Anxiety Disorders

Fear vs. Anxiety

  • Fear: response to real and present danger. Helps organise responses to threat, like “fight or flight”

  • Anxiety: apprehension about anticipated events

    • Physiological changes (ex. Sweating, heart rate, shaking)

    • Difficulty controlling thoughts in state of anxiety

    • Halo effect

  • Anxiety has some helpful uses….up to a point. Without exceptionality, it may become a problem

Classification of Anxiety Disorders

  • Emerged as a distinct group of disorders in DSM-III

  • Previously part of “neuroses” (emotional disturbance, with awareness

    • Awareness dropped in the DSM-5. Now merely necessary for fear and worry to be “disproportionate to the situation”

  • Splitting movement has divided anxiety disorders. Share core symptoms - intense worry disproportionate to actual environmental danger

    • How neat are these categories?

    • What about division from other diagnostic categories?

Rise of Interest in Anxiety

  • Asylums primarily housed those deemed psychotic and / or dangerous

  • Freud’s emphasis on neuroses opened an entirely new domain of human emotion: anxiety

  • What counts as a “psychiatric concern” not fixed

Panic Disorder

  • Characterised by recurrent, unexpected panic attacks. Usually occurs without warning and finished within ten minutes

    • Preponderance of physical symptoms: palpitations; pounding heart, sweating, trembling / shaking, shortness of breath, feeling of choking, chest pain or discomfort, nausea, feeling dizzy / faint

    • Derealisation (unreality) or depersonalisation (detachment from oneself)

  • Person may obsessively worry about another attack

  • May lead to avoidance strategies….avoidance works

Specific (Simple) Phobia

  • Persistent, excessive, narrowly defined fears associated with specific object or situation

  • Phobias are “irrational or unreasonable”

  • Must always occur when exposed to source

  • Daily life consumed on some level with avoidance, fear, dread

Agoraphobia

  • Extreme fear about situations where escape is difficult or embarrassing - crowded shops, tunnels

  • Unlike other phobias, not closeness to a specific object but distance from “safety” that’s the problem

  • ”Most complex and incapacitating phobic disorder”

Social Anxiety Disorder

  • How does social phobia differ from specific phobia?

    • Focused on performance or interpersonal interactions

  • Involves concerns of being humiliated or embarrassed. If anxiety related to specific situation (e.g. a speech), anxiety disappears if task performed privately

  • Introduced in DSM-III: 

    • 1980s: 0.5%, 2019 (pre-pandemic): 9-15%

    • Criteria expanded to be more inclusive with subsequent editions

    • Culture bound?

    • Archetype of medicalization?

Generalized Anxiety Disorder

  • “Chronic worriers”, distress/impairment in occupational or social functioning.

  • Worry not fixed, may not even have clear source.

  • Accompanied by minor disturbances in sleep, irritability, concentration, restlessness.

  • Chronic, low-key, long lasting.

  • Key issues:

    • Lower diagnostic reliability.

    • Far more common in women (roles? stereotypes?)

    • Overlap: a distinct disorder or just a symptom?

    • If low key, is this really a distinct syndrome?

Comorbidity

  • 50% of people that meet criteria for one anxiety disorder meet criteria for another.

  • Anxiety and mood disorders, high degree of comorbidity (61% of people w/ MDD qualify for anxiety disorder).

    • How distinct?

  • Those w/ anxiety disorders roughly 3x more likely to be diagnosed w/ substance abuse disorder. Chicken/egg?

  • Some argue “splitting movement” behind high level of comorbidity b/t disorders.

  • Artificial divisions create overlapping disorders, “pure” cases of most types very rare.

Diagnostic Growth

  • Anxiety disorders at forefront of increase in prevalence of psychopathology. Why?

    • Medicalization of ‘uncomfortable’ feelings into ‘ill’ ones?

    • Blurred lines between wellness and disturbance, when does discomfort become disorder?

    • Environmental shifts to produce stress?

    • Does greater awareness (of ourselves and the world) mean greater anxiety? Can this be stopped?

    • Medications produce clear effect – we can see them “work” and this seems to validate diagnoses.

Women and Anxiety Disorders

  • Like w/ depression, women are diagnosed with anxiety disorders at a far greater rate than men. Why?

    • Gender differences in seeking treatment?

    • Biological?

    • More likely to experience stressful life events?

    • Social roles that are less fulfilling / more stressful.

    • Diagnostic bias?

  • No simple answers, but plenty of debate. Answers tends to reveal much about one’s personal (even political) ideologies and assumptions about both gender and mental illness.

Brinkmann - Mad or Normal

Introduction

  • The global cost of mental illness has been estimated at 2.5 trillion US dollars - a number that is expected to grow to a shocking 6 trillion dollars by 2030

  • People in the West are today rarely dying because of material poverty, hunger or appalling physical working conditions – as in the times of Karl Marx – but they are suffering from various mental disorders, ranging from depression and anxiety to eating disorders and bipolar conditions, because of terrible and alienating social life circumstances

  • The recognition of the emergence of diagnostic cultures as a widespread and pervasive aspect of contemporary cultural life should lead us to discuss the prevalent explanations in a different light: The psychiatric (we can finally find the ill) and the sociological (modern society is the source of the rising prevalence of mental disorders)

  • It has become normal to be abnormal

A Diagnostic Quiz Show: “Mad or Normal?”

  • In 2012 the national Danish Broadcasting Company aired the documentary “Mad or normal?” 

    • The explicit idea was to challenge people’s biases about the mentally ill by showing that they are in most respects “just like you and me”.

    • Three experts (one psychiatrist, one psychologist and one psychiatric nurse) were confronted with a group of ten people they had not met before, and five of these people had different psychiatric diagnoses

    • Through the episodes, the experts were supposed to make a qualified guess and match the diagnoses with five of the participants.

    • In the end, they could not guess who was ill

    • A couple of years later, in 2014, the show was followed up with two new episodes called “Mad or normal? At the job interview”

    • In the second season it was instead of mental health professionals acting as experts, three business managers who were confronted with disguised psychiatric patients in a group of job applicants

    • They were asked, who among the participants they would be most likely to offer a job. And, interestingly, they were very positive toward many of the people with diagnoses, and the “winner” of the program was in fact a psychiatric patient.

Just Like Somatic Illness?

  • The show and the accompanying book repeatedly use the term “mental illness”, and there is a constant comparison with visible somatic illness (especially fractured bones), which is allegedly easier to handle because of its visibility.

  • Recently, in Denmark, a ”diagnosis guarantee” has been established by the government, which means that patients have the right to obtain a diagnosis within one month after contacting the medical system.

    • At first this guarantee did not pertain to psychiatric diagnoses, but from September 2015 this has been changed, so that all kinds of health problems are put on an equal footing. 

    • On the one hand, this can be seen as a very positive development guaranteeing the rights of the mentally ill, but, on the other, it has the downside that a diagnosis can be prematurely formulated and stigmatise the individual very quickly.

Summing Up

  • It can be observed that a show like this would be quite unthinkable just a few years ago

  • This indicates that psychiatric problems are no longer taboo to the same extent as before and that stigmatisation due to diagnoses might have decreased

  • To sum up, we have seen that a number of paradoxes are likely to emerge when dealing with psychiatric diagnoses today:

    • Through diagnoses psychiatric problems appear as “nothing special”, because many of us could be diagnosed - and yet normalising the disorders may causes problems for people if it means that their problems cannot be recognised as sufficiently serious

    • Through diagnoses psychiatric problems are addressed as medical problems - and yet they are simultaneously enacted as not just that

    • Through diagnoses psychiatric problems are equated with manifest and sometimes transient symptoms – and yet diagnoses have a tendency to reinforce chronicity

  • Such paradoxes inherent in the logics of current diagnostic cultures might in themselves add to the suffering felt by those who live in these cultures and are diagnosed

The Medicalised Commodification of Diagnoses

  • The fact that psychiatric diagnoses have entered the entertainment (or ‘edutainment’) industry, in prime time on the largest TV station in Denmark, represents one significant aspect of our diagnostic cultures.

  • The mass media work by subjectifying people to think of themselves as consumers and even commodities, while simul- taneously covering over this very function by making people believe that they are free to choose - in the present case between different understandings of psychia - tric diagnoses.

  • Psychiatric diagnoses can indeed be thought of as ‘products’ and patients as ‘consumers’

    • This is pushed in particular by the medical industry, which has an interest not only in selling drugs to help alleviate people’s symptoms, but also in “selling sickness” by making diagnoses publicly visible