"I think that anxiety is the fever of psychiatry, not a disease, it's not a diagnosis, it's not an illness. It's just a symptom, usually of other illnesses or condition." - Nassir Ghaemi
Published On: 09/07/2023
Duration: 21 minutes, 43 seconds
KELLIE NEWSOME: Welcome to the Carlat Psychiatry Podcast, keeping psychiatry honest since 2003. This is a throwback Thursday episode, where we’re going to update this 2019 classic with new research and CME credits at the end.
This month we are focusing on the fever of psychiatry: anxiety. Our opening quote is from a recent interview we did with Nassir Ghaemi.
CHRIS AIKEN: He reminded us that anxiety can be caused by just about every psychiatric disorder, including one that's not in the DSM.
NASSIR GHAEMI: The most common cause of anxiety is depression and depressive related mood illnesses, mania and depression can cause anxiety. Mycosis can make something anxious, obviously. And another common scenario is neuroticism as a personality trait.
CHRIS AIKEN: A person with neuroticism experiences negative emotions more intensely. Emotions like anger, anxiety, depression, jealousy, guilt. Unfortunately, the list just goes on. People with neurotism take things personally and they are often dissatisfied with life.
KELLIE NEWSOME: People with the straight see the world is a dangerous place and feel unable to cope with those dangers. They sweat the small stuff, minor frustrations feel hopelessly difficult.
CHRIS AIKEN: Neurotism is not in the DSM because it's not a disorder, it's a temperament, which means it's a personality trait with a strong biological basis, that doesn't change much over time. People have tried to narrow down the core elements of temperament for ages, going back to the four humors of the ancient Greeks. Those were sanguine, which is active and social and positive. Choleric, angry or irritable. Phlegmatic or apathetic. And melancholic depressive.
KELLIE NEWSOME: Moving ahead to the modern times, the most widely accepted classification of personality is the Big 5 personality traits. Openness, open to experience, inventive and creative. Conscientious, organized planning, careful. Extroverted, outgoing and energetic. And there is agreeable, friendly and compassionate. And neuroticism.
CHRIS AIKEN: Despite their similarity and names, Neuroticism has nothing to do with neurosis. Neurosis, which we covered in last episode, it was the forerunner of generalized anxiety disorder. It's a psychoanalytic term for unconscious conflict that causes mental symptoms. The word was widely used in psychiatry until 1980, when Robert Spitzer removed it from the DSM 3. He didn't want the book to imply that we knew the cause of any psychiatric disorder, whether that cause was unconscious conflict or neurobiological.
Neuroticism entered our language in the 1950s through the psychologist Hans Eysenck. Hans Eysenck was no friend to psychoanalysis, and he didn't mean the term to be related to neurosis at all. In fact, he set out to prove that these neurotic traits were genetic and could not be changed with psychotherapy. Hans Eysenck brought many ideas to the field, some of them have been discarded, but neuroticism remains. It gained wider acceptance when it was included in the Minnesota Multiphasic Personality Inventory, better known as the MMPI.
KELLIE NEWSOME: Hans Eysenck was a controversial psychologist. In addition to describing neuroticism, he also believed in a cancer prone personality type that explained the association between nicotine and cancer. They were the ones more likely to smoke. In other words, it was the personality of the smoker who was just as responsible for the lung cancer, as the cigarettes they smoked. And that sounds widely inaccurate or even offensive, but the theory was beloved by the tobacco industry, who paid Dr. Eysenck millions of dollars.
CHRIS AIKEN: But when it came to neuroticism, there was more than one grain of truth in Dr. Eysenck’s theories. His early family studies suggested that this was an inborn trait and now when we put all the twin data together that we have, it looks like neuroticism is hereditable, about 40 to 60% heritable.
KELLIE NEWSOME: Wait, where does the other half come from?
CHRIS AIKEN: From what we know, there are environmental factors that can increase neuroticism. For example, helicopter parenting. That can lead the child to grow up thinking the world is not a safe place, or that they're not able to handle those dangers on their own. Also, when a parent is not very available emotionally and withdrawn. That can make the child feel very insecure and more likely to develop neurotic traits. We covered these parenting styles last spring in the Carlat Report.
KELLIE NEWSOME: But what about his idea that therapy doesn't work for neuroticism? Just because something is genetic doesn't mean it can't get better with therapy.
CHRIS AIKEN: A few studies have looked at that question, and so far the results generally agree with Dr. Eysenck. For example, in 2008, a group of psychologists led by Dr. Michael Bagby at the University of Toronto tested whether any of those Big 5 personality traits would predict response to therapy versus medicaion. The design was a randomized controlled trial with several 100 depressed patients. None of the five personality traits predicted response except neuroticism, and the depressed patients with neurotic traits responded better to antidepressants than to CBT. Just how much better? The remission were 75% for medication and 57% for therapy when it came to having depression with neurotic traits.
KELLIE NEWSOME: Well, 57% isn't bad, so therapy can work if you have these neurotic traits, just not as well as an antidepressant. That makes a bit of sense. I mean, if it's a biologically based trait, then a biological treatment might work better. But that study only looking at depression. Do medications actually affect neurotic traits?
CHRIS AIKEN: Yes, they do, particularly the SSRIs.
NASSIR GHAEMI: My view is that SSRI's can help long term anxiety symptoms if you have those personality traits for neurotisism. But the help the benefit is symptomatic and mild, still mild to moderate.
CHRIS AIKEN: The SSRI antidepressants have been tested extensively in normal subjects and based on what they do there, it looks like they might turn down neurotic traits when normal subjects take an SSRI, they are more cooperative with others, they're better able to read emotions and faces, and they're less bothered by daily hassles, and less reactive to frightening pictures. These are pictures of blood and gore and dead animals that they show people when they're in a pet scan or MRI to see how their brain lights up. Most of those changes can be seen within one to two weeks. Now turning to neuroticism, there are a few studies that have extended those findings and they seem to show the same trends. When neurotic people take an SSRI, they are better able to recognize positive emotions than other people. Think about your neurotic patients that you see in practice.
They are overflowing with stories of how poorly they're treated by others. It can seem like they live in a world of gossipers haters and miscreants. They do, but no more than the rest of us. The problem is the neurotic person can't see the positive interactions. They don't recognize all the warm accepting faces out there and only recall the rejecting ones. Neurotic people also made better eye contact when they took SSRIs and are less ruminative and worried all the time.
KELLIE NEWSOME: That reminds me of a book I read “Listening to Prozac” by Peter Kramer. Doctor Kramer was a psychiatrist who primarily practiced psychotherapy and when Prozac came out in 1987, he started some of his therapy cases on it and noticed profound changes in their personality. The book became a best seller in 1994, and it sparked a debate about cosmetic psychopharmacology that still goes on. Dr. Cramer implied that people might become better than well on antidepressants, more optimistic social and confident. Basically less neurotic.
CHRIS AIKEN: Before Prozac, antidepressants had too many side effects to consider giving them to people who didn't have depression. But Dr. Cramer's book brought that possibility to the forefront of the public imagination. Psychiatry, however, was not, and still isn't comfortable with the idea that antidepressants can change personality traits. I once heard Dr. Cramer give a lecture. He didn't talk about this better than well concept, but afterwards several prominent psychiatrists stood up to challenge him on it, insisting that antidepressants simply treat depression and do nothing when given to people who aren't depressed, but maybe a little neurotic.
KELLIE NEWSOME: Is it just the SSRIs that affect neuroticism?
CHRIS AIKEN: One study looked at that question and concluded that only the SSRIs, not the noradrenergic or dopaminergic antidepressants, changed neurotic traits when depressed people took them. Most of the research, and there's about half a dozen trials here, have looked at whether neuroticism, predicts, or even explains the antidepressant effects of SSRIs. The evidence seems to point that way. For example, if you give a large group of people with depression an SSRI, the ones with neurotic traits are the most likely to recover on it. And those recoveries are associated with the change in the neurotic traits and implies that it might be that the antidepressant works first by treating the neurotic traits in the first two weeks, then the patient is perhaps better able to be more active, more social, live a more effective life, and following through in week 3 to 4 is less depressed.
KELLIE NEWSOME: It would make sense then to choose an SSRI if your depressed patient has neuroticism. But how do you figure that out? Let me read a few items from the neuroticism scale. These sound like things that anyone with depression might endorse. I dislike myself. I worry about things. I get stressed out easily. I often feel blue. I feel threatened easily. I am uncomfortable with myself.
CHRIS AIKEN: It's not easy to figure out if someone has neuroticism when they're actively depressed. Even if you ask them about how they were before the depression, their memory is likely to be impacted by the state that they're in. I actually find that this research is more useful when I'm stopping an SSRI. When someone has been well and recovered from depression for a while, at least six months and possibly more if they have highly recurrent depression. When that person wants to come off an SSRI, I'll taper it down slowly. There's a strategy for tapering antidepressants that came out this year. You can find that on our website, search for the article “A New Proposal for SSRI Withdrawl.” Anyway, one thing that I watch for besides SSRI withdrawal symptoms is that the patient just might come back when they're off the SSRI or have lowered the dose and say “I'm not depressed, but I get irritated at my spouse more often and I cry easily. It's harder to shake things off. I keep worrying about stuff and can't get it out of my head.” Then I'll ask if this is anything like the way they were before they took the SSRI, before they got depressed in the 1st place, and if it turns out then that they had a long history of neurotic traits. Well, that starts to open up a discussion.
KELLIE NEWSOME: So they might continue the SSRI to treat the neuroticism, but isn't that cosmetic psychopharmacology. I mean, neuroticism is a trait, not a disorder. It's not even in the DSM.
CHRIS AIKEN: That's right, traits are not in the DSM because they're not disorders. They are a mix of good and bad, positive and negative. Things are only a disorder if they cause significant distress or impairment. Now, sometimes neuroticism can get that bad, but at that point the patient will nearly always meet criteria for one of our DSM categories, like generalized anxiety disorder or depression. And indeed, neuroticism is a strong risk factor for most psychiatric disorders, so from that point of view, treating neuroticism in someone who's had problems with depression could be justified and helpful from a preventative point of view. But we have to be careful there, sometimes the patient doesn't want to treat it.
KELLIE NEWSOME: That's interesting. Why not? What do they like about the neuroticism?
CHRIS AIKEN: When the neurotic traits are active, they have strong feelings and somehow they feel more authentic and more connected to the world. It feels more natural, like it's their true self. And although we've listed a lot of negative aspects of neuroticism, this trait also comes with strengths. Every human trait can be a strength or a weakness, depending on the context that it's in. Like, take the cautiousness and hypervigilance of neuroticism.
KELLIE NEWSOME: That would make them pay closer attention to risks that others ignore and might serve them well in professions where it pays to be aware of the worst possibilities, like medicine, law, quality control and insurance.
CHRIS AIKEN: They also have rich inner lives. People with neuroticism feel things intensely and analyze their own thoughts and feelings. When that's paired with creativity, it can lead to great works of art and indeed, neurotic people tend to be more creative on average. And here's another thing, people with neuroticism often dream up the worst possible scenarios. They worry about future outcomes, imagining the worst, and what other people might think about them. And all of this is totally in their head, ungrounded from reality. Well, that's what we see in practice, but another way of looking at that is that they have big imaginations. They are dissatisfied with the world, full of angst about it, and they're also able to imagine that things could be different. As psychologist Adam Perkins put it, they have representations of information that are unrelated to the way the world is. Neuroticism is part genetic, but think about what happens when someone with those traits and those genes is raised in a supportive environment. How might neuroticism come out in that scenario when those neurotic traits are channeled in a positive way? We might get someone like Bobby Kennedy.
BOBBY KENNEDY: Some men see things as they are and say why? I dream things that never were and say why not?
KELLIE NEWSOME: We have update from this episode, but first, a preview of the CME test:
1. Which of these statements is not a neurotic trait
A. “I often act on impulse”
B. “I get stressed out easily”
C. “I am uncomfortable with myself”
D. “I feel threatened easily”
Start earning CME through the link in the show notes.
This year, a randomized controlled trial from Japan tested out the theory that SSRIs work a little better in neuroticism, this time by comparing SSRIs to mirtazapine in a randomized controlled trial in 101 patients with major depression. As our episode predicted, the SSRIs – in this case sertraline and paroxetine – worked better in patients with high levels of neuroticism, and much better – they had double the remission rates with the SSRIs. But the study tells us more. First, it took 2 months to see that difference, so if you’re treating a neurotic patient you can expect those SSRI benefits to build over at least 2 months.
Second, and this one surprised us – mirtazapine worked much better in those with low levels of neuroticism – bringing about remission rates in the non-neurotics that were nearly double those on the SSRI.
CHRIS AIKEN: I’ve dug a little deeper into the neuroticism-creativity link this summer, as I had the honor of presenting a grand rounds on the subject at University California Davis – thank you Jesse J Koskey and everyone for the warm welcome there. UC Davis has a wonderful psychiatry department there in Sacremento with a strong balance of psychotherapy and enough writers and artists among their psychiatrists to support an annual grand rounds on writing and medicine.
And here’s the conundrum. Creative people do have more neuroticism, but neurotics aren’t necessarily more creative, which means there must be more to this story, and that is another of the Big-5 personality traits: openness.
KELLIE NEWSOME: We touched on that in the podcast. People with high levels of openness are intellectually curious, open to experiencing emotions, sensitive to beauty, willing to try new things. We see this trait more often in people with bipolar disorder and it’s a strength – it predicts a better response in psychotherapy.
CHRIS AIKEN: And that’s one pathway out of neuroticism – to help them find their creative, open side. Neuroticism carries with it another trait that can help in creative work – rumination – that repetitive, negative thinking that spirals and spirals. But rumination can also be a strength – it is a dogged, determined type of problem-solving, and creatives need that – to stick with the problem at hand until they arrive at the creative solution. In one study of healthy college students, those who tended to ruminate in a functional way – where it moved them toward real solutions and positive actions instead of just anxiety and avoidance – they had the highest levels of psychological well-being. Below them were people who don’t ruminate much at all – they just take everything as it comes - and at the bottom of the well-being scale were people who engage in depressive rumination.
One way to get to functional rumination is through a combination of neuroticism and openness, and that is also a pathway to creativity. It takes a neurotic mind to find problems, a ruminative mind to stick with them, and an open mind to take that leap into the unknown and seek new solutions.
KELLIE NEWSOME: That was President John F. Kennedy delivering the quote that inspired his brother, Bobby Kennedy.