The Worried and the Well

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COMMENTARY

JD: What do you think will happen when you get home?

Rudolph Abel: I think I’ll have a vodka.

JD: Yeah…but Rudolph, is there not the possibility…

Rudolph Abel: That my people are going to shoot me?

JD: Yes. You’re not worried?

Rudolph Abel: Would it help?

-Scene from “Bridge of Spies” (2015)

To talk with another human being—be it a patient, a friend, a colleague, or a family member—often is about sitting with their worry. Worry is something that we all do, sometimes in subtle ways, but sometimes in very visceral ways. Some individuals are worriers—they go to the worst case scenario and negative thoughts form an almost physical vise around their brain, settling into their throat, chest, and abdomen, keeping them from sleep or threading their way through nightmares. As psychiatrists, we are used to differentiating worry from anxiety disorders. And yet, few of us would tell someone who is awaiting biopsy results or who has reason to believe their job will be eliminated that their worry is the product of a disorder, even when it is uncomfortable or causes transient physical symptoms.

Some individuals, like the character of KGB spy Rudolph Abel, played by Mark Rylance, in the 2015 Steven Spielberg movie “Bridge of Spies,” are not worriers—they wait for an untoward event to actually happen before they become distressed. But worry likely happens along a spectrum with our KGB spy at one end and those with anxiety disorders at the other. When worry goes too far astray, we think more about delusions and psychotic disorders.

It is hard to talk about worry in a clinical sense. How do we judge what are reasonable concerns to assign mental energy? And then how much energy, for how long, and with what intensity? The literature on worry blends with that for anxiety disorders, and worry is considered the cardinal symptom of generalized anxiety disorder. But worry itself is not a disorder, and while it seems intuitive that individuals with anxiety disorders might worry more, it is not true that all individuals who worry have anxiety disorders. At one point, we referred to the “worried well” as those who were taking resources from those with true pathology.

I spoke with Sally Winston, PsyD, who is coauthor of Overcoming Anticipatory Anxiety: A CBT Guide for Moving past Chronic Indecisiveness, Avoidance, and Catastrophic Thinking (New Harbinger, 2022), about this concept.

“A lot of people think of themselves as worrywarts and they feel stuck,” Winston said. “I like to distinguish between productive worry, something we all do. With this type of worry, there is an action plan, and then the worrying stops. In unproductive worry, the focus is on the future and there is no answer, just rumination. We talk about ‘what if-ing’ and ‘going down the rabbit hole.’ It’s incapacitating and focuses on disaster.”

Nor is it true that everyone’s worry is the same—for some the word connotes a passing concern, while for others there may be intense preoccupation. There are surprisingly few synonyms in the English language for a word that is used to capture such a wide range of emotions—fret, stew, and agonize are possible stand-ins. It can also be remarkable what any individual might not worry about; for example, a person might worry a great deal about a child’s school performance but not about the consequences of their own chain smoking.

The COVID-19 pandemic brought worrying to life in a new way. For a short while, we had a single national page. Schools and businesses closed, transmission was uncertain, and individuals scurried through grocery stores with masks and stood on circles strategically placed 6-feet apart. We formed family and social pods, were legally forbidden from congregating, and learned about Zoom. The consensus soon splintered as immunity built, vaccinations became available, and politics intruded. Five years later, there are healthy individuals who avoid indoor spaces, who mask at work and social events, and who feel the risk of long COVID justifies this level of precaution. “The science is with me on this,” they may say, and there is no definitive line as to when precaution becomes pathology.

From an evolutionary perspective, it makes sense that worrying would be protective. Any trait that improves the likelihood of survival through reproductive age is likely to confer advantage, so perhaps worriers might be more likely to settle farther from hungry lions. To the extent that it focuses behavior away from high-risk activities and negative consequences, it may be good, but worry often focuses on matters beyond one’s control.

“People have beliefs that they are not aware of,” Winston said. “They may think that worry keeps them safe or that it protects their children. It may become a part of their identity, and they may think ‘what kind of person would I be if I did not worry about my family?’”

Depression and anxiety are uncomfortable states, ones that patients often feel is foreign and unexplained, and they may seek help for relief. Worry can also be uncomfortable, but it often makes sense to the person who is experiencing it, and they may try to justify, explain, or defend their right to their desire for precautions. With our current political divide, we may stoke worry in one another as part of our tribalism, whether it is about occupational and financial security, personal and public health, current or threatened war, natural disasters and climate change, or social injustice—to name just a few topics of public interest.

At some level, worrying is simply part of the human experience—it is hard to find a parent who does not anticipate issues of health and safety, much less someone who does not feel impacted by the high anxiety of the latest news. The media is constantly telling us of impending disasters, the latest findings on what will impact our health or safety, and general bad news. “There are things we will never be able to plan for, figure out, or know for sure and the looping ruminations of worry won't actually help,” Winston said. “And some of what we think of as worry is more about fear.”

The character of Rudolph Abel walks to the end of the bridge with James Donovan, played by Tom Hanks, to be handed off to the East Germans. In the movie, he makes a good point that worrying will not change whether he is headed home to a glass of vodka or to be executed. It would be nice if real world emotions made as much sense as those created by screenwriters.

Dr Miller is a clinical psychiatrist and writer in Baltimore. She is on the faculty at the Johns Hopkins School of Medicine.