Anxiety A Short History

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To Jane
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 CONTENTS

Foreword, by Charles E. Rosenberg ix

Acknowledgments xv

Chapter 1. Afraid 1
Chapter 2. Classical Anxiety 19
Chapter 3. From Medicine to Religion—and
Back 36
Chapter 4. The Nineteenth Century’s New
Uncertainties 56
Chapter 5. The Freudian Revolution 75
Chapter 6. Psychology’s Ascendance 98
Chapter 7. The Age of Anxiety 118
Chapter 8. The Future of Anxiety 143

Notes 163
Index 185
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 FOR EW OR D

Disease is a fundamental aspect of the human condition. Ancient

bones tell us that pathological processes are older than human-
kind’s written records, and sickness and death still confound us.
We have not banished pain, disability, or the fear of death, even
though we now die on average at older ages, of chronic more of-
ten than acute ills, and in hospital or hospice beds and not in
our own homes. Disease is something men and women feel. It is
experienced in our bodies—but also in our minds and emotions.
It can bring pain and incapacity and hinder us at work and in
meeting family responsibilities. Disease demands explanation; we
think about it and we think with it. Why have I become ill? And
why now? How is my body different in sickness from its quiet and
unobtrusive functioning in health? Why in times of epidemic has
a community been scourged?
Answers to such timeless questions necessarily mirror and in-
corporate time- and place-specific ideas, social assumptions, and
technological options. In this sense, disease has always been a so-
cial and linguistic, a cultural as well as biological, entity. In the
Hippocratic era more than two thousand years ago, physicians
(we have always had them with us) were limited to the evidence
of their senses in diagnosing a fever, an abnormal discharge, or
seizure. Their notions of the material basis for such felt and visible
symptoms necessarily reflected and incorporated contemporary
philosophical and physiological notions, a speculative world of
disordered humors, “breath,” and pathogenic local environments.
Today we can call upon a rather different variety of scientific un-
derstandings and an armory of diagnostic practices—tools that
allow us to diagnose ailments unfelt by patients and imperceptible
to the doctor’s unaided senses. In the past century disease has also

ix
x Foreword

become increasingly a bureaucratic phenomenon, as sickness has

been defined—and in that sense constituted—by formal disease
classifications, treatment protocols, and laboratory thresholds.
Sickness is also linked to climatic and geographic factors. How
and where we live and how we distribute our resources contribute
to the incidence of disease. For example, ailments such as typhus
fever, plague, malaria, dengue, and yellow fever reflect specific en-
vironments that we have shared with our insect contemporaries.
But humankind’s physical circumstances are determined in part
by culture, and especially by agricultural practice in the millen-
nia before the growth of cities and industry. What we eat and
the work we do or do not do—our physical as well as cultural
environment—all help determine our health and longevity. En-
vironment, demography, economic circumstances, and applied
medical knowledge all interact to create particular distributions
of disease at particular places and specific moments in time. The
twenty-first-century ecology of sickness in the developed world is
marked, for example, by the dominance of chronic and degenera-
tive illnesses—ailments of the cardiovascular system, of the kid-
neys, and cancer.
Disease is historically as well as ecologically specific. Or per-
haps I should say that every disease has a unique past. Once dis-
cerned and named, every disease claims its own history. At one
level, biology creates that identity. Symptoms and epidemiology,
but also generation-specific cultural values and scientific under-
standings, shape our responses to illness. Some writers may have
romanticized tuberculosis—think of Greta Garbo as Camille—
but, as the distinguished medical historian Owsei Temkin noted
dryly, no one ever thought to romanticize dysentery. Tuberculosis
was pervasive in nineteenth-century Europe and North America
and killed far more women and men than cholera did, but it never
mobilized the same widespread and policy-shifting concern. It was
a familiar aspect of life, to be endured if not precisely accepted.
Unlike tuberculosis, cholera killed quickly and dramatically; it
was never accepted as a condition of life in Europe and North
America. Its episodic visits were anticipated with fear. Sporadic
 Foreword xi

cases of influenza are normally invisible, indistinguishable among

a variety of respiratory infections; waves of epidemic flu are all too
visible. Syphilis and other sexually transmitted diseases, to cite an-
other example, have had a peculiar and morally inflected history.
Some diseases, such as smallpox and malaria, have a long history;
others, like AIDS, a rather short one. Some diseases, like diabetes
and cardiovascular disorders, have flourished in modern circum-
stances; others reflect the realities of an earlier and economically
less developed world.
These arguments constitute the logic motivating and underly-
ing the Johns Hopkins Biographies of Disease. Biography implies
an identity, a chronology, and a narrative—a movement in and
through time. Once inscribed by name in our collective under-
standing of medicine and the body, each disease entity becomes
a part of that collective understanding and thus inevitably shapes
the way individual men and women think about their own felt
symptoms and prospects for future health. Each historically vis-
ible entity—each disease—has a distinct history, even if that his-
tory is not always defined in terms familiar to twenty-first-century
physicians. The very notion of specific disease entities—fixed and
based on a defining mechanism—is in itself a historical artifact.
“Dropsy” and “Bright’s disease” are no longer terms of everyday
clinical practice, but they are an unavoidable part of the history
of chronic kidney disease. Nor do we speak of “essential,” “con-
tinued,” “bilious,” or “remittent” fevers; they are not meaningful
designations in today’s disease classifications. Fever is now a symp-
tom, the body’s response to a triggering circumstance. It is no
longer a “disease,” as it was through millennia of human history.
“Flux,” or diarrhea, is similarly no longer a disease but a symptom
associated with a variety of specific and nonspecific causes. We
have come to assume and expect a diagnosis when we feel pain
or suffer incapacity; we expect the world of medicine to at once
categorize, explain, and predict.
But today’s diagnostic categories are not always sharp-edged
and unambiguous, even if they exist as entities in accepted disease
taxonomies. Emotional states present a particularly difficult prob-
xii Foreword

lem. Like fevers, loose bowels, and seizures, anxiety, sadness, pho-
bias, and compulsions have always been with us. But when are ex-
treme feelings and atypical behavior considered sickness? Fear and
sadness, for example, are both unavoidable—normal—aspects of
the human condition, yet both can become the core of powerful
emotions that bring pain, stigma, and social incapacity. When
do such felt emotions and the behaviors they structure transcend
the randomness of human idiosyncrasy and the particularity of
circumstance and become what clinicians have over time become
willing to recognize as disease? It is an elusive and ever-more-ubiq-
uitous question.
Is depression a discrete thing or an agreed-upon set of be-
havioral responses and thresholds? Once diagnosed, it becomes
a bureaucratic entity, a circumstantial variable helping struc-
ture interactions among sufferers, physicians, families, and—at
the moment—insurers and pharmaceutical manufacturers. But
though a real social entity, depression rests on shaky and con-
tested epistemological grounds. Can a prolonged depression be an
understandable response to circumstance—a kind of emotional
reality testing—or is it always a disease process? How is one to dif-
ferentiate the idiosyncratic and statistically predictable variation
among people from the pathological and dysfunctional? How to
tell the personal adjustment from the serious ailment?
Anxiety is equally and symmetrically elusive. Allan V. Hor-
witz has, in the present study, traced the complex and ambiguous
but continuous history of the cluster of emotions and feelings
we have come to call anxiety disorders. Humankind has always
known fear, and evolution has presumably made it a normal—
adaptive—component of humans as we perceive and anticipate
our surroundings. But when do generalized anxieties, phobias,
and compulsions become diseases? When does inappropriate fear
cease to be a quirk of personality and become a clinically visible
and legitimately treatable thing? Since Classical antiquity, physi-
cians have been aware that fear could incapacitate, make “cow-
ards” of soldiers, unhinge the ordinarily rational. That spectrum
from normal to incapacitating anxieties has always been under-
 Foreword xiii

stood as an unavoidable aspect of the collective human condition.

Since the mid-nineteenth century, however, as Western medicine
has sought to understand disease in terms of discrete entities, anxi-
ety has increasingly been regarded as the unstructured raw mate-
rial from which to construct clinically usable disease categories.
Phobias, compulsions, and anxiety states have been described,
“discovered,” and explained, from George Beard’s neurasthenia
in Gilded Age America and Sigmund Freud’s anxiety neurosis in
late-nineteenth-century Vienna, to the American Psychiatric As-
sociation’s DSM (Diagnostic and Statistical Manual ) categories
in late-twentieth-century America. Though these categories are
still unsettled and continuously being renegotiated, the drive to
make anxiety a neatly disaggregated list of nameable things seems
relentless. Anxiety disorders occupied fifteen pages in the APA’s
1980 DSM III, eighteen pages in the revised edition of 1987, and
fifty-one pages in the DSM IV of 1994. The fifth edition, of 2013,
devotes ninety-nine pages to what had been considered anxiety
disorders, though it defines separate categories for obsessive-com-
pulsive and related disorders and trauma- and stressor-related dis-
orders. The elaboration proceeds. Allan Horwitz has described an
evolution that is both a substantive part of the modern experience
and a microcosm symbolic of the way in which we have created
conceptual and bureaucratic entities that—for better or worse—
define us, constrain us, help us to think about who we are.

Charles E. Rosenberg
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 ACKNOWLED GMENTS

The first known representations of anxiety are found in cave paint-

ings from the Paleolithic era. They vividly depict sources of fear—
usually dangerous predators such as lions, wolves, and bears—
among our primeval ancestors. Sophisticated discussions of the
nature and sources of anxiety emerged during the fourth century
BCE in Hippocratic medicine and Aristotelian philosophy. The
vast array of available works spans both a temporal range of thou-
sands of years and a variety of medical, philosophical, religious,
psychological, and sociological discourses. A book of this length
can hardly encompass the huge sweep of material about anxiety.
Therefore, I have limited the scope of the book to Western discus-
sions and neglected the diverse understandings of anxiety found
in, among other places, China, Japan, India, and the Middle East.
In addition, the enormity of the range of literature has meant that
I have made unusually heavy reliance on the writings of other
historically oriented scholars. I have found especially valuable the
studies of Germain Berrios, Joanna Bourke, Gerrit Glas, David
Herzberg, Stanley Jackson, Michael MacDonald, George Makari,
Mark Micale, Janet Oppenheim, Roy Porter, Charles Rosenberg,
Andrew Scull, Edward Shorter, Andrea Tone, and Yi-fu Tuan.
None of these outstanding researchers, of course, is responsible
for the uses to which I have put their work.
I am grateful for the institutional support I received while writ-
ing this book. It was completed while I was a fellow at the Center
for Advanced Study in Behavioral Science at Stanford University.
I greatly appreciate the opportunity that the center and its direc-
tor, first Stephen Kosslyn and then Iris Litt, gave me to spend a
year in its unparalleled environment. As always, David Mechanic,
the director of the Institute for Health, Health Care Policy, and

xv
xvi Acknowledgments

Aging Research at Rutgers University, provided invaluable sup-

port for my work. David is also responsible for creating at Rutgers
a unique climate in which historical vision is seen as an essential
framework for understanding current issues regarding health and
health policy. My interactions at the institute with such gifted
historians as Gerald Grob, Keith Wailoo, Elizabeth Lunbeck, and
Nancy Tomes have profoundly shaped my own scholarship. I’m
also grateful to Melissa Lane, Helene Pott, and Jamie Walkup for
their ideas about improving this manuscript. My editor at the
Johns Hopkins University Press, Jacqueline Wehmuller, provided
insightful suggestions that have greatly enhanced the book, and
Anne Whitmore at the Press was an unusually capable copy editor.
I am especially appreciative of the efforts of distinguished histo-
rian Charles Rosenberg, the editor of the series of biographies of
diseases in which this book appears. Charles provided astute ad-
vice from the book’s initial conception to its final drafts. I thank
him for the opportunity to extend my writing from its native so-
ciological grounds to new historical territory.
ANXIETY
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 CHAPTER ONE

Afraid

F F F

Scientific views in the twenty-first century attempt to root the

psychological and the physiological aspects of anxiousness in bi-
ological processes that include brain circuitry, neurochemicals,
and genes. Anxiety and its disorders involve brain regions that are
devoted to fear recognition, including the amygdala, prefrontal
cortex, and hippocampus, and neurochemicals, such as GABA,
epinephrine, dopamine, and serotonin. Neuroimaging techniques
allow scientists to see how these neural networks activate in re-
sponse to threats and let them pinpoint how different kinds of
brains react to fearful stimuli. The mapping of the human ge-
nome has opened the pathway to examining the genetic correlates
of anxiousness. Anti-anxiety drugs can now target the particular
neurotransmitters related to this emotion.1
How do neuroscientists know whether what they are seeing
represents a pathological or a natural form of anxiety? Modern
societies have granted the preeminent power to define dysfunc-
tional anxiety (and other mental disorders) to the psychiatric pro-
fession. Psychiatry’s view of anxiety is embodied in the Diagnostic
and Statistical Manual (DSM ).2 Since its landmark third edition,
which was published in 1980, the DSM has used a medical model
in which constellations of manifest symptoms define each disor-