by Allan V. Horwitz
Johns Hopkins University Press, 2013
Review by Lloyd A. Wells, Ph.D., M.D., on May 5th 2015
This short book provides an overview of anxiety symptoms over recorded history, the social reactions to anxiety through the ages, and its diagnosis and treatment. The author is a sociologist, and he pays wise attention to the cultural matrices in which anxiety has occurred, through millennia, which adds greatly to the richness of the book. Anxiety is fundamental to the human condition, an important component of who we are. With us for two millennia and more, it continues with us today, sanitized, medicalized, and highly prevalent. This book does a good job of explaining how that has occurred and the continuity of anxiety over time.
After a thoughtful foreword by Charles Rosenberg, Horwitz provides an introductory chapter aptly titled, "Afraid". He introduces a leitmotif of the book: "Like previous classifications, current definitions of anxiety disorders are social constructions that reflect a particular historical context…" He argues well for this point throughout the book, examining very important differences between fear and anxiety. A great quote from Erasmus exemplifies this point. Erasmus was fleeing a site of the plague: "I consider total absence of fear in situations such as mine, to be the mark not of a valiant fellow but of a dolt." Horwitz concludes this chapter with a thought-provoking comment which is worth reference as one reads the rest of the book: "The great paradox of anxiety in the twenty-first century is that, despite unprecedented progress in capacities to view neural networks, neurotransmitters, and genes, our definitions of anxiety disorders, understanding of what causes them, and treatments for them might not be significantly better than those possessed by Hippocratic medicine." I do not agree with this statement, but it merits consideration as one reads the book.
The next chapter is about the perception of anxiety in antiquity, with some emphasis on Greek concepts of anxiety related to warfare. After a discussion of Hippocratic and philosophical concepts, there is a good discussion of clinical views and treatments. Galen proposed that "each patient acts quite differently than the others, all of them exhibit fear or despondency." This remains the case. Horwitz describes treatment approaches which included ritualistic ceremonies including dance and character training.
The author next considers the period between antiquity and the nineteenth century, with some emphasis on Locke and Hume later in the chapter. Locke predicts future approaches: "If your child shrieks and runs away at the sight of a frog, let another catch it and lay it down at a good distance from him; at first accustom him to look upon it; when he can do that, to come nearer to it and see it leap without emotion; then to touch it lightly, when it is held fast in another's hand; and so on, until he can come to handle it…" This is the approach of very effective behavioral treatments today. He also features George Cheyne, arguably the first psychiatric epidemiologist, who argued that what we now call anxiety disorders accounted for almost a third of medical conditions in England in the eighteenth century – a finding remarkably concordant with modern ones.
The next chapter considers the nineteenth century, with quite a bit on Pinel, the progenitor of modern psychiatry and the concept that if a medicine is associated with improvement in a syndrome, then the syndrome must be "organic" – a fallacy with which the field continues to have to contend. He describes the long infatuation with the diagnosis of "neurasthenia", with which we continue to deal under different names. There are excellent descriptions of variants of anxiety disorder which we continue to see, but without their very specific names: for example, "paroxystic anxiety" was the certainty that death was imminent in spite of a lack of physical symptoms.
The next chapter is about Freud and leads into modern views of anxiety disorders. Freud's earliest writings about anxiety – though certainly not his later and definitive ones – actually place him in a position quite central to current thinking about anxiety.
The following chapter is about the ascendance of psychology in the conceptualization and treatment of anxiety disorders, with an emphasis on behavioral approaches in the twentieth century. Watson's "Little Albert" is, of course, mentioned, as is William James, from whom Horwitz has a wonderful quote: "We feel sorry because we cry, angry because we strike, afraid because we tremble, and not that we cry, strike, or tremble because we are sorry, angry or fearful." After descriptions of the important work of Eysenck and Wolpe, he goes on to a description of the development and use of cognitive behavioral therapy in anxiety.
The next chapter is entitled "The Age of Anxiety" and has to do with the last half of the twentieth century up to relatively modern times. Horwitz begins with Sartre and the existentialists viewing anxiety not as a disease but as a central feature of human life. But beyond the philosophers, anxiety became widely perceived as a very troublesome component of everyday life. The phenomenon became so ubiquitous that the author's comment, "'Anxiety' was, in essence, a synonym for 'distress'", seems reasonable. Horwitz does a fine job of discussing the introduction of the first modern tranquilizers, such as meprobamate. The influence of the Pharma profit motive even in the 1950's was strong, as evidenced by this quote from Nathan Kline, the psychopharmacologist, to Frank Berger, the chemist who developed meprobamate: "What the world really needs is a tranquilizer… The world needs tranquility. Why don't you call this a tranquilizer? You will sell ten times more." (And, thus, the birth of a pharmacologic word!) And Berger was also predictive of future advertising approaches when he wrote about brain mechanisms of meprobamate, with insufficient knowledge to do so. Instead of writing about the later purported "chemical imbalances", he wrote about putative brain "constructions" and "blockages".
One year after its introduction, 5 per cent of the U.S. adult population had used meprobamate. In spite of its immediate popularity, it was not an especially effective drug, and benzodiazepines were introduced shortly thereafter. Lithium and Valium were more potent, even more popular, and much more marketable, with shrewd public relations and advertising. Librium, for example, was advertised for a time "for the treatment of normal college life". (The author does a fine job of demonstrating the positive role of the F.D.A. in ending these excesses.) Taking these drugs soon became extremely common, and their adverse effects, including addiction, became known. Nevertheless, these "minor" tranquilizers, along with other such as Xanax, are in wide use – and they are sometimes very helpful. This chapter concludes with a rather long discussion of the first four DSM's – their pronouncements about anxiety and their impact on the perception and diagnosis of anxiety disorders. At the end of the chapter, Horwitz asserts, "Psychopharmacology has largely displaced analytic and other treatments."
The final chapter addresses the future of anxiety. The author notes the great rise in diagnosis of anxiety disorders and attributes it largely to artifacts of the DSM system – though the fact that physicians are much more aware of these disorders than they once were may play a role independent of the DSM. He talks of efforts to show that treatments – including non-pharmacologic treatments -- "change brains"; the evidence remains fairly weak. He turns to a lengthy examination of the DSM-5, going into significant details about factors in the manual which could affect views about and diagnosis of anxiety disorders.
I liked the book. Its brevity made it reasonable. As befits a social history, there are no villains in its pages. The account of anxiety in antiquity provides a scholarly and helpful background to the rest of the book. There are wonderful quotes in the sections on the Middle Ages, Renaissance and Enlightenment. So much happened in the nineteenth century and beyond that Horwitz had to pick and choose his topics, but I think he chose well. His questions for the future, at the end of the book, are outstanding and actually central to much current research.
I have criticisms, as well. Just as the book's brevity is a delight, it is also a problem. Many important issues have to be dealt with in a brief, sometimes cursory way, if at all. While it is necessary to feature the DSM diagnostic criteria in any discussion of the modern development of anxiety disorders, Horwitz sometimes goes into a level of detail which is unnecessary and does not fit the book as a whole. The placement of the bulk of the DSM material in two separate chapters is perhaps unnecessary, and I suspect that the book would flow more freely if all of this material were condensed and stood on its own in one chapter devoted to it. A few statements in the book are stretches: the author states, for example, that Beck is not well known for his work on anxiety -- yet he is. My major criticism, however, is the author's assertion that anxiety-specific psychotherapies have largely been discarded for medication treatments. Evidence-based psychotherapies for anxiety are demonstrating considerable efficacy and are a huge part of the current, best-practice treatment approach to anxiety disorders.
That said, this is an excellent book, which I recommend.
© 2015 Lloyd A. Wells
Lloyd A. Wells, Ph.D., M.D., Emeritus Consultant, Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota