NEW YORK: When Cynthia Craig was diagnosed with postpartum depression eight years ago, she told her family doctor she felt anxious about motherhood. She wondered whether she had made a catastrophic mistake by quitting her job, whether she could cope with the long, lonely hours stay-at-home mothers face—and even whether she should have had children.
"Anxiety is something I have always had, especially during times of change," said Craig, 40, who lives in Scotland, Ontario.
"But I was never worried about the level of anxiety, and it never prevented me from leaving the house, driving, socializing or even speaking in front of people."
Her doctor referred her to an anxiety clinic, where a nurse asked Craig dozens of yes-or-no questions - are you afraid of snakes? do you hear voices? do you vomit from anxiety?—and made a diagnosis.
"She said, 'Let's call it Generalized Anxiety Disorder with a touch of social phobia,'" Craig said.
That didn't feel right to her, but the clinic's psychiatrist agreed with the nurse and said Craig's concerns about motherhood constituted an anxiety disorder, a form of mental illness, and prescribed Pfizer's Effexor and then GlaxoSmithKline's Paxil. Craig says the drugs exacerbated the very anxiety that she doubted required medication.
Craig's case is one of millions that constitute an extraordinary trend in mental illness: an increase in the prevalence of reported anxiety disorders of more than 1,200 per cent since 1980.
In that year, two per cent to four per cent of Americans suffered from an anxiety disorder, according to the American Psychiatric Association's Diagnostic and Statistical Manual (DSM) of Mental Disorders, used by psychiatrists and others worldwide to diagnose mental illness.
In 1994, a study asking a random sample of thousands of Americans about their mental health reported that 15 per cent had ever suffered from anxiety disorders. A 2009 study of people interviewed about their anxiety repeatedly for years raised that estimate to 49.5 per cent—which would be 117 million US adults.
Some psychiatrists say the increase in the prevalence of anxiety from about four per cent to 50 per cent is the result of psychiatrists and others "getting better at diagnosing anxiety," as Dr Carolyn Robinowitz, a past president of the APA who is in private practice in Washington, DC, 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.
"No human emotion is more basic than anxiety," said sociologist Allan Horwitz of Rutgers University.
"Many forms of it simply should not be categorized as disorders, because they're the result of the way people evolved thousands of years ago, rather than something going wrong."
Identifying the truly ill
Horwitz and other critics recognize that 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.
"Anxiety or panic symptoms that have been severe, persistent and cause clinically significant distress or impairment need to be diagnosed promptly," said Dr Allen Frances, a psychiatrist who led the previous DSM revision and questions some of the new criteria.
"Very effective treatments are available."
"We don't oppose people getting treatment," said Horwitz, co-author of the new book "All We Have to Fear: Psychiatry's Transformation of Natural Anxieties into Mental Disorders."
"But people are much too willing to think they have a disorder that requires treatment."
Many psychiatrists don't see it that way. 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.
"Because its 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," said Frances.
Dr Donna Rockwell, a clinical psychologist who has organized opposition to aspects of the DSM-5 process, warned that "unless [the APA's experts] come to their senses, GAD will be identical to the existential worries all of us face as part of being human." That will bring "a bonanza to the drug companies," she added, opening the floodgates to "more inappropriate, expensive and potentially harmful drug use."