Social Construct of Anxiety
Social Construct of Anxiety
Social Construct of Anxiety
Anxiety has always been part of the human condition, with accounts of its various
manifestations, including acute shyness and stage fright, dating back to classical antiquity.
Nonetheless, since the end of the Second World War, reported levels of anxiety have risen
alarmingly. At the beginning of the 21st century, anxiety disorders constitute the most
prevalent mental health problem around the globe, afflicting millions of people. What
social factors account for this stunning development in the mental health field during the
past half century? Some observers target the ever increasing pace and demands of modern
life. Nonetheless, a larger body of evidence suggests that the prevalence of anxiety is due
less to these pressures themselves than to a prevailing social ethos that teaches people that
anxiety-related symptoms are a socially and medically legitimate response to life in the
modern age.
Can J Psychiatry. 2009;54(7):429–436.
Highlights
· The influence of third-party reimbursement on the history of psychiatric diagnosis has been
significant.
· Social and cultural trends have altered the history of psychiatric diagnosis.
· The power of the pharmaceutical industry has shaped the classification of mental illnesses.
Key Words: anxiety, anxiety disorders, DSM, social anxiety disorder, posttraumatic stress
disorder, self-help and recovery movement
t first glance, Gail Andrews, a middle-aged Torontonian, SAD is not just a Canadian issue, but a global concern. Gail is
A had it all: she was trilingual, well-read, a long-distance
cyclist, and an accomplished musician. As of 2008, she had a
one of millions of people around the world wracked by anxi-
ety about social interactions, what the drug industry aptly
great job as a senior executive at a major accounting firm. calls being allergic to people. Defined as a feeling of appre-
Other companies tried to recruit her as a partner. Nonetheless, hension or fear accompanied by a range of physical symp-
in Gail’s own words, she was an “imposter,” a “fraud,” living toms including sweating, dizziness, fainting, nausea, or heart
in dread of social scrutiny. palpitations, anxiety afflicted almost 20 million adult
Americans by the early 21st century. In 2001, the National
Institute of Mental Health declared anxiety the most common
Similar to 3 million other Canadians in the early 21st century,
mental health problem in the United States.2, p 377 In 2002, the
Gail suffers from SAD, also called crippling shyness.
World Mental Health Survey reported that anxiety was the
Although by all measures she was a professional success,
most prevalent mental health problem around the globe, a
nearly all the situations that triggered her anxiety were
plague that showed few signs of abating any time soon.3, p 13
work-related: leading workshops, giving presentations, doing
power lunches, even taking phone calls. Her fear of social per- SAD is just one of several disorders included under the
formance left her “never able to relax.” As she told a reporter broader rubric of anxiety disorders, a category that includes
in 2008, “If you really knew me, you wouldn’t like me . . . SAD (or social phobia), GAD, OCD, PD, specific phobias,
at all.”1 and PTSD. The most recent turning point in the history of the
anxiety diagnosis was 1980, when the American Psychiatric anxiety, notably the self-help and recovery movements. If
Association issued DSM-III. Sometimes called the bible of more people were feeling anxious at the dawn of the millen-
psychiatry, but more often simply a dictionary of diagnoses, nium, it was chiefly because the prevailing ethos of society
DSM-III separated depression and anxiety and sub-divided tended to validate victimization and powerlessness rather
anxiety into SAD, GAD, PD, and so on. Researchers maintain than vanity, self-promotion, or cutthroat assertiveness. When
that OCD and SAD are equally common in both sexes, but people today experience the emotional and physical symp-
women are more likely than men to suffer from GAD, PD, toms of anxiety, they undergo a “flight into illness”4, p 1645
PTSD, and specific phobias. similar to what late 19th-century people experienced when
Though the rate of anxiety disorders varies from one country they suffered from what neurologists of the day called “neur-
and culture to another, reported anxiety levels have been asthenia” or “the American nervousness.”4, p 1645 Anxiety is so
mounting ominously in successive birth cohorts since the end prevalent in the early 21st century, not because it is an
of the Second World War. What social factors account for this unwanted by-product of an unprecedentedly nerve-racking
stunning development in the mental health field during the last world but because society’s chief institutions (education,
century? How has the evolution of trends outside medical sci- government, medicine, corporations, and the media) teach
ence shaped patients’ presentations of anxiety? In her chatty A people that anxiety is an acceptable emotional response to the
Brief History of Anxiety (Yours and Mine),3 Canadian journal- modern age. In other words, owing to a revolutionary shift in
ist Patricia Pearson, writing about her own battle with SAD, history, the symptoms of anxiety have become both “socially
argues that the widespread symptoms of anxiety at the end of and medically correct.”5, p 205
the 20th century are due to a culture that celebrates fierce,
winner-take-all competition, notably on college campuses, in History
the information industries, and throughout the corporate busi- With all the public concern about the skyrocketing incidence
ness world. According to Pearson, the message that there is of anxiety in the early 21st century, it is easily forgotten that
“no shame in shamelessness”3, p 129 puts a premium on grab- the condition has always been with us. In the words of
bing all the attention we can, thereby triggering acute fears of St Thomas More in 1525, only Jesus Christ Himself was said
failure in countless people who temperamentally find it diffi- to die “without grudge, without anxietie [sic].”6, p 11 The poet
cult to emulate the Donald Trumps of the world. Living within John Keats called it “wakeful anguish.”3, p 4 Reports of anxi-
a culture that privileges “hucksterism,”3 p 129 Pearson main- ety, including acute shyness and stage fright, stretch back to
tains, systemically breeds intense anxiety. classical antiquity, but before the 19th century, the majority
view was that most social anxiety was normal and even an
Pearson is onto something about the self-promotional state of
asset in some situations that called for vigilance. In cultures
modern culture. The values espoused by television shows
that prized bashfulness as a mark of modesty, shyness was
such as Survivor and American Idol undoubtedly make many
widely praised in women and young men.
people edgy. The fast pace of modern life and its premium on
multitasking are other reasons people feel they are at their The first cracks in this consensus appeared in the late 19th
wits’ end. century, when physicians began describing patients who
However, I shall argue that there are other, more powerful complained that in certain social situations—for example,
social trends that account for the high levels of reported open or closed spaces, speech-making, workplaces—they
had trouble breathing, their hearts started pounding, their
pulses raced, their palms sweated, their limbs tingled, their
heads ached, and their stomachs felt as if butterflies were
Abbreviations used in this article
swarming inside. At least one historian has noted that the first
AIDS acquired immune deficiency syndrome
significant signs of clinical anxiety coincided with the “age
BDD body dysmorphic disorder of progress,”7, p 59 a time when many of the old dangers that
DSM Diagnostic and Statistical Manual of Mental Disorders had threatened humanity for centuries—starvation, epidemic
ETS endoscopic thoracic sympathectomy disease, and high rates of infant mortality—began to abate in
GAD generalized anxiety disorder severity, leaving people to fret about less immediate
OCD obsessive–compulsive disorder worries.7, p 61 In other words, the healthier people became, the
PD panic disorder more they worried about their personal health.8, p 212
PTSD posttraumatic stress disorder In the early 20th century, Sigmund Freud argued that anxiety
SAD social anxiety disorder was a neurotic reaction to the underlying psychological fac-
SHRM self-help and recovery movement tor of “unconsummated [libidinal] excitation.”9, p 115 Freudian
theory stated that the symptoms of anxiety were secondary to
deep-rooted psychological mechanisms that held the key to surrounding its strict definition, the concept of stress caught
analytic treatment.9, p 115–117 As psychoanalysis came to domi- on quickly, and soon millions were using it to explain how
nate 20th-century psychiatry, these Freudian views trumped c ir c u ms ta n c e s b e yo n d th e ir co n tr o l ma d e th e m
psychiatric efforts to classify nervous illnesses according to psychologically uneasy.
symptoms.
Anxiety, similar to stress, became a commonplace term dur-
Events moved swiftly after the Second World War as the trend ing the second half of the 20th century. In 1950, American
toward labelling normal feelings as sickness became a stam- composer Leonard Bernstein named his Second Symphony
pede. Within a few decades, countries such as the United after WH Auden’s 1947 Pulitzer Prize–winning poem “The
States and Canada were reporting that as much as 10% of their Age of Anxiety.” Media coverage of the build-up of nuclear
respective populations suffered from social anxiety. By the weapons, the energy crises of the 1970s, the outbreak of
turn of the 21st century, the anxiety diagnosis was thriving AIDS in the 1980s, the horrors of Bosnia and Rwanda in the
across the Atlantic Ocean as much as in North America. The 1990s, and the threat of climate change and global warming
French, typically hailed for their joie de vivre, were reputed to convinced millions that they lived in a world of grim uncer-
be the world’s biggest consumers of tranquilizers and tainty, diminishing natural resources, deadly ethnic violence,
antianxiety pills, with nearly 1 in 5 men and women taking runaway killer diseases, and imminent environmental
antidepressants.10 catastrophe.
SAD actually shares symptoms with many other psychiatric Then came the terrorist attacks on the World Trade Center
conditions, including the so-called phobias. Agoraphobia, and the Pentagon on September 11, 2001. Polls after 9/11
first identified in 1876 by German psychiatrist Carl Westphal reported that stress and fear levels rose in numerous coun-
as a dread of public places, morphed in the 20th century into tries, notably the United States, Canada, and the United
panic attacks in any place or situation where one feels unsafe Kingdom. Americans told pollsters that after 9/11 they were
or trapped. Dysmorphophobia, the fear of being deformed, more suspicious of people around them and uncomfortable in
was coined by the Italian psychiatrist Enrico Morselli in public places. Train travellers on London’s subway were
1891,11 and is the forerunner of today’s BDD—the “distress much more vigilant than ever after the terrorist bombings of
of imagined ugliness.”12, p 107 BDD is a condition accompanied 2005. In 2006, 1 in 3 people in the United Kingdom said they
by anxiety, although its primary symptom is the delusional harboured suspicious fears about other people. The over-
belief that there is something wrong with one’s physical whelming consensus among psychologists was that the sus-
appearance, for example a large nose or small genitals.13 piciousness bred by terrorism caused acute distress.
Nonetheless, however much the SAD diagnosis overlaps
other conditions, the international psychiatric consensus is Conspiracism
that the anxiety-related disorders constitute discrete diseases. Worries about terrorism exacerbated conspiratorial thinking
Psychiatrists tend to think that most people delay seeking as the new century dawned. Already noticeable before 9/11,
treatment, thereby making their conditions worse. The dis- the paranoid intellectual temper of inveterate mistrust,
tress of people like Gail Andrews suggests to the medical reductive suspicion, and heroic irony has spread even further
community that there are many more out there who never seek since the airliners crashed into the Pentagon and the twin
help. towers of the World Trade Center. The modern-day person
with paranoia insists that nothing is what it seems, nothing
An Age of Anxiety should be accepted at face value, and one should always read
In the early 21st century, why were people reporting higher between the lines.15 Prior to 9/11, commentators had noted
levels of anxiety than ever before? One reason involves the upsurge in what Pipes has called “conspiracism,”15, p 22 the
vocabulary. The words people with SAD use to describe their visceral readiness to believe that all history can be reduced to
feelings owe a great deal to the concept and terminology of clandestine plotting on the part of powerful people or organi-
stress, introduced in the 1930s by the Vienna-born physiolo- zations. Conspiracism seemingly motivated the militiamen
gist Hans Selye.14 As an endocrinologist at McGill University who, in 1995, bombed the federal building in Oklahoma City.
and the Université de Montréal, Selye studied how the body Many African Americans believe that the Central Intelli-
responded to environmental stimuli. He dubbed this process gence Agency practiced genocide by purposely introducing
of physiological adaptation “stress,” but people seemed to crack cocaine and the AIDS virus into inner-city neighbour-
prefer using the term to describe the external factors that hoods. After 9/11, millions, both within and outside society’s
caused bodily and mental changes in the first place. Selye elites, were convinced that the attacks were the work of either
insisted that stress was “not so much what happens to you, but the Bush White House or Israel’s Mossad intelligence
the way you take it.”14, p 79 Perhaps because of this confusion agency.16,17
The taste for unmasking conspiratorial agendas is also spread psychiatric drugs around. To people who sincerely believed
by movies and the Internet. Oliver Stone’s overwrought film in Xanax’s virtues for relieving PD, it was a godsend. How-
JFK insists that there was a plot implicating the highest ever, to insiders, PD was “the Upjohn illness.”21, p 320 Again,
reaches of the US government to assassinate President John F the pharmaceutical industry had impacted psychiatric diag-
Kennedy in 1963. Next to fear, paranoia may be the most com- nosis, transforming PD almost overnight into one of the most
municable mentality,15, p 44 and it has plenty of opportunities to recognized mental illnesses of the day. Drug companies have
proliferate in cyberspace where customary boundaries bolstered the notion that each anxiety diagnosis is a biologi-
between people and things vanish, leaving people feeling cal reality by introducing new medications, such as the sero-
insecure and anxious. The news media also deserve some of tonin reuptake inhibitor sertraline for PTSD. “As often
the blame for propagating a culture of fear that incessantly happens in medicine,” psychiatrist David Healy has written,
reminds the population of its vulnerability and victimiza- “the availability of a treatment leads to an increase in recogni-
tion.18 Television, radio, newspapers, and websites serve up a tion of the disorder that might benefit from that treat-
steady diet of stories about natural disasters, random violent ment.”21, p 319 To psychopharmacologist Thomas Ban, the use
crimes, drug-resistant killer bugs, and negligent government of “newer and newer drugs” as the 20th century drew to a
agencies. The point is not that these stories are imaginary close “artificially created [diagnostic] entities.”22, p 593 For
(though some are), but that in the multichannel universe they e x a mp le , p e o p le w h o q u e s tio n th e d ia g n o s tic
are told repeatedly to an audience who seem inveterately inca- “firewall”23, p 158 between anxiety and depression find them-
pable of shutting their eyes and ears. selves swimming upstream against the powerful current of
the pharmaceutical companies.23
Another important difference in recent years is that political
paranoia has migrated from the fringes of society to the edu-
cated elites. In 1998, when then First Lady Hillary Rodham Drug therapy is not the only form of treatment that sustains
Clinton blamed a “vast right-wing conspiracy”17, p 114 for her the anxiety diagnoses. BDD patients often resort to surgery
husband’s difficulties as president, she demonstrated how or dermatological help to allay their anxiety over their imag-
conspiracism had become both mainstream and accept- ined bodily defects. Some people with social phobia also opt
able.17,19 When occupants of the White House use conspiracist for surgery when they feel publicly humiliated over chronic
terminology, it is understandable how paranoid fears flourish facial blushing. In 2001, a Toronto doctor revealed that one
in the modern-day global village, fanning anxiety to unprece- of his patients (known as Nicole) was a teacher who in an
dented levels. effort to conceal her blushing conducted all her classes using
an overhead projector with the lights off. An administrative
Mood Medicine assistant aged 31 years who frequently turned beet red in
If levels of anxiety were on the rise, developments in social situations, Nicole confessed “I get really uncomfort-
psychopharmacology were another key reason. The great fan- able because . . . I’m thinking they’re probably wondering
fare surrounding the introduction of the tranquilizers in the ‘Why is she doing that?’” After trying antidepressants, tran-
1950s and 1960s made it appear to anxious people that relief quilizers, and hypnosis, Nicole opted for an ETS by clipping,
was just a prescription away. Called “happiness pills”20, p 338 which, by destroying certain portions of the sympathetic
and “emotional aspirin,”20, p 344 tranquilizers showed that anxi- nerve trunk, inhibits blushing. Nicole was gratified that the
ety was “as amenable to control as other illnesses.”20, p 346 Phy- surgery seemed to prove that she had a real illness with a
sicians’ overprescription of tranquilizers, often driven by bonafide medical name. No less important was the fact that
pressure from the pharmaceutical industry’s so-called detail ETS is covered by medical insurance in Canada.24
men, also helped to stimulate consumption of the
benzodiazepines. The mounting publicity—both good and
Thus the politics of reimbursement share responsibility for
bad—surrounding the minor tranquilizers had concrete con-
popularizing anxiety disorders. The development of new
sequences. In 1980, DSM-III said goodbye to the theory that
drugs influences the official recognition of psychiatric dis-
anxiety-related panic and social phobia were simply neurotic
ease categories because patients have a better chance at
symptoms and defined them instead as official, full-fledged
third-party reimbursement for pharmaceutical treatment,
psychiatric diagnoses.
especially in contrast to long-term and intensive psychother-
By the 1980s, society’s honeymoon with tranquilizers was apy. Evidence that drug treatment affects mood indicates that
ending, as critics increasingly warned about rising rates of the emotional condition in question is biological, and hence a
addiction. But society’s marriage to “mood medicine”20, p 349 valid and serious illness that in turn qualifies patients for
was still intact. Indeed, just as the authors were putting their reimbursement for treatment. Both patients and clinicians
finishing touches to DSM-III, the Upjohn Company was pre- benefit from a DSM diagnosis; little wonder that a DSM diag-
paring to market the new benzodiazepine alprazolam (Xanax) nosis has been sardonically called an “insurance
as a drug for PD. By the 1990s, it was one of the hottest claim.”25, p 235
Milking the System World War: reimbursement policies can heavily shape the
PTSD stands out as an anxiety-related diagnosis whose accep- destiny of a specific psychiatric diagnosis.30
tance has been smoothed by third-party disability benefits, in
this case the US Department of Veterans Affairs compensa- Victimization
tion program for war veterans. The symptoms of PTSD, a con- The standard interpretation of PTSD was that its sufferers
d itio n ch aracterized b y th e emo tio n ally p ain fu l were victims twice over: first at the hands of the original per-
re-experiencing of a horrific event, include nightmares, flash- petrators and then at the hands of an indifferent society that
backs, irritability, severe anxiety, and crippling phobias. In supposedly disregarded patients’ pain.26, p 142 Thus PTSD was
1980, PTSD became an official psychiatric diagnosis, but an excellent example of how anxiety disorders dovetailed
belief in the pathologically emotional impacts of traumatic with the emergence of SHRM and its heavy emphasis on vic-
experiences had been building since the late 19th century. timization. This movement stretched back to the early 20th
Treatment of veterans from the First and Second World Wars century, the heyday of mental healing.32, p 225–247 Books such
bolstered the notion that modern warfare produced high rates as Dale Carnegie’s How to Win Friends and Influence People
of nervous disorders. However, the real impetus behind the (1937) and Norman Vincent Peale’s The Power of Positive
PTSD diagnosis occurred when its advocates aggressively Thinking (1952) continued the tradition of self-help, but the
and successfully lobbied for its inclusion in DSM-III’s section dam broke in 1967 with Thomas A Harris’s smash I’m
on anxiety disorders.26, p 107–116 In 1982, the Journal of Ner- OK–You’re OK. In no time, authors of similar books became
vous and Mental Diseases estimated that 500 000 to 700 000 virtual gurus themselves, notably Doctor Phil McGraw,
veterans suffered from PTSD out of the 3 million who served Tony Robbins, Deepak Chopra, and Robert Fulghum. Day-
in the Vietnam theatre of war. A 1990 government study time television programs with millions of viewers, including
claimed that one-half of all veterans were PTSD victims, even The Oprah Winfrey Show and The Phil Donahue Show, pro-
though only 15% actually served in combat units.27, p 151–152 vided forums for these self-appointed experts to spread their
teachings. Mainstream magazines such as Redbook and
Skeptics of PTSD alleged that the chief advocates of the Ladies’ Home Journal joined the movement, running count-
diagnosis were “self-serving psychologists and psychia- less stories on how to improve the quality of one’s emotional
trists”26, p 113 who opposed the Vietnam War and wanted to life. In 2003 alone, between 3500 and 4000 new self-help
milk Veterans Affairs. Proponents of the PTSD diagnosis also books were published.32, p 8 In the words of one critic in 2005,
included the Vietnam Veterans Against the War, “the most the SHRM doctrine has “pervaded our culture—from our
visible and activist symbol of the antiwar movement.”26, p 113 schools to our offices to our homes and even to our
In the short term, the PTSD diagnosis enabled veterans to hospitals.”32, p 39
attach meaning to their Vietnam experience and helped to
The main themes of SHRM were vulnerability, powerless-
boost their self-esteem when the trials and tribulations of
ness, victimization, and authenticity. Though the proponents
adjusting to peacetime proved highly stressful. Nonetheless,
of SHRM differed on a range of issues, they tended to preach
the theory that traumatic events caused emotional illness
that almost everyone lived in a hostile world, filled with, for
swiftly spread beyond the community of Vietnam veterans to
example, multiple addictions, menacing relatives and neigh-
groups within the women’s movement who saw PTSD as a
bours, mendacious governments, wicked corporations, and
handy diagnosis to apply to victims of rape, domestic vio-
fanatical terrorists. In such a world, SHRM advocates
lence, child abuse, and sexual assault. Harvard Medical
argued, there were untold millions who paid a steep emo-
School professor Judith Lewis Herman wrote in 1992 that
tional price trying merely to survive. The SHRM industry,
“not until the women’s liberation movement of the 1970s was
c o mp r is e d o f co u n tles s th e r a p is ts , co u n s e llo r s ,
it recognized that the most common post-traumatic disorders
workshoppers, and social scientists, claimed to be able to
are those not of men in war but of women in civilian
help millions of people to recognize that their psychological
life.”28, p 144 Soon, many therapists sympathetic to Herman’s
and physical symptoms were not their fault; their ailments
theory were equating a husband’s harsh language with the ter-
were caused by traumatic, abusive events from the past, they
rors and hardships of frontline combat in the jungles of South-
deserved better emotional health, and they could enjoy a
east Asia.
much higher sense of self-esteem and self-worth. Joseph
Jennings,32 a former gang leader and drug addict-turned-
Meanwhile, the number of veterans receiving disability
motivational speaker, told his inner-city audiences that with
cheques for PTSD increased by 80%, from 120 000 in 1999 to
his help “you can be anything you want.” 32, p 34 However, if
216 000 in 2004. That increase alone amounted to an addi-
they ultimately failed to shake their pathology, Jennings
tional $2.6 billion in benefits.29 In 2003, people who qualified
blamed “the legacy of slavery,”32, p 34 not them.
for the diagnosis were entitled to as much as $2100 per month,
tax-free.27, p 161 In the final analysis, the US government dis- At one time, unhappy North Americans would have been told
covered what the British learned in the wake of the First to stop blaming others for their misery and get on with their
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