This interesting book charts the development of the concept of anxiety from Classical Greece to the era of DSM-5. Throughout history, one observes a perpetual oscillation between physical and psychological explanations for anxiety. An example of the former is George Beard’s neurasthenia which perfectly captured the zeitgeist of the 19th century and the various stresses associated with progress and civilisation. He situated it clearly in the realm of physical conditions, ‘employing drugs, injections, electricity and the like and did not use psychological therapies [which] helps account for the immense popularity the diagnosis enjoyed: it removed a stigma from people who suffered from what they and their physicians could believe was a genuine physical disease’ (p. 67).
Brain and mind continue to shift in and out of fashion. Citing a historical perspective, Horwitz resists the recent swing back towards biological explanations and maintains that ‘[c]urrent views of anxiety and its disorders… are infused with cultural templates, social influences, and material interests’ (pp. 3-4). His concerns remind me of the preface to Hunter & Macalpine’s Three Hundred Years of Psychiatry 1535-1860 (Oxford University Press, 1963), encouraging the re-integration of psychiatry with medicine, ‘so long as it does not mean putting the clock back and once again summarily equating mind disease with brain disease and so denying the heterogeneous group of illnesses and conditions which make up psychiatry their distinctive features and the special skills and methods they demand - the hard learned lesson of the past’ (p. ix).
The normality or abnormality of anxiety is a complex issue and perhaps this book raises more questions than anything else, not least, exactly what it is the author is criticising - is it DSM, brain-based explanations, or current delineations of ‘normal’ v. ‘pathological’ anxiety? In any case, these questions are central to the practice of psychiatry and I suspect we would all benefit from this reminder of the complexity of people and the problems which occasionally lead them into contact with a psychiatrist.
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