Textbook of Anxiety Disorders

by Dan J. Stein and Eric Hollander (editors)
American Psychiatric Publishing, 2002
Review by Peter B. Raabe, Ph.D. on Aug 12th 2002

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.

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).

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