“Without a full spectrum of voices from partisan political elites, though, anxious citizens in search of protection from threats to their health and way of life may support charlatans or madmen who offer bodily protection while destroying the body politic.”1
There are plenty of reasons to be anxious about the state of the nation: the coronavirus pandemic, the economy, climate instability, physician burnout, an endless war on terrorism, returning to the classroom (or not), and racism, among other societal and personal stressors. All these major dangers are on top of the still-looming nuclear risk that could blot out human life on earth in virtually an instant. No wonder some individuals are calling 2020 “the worst year ever.”
As if that were not enough, now we have a presidential election happening in the midst of partisan political warfare, civil unrest, and frightening conspiracy theories on TV and the internet. The stakes seem sky high, perhaps because the president has so much influence on how we address every other crisis. How might mental health professionals potentially assess and address this “election anxiety”?
Election anxiety polls
The polls confirm our intuition: we are a nervous nation. Earlier this year, the American Psychological Association conducted a “Stress in America” survey2, in which they found more than half (about 56%) respondents identified the 2020 election as a significant stressor. At the end of June, the Centers for Disease Control reported that the highest rising levels of anxiety were among young adults, as well as black and Latino people of all ages. The prevalence of anxiety symptoms among all populations was 3 times higher than the corresponding period in 2019.3
Certain groups of minorities, especially educated and higher-earning black males, are at risk for more anxiety.4 This possibly counterintuitive finding may stem from blocked opportunities, which in turn may be related to the higher implicit bias of white men.5
Anxiety also seems to differ along partisan party lines. About two-thirds of recent Joe Biden supporters say they are scared about the country’s future, compared to about one-third of President Donald Trump’s supporters.6 Of course, these sources of anxiety can change, and change quickly, depending on societal developments.
In our Psychiatric Times polls (Figure 1 and Figure 2) inquiring about the upcoming elections, the trend was clearly slanted toward being very worried, with about half of respondents doing something productive about it and half not. As far as our patients are concerned, the second poll suggested a similarly strong degree of concern. If these trends hold up, the anxiety level would be even higher in our psychiatric world than in the greater society.
Varieties of anxiety
Anxiety refers to a prolonged state of apprehension brought on by uncertainty about future threats. Past threats logged in our memories and unconscious can also influence our view of upcoming risk. As such, anxiety is a natural emotion and vital for survival. In contrast to anxiety, fear is an acute or phasic response to an immediate and identifiable threat, as we explained in a prior article for Psychiatric Times titled “FDR, the Bene Gesserit, and the Psychiatry of Fear.”7 Perception is a key for both anxiety and fear because the threat can be an imagined one. If anxiety is punctuated by acute episodes of fear, such as fear-mongering political campaign ads, it can feel like a one-two punch to our sense of security.
The physical and psychological symptoms of anxiety, such as feeling tense or having trouble concentrating, can be so uncomfortable that they cause behavioral changes. Fight or flight stress responses range from avoidance to aggression, as well as self-medicating with alcohol and street drugs. Peaceful protests in presidential elections can reflect a normal and appropriate expression of anxiety, such as is emerging virtually with the “Rage Moms,” who are fed up with being teacher, caregiver, employee, and parent all at the same time. When protests turn into riots, however, they may be a reflection in part of too much anxiety, an overreaction to perceived threats. Similarly, police may have appropriate anxiety for their role and risk, or not.
There are several kinds of anxiety. Given the power of the presidency, a presidential election may tend to elicit anxiety about one’s very existence and the meaning of one’s life. That is called existential anxiety.8
Individuals who are more intolerant of uncertainty are especially vulnerable to excessiveanxiety.9 The brain correlate of this intolerance is an increase in striata volume, particularly in the putamen. One brain model of subclinical and clinical anxiety is the uncertainly and anticipation model.10 This is a feedback model, in which there is either a disrupted cognitive estimation of probability and cost of a future threat, or heightened subjective feelings about negative future events. That it is a feedback model suggests why it is difficult to stop until neuroplasticity develops new anxiety pathways.
Although many individuals are overly anxious, others may not be anxious enough given the circumstances. They suffer from inadequate anxiety. Inadequate anxiety can lead to ignoring various risks and, in this case, not voting. Those individuals who have sociopathic tendencies tend to have less anxiety, which in turn may allow them to manipulate individuals with higher anxiety levels.11
If there is an appropriate amount of anxiety, it would be an amount proportionate to the assessment of future danger, which in itself is difficult to predict and may change over time. Therefore, appropriate anxiety is a moving target. It needs regular monitoring and recalibration.
The deep history of anxiety
Anxiety has apparently persisted over human history, indicating that it has an important evolutionary role. Simply put, the evolutionary advantage of anxiety could be that it leads individuals to take fewer risks, seek safety, and focus on doing things well. On the other hand, anxiety can limit the risk-taking that advances human adaptability.
In terms of evolutionary psychology, anxiety would help us survive as a species. One way that anxiety can do this is to organize our cognitive functions quickly in response to danger. Additionally, another thesis is that chronic anxiety can be a driver of genius.12 Anxiety can also be a negative reinforcer that encourages the socialization necessary for survival and reproduction, because anxiety is generally most intense when we are isolated.13
A history of election anxiety
Reviewing some historical elections may be informative, and perhaps reassuring, as we approach this upcoming election.
A clear parallel can be drawn between our upcoming election and the election of 1920. It was during another devastating pandemic, the so-called “Spanish flu” that began in 1918. (President Trump’s grandfather died of this flu.) The worst of it was over by 1920, and the Republican nominee, Warren Harding, ran and won on a “return to normalcy” platform. His message resonated with the electorate, and he seemed to reduce the public’s fears. He was viewed positively while president but died only about 2 years into his term. Soon after he died, his reputation fell amid multiple scandals, stemming from his habit of giving government jobs to friends.
Our society today is split along ideological, racial, and class lines. The same was true during the election of 1968. On March 31, 1968, President Lyndon Johnson announced that not only was he partially halting the United States bombing of Vietnam, but also that he would not seek the nomination for president. Although his withdrawal offered hope for reconciliation, that dissipated quickly. Only 5 days later, Martin Luther King Jr was killed. Only a couple of months after that, Robert F. Kennedy, who was running for the Democratic nominee, was murdered. The nomination of Hubert Humphrey occurred during a violent, conflictual convention in Chicago. Richard Nixon won the presidency with a law-and-order message and a (secret) plan to end the war in Vietnam. Nixon knew what millions of Americans were worried about, and he promised to eliminate the sources of their fear.
Another election that has a lesson to teach us is 1980. The incumbent, Jimmy Carter, was defeated in part because the economy was awful, which caused increased anxiety and unhappiness. In his infamous “crisis of confidence” speech, he tried to address the nation’s concerns, but the voting public concluded that President Carter was in over his head. Similarly, the COVID-19 pandemic has adversely affected our economy, although it remains to be seen if the electorate will hold the president accountable.
The concern about the economy also brings 1932 into the picture. High unemployment levels contributed to Herbert Hoover’s landslide defeat. Franklin Delano Roosevelt led the recovery with federal work projects and mobilization for World War II. In his first inaugural address, Roosevelt told Americans that that they had “nothing to fear but fear itself.” He was effective because he at once calmed the nation’s nerves and tackled the underlying sources of its anxiety: poverty, unemployment, and hunger.
For psychiatrists in particular, perhaps the most anxiety-provoking election was in 1964. Answering a poll conducted by FACT magazine on whether Barry Goldwater was mentally fit to be president, about half of the replying psychiatrists provided what Freud would call “wild analysis.” Goldwater sued the magazine, won his case, and psychiatrists were embarrassed. The result was the 1973 Goldwater Rule, set by the American Psychiatric Association. The rule barred psychiatrists from diagnosing or analyzing a public figure, an admonishment stirring anxiety and debate among psychiatrists in our time.14 Goldwater lost the 1964 election to Johnson in part because the electorate feared he might overreact to a perceived Russian threat and start a nuclear war.
In the 2016 election, our Psychiatric Times poll found that two-thirds of responders preferred Hillary Clinton. We had a comment section then, and the discussion was passionate, suggesting some intense underlying anxiety in the mental health professional community.
Although less attention is given to vice presidents and vice-presidential nominees, they can make a difference, and their influence is not lost on voters or candidates. For instance, George McGovern initially added Thomas Eagleton as his vice president on the 1972 democratic ticket. Upon learning that Eagleton had clinical depressive episodes, McGovern consulted with psychiatrists who apparently advised him that a recurrence of depression was possible and could endanger the country.15 As a result, McGovern dropped him from the ticket. Interestingly, Eagleton went on to be reelected to the senate and achieved other career successes, and McGovern lost in a landslide. McGovern may have been too anxious about Eagleton’s depressive episodes, which may have cost him the seat. And, as we psychiatrists know, recurrence may be a risk, but it is not a good reason to think an individual is incapable of serving in a public office.
The vice president can represent other personal qualities that are important to the public. Joe Biden, Donald Trump, and Mike Pence are all older white males. In contrast, Biden chose Kamala Harris as his running mate. In picking a woman who is the child of Indian and Jamaican immigrants, he may be trying to assure the younger and more ethnically diverse parts of the electorate that he shares their concerns with racism, sexism, and other forms of discrimination.
Looking back on this historical survey, it appears that Americans reward politicians who are able to acknowledge their anxieties and put forth credible plans to eliminate the sources of their fears. Politicians who appear to be overly anxious, or blithely unconcerned, fare poorly.
Although you will not find “election stress disorder” in DSM 5, it has been described.16 This “disorder” leads to all-or-nothing thinking and defense mechanisms of blame, denial, and avoidance. These reactions can lead to cult-like, brainwashed adherence to a one-sided perspective. Should you or your patients feel overwhelmed or anxious, many of the traditional behavioral approaches may prove to be helpful (Table). We need to be especially cognizant of countertransference, reactions where our own anxiety and political beliefs intrude into the therapeutic arena.
After the election, another informal disorder may emerge: a so-called post-election stress disorder. This phrase was first coined when President Obama was elected as a result of conflict and rising anxiety, especially around the issue of race.17 Therefore, it was not surprising to see some post-election emotional fallout and backlash regarding the country’s first Black President. Did those reactions last and influence the election of President Trump?
Whatever the case, the period after the 2020 election may be more anxious still. There are already wide-spread fears of voter suppression, voter fraud, and delayed results. Post-election anxiety could escalate even more than in 2000, when a controversial Supreme Court decision ended the Bush-Gore race.
The role of psychiatry
At least going back to the time of Plato, philosophers have tried to reduce the role of emotions such as anxiety in politics and promote rationality alone.1 Given the importance of anxiety in our evolution, psychiatry should not be surprised at the limitations of that approach.
Of course, undo anxiety about safety and security leads to vulnerability, a propensity to being manipulated instead of educated. Recent polls indicate that such groups as young adults, Blacks, and Latinos are becoming increasingly anxious, likely due to uncertainty about their future. Particular attention needs to be paid to the well-being of these groups in terms of family and community psychological support, which in turn can make them more resilient.
Charismatic leaders more concerned with themselves and their public image than with the public good are particularly problematic. With our 2-party system, political leadership can change suddenly, and the losing party is often afraid of what will happen to them under the new regime. Leadership for all is necessary to reassure the losing side that it does not need to panic or lash out.
Anxiety is an essential emotion that can help us assess and respond to future risks to our safety and security, a basic human psychological need as Maslow has taught us.18 However, to use anxiety successfully, people need to be able to assess risks rationally. Although the future is unknowable, educated estimates can still be made—if there are accurate information and facts. One of the psychiatric lessons from the Spanish flu and the public panic that accompanied it was the need for the government to be honest and open.19
Since psychiatry has expertise in distinguishing fantasy from reality, as well as managing anxiety, we are essential for making presidential anxiety useful, rather than harmful for the public, patients, and for ourselves. Our Psychiatric Times polls indicate that both we and our patients are quite worried, with the good news that about half of us are already trying to do something productive about it.
The role of psychiatry in politics has been limited by the Goldwater Rule against commenting on public figures that we have not evaluated. As a result, psychiatry has retreated to the margins of the political arena. How might psychiatrists play a larger, more productive role in American public life? Psychiatrists could be involved in routine mental health assessments of any presidential candidate and annually for the president. Additionally, there is no prohibition against educating the public and our patients about the role of anxiety in politics. Psychiatrists could help their fellow citizens hit the sweet spot of anxiety: enlightened participation, voting, realistic hope, and improved mental well-being. In fact, it is psychiatry’s ethical responsibility to contribute what we can “to the improvement of the community and the betterment of public health.”20
Psychiatric Times has featured a series looking at the psychiatric challenges for the 2020s, and it now seems that politics and psychiatry will be one of them. This is one of the social aspects of psychiatry.21 There are 2 more elections scheduled during this decade. Just like finding the right amount of anxiety, we need to find the right amount of political engagement, not too much and not too little, in the 2020s.
Dr Moffic is an award-winning psychiatrist who has specialized in the cultural and ethical aspects of psychiatry. A prolific writer and speaker, he received the one-time designation of being a Hero of Public Psychiatry from the Assembly of the American Psychiatric Association in 2002. He has recently been leading Tikkun Olam advocacy movements on climate instability, burnout, Islamophobia, and Anti-Semitism for a better world. He serves on the Editorial Board of Psychiatric Times.
1. Albertson B. Anxious Politics: Democratic Citizenship in a Threatening World. Cambridge University Press; 2015.
3. Czeisler MÉ, Lane RI, Petrosky E, et al. Mental Health, Substance Use, and Suicidal Ideation During the COVID-19 Pandemic – United States, June 24-30, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(32):1049-1057. Published 2020 Aug 14.
4. Assari S, Curry TJ. Black men face higher discrimination and depression, even as their education and incomes rise. The Conversation. July 21, 2020.
5. Assari S. Interaction between race and gender on implicit racial bias against blacks. Intern J Epidemiologic Research. 2018;5(2):43-49.
6. Lerer L, Plott E, Gamio L. How Americans feel about the country right now: Anxious. Hopeful. New York Times. June 27, 2020.