Arab and Muslim immigrants, for the most part with no credible evidence that they were connected to al Qaeda. By 2003, we were invading Iraq – again, without credible evidence of a connection to al Qaeda.

Or step two: understanding fear’s cause. Al Qaeda has always been forthcoming with its reasons for targeting the United States; essentially, what bin Laden and his followers consider U.S. meddling in Islamic regions of the world: our covert but significant role in Afghan resistance to Soviet occupation in the 1980s, our ongoing military presence in Saudi Arabia and other Islamic countries, and our longstanding, steadfast support of Israel. But instead of explicitly acknowledging this complaint, we chose to focus on other, often completely fabricated reasons for the attacks on the World Trade Center and the Pentagon. “Islam is a violent, evil religion,” the voices of ignorance exclaimed. “They’re jealous of our freedom.”

Painting all of Islam with the “terrorist” brush is simply ignorant at best and utterly counterproductive at worst; calling their religion evil has almost certainly increased anti-American sentiment among Muslims around the world. And while we should certainly hold al Qaeda to account for its murderous acts, if we were smart – if we really wanted to lessen the threat that al Qaeda poses – we’d at least acknowledge, and consider the validity of, that organization’s political complaints.

Or step three: challenging fearful thoughts. Rather than managing our frightening but unrealistic cognitions in the wake of 9/11 by questioning their validity, our leaders went out of their way to provoke them, conjuring images of suitcase nukes and mushroom clouds rising over American cities. Everything was different, now; we had been forced into a global war on terror with no end in sight, a crusade against death-minded, heathen hordes. The threats were everywhere; no one could be trusted. Foreign-sounding strangers, people taking snapshots of government buildings – all these things justified fear, or so we were told.

Or step four: taking steps to relieve stress. We didn’t do much relaxing after 9/11. It wasn’t really possible, what with the flood of messages telling us to be afraid – very afraid. On TV, Fox News became a one-station fear machine. Each week during prime time, Jack Bauer reinforced the message that there were terrorists everywhere, that we should trust no one. At the airport, disembodied voices warned us to beware unattended baggage. I have no way of knowing whether I’m correct, but it’s my belief that a society which encourages constant vigilance and complete distrust is a society that promises to become increasingly unlivable.

And then there’s step five: avoiding avoidance. To avoid giving people, places, and situations a power over us they don’t merit in reality – to live fully in the world, going where we want to go, doing what we want to do, and in general giving ourselves the best possible shot at achieving our personal and professional aspirations – we much force ourselves to enter fearsome situations and learn to cope with the anxiety they provoke. After 9/11, though, as a society we tended more towards avoiding what we didn’t want to face. For instance, we stopped flying when (thanks to heightened security) airliners were probably the safest mode of transport available. “Just go shopping like you usually would, and everything will be okay,” our leaders told us, as though distraction and avoidance rather than honesty and engagement were the most effective ways to negotiate our way through fear.

Each step along the way, we failed to think and act in ways that are known to be effective in coping with fear. As a result, our civil liberties have been curtailed. We’ve become a nation that tortures. Our Muslim communities have been marginalized. Resentment of the U.S. is at an all-time high, and a new generation of Muslim kids has been radicalized in the Middle East and around the world. All the while, 24/7 cable newscasts and radio talk show blowhards ensure that our fear remains at fever pitch. Meanwhile, hundreds of thousands have died in an unnecessary war in Iraq – and bin Laden remains free, continuing to lead a terrorist organization that may be more powerful today than it was in 2001.

Are we better off as a result of the steps we’ve taken in response to 9/11? As the announcer used to say during Monday Night Football advertising breaks, “You make the call."

Fear, panic, and society, part one.

Is panic a rational response to 21st century business politics and society

This essay -- "The New World Disorder: The much-heralded individualist spirit of American society relies on nurturing a fear of other people" -- opens with the line, "Panic is our national pastime," then goes on to detail how the U.S. has become a more frightening place in recent times, making thoughtful, provocative statements like:

We locate panic at the extreme end of the anxiety spectrum, as the awful truth of a phobia, the end result of what psychiatrist Robert L. DuPont refers to as the "what if?" of horrific possibility. The possibility of panic, however, covers a much broader band of the spectrum. The news media may not want panic attacks to actually occur, but they like us to routinely consider the possibility that something awful might happen if we do not maintain a healthy level of anxiety — and keep watching the news for updates. Witness coverage of the scare of African killer bees a few years ago, recently featured in Bowling for Columbine. Be alert. Get scared. This anxiety constitutes a sort of pre-emptive strike, if you will, on the panic state. Awful things often do happen. A smoking gun does not need to be fired; the suggestion of a gun's potential is enough. The very possibility of weapons of mass destruction, for example, can inspire a state of panic. The weapons don't need to be there.

and

One cannot underestimate the power of military ideology to redefine a citizenry. To see the world as a never-ending series of conflicts with other nations and peoples is very narrow-minded — but it's how we teach American history, and how the current government defines the agenda for American foreign policy. It also defines how we view the future of security in general. As we develop greater means by which to treat illness and vanquish terrorists, the future should seem brighter — but it can't seem too bright. With the promulgation of Patriot Acts and Total Information Awareness, the distinction between military and psychological notions of panic is becoming scant indeed. The sensation that someone is always watching, that our worst fears are always on the verge of being realized, and that somehow our private lives are being infiltrated by Big Brother — this may be the Orwellian reality of the future, but it sounds like today's domestic policy to me.

and

Along with psychologist Kay Redfield Jamison and countless others, I have experimented with and benefited from the wonders of drug therapy. But it gives me the panic to find myself discussing medication within ten minutes of meeting a therapist for the first time. Undoubtedly, expediency is a consideration in these matters, as many people are panicky and depressed — and psychologists are overbooked. The turn to expedient solutions, however, corresponds to the hasty, undemocratic way in which American politics currently operate. Rather than acknowledge the collective dimensions of panic inspired by threats of war, economic downturns, environmental holocaust, general greed and corruption, and so on, psychopharmacology aims to find the appropriate pill for an individualized illness. Like the "one person, one vote" approach to democracy, psychopharmacology may have good effects, but it is not geared to make the world a hospitable place. It won't bring back the sense of neighborhoods earlier generations enjoyed as children, for that requires a trust in one's neighbors. Treating the symptoms of illness allows us to more or less dismiss its larger social causes. If panic is treated primarily as something located within individual psyches, then the world doesn't have a problem. The advice of W. after 9/11 — business as usual, go out and spend — is offered as a sort of panacea for panicked America. To those who already felt insecure and panicky . . . well, just watch your TV screens. We've got a new reality show on CNN we're sure you're going to love.

Good stuff.