With the Diagnostic and Statistical Manual 5th Edition set to publish in May, I have been doing a lot of research on the DSM and writing an essay on it (coming soon to a blog very near here!). I just finished an excellent book entitled, “All We Have to Fear: Psychiatry’s Transformation of Natural Anxieties into Mental Disorders,” by Allan V. Horwitz, PhD, and Jerome C. Wakefield, PhD, DSW. I was intrigued by this book because the title seemed to parallel some of my theories in Pack Leader Psychology, that humans have natural fears and reactions to those fears. And one of my main complaints about the DSM is that is pathologizes what are actually normal, adaptive behaviors.

This book did not disappoint and I would highly recommend it to any clinicians interested in anxiety “disorders,” evolutionary psychology, the philosophy of psychology, or the DSM and its troubled history.The authors do a very thorough job of defining anxieties per the DSM and presenting a brief history of anxieties in the psychiatric field.

The meat of the book begins in Chapter 2: An Evolutionary Approach to Normal and Pathological Anxiety. (It’s not as dreadful as it sounds!  Actually, the book is quite readable and accessible, with a down-to-earth approach and tone.) This chapter has an excellent summary of five philosophical approaches to differentiating between “normal behavior” and “mental disorders:”

– Are disorders caused by brain malfunctioning?

– Are they the result of learned experiences (conditioning)?

– Are they defined by changes in social values (homosexuality used to be considered a mental disorder!)?

Are disorders defined by statistical rarity?

Are disorders judged as such when they are “clinically significant” or “impairing” to the patient?

After critiquing each approach, the authors offer an evolutionary approach to anxiety. (An approach I believe that also works for most other psychological “disorders.”) Quite simply: “Psychological functions arose to respond to prehistoric, not contemporary, conditions.” (p. 35)

Emotions developed over thousands of years of human evolution to help us survive. Each emotion has a natural function, with related physiological, psychological, and behavioral processes, to allow humans respond to social and environmental situations.

Fear helped us survive by sensitizing us to dangerous people or situations. It prepared us to attack or retreat, to placate a dominant tribe member, or taught us to avoid a dangerous watering hole or a poisonous berry. Considerable research has proven that we have innate fears of heights, snakes, spiders, darkness, strangers, public humiliation, and social ostracizing. These fears were survival enhancers when we lived in caves and tepees and with a small group of protective tribesmen.

Horwitz and Wakefield have irrefutable evidence, as well as significant common sense logic, that most anxieties, phobias, PTSD, and obsessions/compulsions, as defined by the DSM, are really normative, expectable reactions that should not be labeled as disordered. Horwitz and Wakefield note that today’s anxieties are “mismatched” with today’s environment. In essence, we are using primal survival emotions and behaviors to try to live in a world that is very different from our hunter-gatherer forebears. “Many natural fears are not grounded in responses to any current environmental danger but are manifestations of ancestral fear mechanisms.” (p. 76)

The book then goes into a history of anxiety diagnoses and the DSM’s changing definitions of and criteria for anxiety disorders, using their evolutionary perspective to point out inconsistencies and errors in logic.

For example, after explaining that fear of social exclusion is innate in humans and one of the strongest primal fears, they note: “Perhaps the oddest thing about the DSM-IV definition of social phobia is that it classifies as disordered those people who are afraid in exactly those situations in which fear is most natural… Unfamiliar people are inherently more threatening than familiar ones, and humiliation is a potent threat to people when others  — especially, say, their bosses or competitors — evaluate them.” (p. 132-3)

They then critique several large-scale studies of the rates of mental disorders in the population. Among other complaints, the authors note that the studies fail to take into consideration the context of a person’s anxiety. For example, studies of people following natural disasters or the 9/11 terrorist attacks found very high rates of “mental disorders” such as PTSD and anxiety.  “It is hardly imaginable that a clinician would consider ‘mentally ill’ a patient who has recently survived a major disaster that destroyed her home, ruined her possessions, forced the relocation of her family, and bankrupted her finances and then affirmed that she is feeling anxious and depressed. Calling half the population of a major metropolitan area ‘mentally disordered’ after a natural disaster based on such feelings is inconsistent with any sensible concept of mental disorder.” (p. 167)

Overall the book was very thorough and well researched, and I wholeheartedly agree that the DSM should incorporate an evolutionary approach. However, I believe that Pack Leader Psychology makes some additional connections that further explain human behavior. While anxiety is a normal reaction to fears, I do believe that people today suffer from more anxiety than they ought to. This is largely due to the fact that we our fears of social exclusion are too highly sensitized. Because we do not have strong, stable “packs” or social groups, as we did in the past, we do not have an inherent feeling of safety and social acceptance. This may have resulted because we were raised by parents who were insecure and emotionally unstable, causing us to fail to develop strong self-worth. Consequently, when we go out into the world, we search for social acceptance because we lack internal self-acceptance. A baseline of low self-worth predisposes us to anxiety, depression, personality disorders and the like.

Lots more is in “Pack Leader Psychology.” Watch for my anti-DSM essay with more on this topic as well.

Horwitz, A. V., Wakefield, J.C. (2012) “All We Have to Fear: Psychiatry’s Transformation of Natural Anxieties into Mental Disorders” Oxford: Oxford University Press.

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