As its title suggests, this is a
large format publication, and a huge book, which its publisher—American
Psychiatric Publishing—clearly intends to be used as an academic course
text. It contains 37 essay chapters
written either individually or collaboratively by theoreticians and
practitioners in the field of psychotherapy. 
They discuss in clinical language the phenomenology and theoretical
models of anxiety disorders as well as their treatment by means of
psychotherapy and medication. The book
is subdivided into ten parts: the first
part deals with the history and various conceptions of anxiety disorders; part
two and three cover generalized anxiety disorders and mixed anxiety-depressive
disorders. From the fourth part onward
the topics are more specific, covering issues such as obsessive-compulsive
disorders, panic disorders and agoraphobia, social phobia, specific phobia,
posttraumatic and acute stress disorder, and anxiety disorders in certain
populations such as children, the elderly, and substance abusers. The final part takes a step back from the
discussion of the disorders themselves and considers the cultural and social
aspects of anxiety disorders including the economic costs of both the
consequences of their occurrence in a population and the actual cost of
treating them. It ends with a short
appendix of Internet resources and a satisfyingly substantial index.

While this book contains
informative reports on various problems that can arise in the human condition,
such as the lingering distress after experiencing a traumatic event and the
fear of certain situations, there’s an unsettling and sustained equivocation in
the overall conception of anxiety. It’s
discussed at times as a physical problem and at other times as a problem in
logic and reasoning. There’s a constant
switching back and forth between talk of anxiety as a medical disease (caused by inferior genetics, faulty
neurochemistry, or malfunctioning brain circuitry) and anxiety as experienced
for a reason (worry or stress associated with problems in everyday life). In one chapter the authors claim, “The
medial prefrontal cortex also plays a prominent role in anxiety” (p. 54), while in the next chapter the
author states, “Environmental stresses play a central role in the expression of
anxiety and in the precipitation of episodes of mental illness” (p. 60). The tension between these two
models remains unresolved throughout.

Every section of the book offers
both a chapter on neurobiology and pharmacotherapy as well as a chapter on
psychology and psychotherapy. It’s as
though the writers as a group are of two minds. For example, the section on Generalized Anxiety Disorder first
presents a chapter which maintains that there are a number of pharmacological
agents that can be used to treat the biomedical disease of anxiety (albeit with some serious side effects),
followed by a chapter which explains the effectiveness of cognitive/discursive
therapy in treating anxiety with no mention of drugs. It makes me wonder, since
this equivocation throughout the entire book has caused anxiety in me does it
mean I’m now suffering from a biomedical disease?

One of the passages that most
clearly illustrates why this book makes me uneasy is located in chapter 31,
which deals with cultural aspects of anxiety disorders. The two authors argue that cross-cultural
instances of panic attacks are evidence that they could be a biomedical disease
involving “a false suffocation alarm.” 
As an example they cite the case of the Inuit who has a fear of
kayaking (p. 465). The authors claim that this case is
equivalent to western cases of fear of driving, and argue that because these
similar fears occur in various cultures it may therefor be concluded that they
are in fact the same biomedical disease. 
Now I imagine that most people would assume that an Inuit’s fear of
kayaking is probably related to an earlier life-threatening experience
involving water or kayaking and what the Inuit imagines might happen if he goes
near the water again. A fear of driving
may have similar experiential reasons behind it, but the authors suggest that
the similarity between the Inuit’s fear of kayaking and the fear of driving is
evidence of a biomedical disease. They conclude,
“a range of evidence indicates that panic disorder is a universal biomedical
disorder and that this diagnosis does not represent a category fallacy” because “specific neuroanatomical circuits and
neurochemical systems underpin the symptoms of panic disorder" (p.
466). But don’t specific
neuroanatomical circuits and neurochemical systems underpin every human
emotion? There’s something very odd
about an argument that says, because an emotion involves neuroanatomical
circuits and neurochemical systems it must therefor be a biomedical
disease.

While there’s a lot said about the
effects of various drugs in the ostensibly successful treatment of anxiety
disorders, there’s no mention of what actually constitutes treatment
success. It’s simply taken for granted
that medications are good because they eliminate undesirable things such as
excessive worry. But the question is
how? If a pill inhibits a patient’s
customary thoughts and emotions by suppressing them with a drug-induced stupor,
should this drug-induced stupor then count as a treatment success? If a drug reduces worry but forces the
patient to suffer instead from a number of physical side effects is this a
treatment success? In fact I’m puzzled
as to why the editors of this textbook would expend so many pages promoting
medication in the first place when the evidence from clinical research, cited
throughout this volume itself (e.g.,
86, 99, 144, 275, etc.), has repeatedly and convincingly shown that talk
therapy produces significantly better long-term results than drug therapy, and
without the debilitating side effects.

Furthermore, there’s a strange sort
of selective perspective in many of the chapters. For example, in the third chapter the authors refer to medical
experiments conducted on rats and rhesus monkeys, and the effectiveness of
tricyclic antidepressants and selective seratonin reuptake inhibitors in
sedating these animals that have been specifically raised to be
anxiety-ridden (p. 37). But they fail to mention the fact that,
unlike rats and monkeys, it’s possible to substantially reduce the anxiety of a
rational human being by helping him or her, in a calm and empathetic manner, to
think things through without the use of drugs. 
I suppose the authors felt there was no need to mention empathetic human
discussions in a chapter on the effects of anti-anxiety drugs on rats and
monkeys, but by focusing exclusively on medications it gives the impression
that empirical research favors the medical model, which is clearly not the
case. In fact studies have found that the
most recent “wonder drug,” Ritalin 
(given to children diagnosed with problematic attention spans), has the
same harmful long-term effects on the brains of laboratory rats as amphetamines
and cocaine.

This is a well-organized academic
textbook written in highly technical language. 
I believe educators and students in clinical psychology and psychiatry
will find it similar to other contemporary academic texts in the field. It strongly advocates the medical model of
mental illness found in the latest edition of the DSM, it vigorously promotes
the use of psychopharmaceuticals, and it offers typically ambiguous messages
concerning the cause, nature, and treatment of non-physical distress. But I see it as only of limited interest to
psychotherapists who don’t have a license to prescribe medications, counselors
who don’t subscribe to the medical model, and mental health services consumers
who are not proficient in psychotherapeutic and psychopharmacological
phraseology.

© 2002 Peter B. Raabe

Peter B. Raabe
teaches philosophy and has a private practice in philosophical counseling in
North Vancouver, Canada. He is the author of the books Philosophical
Counseling: Theory and Practice (Praeger, 2001) and Issues
in Philosophical Counseling (Praeger, 2002).

Categories: Anxiety