Pathologizing Anxiety: When Is it

Pathologizing Anxiety: When is it Healthy to be Anxious?

Psychiatry and psychology have a history of confusing normal behavior that is outside of the average with pathology. Anyone with any familiarity with the history of the DSM can look at conditions that were previously considered disorders, such as homosexuality, to see that there has been a push to pathologize the extreme normal ends of human variation. In modern times, the big push is to pathologize anxiety. This push started out with wonderful intentions. There is no doubt that severe clinical depression and its accompanying anxiety can be crippling to those who suffer from it, and there is a wide variety of available medications available to treat this subjective distress and alleviate many of the other symptoms of depression. However, as practitioners saw results in people at the ends of the spectrum, they began to treat people who were suffering but not necessarily diseased. This trend spilled over to some of the symptoms of depression as well, and because anxiety does respond well to medications, anxiety has been one of the areas that have been targeted for diagnosis and treatment as a pathology.

That is not to say that anxiety can never be indicative of pathology; the problem is developing a working definition of when subjective distress should be a criterion of mental disorder and when it should just be an indication of normal, human unhappiness. I think that most people would agree that a condition like agoraphobia, in which the person literally experiences enough anxiety about the thought of going out in public that he or she becomes a shut-in, has subjective distress as a criterion of mental disorder. However, if one looks at the surrounding conditions, it might be a healthy adaptation to avoid going into a certain location. For example, the fear of public speaking may be somewhere on the same continuum as agoraphobia, but most people exhibit some anxiety about public speech. The criteria for determining whether subjective distress is an indication of normal, human unhappiness or indicative of mental illness should be whether it substantially impairs the ability to participate in a functional life. Therefore someone who is literally unable to step outside of their front door would qualify as mentally ill. However, a person who only had to avoid certain locations to minimize anxiety, such as avoiding the mall, festivals, or other places with large numbers of people, might have anxiety that dictates that he alter his life in some way, but not anxiety that prevents him from leading a functional life.

The problem comes when one is trying to define a functional life. There are many common human activities that are outside of the realm of normal behavior for a lot of people. For example, many people say that they could not do certain jobs or interact with certain people. It is true that these self-imposed limitations, which are seen as part of normal human variation, do limit a person's options. However, labeling something a pathology should not simply look at whether that person's options are limited, but whether limiting those options causes the person further distress. In the essay prompt, examples were given including working on scaffolding, doing surgery, extracting teeth, or fighting in combat, and the vast majority of people avoid doing all of these activities, though people who do those activities are certainly not considered abnormal. To me, I would need to look at whether avoiding those situations creates additional stress, anxiety, or guilt in the person. I do not believe I have the temperament to be an air-traffic controller, which I understand is a very high-stress job. However, I have never once felt even the slightest twinge of guilt, anxiety, or other negative emotion related to my lack of willingness or ability to be an air traffic controller. Therefore, I would state that my aversion to that field is within the realm of normal behavior. However, imagine that I had a significant social phobia that prevented me from interacting with others, to the degree that I was unable to interview to get a job or interact with people to keep the job. In that scenario, I would label my subjective distress as impairing my ability to be a functional self-supporting adult. I would also suggest that if the subjective anxiety were preventing me from accomplishing my wants that it would be at the level of a pathology. For example, I have no desire to go up on scaffolding, but if I were an agoraphobe who was missing my child's wedding because I could not bring myself to go into public, I believe that condition would be interfering with my wants.

Clearly, I do believe that there are some conditions where subjective distress is indicative of a disorder. However, I also fervently believe that both psychologists and psychiatrists are likely to over diagnose people, turning normal variation into illness. Normal and average are not the same thing, and they should not be treated as such by mental health professionals. I believe that simple phobias are probably the best candidate for being excluded from the DSM. Specific phobias rarely meaningfully impact quality of life. For example, I have a friend who has a rodent phobia. She does not find rodents simply distasteful; she is irrationally scared of them. If she sees a rodent, she runs and screams, she has been known to lose bladder control when around rodents, and she avoids scenarios where seeing a rodent is likely. For example, she rides horses, and when she saw rodent horses at her stable she purchased traps and rodent-proof feed containers, and avoided the feed room until other people could reassure her that the rodents had been trapped and killed and that no new droppings had appeared for some time. There is no doubt that her fear of rodents impacts her daily activities in some way. However, her fear of rodents does not prevent her from engaging in activities she enjoys. Furthermore, her fear of rodents, like most phobias, is an extreme version of a rational fear; humans naturally fear rodents because they carry disease and are associated with illness. While I do not feel that a single specific phobia should be enough to qualify for a pathology, I do think it is important to note that I would change diagnostic criteria for generalized anxiety to disorder to include people who suffer from a sufficient number of specific phobias to prevent them from being able to be functional.