Isolation

Isolation (pronounced ahy-suh-ley-shuhn)

(1) An act or instance of isolating; the state of being isolated.

(2) In medicine, the complete separation from others of a person suffering from contagious or infectious disease; quarantine.

(3) In diplomacy, the separation, as a deliberate choice by government, of a nation from other nations by nonparticipation in or withdrawal from international relations and institutions.

(4) In psychoanalysis, a process whereby an idea or memory is divested of its emotional component.

(5) In social psychology, the failure of an individual to maintain contact with others or genuine communication where interaction with others persists.

(6) In linguistics and other fields, to consider matters without regard to context.

(7) In chemistry, obtaining an element from one of its compounds, or of a compound from a mixture

(8) In computing, a database property that determines when and how changes made in one transaction are visible to other concurrent transactions.

1830s: A compound word, isolate + -ion.  A modern English borrowing from the French isolé (placed on an island (thus away from other people)).  Isolé was from the Italian isolato, past participle of isolare, the root of which was the Latin insulātus & insulātes (made into an island), from insula (island).  From circa 1740, English at first used the French isolé (rendered as isole) which appeared also as isole'd in the 1750s, isolate the verb emerging in the 1830s; isolated the past participle.  Isolation is now the most familiar form, the suffix –ion is from the Latin -iō (genitive -iōnis), appended to a perfect passive participle to form a noun of action.  Words with similar meanings, often varying by context, includes solitude, desolation, confinement, segregation, remoteness, privacy, quarantine, sequestration, aloofness, detachment, withdrawal, exile, aloneness, concealment, retreat, hiding, reclusion, monkhood, and seclusion.

Isolation, Social Phobia and Social Anxiety Disorder

As long ago as 400 BC, Greek physician Hippocrates (circa 460–c 370 BC) noted there were people who sought social isolation, describing them as those who "love darkness as life" adding, in a hint at later understandings of mental illness, they tended also to "think every man observes them."  Such folk doubtless pre-dated antiquity, being always part of organized societies but it wasn’t until the late nineteenth century when psychiatry emerged as a distinct field that the particular human condition came to be known as social phobia or social neurosis, then thought of as a descriptor of extremely shy patients who sought isolation by choice.

Desolate: an emo in isolation.

Despite the increasing medicalization of the spectrum of the human condition, it wasn’t until 1968, in the second edition of the American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM-II), that social isolation was described as a specific phobia of social situations or excessive fear of being observed or scrutinized by others but at this point the definition of social phobia was very narrow.  With the release in 1980 of the DSM-III, social phobia was included as an official psychiatric diagnosis although it restricted the criteria, noting those who sought social isolation did so because of a fear of “performance situations” and did not include fears of less formal encounters such as casual conversations.  Those with such broad fears were instead to be diagnosed with “avoidant personality disorder” which, for technical reasons defined within the DSM-III, could not be co-diagnosed as social phobia, an attitude reflecting the editors’ view that phobias and neuroses needed specifically to be codified rather than acknowledging there existed in some a “general anxiety” disorder.  This neglect was addressed in the 1987 revision to the DSM-III (DSM-III-R) which changed the diagnostic criteria, making it possible to diagnose social phobia and avoidant personality disorder in the same patient.  In this revision, the term "generalized social phobia" was introduced.  DSM-IV was published in 1994 and the term “social anxiety disorder” (SAD) replaced social phobia, this reflecting how broad and generalized fears are in the condition although the diagnostic criteria differed only slightly from those in the DSM-III-R.  The DSM-IV position remains essentially current; the modifications in the DSM-5 (2013) not substantively changing the diagnosis, altering little more than the wording of the time frame although the emphasis on recognizing whether the experience of anxiety is unreasonable or excessive was shifted from patient to clinician.

For some, COVID-19 isolation was a business opportunity.

Generalized anxiety disorder (GAD) and panic disorder (PD) were formalized when DSM-III was released in 1980 although among clinicians, GAD had for some years been a noted thread in the literature but what was done in DSM-III was to map GAD onto the usual pattern of diagnostic criteria.  In practice, because of the high degree of co-morbidity with other disorders, the utility of GAD as defined was soon a regular topic of discussion at conferences and the DSM’s editors responded, the parameters of GAD refined in subsequent releases between 1987-1994 when GAD’s diagnostic criteria emerged in its recognizably modern form.  By the time the terminology for mental disorders began in the nineteenth century to be codified, the word anxiety had for hundreds of years been used in English to describe feelings of disquiet or apprehension and in the seventeenth century there was even a school of thought it was a pathological condition.  It was thus unsurprising that “anxiety” was so often an element in the psychiatry’s early diagnostic descriptors such as “pantophobia” and “anxiety neurosis”, terms which designated paroxysmal manifestations (panic attacks) as well as “interparoxysmal phenomenology” (the apprehensive mental state).  The notion of “generalized anxiety”, although not then in itself a diagnosis, was also one of the symptoms of many conditions including the vaguely defined neurasthenia which was probably understood by many clinicians as something similar to what would later be formalized as GAD.  As a distinct diagnostic category however, it wasn’t until the DSM-III was released in 1980 that GAD appeared, anxiety neurosis split into (1) panic disorder and (2) GAD.  When the change was made, the editors noted it was a response to comments from clinicians, something emphasised when DSM-III was in 1987 revised (DSM-III-R), in effect to acknowledge there was a class of patient naturally anxious (who might once have been called neurotic or pantophobic) quite distinct from those for whom a source of anxiety could be deduced.  Thus, the cognitive aspect of anxiety became the critical criterion but within the profession, some scepticism about the validity of GAD as a distinct diagnostic category emerged, the most common concern being the difficulty in determining clear boundaries between GAD, other anxiety-spectrum disorders and certain manifestations of depression.

The modern label aside, GAD has a really long lineage and elements of the diagnosis found in case histories written by doctors over the centuries would have seemed familiar to those working in the early nineteenth century, tales of concern or apprehension about the vicissitudes of life a common thing.  As psychiatry in those years began to coalesce as a speciality and papers increasingly published, it was clear the behaviour of those suffering chronic anxiety could culminate in paroxysmal attacks, thus it was that GAD and panic attacks came to be so associated.  In English, the term panophobia (sometimes as pantaphobia, pantophobia or panphobia) dates from 1871, the word from the Late Latin pantŏphŏbŏs, from the Ancient Greek παντοφόβος (all-fearing (literally “anxiety about everything”)).  It appears in the surviving works of medieval physicians and it seems clear there were plenty of “pantophobic patients” who allegedly were afraid of everything and it was not a product of the Dark Ages, Aristotle (384-322 BC) in the seventh book of his Nicomachean Ethics (350 BC) writing there were men “…by nature apt to fear everything, even the squeak of a mouse”.

The first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-I (1952) comprised what seems now a modest 130 pages.  The latest edition (DSM-5-TR (2022)) has 991 pages.  The growth is said to be the result of advances in science and a measure of the increasing comprehensiveness of the manual, not an indication that madness in the Western world is increasing.  The editors of the DSM would never use the word "madness" but for non-clinicians it's a handy term which can be applied to those beyond some point on the spectrum of instability.

Between Aristotle and the publication of the first edition of the DSM in 1952, physicians (and others) pondered, treated and discussed the nature of anxiety and theories of its origin and recommendations for treatment came and went.  The DSM (retrospectively labelled DSM-I) was by later standards a remarkably slim document but unsurprisingly, anxiety was included and discussed in the chapter called “Psychoneurotic Disorders”, the orthodoxy of the time that anxiety was a kind of trigger perceived by the conscious part of the personality and produced by a threat from within; how the patient reacted to this resulted in their reaction(s).  There was in the profession a structural determinism to this approach, the concept of defined “reaction patterns” at the time one of the benchmarks in US psychiatry.  When DSM-II was released in 1968, the category “anxiety reaction” was diagnosed when the anxiety was diffuse and neither restricted to specific situations or objects (ie the phobic reactions) nor controlled by any specific psychological defense mechanism as was the case in dissociative, conversion or obsessive-compulsive reactions. Anxiety reaction was characterized by anxious expectation and differentiated from normal apprehensiveness or fear.  Significantly, in DSM-II the reactions were re-named as “neuroses” and it was held anxiety was the chief characteristic of “neuroses”, something which could be felt or controlled unconsciously by various symptoms.  This had the effect that the diagnostic category “anxiety neurosis” encompassed what would later be expressed as panic attacks and GAD.

A: Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or matters relating to educational institutions).

B: The patient finds it difficult to control the worry.

C: The anxiety and worry are associated with three (or more) of the following six symptoms:

(1) Restlessness or feeling keyed up or on edge.

(2) Being easily fatigued.

(3) Difficulty concentrating or mind going blank.

(4) Irritability.

(5) Muscle tension.

(6) Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep).

The key change really was for the criteria for GAD requiring fewer symptoms. Whereas with the DSM-IV-TR (2000) individuals needed to exhibit at least three physical and three cognitive symptoms for a diagnosis of GAD, under DSM-5 (2013), only one of each was required so not only was the accuracy and consistency of diagnosis (by definition) improved, the obvious practical effect was better to differentiate GAD from other anxiety disorders and (importantly) the usual worries and concerns endemic to the human condition.  The final significant aspect of the evolution was that by the time of DSM-5, GAD had become effectively a exclusionary diagnosis in that it cannot be diagnosed if the anxiety is better explained by other anxiety disorders and nor can GAD be caused directly by stressors or trauma.