Signs of anxiety
Are we treating the symptoms of our problems rather than the causes?
By May 2016
“I think I’m stuck,” Louis* said when I asked why he had come to see me. “I finished my commerce degree last year and I started in a job, which I thought was going to be fine. And it is … but I’ve started feeling really anxious again, like when I was a teenager.”
I glanced down at the referral for a psychological consultation from his GP. “Thank you for seeing Louis, aged 23, for opinion and management of Generalised Anxiety Disorder? Panic Disorder and Agoraphobia?”
In the academic database ProQuest, the word “anxiety” appears in the title of six papers published before 1930. There are 163 before 1950, 2414 before 1970, 7692 before 1990, and 50,228 today. Of the several journals now devoted solely to the study of anxiety, the vast majority follow the definitions cited in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The DSM-5’s categories – its diagnostic function – are the foundation of a complex edifice of culturally sanctioned forms of suffering, in this case around anxiety. This suffering is very real. Fourteen per cent of all adult Australians are affected by an anxiety disorder each year, and perhaps one quarter of the population will suffer from one in their lifetime. These are figures calculated by epidemiologists, health bureaucrats and government planners on the basis of the DSM-5’s statistical function. The statistics may represent the population’s experience of anxiety. They certainly represent a change in how much we discuss, write about and diagnose it.
Further into our consultation, Louis said, “When I saw a psychiatrist years ago, he said my anxiety was biologically based. He told me I was activating my fight–flight response, and that a pill would help me control it. He was right! At first, I couldn’t get to school until I took the pill.”
Louis explained that he had soon stopped taking the pill once he felt better. “Now my anxiety has come back. Even though it’s years later, I went back to the same GP, because I wanted her to give me that pill again. But this time she said I should come and talk to you. So, here I am. What are you going to do?”
Benzodiazepines have become a common treatment for anxiety, with ten million scripts written in Australia each year. They help by changing the levels of gamma-aminobutyric acid–mediated neurotransmission and dopamine in the brain. Broadly speaking, these medications act rapidly to reduce the physical symptoms of anxiety (racing heart, sweating, rapid breathing, gastric changes). Benzodiazepines also tend to induce a feeling of ease, and that everything is OK.
The pill that Louis took as a teenager was alprazolam (also known as Xanax), the shortest-acting benzodiazepine. The prescription rate of alprazolam in Australia rose rapidly in the 2000s to a high of more than 10,000 scripts per month. After the federal government’s Therapeutic Goods Administration moved alprazolam to a restricted prescription schedule in 2014, the monthly prescription rate fell to 5000. The overall prescription rate of benzodiazepines has not changed, however, which means those taking alprazolam have mostly shifted to taking other, less-restricted types of benzodiazepines, such as temazepam (Normison) or diazepam (Valium).
One of the effects of all the anxiety-focused science has been to change the manner in which we think about such an affliction. While the DSM-5 itself contains no formulations about causes or treatments, the 50,000 academic articles on anxiety science do. The Beyond Blue website provides a useful summary of this science in ‘A Guide to What Works for Anxiety Disorders’. Treatments are evaluated for the degree to which they reduce symptoms. These are the mechanisms that science is best able to measure, and what benzodiazepines are effective at reducing. It was Louis’ not-unreasonable expectation that I could help reduce such symptoms.
Originally a bewildering puzzle, Louis’ anxiety had become a collection of symptoms constituting a disease or disorder. He had discovered meanings for his diagnosis, based on the DSM-5 categories that he found online. This shift gave him a sense of relief: he had a set of terms for what was wrong.
“The problem,” continued Louis, “is that since I googled ‘panic disorder’, I haven’t been able to go to shopping centres or to crowded places because I’ve been worried about having another panic attack. Whenever something bothers me I’ve started checking my pulse to make sure my heart isn’t going too fast, and I worry I’m starting to feel dizzy.”
What makes the diagnosis of an anxiety disorder different from other medical diagnoses is how anxiety can feed itself. Worrying about cancer doesn’t make the cancer worse. Worrying about having an anxiety attack, however, leads to more anxiety. The assignation of generalised anxiety disorder and panic disorder led to Louis being constantly alert to the physiological cues that he may be about to have another panic attack. It induced in him a fear of fear.
Anxiety-as-disease is treated much like an infection, as if the symptoms were a bacterium that should be eradicated. The diagnosis, and treatment via medication, reduces anxiety to a set of bodily mechanisms that is uniform across individuals. This uniformity elides any subjective or meaningful aspects. The question of why someone is anxious need not be asked.
The British Psychological Society’s Division of Clinical Psychology (DCP) has noted that “serious concerns have been raised about the increasing medicalisation of distress and behaviour in both adults and children”. The DCP has called for a paradigm shift away from the disease model of diagnosing mental disorders. Among other problems, the DCP points to an over-reliance on medication.
Towards the end of Louis’ consultation I asked him to tell me about his very first panic attack. “Well, we had just returned from holidays overseas and I was going back to school – Year 11 – in a day or two. Coming off the plane, I looked down from the top of the stairs. It was a very sunny day and the light hurt my eyes. When I was walking across the tarmac I started feeling really bad. It said somewhere on the web that fear of open spaces is part of it … and when we were in getting our bags I just found the hordes of people too much … I read somewhere that fear of crowds is part of it too …”
I asked Louis about Year 11. “I was thinking about death a lot. I had no idea what subjects to do. So, Mum chose them for me and I just went along to the classes on the timetable.” I asked Louis why he had studied commerce. He struggled to answer. “I don’t really have a why … Mum and Dad are both business people, and they insisted I go to university …”
At this point Louis became upset and said, accusingly, “You’re saying I’m anxious because I’ve never really thought about what it is I want to do with my life.”
“Louis,” I replied, “you studied a commerce degree, and work in a merchant bank, and you’ve got agoraphobia: literally, fear of the marketplace.”
From a dizzying array of choices and events, people make a narrative of their life. This narrative is the glue that gives life consistency and stability, and anxiety is the feeling often evoked when this narrative is disrupted. Suppressing his symptoms, rather than questioning their source, enabled Louis to get on with a life he wasn’t sure he wanted to lead.
* Name has been changed.