Fri Jul 13, 2012 10:29am IST
* Anxiety disorders have soared more than 12-fold in 30
years
* Critics see a “pathologizing” of normal emotion
* Psychiatrists say sufferers are being identified and
helped
By Sharon Begley
NEW YORK, July 13 (Reuters) – When Cynthia Craig was
diagnosed with postpartum depression eight years ago, she told
her family doctor she felt anxious about motherhood. She
wondered whether she had made a catastrophic mistake by quitting
her job, whether she could cope with the long, lonely hours
stay-at-home mothers face – and even whether she should have had
children.
“Anxiety is something I have always had, especially during
times of change,” said Craig, 40, who lives in Scotland,
Ontario. “But I was never worried about the level of anxiety,
and it never prevented me from leaving the house, driving,
socializing or even speaking in front of people.”
Her doctor referred her to an anxiety clinic, where a nurse
asked Craig dozens of yes-or-no questions – are you afraid of
snakes? do you hear voices? do you vomit from anxiety? – and
made a diagnosis. “She said, ‘Let’s call it Generalized Anxiety
Disorder with a touch of social phobia,’” Craig said.
That didn’t feel right to her, but the clinic’s psychiatrist
agreed with the nurse and said Craig’s concerns about motherhood
constituted an anxiety disorder, a form of mental illness, and
prescribed Pfizer’s Effexor and then GlaxoSmithKline’s
Paxil. Craig says the drugs exacerbated the very anxiety
that she doubted required medication.
Craig’s case is one of millions that constitute an
extraordinary trend in mental illness: an increase in the
prevalence of reported anxiety disorders of more than 1,200
percent since 1980.
In that year, 2 percent to 4 percent of Americans suffered
from an anxiety disorder, according to the American Psychiatric
Association’s Diagnostic and Statistical Manual (DSM) of Mental
Disorders, used by psychiatrists and others worldwide to
diagnose mental illness.
In 1994, a study asking a random sample of thousands of
Americans about their mental health reported that 15 percent had
ever suffered from anxiety disorders. A 2009 study of people
interviewed about their anxiety repeatedly for years raised that
estimate to 49.5 percent – which would be 117 million U.S.
adults.
Some psychiatrists say the increase in the prevalence of
anxiety from about 4 percent to 50 percent is the result of
psychiatrists and others “getting better at diagnosing anxiety,”
as Dr. Carolyn Robinowitz, a past president of the APA who is in
private practice in Washington, D.C., put it. “People who
criticize that are showing their bias,” she said. “When we get
better at diagnosing hypertension, we don’t say that’s
terrible.”
Critics, including other leading psychiatrists, disagree.
They say the apparent explosion in anxiety shows there is
something seriously and dangerously wrong with the DSM. Its next
edition, due in May, would lower the threshold for identifying
anxiety.
The criticism rests on three arguments. First, the DSM fails
to recognize that anxiety is normal and even beneficial in many
situations, so it conflates a properly functioning brain system
with a pathology. Second, the DSM’s description of anxiety is
more about enforcing social norms than medicine.
Finally, they say, anxiety is adaptive. Its brain circuitry
was honed by evolution for a purpose. Only when that mechanism
misfires should a person be diagnosed as mentally ill.
“No human emotion is more basic than anxiety,” said
sociologist Allan Horwitz of Rutgers University. “Many forms of
it simply should not be categorized as disorders, because
they’re the result of the way people evolved thousands of years
ago, rather than something going wrong.”
IDENTIFYING THE TRULY ILL
Horwitz and other critics recognize that when the brain’s
anxiety system misfires it can prevent people from functioning,
as when someone is unable to leave home, interact with friends
and family or walk past even a leashed dog. But the anxiety
system is working properly when it makes someone afraid of
heights or wild dogs or threatening strangers.
“Anxiety or panic symptoms that have been severe, persistent
and cause clinically significant distress or impairment need to
be diagnosed promptly,” said Dr. Allen Frances, a psychiatrist
who led the previous DSM revision and questions some of the new
criteria. “Very effective treatments are available.”
“We don’t oppose people getting treatment,” said Horwitz,
co-author of the new book “All We Have to Fear: Psychiatry’s
Transformation of Natural Anxieties into Mental Disorders.” “But
people are much too willing to think they have a disorder that
requires treatment.”
Many psychiatrists don’t see it that way. Under changes for
the DSM-5 proposed by experts convened by the APA, symptoms such
as excessive worry, restlessness, feeling on edge, avoiding
activities that cause anxiety, and being overly concerned about
health or finances or family would have to be present for only
three months rather than six to justify a diagnosis of
Generalized Anxiety Disorder (GAD). And people would have to
display one physical symptom, not the current three.
“Because its threshold for GAD is set so ridiculously low,
DSM-5 will mislabel as mentally ill many people who are
experiencing no more than the normal and expected worries of
everyday life,” said Frances.
Dr. Donna Rockwell, a clinical psychologist who has
organized opposition to aspects of the DSM-5 process, warned
that “unless [the APA's experts] come to their senses, GAD will
be identical to the existential worries all of us face as part
of being human.” That will bring “a bonanza to the drug
companies,” she added, opening the floodgates to “more
inappropriate, expensive and potentially harmful drug use.”
Drugmakers reported $661 million in U.S. sales of
anti-anxiety drugs last year, according to IMS Health. Most
psychiatrists see that as evidence people suffering from mental
illness are getting help. On Thursday the Pharmaceutical
Research and Manufacturers of America issued a report touting
the many drugs being developed for mental illnesses, including
26 for anxiety.
“When anxiety symptoms impair a person’s functioning, what’s
so bad about helping them get back to a normal state and using
medication if appropriate?” asked Robinowitz.
The message that what used to be considered part of the
human condition is pathological is getting through, at least to
some people.
James Heaney, 44, told his family physician in 2000 that he
often felt shy or mildly depressed in social situations – “like
I saw on the TV commercial” telling viewers to “ask your doctor”
about social anxiety. “There was no in-depth evaluation of my
symptoms,” said Heaney, then a network administrator for a
school district near Rochester, New York. After a 10-minute
interview, he had a diagnosis of “mild social anxiety” and a
prescription for Paxil. “For such a powerful drug,” he said, “it
was remarkably easy to get.”
EVOLUTIONARY RESPONSE
Research over the past decade shows that feeling anxious is
how the brain’s emotion centers send signals to its thinking
centers that something is amiss.
For instance, it is normal to be anxious over a sick child,
a loved one’s illness, unemployment or other setbacks in life,
said N e w York University sociologist Jerome Wakefield, co-author
of “All We Have to Fear.”
“The feeling of anxiety tells you something poses a threat,
which can motivate you to stay vigilant” – about, say, a change
in a sick child’s symptoms, he said.
In the Paleolithic era, when our prehistoric ancestors lived
in small clans, how people were viewed by strangers and kin
could determine survival. So when people fret over going to a
party, giving a speech or otherwise subject themselves to
judgment, it reflects an adaptive response to the millennia-old
need to be attuned to other people’s disapproval, researchers
say. Anxiety about public speaking accounts for about half the
diagnoses of social anxiety disorder.
“There is great evolutionary and survival value in anxiety,
which makes it difficult to identify as an illness or
pathology,” said psychologist Frank Farley of Temple University.
Anxiety was working properly among survivors of Hurricane
Katrina, Wakefield and Horwitz contend. Years after the
devastating 2005 storm, schools, housing, policing and other
aspects of life in New Orleans had still not returned to normal.
Using DSM criteria, a 2007 study concluded that half the
surviving residents were “mentally ill” because they experienced
anxiety about those lingering effects.
“If you survived Katrina, anxiety is not a sign of mental
illness; it’s the brain working as it should,” said Wakefield.
Such emotions can spur survivors to agitate for rebuilding
neighborhoods, he said.
Another concern is that by labeling normal human variation -
being more anxious, fearful or worried than the average person -
a mental illness, psychiatry is venturing into social control.
“To suggest that anyone who’s afraid to speak in front of
hundreds of strangers has a mental illness creates social
pressure to change,” said Wakefield. “And that pushes psychiatry
away from medicine and into enforcing social values.”
BAD REACTIONS
In retrospect, Marla Royce (who asked that her real name not
be used) thinks her brain’s anxiety system was working as
evolution intended. A successful Texas novelist, she was upset
about the death of her father in 2004. Her anxiety was
compounded when her publisher did not promote her new book,
leading Royce to worry that her writing career was over.
“It was just garden-variety situational anxiety,” she says
now about the agitation and disorientation she felt.
Royce said she went along “trustingly and blithely” when a
family physician diagnosed her with GAD. “He said the pharma
sales rep had just left some samples, so he gave me Lexapro,” to
which a psychiatrist added Paxil, Xanax and Klonopin.
She became dependent on the drugs, taking ever-higher doses.
Her psychiatrist told her that “was proof my anxiety disorder
was out of control and that I would have to be medicated for
life.” She suffered “steadily declining mental and physical
health” until she stopped the meds five years ago and shared her
story with the online support group PaxilProgress.
James Heaney’s shyness turned to numbness on Paxil. “It made
me insular and nonresponsive to my friends and family,” he said.
“My mood became very variable,” and co-workers told him they
felt uncomfortable asking him for computer help as they once did
“because they weren’t sure which James they would get.”
He weaned himself off psychiatric drugs in 2011. The social
anxiety he still occasionally feels “is a relatively easy
problem to deal with,” he said.
For Cynthia Craig, the drugs she was prescribed triggered
“excruciating anxiety symptoms like I had never experienced in
my entire life.”
“I told my doctor I don’t want to be on anything,” she said.
“My anxiety is predictable and something I can handle.”
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