Anxiety

Anxiety (pronounced ang-zahy-i-tee)

(1) Fear, foreboding, worry, disquiet, distress, uneasiness or tension caused by apprehension of possible future misfortune, danger etc, often to a degree that normal physical and psychological functioning is disrupted (can occur without an identifiable cause in which case the patient may be diagnosed with an anxiety disorder).

(2) Earnest but tense desire; eagerness; an uneasy or distressing desire for someone or something.

(3) In psychiatry, a state of intense apprehension or worry often accompanied by physical symptoms such as shaking, intense feelings in the gut etc, common in mental illness or after a distressing experience; a generalised state of apprehension and psychic tension occurring in some forms of mental disorder.

1515–1525: From the Middle English anxumnesse (apprehension caused by danger, misfortune, or error, uneasiness of mind respecting some uncertainty, a restless dread of some evil), from the Old English angsumnes, from the Latin anxietatem (nominative anxietas) (anguish, anxiety, solicitude) a noun of quality from anxius (uneasy, anxious, solicitous, distressed, troubled in mind) from angō (to distress, trouble), akin to the Ancient Greek ἄγχω (ánkhō) (to choke).  The construct of the Latin anxietās was anxi(us) (anxious) + -etās, a variant of -itās used if appearing before a vowel.  The -itas suffix was from the Proto-Italic -itāts & -otāts (-tās added to i-stems or o-stems, later used freely) and ultimately from the primitive Indo-European -tehats.    Synonyms include foreboding, uneasiness, perplexity, disquietude, disquiet, trouble, apprehension, restlessness & distress and it’s become a popular modifier (range anxiety, climate anxiety, separation anxiety, performance anxiety etc).  Anxiety is a noun; the noun plural is anxieties.

Xanax tablets.

Xanax is the brand name for the drug alprazolam which is a benzodiazepine.  It is a prescription medication primarily used to treat anxiety disorders, panic disorders and (more controversially) depression.  A fast & short-acting benzodiazepine, Xanax works by enhancing the activity of a neurotransmitter called gamma-aminobutyric acid (GABA), which helps to reduce anxiety and promote relaxation.  Xanax is regarded as effective for treating anxiety and related disorders when used as prescribed but can be habit-forming, leading to dependence and addiction.  Lindsay Lohan released (or "dropped" in the fashionable parlance) the track Xanax in 2019.  With a contribution from Finnish pop star Alma (Alma-Sofia Miettinen; b 1996), the accompanying music video was said to be “a compilation of vignettes of life”, Xanax reported as being inspired by Ms Lohan’s “personal life, including an ex-boyfriend and toxic friends”.  Structurally, Xanax was quoted as being based around "an interpolation of" Better Off Alone, by Dutch Eurodance-pop collective Alice Deejay, slowed to a Xanax-appropriate tempo.

Generalized anxiety disorder (GAD) and panic disorder (PD) were formalized when the third edition of the American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders (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.

Leonard Bernstein's Symphony No 2 (The Age of Anxiety) was inspired by WH Auden's long poem of the same name.

WH Auden's (1907-1973) The Age of Anxiety: A Baroque Eclogue (1944) divided critics, said by some to be "his best work to date" and by others to be "dull and an obvious failure", some of whom rubbed in the critical salt by adding Leonard Bernstein's (1918-1990) Symphony No 2 (1948-1949), inspired by the poem, was the finer piece of art.  It was better received in the US where it was written, winning the Pulitzer prize but whether or not influenced by the reaction, Auden would never again complete an epic-length work.  Like HG Wells' (1866-1946) Mind at the End of its Tether (1945), it was very much a work of the unhappy time in which Auden found himself and in some ways picked up from his lament September 1st, 1939 (a poem he later renounced).  As a poem, The Age of Anxiety is a delight for structuralists, its six sections (prologue, life-story, dream-quest, dirge, masque & epilogue (and emulated by the six movements in Bernstein's symphony (each movement sub-divided))) able to be deconstructed even mathematically but, the most common complaint is that although his four protagonists (three men and a woman) are very different people and all from a world of vernacular American English, their thoughts on the human condition and their own are expressed as if each had once gone up to Oxford to take a degree in English, as Auden in his youth had done.  Such voices in poems are not unusual but the critics go further in claiming that anyone new to the work, were the characters' names to be concealed, could not possibly guess which of the four is talking.  While it becomes clear the abstractions he maps upon his four represent thought, intuition, sensation & feeling, while helpful as a device through which his word-view can be discussed, as flesh & blood characters they are vague indeed.  Still, literature should perhaps be enjoyed for what it is rather than what it's not; one doesn't need to find plausible what Philip Roth (1933-1918) thinks might be the thoughts of a woman to find pleasure in the text and it's the same with Auden's The Age of Anxiety.  Those interested in poetry as art will read such cleverness with relish, ticking the boxes on the path to technical ecstasy.  Those who want to feel something should stick to Sylvia Path (1932-1963).      

We would rather be ruined than changed
We would rather die in our dread
Than climb the cross of the moment
And let our illusions die.

WH Auden in The Age of Anxiety (1944).