anxiety disorders: a conceptual history

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  • Journal of Affective Disorders 56 (1999) 8394www.elsevier.com/ 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 century.to 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 disease.as 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