Understanding the Most Anxious Country in the World

- Antonio Salazar is the most successful fascist ever, and you've probably never heard of him. He ruled far longer than this guy, controlled more territory than this guy, and faced way less political opposition than this guy. Now, unlike the other fascist, Salazar came to power reluctantly.

He was a boring bureaucrat. He had no romantic visions of returning Portugal's imperial glory. He sought no cult of personality.

He refrained from grand public displays. He avoided wars and violence whenever he possibly could. For over 40 years, he encouraged a quiet, traditional lifestyle onto the Portuguese population.

No drama, no striving, no politicking, just a simple family life and church. This lifestyle was symbolized by what he called the three Fs, and he reiterated them constantly, fado, Fatima, and futebol. In the 1970s, after 40 years, Salazar's regime collapsed and Portugal became democratic.

(crowd chanting) - In the 1980s, the first studies on generalized anxiety emerged and found that the Portuguese population was teaming with it and numbers rarely seen elsewhere. In the first large international survey of generalized anxiety disorder in 1990, Portugal placed first in the world in general anxiety disorder diagnoses. For such a quiet and peaceful country, Portugal's mental health data are shockingly bad.

In the US, 44% of college students self-report struggling with anxiety on a regular basis. In the EU, that number is 31%, and Portugal, 75%. (dramatic music) I've come to Portugal to figure out what the hell is going on here.

I thought this place was like sunny beaches and cappuccinos on cobblestone streets. I mean, what the hell is everybody freaking out about? To find out, I talked to journalists, psychologists, even a local pop star.

And as it turns out, the story of Portugal's mental health crisis is far deeper and more profound than I ever could have imagined. Our story will take us far beyond Salazar's dictatorship. As we go, we will consider the world's biggest football star, mass migrations, Virgin Mary sightings, a 250-year-old form of music in the basis of human nature itself.

And the conclusion will be as shocking as it is obvious. (dramatic music) But first, this. (crowd cheering) - [Commentator 1] Here he comes.

Oh my word! (crowd cheering) (robust music) Can you believe the genius of this man? What a hit.

- [Mark] Football is a game of anxiety. Other sports are built around the spectacle of scoring, (crowd cheering) whereas football is about the agonizing anticipation of scoring. Goals are so scarce, so special that every pass, every dribble, every mistake is imbued with an overwhelming significance.

Is this the one? Is this the one? Is this the one?

(robust music) Then, the goal comes and a cathartic release of the game stress comes pouring out all at once. And no one in the history of the game has mastered that catharsis more than Portugal's biggest star. (crowd cheering) - [Commentator 1] Cristiano Ronaldo with (indistinct) flick.

Ronaldo! - [Commentator 2] Ronaldo hit it. Oh!

What a strike. (crowd cheering) The man is a machine. - In case you're wondering, football fandom does not correlate to anxiety.

If that were true, South America would be the most anxious place in the world. But Portugal's obsession with the sport is actually interesting, because Portuguese football is in many ways, a microcosm of the problems that Portugal faces as a whole. For example, the Portuguese football lead trails far behind the other European leagues in popularity, partly because it is rife with corruption and financial mismanagement.

This has resulted in gaping inequality between teams and causes the most talented players to move abroad. Of the 26 players on the current men's national team, 21 of them live and play in other countries. And this brings us to our first theory to explain Portugal's anxiety, rampant economic insecurity.

(tensed music) This was the favorite explanation of every journalist I talked to. Some noted Portugal's low wage growth, others talked about the unemployment rate, others talked about the high cost of living. But some Google searches quickly showed that this doesn't explain it at all.

In the EU, Portugal's unemployment is middle of the pack. Its poverty rate is below average. Its average work week is a reasonable 37 hours.

One person noted that the population is aging, but research shows that old people on average experience less anxiety, not more. Some noted that Portugal is much poorer than its neighbors, but again, the data shows that richer countries tend to be more anxious, not less, which raises the question, what the hell actually causes anxiety? (subdued music) According to meta-analysis, these are the most documented correlates of anxiety.

We'll be using this list as our guide to try and understand what is unique about Portugal's culture that could be causing so much anxiety across the population. And we can already cross off a couple of items from this list. And while we're here, the fact that Portugal has not experienced any major wars in a hundred years and has some of the lowest rates of domestic violence in Europe means that we can probably rule out trauma and abuse from this list as well.

So, if it's not economic issues and it's not war, then what is it? To find out, I sat down with Sara Crispim, a clinical psychologist and author of a book about anxiety, and I asked her in my terrible Portuguese to help me figure out what the hell was going on. (Mark speaking in Portuguese) (Sara speaking in Portuguese) (Mark speaking in Portuguese) (Sara speaking in Portuguese) - [Mark] Mm-hm.

(Sara speaking in Portuguese) - According to Sara, there seems to be a disproportionate amount of expectation on people to conform in Portugal to avoid taking risks and follow the crowd. I came across a similar observation in some research by the celebrated social psychologist, Geert Hofstede. Hofstede famously measured cultures on six metrics to determine their national character.

One of these metrics was called uncertainty avoidance. Cultures high in uncertainty avoidance hate ambiguity and they're highly conformist. Hofstede wrote that their defining features as a culture tend to be perpetual anxiety about external judgment or disruption.

And in his dataset, the country that scored highest in uncertainty avoidance, Portugal. But this raises the question, why did Portugal become so traditional? Was it the dictatorship or was it something else?

(subdued music) This (solemn music) is Fatima. (instrumental music) A hundred years ago, Fatima was a tiny farming village. Then, one day in the spring of 1917, 3 young shepherds all around the age of 10 were out tending sheep when the Virgin Mary appeared to them in the sky.

Lucia Santos, the youngest, would later say that our lady appeared and was brighter than the sun. Crowds began to gather in the small town. And finally, on October 13th, six months after the first appearance, over 30,000 people gathered and all claimed to have seen the Virgin Mary at Fatima.

Millions of Catholics have made the pilgrimage here ever since. There are Virgin Mary sightings all over the world. They're nothing new.

They happen constantly, and they happen in all sorts of countries. I remember growing up in Texas hearing about a Virgin Mary sighting under an underpass in Chicago. Hell, I remember at one point there was a Virgin Mary sighting on a piece of toast.

There had been an estimated 21,000 claimed Virgin Mary sightings across the world. The Catholic church officially recognizes 386 of them as being real. But of those 386 miracles, nobody, and I mean nobody has built this.

(frantic music) Oh my god. (laughs) This place is gigantic. Holy shit.

This is like four football fields. The fuck. I don't even know what to say.

Like why? Why is this necessary? Now, the obvious take here is it's Catholicism's fault.

We all associate Catholics with being shame-ridden and feeling guilty all the time, and constantly worrying that they're gonna burn in hell for eternity. So, of course they're gonna be more anxious, right? But that's actually not true, because there's plenty of psychological research showing that religiosity leads to better mental health outcomes.

It might be counterintuitive, but religious people, they tend to be happier, they tend to have better relationships, they tend to be less stressed, and they tend to live longer. (gentle music) But what about the social pressure? Well, if social pressure from religious doctrine correlated to anxiety, we would expect to see the strictest Muslim countries at the top of the charts, but we don't.

Other than Iran, most Muslim countries have relatively low rates of anxiety. So, social pressure doesn't seem like a valid answer. And given how communal and family-oriented Portuguese culture is, neither does social isolation.

So, no, I don't think the story here in Portugal is about religion. I think it's much more subtle than that. I think it's about Fatima, because here's the thing, this wasn't built by the church.

In fact, the church took decades to recognize Fatima as a legitimate miracle site. This was built by the Portuguese faithful, almost entirely through donations from pilgrims. Out of all the miraculous Virgin Mary sightings all over the world, this only happened in Portugal.

And I think that says something about a culture, about a people. My working theory at this point is that the economic stress and traditional pressures are not the cause of Portugal's mental health crisis, but the shared effects. There is some hidden underlying thing driving all of the above.

To explore this idea, I sat down with psychiatrist, Gustavo Jesus. Gustavo specializes in anxiety disorders and has written multiple books on the topic. Tell me what the evolutionary function of anxiety is.

What are the good things about anxiety? - So, anxiety is an emotion. It's a normal emotion.

Everybody gets anxious sometimes. A lot of people feel the same things. They feel psychological effects.

They are more alert, they're preoccupied, they are worried. They cannot turn off the things they're thinking about that worries them. And these symptoms, they can be very well-understood if you look at the evolutionary role of anxiety.

- Mm-hmm. - Because you were here for 300,000 years and your lifestyle has 200 years. So, of course, natural selection worked in a way that was useful, but it's not very useful in our daily lifestyle.

Working night shifts and day shifts, waking up early, dressing up the kids, taking 'em to school, traffic jams, appointments all the time. You are connected all the time. Our body and our brain is prepared for acute stress, but not for chronic stress, and we live in a chronic stress environment.

- What is the relationship between sleep and anxiety? - Mm-hmm. - I think people underestimate that.

- Yeah, I totally agree. Poor sleep is very well-recognized as a risk factor for a lot of medical disorders, cardiovascular disorders, so stroke, heart infarction, autoimmune disorders, and also mental illnesses, major depressive disorder, and anxiety disorder. - Did you know that one of leading causes of anxiety is lack of good sleep?

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Of course they will play a part. And of course, everybody says, oh, that's why Portuguese people are so anxious. But we look at nowadays, and now we are not economically as bad as we were back then, and we are more anxious.

So, that cannot be the whole problem. So, we should go further back in time to look at before all that. For example, we have an authoritarian regime for 40 years, but then again, if we look at Spain, you had an authoritarian regime.

Not even to speak about Germany or Italy. - Right. - And still, they don't have as much anxieties as we have.

So, I think we should go even further back in time to understand, for example, the most traditional song in Portugal is fado. - Yeah. - And fado means in English fate.

So, it's about fate. It's about our destiny. And if you already heard fado, and I hope you do, because it's very beautiful, but it's more like the sad side.

- Yeah. - Like the stories are a little sad. The tone of the music is sad.

So, fado is predominantly more sad than happy. (Carminho singing in foreign language) - [Mark] I was fortunate enough to meet Carminho, an award-winning fado singer. (Carminho singing in foreign language) - It's the translation of Portuguese hearts.

- Mm-hmm. - It can be compared to the soul, to the blues, - Mm. - to the blues, American blues.

It was born in the poorest neighborhoods with people marginalized and they have to share in as a community. - How old is it? - More than 200 years old.

More or less 200 years old. - Yeah. - How would you describe fado music musically?

What's the elements of a classic fado song? - Fado is a acoustic kind of song, where the voice leads. Music and poetry is separated and you can change the subject and you can change the lyrics.

That is a very important thing in fado. (Carminho singing in foreign language) And the reason I still think that fado is for me till I die, because it's a live language. - And what is the cultural significance?

Is it something that every Portuguese person is familiar with? - Fado is something that every Portuguese people know, - [Mark] Mm. - but had a lot of curves in its history.

With times, very popular times, and other times very connected with the dictator or religion or generation's love. And after that, another generation of hate. - Yeah.

(laughs) - And it's normal and it's very interesting. Those kind of moves reflect how important and how powerful is this culture to people and how can this culture translate the society in the moment. - Mm-hmm.

- Carminho helped me understand that fado was part of a wider Portuguese culture of saudade. Saudade is huge for understanding Portuguese culture, to the point that many Portuguese people themselves believe that is the defining concept of their culture. Now, saudade has no direct translation into other languages, and when you ask a Portuguese person to define it, you get these vague, hand wavy answers.

But it's some combination of a longing for or a dreading of something that could have happened but didn't. This sadness or longing seems to imbue a lot of Portuguese attitudes, but especially its art. It is the central theme of many famous Portuguese poets and artists, from Louis de Camoes to Silva Porto to the Grupo de Leao.

It's explored a lot in Portuguese literature, and of course there is the musical form of saudade, fado. But why is such a melancholy concept come to dominate Portuguese culture? Well, there is kind of a common sense explanation for this dating back hundreds of years.

Sara had actually mentioned it to me when I met her on the first day, but at the time, I missed the significance. (Mark speaking in Portuguese) (Sara speaking in Portuguese) (Sara speaking in Portuguese continues) - [Mark] Mm-hmm. (Sara speaking in Portuguese) (gentle music) - For centuries, hundreds of thousands of Portuguese set out to sea for a better life, many of whom were never to be seen again.

These were fathers, brothers, sons. Their families would often spend years waiting for them, not knowing if they were alive or dead, if they were rich or poor, and most importantly, never knowing if they might return. In this way, the obsession about the past and rumination about the future became a way of life, and thus the culture of saudade was born.

Fado soon followed. I began to see saudade as a kind of amplifier of anxiety, and this would be the underlying cause, not only of the obsessively traditional culture, but the desire to always keep things the same. And that would then explain the economic problems, the political dictatorship, and so on.

Now, I'm not gonna lie. By this point, I thought I had this figured out. I thought I understood what was going on here.

Thousands of people left Portugal during the colonial era, creating a culture around longing and dread and nostalgia. This culture then fostered constant rumination and worry, which then led to more anxiety, or so I thought. Turns out, I was wrong.

It actually goes quite a bit deeper than that. Do you think there could be a connection between fado and this culture of saudade and this past rumination? If you're always glorifying this through art and culture - Mm-hmm.

- and your interactions with friends and family, could that reinforce some of these feelings, do you think? - I don't think so. I think that this culture, the fado culture, the saudade culture is not a cause of anxiety, - Yeah.

- but more a translation of something. - Of that. Yeah.

- A translation of, for example, the selection, that artificial selection that Portuguese people were through. (tensed music) During the discovery time, the immigration, the historic immigration that the Portuguese people went through. I think more that death, it's my opinion, could select some genes, some personality traits of neuroticism, for example, that could become or could have become a little bit more prevalent than the general population.

And that probably turns Portuguese population into a population with more prevalence and more proneness to anxiety. - Mm. Gustavo was blowing my mind here.

What he was suggesting was a theory that in all of my research, I never came across once. Yet, it was so simple, so obvious. (instrumental music) Imagine you have a population of people with a normal distribution of anxiety, and every generation, the 10% least anxious, most risk taking people leave.

Within a few centuries, the population's genetic profile around anxiety would be dramatically different. (instrumental music) - A lot of Portuguese generations were the only ones around the world discovering places and crossing the oceans and dying, and the other ones were staying here. So, I think this could be important and could have an impact on the general prevalence of comparative European prevalences.

- And sure enough, if there's anything dramatic or remarkable about Portugal, it is how many of its people have left. During the colonial period, Portugal lost almost 40% of its population, whereas other European powers lost a fraction of that. Multiple Portuguese kings of the 16th and 17th centuries had to ban or institute quotas for Portuguese moving overseas, because it was collapsing the economy back home.

Even today, Portugal still struggles with a mass exodus of its own people. In the years after the financial crisis, it's estimated that 1 million Portuguese or 10% of its population has left the country. (instrumental music) These people leaving, they are not the anxious and afraid.

They're not the ones bound by tradition. It's the ones who stay behind that are. Therefore, our story goes a level deeper, beyond politics, past culture, and straight into biology.

This is, as Gustavo pointed out, ultimately about genes in the artificial selection of a population that is a manmade shift in who exited and who survived. Fado was not a cause, but an effect of a nation that watched for centuries as its boldest and bravest left, never to return. With the risk takers gone, this spawned a culture obsessed with tradition and conformity.

Fatima was therefore not a cause, but an effect of Portugal's artificial selection. And this highly conformist culture then created a political environment where Salazar was not a cause, but an effect of Portugal's uncertainty avoidance. This resulted in an economically stagnant country with all of the wage, labor, and cost of living issues that we know today.

(Carminho singing in foreign language) - [Mark] This may strike you as depressing. Nobody likes hearing that genetics play a large factor in our mental health issues, because it makes us feel as though we have no control, that we can't change. (Carminho singing in foreign language) - [Mark] But here's the thing about anxiety.

You don't control it. (Carminho singing in foreign language) - [Mark] You simply adapt to it. (Carminho singing in foreign language) - [Mark] You do your best to harness it to make your life better and not worse.

(Carminho singing in foreign language) - [Mark] Because anxiety, like any emotion, has costs, but it also has benefits. (Carminho singing in foreign language) - [Mark] Portugal is the oldest country in Europe. It is one of the most storied and intact traditions in the world.

(Carminho singing in foreign language) - [Mark] It is that same anxiety that causes so many problems that has helped crystallize and preserve this heritage. (Carminho singing in foreign language) - [Mark] In that sense, there is a subtle beauty to Portugal's anxiety, (Carminho singing in foreign language) - [Mark] a history encased and protected by their pain. (Carminho singing in foreign language) - [Mark] And perhaps this is the lesson that the Portuguese have for us all, saudade, that there is a beauty and the longing, that you can savor the feelings of loss.

And while the anxiety may torture you, it also keeps everything you love and care about safe.