The Blog by Ziyad Nazem

Are we all mentally ill?

Thanks to DSM-5’s new definition of General Anxiety Disorder, we can now all be labeled ‘mentally ill’. The psychiatric, and pharmacological industries approve.

To start, let’s go back in time..

In 1994, a study asking a random sample of thousands of Americans about their mental health reported that 15% had ever suffered from anxiety disorders. A 2009 study of people interviewed about their anxiety repeatedly for years raised that estimate to 49.5% — which would translate to about 117 million U.S. adults.

Some psychiatrists say the increase in the prevalence of anxiety from about 4% to 50% is the result of psychiatrists and others “getting better at diagnosing anxiety,” as Dr. Carolyn Robinowitz, a past president of the APA, put it. “People who criticize that are showing their bias,” she said. “When we get better at diagnosing hypertension, we don’t say that’s terrible.”

Critics, including other leading psychiatrists, disagree. They say the apparent explosion in anxiety shows there is something seriously and dangerously wrong with the DSM. Its next edition, due in May, would lower the threshold for identifying anxiety.

The criticism rests on three arguments.

First, the DSM fails to recognize that anxiety is normal and even beneficial in many situations, so it conflates a properly functioning brain system with a pathology.

Second, the DSM’s description of anxiety is more about enforcing social norms than medicine.

Finally, they say, anxiety is adaptive. Its brain circuitry was honed by evolution for a purpose. Only when that mechanism misfires should a person be diagnosed as mentally ill.

But wait, is there any other human emotion more basic than anxiety? Many forms of it simply should not be categorized as disorders — because, they’re just the result of evolution over thousands of years, rather than something going wrong.

When the brain’s anxiety system misfires it can prevent people from functioning, as when someone is unable to leave home, interact with friends and family or walk past even a leashed dog. But the anxiety system is working properly when it makes someone afraid of heights or wild dogs or threatening strangers.

I agree, anxiety or panic symptoms that have been severe, persistent and cause clinically significant distress or impairment need to be diagnosed promptly — we have some great treatment options for them. I don’t oppose people getting treatment, I just think people are much too willing to think they have a disorder that requires treatment.

Under changes for the DSM-5 proposed by experts convened by the APA, symptoms such as excessive worry, restlessness, feeling on edge, avoiding activities that cause anxiety, and being overly concerned about health or finances or family would have to be present for only three months rather than six to justify a diagnosis of Generalized Anxiety Disorder (GAD). And people would have to display one physical symptom, not the current three.

With this, the threshold for GAD is set so ridiculously low — DSM-5 will mislabel as mentally ill many people who are experiencing no more than the normal and expected worries of everyday life.

But, it’s okay — good ol’ big pharma reported $661 million in U.S. sales of anti-anxiety drugs last year, according to IMS Health. Most psychiatrists see that as evidence people suffering from mental illness are getting help. Last week, the Pharmaceutical Research and Manufacturers of America issued a report touting the many drugs are being developed for mental illnesses, including 26 just for anxiety.

Research over the past decade shows that feeling anxious is how the brain’s emotion centers send signals to its thinking centers that something is amiss. For instance, it is normal to be anxious over a sick child, a loved one’s illness, unemployment or other setbacks in life.

In the Paleolithic era, when our prehistoric ancestors lived in small clans, how people were viewed by strangers and kin could determine survival. So when people fret over going to a party, giving a speech or otherwise subject themselves to judgment, it reflects an adaptive response to the millennia-old need to be attuned to other people’s disapproval, researchers say. Anxiety about public speaking accounts for about half the diagnoses of social anxiety disorder.

Years after the devastating 2005 storm in New Orleans — schools, housing, policing and other aspects of life in New Orleans had still not returned to normal. Using DSM criteria, a 2007 study concluded that half the surviving residents were “mentally ill” because they experienced anxiety about those lingering effects.

If you survived Katrina, anxiety is not a sign of mental illness — it’s the brain working as it should. Such emotions can spur survivors to agitate for rebuilding neighborhoods, he said.

Another concern is that by labeling normal human variation — being more anxious, fearful or worried than the average person — a mental illness, means psychiatry is venturing into social control. To suggest that anyone who’s afraid to speak in front of hundreds of strangers has a mental illness creates social pressure to change, and that pushes psychiatry away from medicine and into enforcing social values.