Anxiety gets a lot of media coverage. Entire social media marketing campaigns are launched to generate awareness and de-stigmatize things like anxiety and depression. Governments also invest extensive resources in trying to ‘battle’ mental health issues in the population. The reason for this is this is quite simple to trace: people have a lot of anxiety nowadays. While there is massive investment being made in terms of ‘what to do’ about it, very little evidence is being shown to sort out what causes it, or why people have more anxiety than they did in other eras.
Indeed, a few decades years ago, the notion of someone having an ‘anxiety disorder’ wasn’t yet proposed by the medical world. The invention of official diagnoses for anxiety only began in 1980 with the publication of a diagnostic manual psychiatrists use to categorize what they believe are mental disorders. Since this remarkable ‘discovery’ – that people have anxiety – the number of people diagnosed with anxiety disorders has skyrocketed as well as the sale of therapies and medications aimed to ‘treat’ it. This could be for a few reasons, either there was an incentive (money) to decide anxiety should be turned into a medical problem, or that there really is a massive statistical increase in how many people have severe anxiety problems. It’s hard to tell which is which because once someone is told by who they perceive as an authority (doctors) that they have a potentially diagnosable medical issue, people will seek out help to treat it. This means it could be the medicalization of anxiety in itself that caused the upswing in anxiety. If this is the case, then what remains in question is whether or not anxiety is, indeed, best considered as a medical problem, and not some normal reaction to social and environmental circumstances (e.g., complex trauma). Perhaps it can be a medical problem based on social causes, but this would depend on the treatment strategies the medical world thinks are appropriate.
At any rate, the upshot here is that anxiety isn’t necessarily ’caused’ by something internal or biological. In fact, one of the anxiety disorder diagnoses, ‘Post-traumatic stress disorder’ (PTSD) is overt in showing that it is the result of environmental circumstances. While they don’t necessarily make this clear in their diagnostic manual, psychiatry also provides hints on other diagnoses such as ‘social anxiety disorder’ (SAD). How could someone have this so-called disorder without some social element?
The result of thinking that anxiety is a medical disorder has left a lot of people thinking they have some ‘chemical imbalance’ in their brains as the cause. They think this because the general attitude in medicine is to look to biology as a discrete causative factor instead of assessing what might have caused the problem in the first place. Indeed, diagnostic constructs of ‘anxiety disorders’ don’t hide this failure very well. For instance, if you have anxiety all the time, you might be diagnosed with “Generalized Anxiety Disorder,” which just describes symptoms and not causes.
Imagine if you had a bully boss that constantly harassed you in your workplace. From their bullying, you experience extensive anxiety all the time. Without the bullying, you never experienced such acute and relentless anxiety. The cause then isn’t some problem with your brain, but instead the toxic workplace your bully boss is creating. In this sense, the diagnosis should be aimed at the root cause and reworded, “Bully Boss Anxiety”, and not “Generalized Anxiety Disorder”. The root of the problem is the boss and the path to recovery is then is social and emotional support to find a new job or to reform workplaces to properly address tyrant bosses and workplace toxicity.
Herein lies a significant philosophical issue with diagnosing anxiety as a medical problem. If the problem isn’t the brain malfunctioning and it is, say, a bully boss making you miserable, then it doesn’t follow to diagnose someone as if they’re the problem. What happens when you tell someone that they have a medical problem because of bullying is that they might think that their anxiety is their weakness and that they should be able to cope with their circumstances. The diagnostic jargon may not intentionally do this, but it certainly doesn’t tell the whole story, does it? If someone were to tell you that they suffered from ‘panic disorder’ without telling you more details, short of being educated on what ‘panic disorder’ implies, you’d be left to think that this person has some issue with their brain. But in the case of panic attacks, the truth is likely closer to the fact that panic falls within the ‘normal’ range of human reactions to stressful circumstances and that there isn’t something wrong with the brain or a weakness in the person experiencing it.
This is why education as a first tier approach to anxiety is so crucial. Say you had your first panic attack. You’re terrified that you’re dying and go to the emergency room. When you get there, they rule out heart problems and other things that might be the case. They finally come to tell you that you had a panic attack and that you might have ‘panic disorder’. The immediate implication for someone who is already in a conscious state of anxiety is perhaps to think, “Oh no, I have to face this all the time for the rest of my life!” The next step for doctors is to write a script for tranquilizers and perhaps ‘antidepressants’ because they believe that these are ‘first line’ treatments for anxiety. The individual then takes the script and begins treatment because they surely do not want to experience this anymore – it needs to go away immediately.
Now if someone was instead told people about the nature of anxiety and why it comes about, there might be a different outcome. If someone could sit with this person and explain how anxiety works and why it comes about, instead of categorizing it as a medical problem the narrative might change. If someone, at first contact asked, “what happened to you?” that might relate to anxiety, then the focus in not on reducing symptoms, but instead at figuring out what is central to the problem.
In the example of a bully boss above, the difference is dramatic. If in the first place someone offers a diagnosis and drugs which assesses ‘what’ someone is experiencing, the focus then shift as to inquire why someone might feel the way they do. There is also risk in victimizing and victim by diagnosing anxiety as an individual’s problem. One of the criticisms with the message of diagnosis is that you have something wrong with your brain or that you might be ‘weak’ and unable to cope. The diagnostic frameworks don’t elaborate and this could confuse people.
Put simply, while the medical model does work for some people, it might just be because of addressing symptoms and not the roots of the problem. The term ‘effective’ requires significant unpacking as well. Indeed, someone could argue that symptom management ‘works’ for anxiety because they don’t feel symptoms. But this is a flawed strategy because this might mean that the person is in chronic treatment for a what might not be a non-chronic issue. This is why I am often confronted with the narrative of “I have been on these drugs for years and I still have ongoing anxiety.” What the person behind this narrative isn’t told is that it’s because both the diagnosis and the treatment have nothing to do with the root of the problem. A strategy that aims to dig to the bottom of the problem in terms of ‘why’ someone has anxiety might result in long term anxiety reduction and a reduced reliance on therapies. This is why there has been extensive and unrelenting criticism aimed at psychiatrists and drug companies, as it is easier to market drugs and profit from symptoms than it is to address the root of the problem. And since fear or anxiety is not something that should or could ever be cured (you need it to survive), the agenda is to ‘treat’ or ‘manage’ it instead. The result is the creation of a massive industry of therapists and the extensive prescription of drugs.
The moral argument here is that the whole story about anxiety isn’t always represented to people and the result is a contribution to the therapists and drug companies bottom-line.
All things considered, to do the ‘right’ thing in any case depends on what the individual knows about anxiety that informs their decision to act on it. A therapist should advise someone that for instance, the concept of anxiety as a disorder is really a subjective and value-laden conclusion to make. What this means is that anxiety could be a medical problem if you want or believe it to be, but there isn’t any great scientific evidence to base that claim upon, these ideas are, well: just someones ideas. People could be told instead that anxiety could as easily interpreted as a social problem or even a problem in living. Some theorists are now looking to ideological factors in culture and society to show why anxiety is so common in the population. The point here though is that each contrasting consideration can allow someone to properly assess what might match up to their life circumstances.
What this all relates to is informed consent to both diagnosis and treatment. Informing someone should be holistic and offer a wide-range of options and philosophies as to why (not just ‘what’) is at the root of their issues. This would mean that a doctor would have to take the time to teach a patient all about the evolutionary perspectives underlying anxiety right to the contemporary ideas underlying the ‘biopsychosocial’ model of causation. Of course, this isn’t happening in our healthcare systems, especially in the front line.
Current healthcare systems simply do not have the resources and time to ask ‘why’ someone is anxious. In some areas in Canada, they cite a 6 month to a year wait to even see a specialized therapist. This is eons to wait if you’re anxious. This also explains one reason why a doctor might dispense symptom blocking drugs, as they may be aware of the systems incapacity to offer timely assistance. A doctor might think, “Well, this person has acute anxiety but we can’t address the root of it because of systemic constraints, so the best I can do now is make the symptoms go away with drugs…”
The other thing to consider when it comes to the medicalized assumption of diagnosis is that the system requires it. To access insurance, measure how many people have diseases, or even to create an official record of treatment (health files) for legal purposes, a diagnosis is justified. But this doesn’t necessarily benefit the person with anxiety as much as it does the needs of a bureaucratized healthcare system. I will write more on this in other posts.
The takeaway from this post is that if you have anxiety, you have many options. Did you ever notice that in bookstores in the self-help section there are dozens of books aimed to solving the same problem? How could it be that this is the case if the problem is assumed to be best described by a simple diagnosis? The truth is, there are a lot of ways (infinitive, really) to conceptualize anxiety and deal with it, That said, there are also some strategies that are very good to short-circuit it given its very nature (we can teach you all about this).
We believe that education as to what these options are is the right way to go about it. This is why education is the first step in the ‘education, empowerment, and self-mastery’ triad (EES). It should be up to a person to decide what’s best for them given the most complete information that can be provided.