Anxiety disorders: a conceptual history

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  • Journal of Affective Disorders 56 (1999) locate / jad

    Invited review

    Anxiety disorders: a conceptual history

    *G. BerriosDepartment of Psychiatry, University of Cambridge, Addenbrookes Hospital, Hills Road, Cambridge CB2 2QQ, UK

    Received 5 January 1998; received in revised form 21 December 1998; accepted 19 February 1999

    1. Matters historiographical According to the first, these are all linguistic con-structions (e.g. Sarbin, 1964, 1968) whose content

    When writing on how the so-called anxiety fully changes from generation to generation, accord-disorders came to be constructed, the historian faces ing to the second, clinical categories reflect stable,three difficulties: identifying the object of research, platonic objects more or less fixed in their ontologychoosing the appropriate historiographical approach, (like plants or animals); the third, to be followed inand setting limits to the data domain. this paper, is that most clinical categories (and the

    The object of research is not as clear cut as it phenomena related to anxiety is one of them) havemight seem. For it would be a bad historian who a neurobiological substratum but that the experientialsimply accepted official definitions, for example, and behavioural signals they generate are culturallyDSM IV: The following disorders are contained in formatted at a very early stage. In practice, thisthis section: Panic Disorder Without Agoraphobia, means that the historian must assume such categoriesPanic Disorder With Agoraphobia, Agoraphobia not to be fixed for ever but undergo secular changesWithout History of Panic Disorder, Specific Phobia, in form and content which should depend both onSocial Phobia, ObsessiveCompulsive Disorder, change in biological programming and societalPosttraumatic Stress Disorder, Acute Stress Disor- change (Berrios, 1996a). Lastly, the object of inquiryder, Generalized Anxiety Disorder, Anxiety Disorder and the historiographical approach will determine theDue to a General Medical Condition, Substance- boundaries of the data domain: in the case of theInduced Anxiety Disorder, and Anxiety anxiety disorders this should certainly go beyond theDisorder . . . (emphases in original) (American minutes of the DSM IV Work Group who drafted thePsychiatric Association, 1994). The reason for not section on Anxiety Disorders.accepting this list as the object of research is that,from an important perspective, writing on the historyof the DSM IV definition of anxiety disorders is not 2. Matters historicalthe same as writing on the history of the anxietydisorders in general. This important perspective None of the clinical phenomena or symptomsrelates to up to three historiographical assumptions now included under the various anxiety disorders isas to the nature of clinical (nosological) categories. new. What has changed is their relative emphasis, the

    permutations and combinations in which they are*Tel.: 1 44-1223-336-965; fax: 1 44-1223-336-968. clustered up, and their social meaning. Reported in

    0165-0327/99/$ see front matter 1999 Elsevier Science B.V. All rights reserved.PI I : S0165-0327( 99 )00036-1

  • 84 G. Berrios / Journal of Affective Disorders 56 (1999) 83 94

    the Bible under the term pachadh, the symptoms of cated to the heart, ear, gut and brain. In other words,abnormal fearfulness were already differentiated up to the middle of the 19th century, they were takenfrom the reverential fear of the Lord of the true at face value and treated as real physical com-believer (Hastings, 1909, p. 261). The same phenom- plaints. Consequently, the primary sources for theena can also be found nicely catalogued in Burtons historical study of the anxiety disorders during this(1883/1620) Anatomy of Melancholy. In both cases, period are medical textbooks; indeed, their study andthe experiential element remains more or less the treatment only became part of the remit of psychi-same. What changes in these reports, both in relation atry at the very end of the 19th each other and to the present is their social The historian will find that the symptoms ofmeaning and conceptual wrapper. Whilst in Biblical anxiety are listed under two headings. Subjectivetimes such experiences were part of the dynamic ones (i.e. those felt as psychological experiences)relationship between men and their God, in Burton included fear, emotional worries, feelings of terror,they become behavioural curiosities, and in the 18th depersonalisation, etc., and occasionally mental actscentury they are medicalized into becoming diseases such as obsession-like thoughts concerning the safetyin their own right (e.g. hyperventilation became a of others, fear of dying, etc. On the other hand, thedisease of the lungs, palpitations one of the heart, objective symptoms of anxiety (also calledetc.). The first half of the 19th century witnesses the somatic and later on anxiety-equivalents) in-culmination of the process of medicalization. A good cluded abdominal pain, nausea, vertigo, dizziness,

    example is La medicine des passions, ou les passions palpitations, dry mouth, hot flushes, hyperventilation, considerees dans leurs rapports avec les maladies, breathlessness, headache, restless legs, and other

    les lois et la religion published in 1844 by Descuret bodily experiences sometimes indistinguishable from(1868) where the author dedicates a chapter to fear complaints caused by physical a medical problem. According to biology, personality, culture, social

    During the second half of the 19th century also class, etc. subjects may present these symptoms instarts the psychologization of the manifestations of different combinations. When repetitive and stableanxiety. By the 1890s, the very symptoms that once enough, they began to be called syndromes and evenhad been independent physical diseases became diseases. Combinations of subjective and somaticclustered up (e.g. by Freud) into a clinical condition symptoms may mimic heart disease (Krishaber,(anxiety-neurosis) whose integrating force was no 1873), inner ear disorder (Benedikt, 1870), stomachlonger a brain lesion but semantics (a sexual link). upset (Johnson, 1840) or neurological disease (Gow-Looking back, there was nothing prima facie natu- ers, 1907). On occasions, such clusters may be calledral about the claim that experiences so disparate had nervous but it would be anachronistic in theall to be manifestations of the same cause, namely extreme to interpret this word before the 1850s asthe unifying construct called anxiety. So, to state having anything to do with psychology. The termthat this move towards integration was the sole nervous meant organic and not localized, andconsequence of a new 19th century conception of the related directly to the nerves and brain in the senseautonomic nervous system (Clarke and Jacyna, that Thomas Willis had introduced during the 17th

    1987) is not the full explanation. As it will be shown century (Lopez Pinero, 1983; Hare, 1991).below, other forces, concepts and expectations were It would seem, therefore, that a proper historicalalso at work. account of the anxiety disorders should deal with

    questions such as: (1) why were such symptoms andsigns, often dissimilar in appearance, brought to-gether under the same banner? (2) Was this the result

    3. Data domains of clinical observation or of theoretical and socialpressures? (3) Were these states considered as ex-

    Before the late 19th century synthesis took place, aggerations of normal psychological phenomena, orhowever, the symptoms of anxiety are found in as morbid forms? (4) How relevant to their con-medical nosologies scattered in the sections dedi- ceptualization were late 19th century theories of

  • G. Berrios / Journal of Affective Disorders 56 (1999) 83 94 85

    emotion and new views on the ganglionar (au- Bossuet used it to refer to pressure on the hearttonomic) nervous system? (Rey, 1997). Consistent with this secular usage, as

    The history of anxiety can be studied from a late as the middle of the 19th century, Littre andmetaphysical, social, poetic and even religious per- Robin (1858) defined angoisse as feelings of close-spective; this paper will focus on its medical ness or pressure on the epigastric region, accom-aspects. Lastly, and to avoid confusion, the historiog- panied by a great difficulty in breathing and exces-raphical technique will be used of separately study- sive sadness; it is the most advanced degree of

    ing the history of the word, concepts and pertaining anxiety (p. 77) and anxiete as troubled and agitatedbehaviours. state, with feelings of difficulty in breathing and

    pressure on the precordial region: inquietude, anxietyand anguish are three stages of the same phenom-

    4. The terms anxiete, angoisse and equivalents enon (p. 93). A similar development is found in theEnglish language and the famous Sydenham Lexicon

    Eys (1950, p. 386), view that anxiete gained its defines anxiety as a condition of agitation andmedical meaning in France at the end of the 19th depression, with a sensation of tightness and distresscentury needs rectification as there is evidence that in the prcordial region. This feeling, or rather itsby the second half of the 17th century the term marked expression in the features, forms a dangerousalready had a psychological meaning (i.e. it re- symptom in acute diseases (Power and Sedgwick,

    `ferred to subjective experiences) (Furetiere, 1701/ 18791899).1690); and that by 1750 it was in wide use in Lewis (1967) has analysed the way in which themedicine (Rey, 1997, p. 87). For example, anxietas etymology of terms such as anxiety, anguish, and

    is used by Boissier de Sauvages, Linne, Vogel, and angor influenced the clinical conceptualisation of theSagar to describe paroxysmal states of restlessness anxiety states. To this it must be added that, whilstand inquietude (Cullen, 1803); and panophobia, the dichotomy anxiety-anguish has little clinicalvertigo, palpitatio, suspirium, palpitatio melan- meaning in Anglo-Saxon psychiatry, as it has beencholica and oscitatio (all redolent of anxiety and hinted at above it found a comfortable niche inpanic attacks) are found scattered amongst many France, Germany, and Spain where Angoisse, Angst,diseases in the work of Continental nosologists. It is and Angustia (respectively) refer to the moreimportant to notice that none of these clinical somatic, paroxysmal and more severe forms of

    categories was ever considered as pertaining to the anxiety (Lopez Ibor, 1950).vesanias (i.e. the category used by 18th century Interestingly enough, during the middle of thenosologists to refer to the mental disorders). 19th century, the language of psychiatry in Germany

    At the beginning of the 19th century, Landre- and England was not yet ready to assimilate the Beauvais (1813) defined anxiete as: a certain subtle semiological distinctions rapidly developing in

    malaise, restlessness, excessive agitation suggesting French psychiatry. Thus, where Guislain (1852) hadthat these states may accompany acute and written craintes and frayeurs (p. 45), Griesinger

    chronic diseases. In Landre, anxiety becomes a (1861) translated Shrecken oder Angst (p. 169), andsyndrome with both subjective and somatic com- Robertson and Rutherford, the English translators ofponents, and which can accompany diverse diseases Griesinger (1867) used shock or anxiety. This drift(see below). in meaning (as the translations moved from frayeur

    Angoisse, in turn, appears early in the European to Angst and to anxiety), reflect the changes ofvernaculars as a translation of the Latin Angustus emphasis that took place in the second half of the(narrow). However, by the beginning of the current 19th century. For whilst Guislain (1852) was onlymillennium, the metaphorical force of the term referring to acute fears, Griesinger (1861) introducedbecomes salient and, for example, by 1080 the Angst, a term that with Kirkegaard (1980/1844)French word angoisse meant tourmenter (Rey, acquired a meaning that went beyond fear (Jolivet,1997). Throughout, however, the term tended to refer 1950) to re-incorporate the old religious dimensionto the somatic components of suffering; for instance of anguish (McCarty, 1981).

  • 86 G. Berrios / Journal of Affective Disorders 56 (1999) 83 94

    As a compromise, the term nervousness became with the old concept of neuroses as defined by Willisavailable during the middle of the 19th century to and Sydenham during the 17th century; on this see

    refer to the subjective aspects of anxiety. Rather Lopez Pinero (1983) and Hare (1991)). The secondtypically, an anonymous (1860) English reviewer of shift concerned the suggestion by Krishaber (1873)

    Bouchuts (1860) book on Nevrosisme, although that the symptoms of anxiety alone might constituteaccepting that there was no good alternative in the a separate disease principally related to the car-English language, complained of the vagueness of diovascular system. The third pertained to the viewthe term. Zeldin (1977) has also suggested that by Axenfeld (1883), Leroux (1889), Westphalnervousness was increasingly recognised as a com- (1872a,b) and Benedikt (1870) that a subset ofplaint after the 1850s (p. 833). Krishabers symptoms, to wit those related to a

    subjective experience of dizziness, motor instability,fear and depersonalization might be a disease of the

    5. Anxiety-related behaviours inner ear. Let us study these three important contri-butions in turn.

    Irrespective of the name these states travelledunder (i.e. of the history of the words) or of how

    they were explained (the history of the concepts), 6.1.1. Morel and delire emotifbehavioural disorders recognizable as anxiety-re- Morel (1866) was perhaps the first one firmly tolated can be found in the literature of the ages suggest that pathological changes (i.e. a neurosis of)(Errera, 1962). Altschule (1976) also reminds one the ganglionic (autonomic) nervous system could

    that Arnold, Locke, Battie, Mead, Smith and Crich- give rise to symptoms which he called delire emotifton described medical states of inquietude and (an inaccurate translation of which is emotionaluneasiness (pp. 119124). As mentioned above, delusion). Analysis of his clinical reports shows thatbefore the 1820s, the manifestations of anxiety are he was focusing on a novel group of patients, onefound included under many nosological rubrics. For which until then had not been the preserve ofexample, Pinel (1818) lists them under epilepsy (p. alienists, namely those whose presentation included80), melancholia (p. 85), rabies (particularly of the permutations and combinations of subjective com-spontaneous variety) (p. 156), and the motility plaints such as fear, anxiety, phobias and obsessionsneuroses (p. 159) and Georget (1820) discussed the (on the latter see Berrios, 1989) and objectivesigns of anxiety in the section on general and complaints referring to the skin, and the cardiovascu-sympathetic symptoms. lar, gastrointestinal or nervous s...


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