Should Anxiety Remain a Stand-Alone Disorder in the DSM?
Anxiety is a driving force behind many mental health issues.
Posted Jan 03, 2020
The Diagnostic and Statistical Manual (DSM–5) is the standard for diagnosing and categorizing mental disorders. If you look at it carefully, you will notice that anxiety is mentioned in many of the diagnoses with few exceptions. Since every human has his or her own set of “less-than-perfect” behaviors to cope with relentless anxiety, it may be incorrect to take one, label it, and have the diagnosis become an identity.
Consider “bipolar disorder,” which is characterized by large mood swings. The swings may be set in motion by anxiety and drive sufferers to many other untoward behaviors such as addictions, obsessive reactions, suppression of self-deprecating thoughts, and social isolation as they attempt to deal with the intensity of the anxiety. Severe anxiety is also just miserable. All of us have mood swings. At what point do they become bipolar disorder? Coping mechanisms may include eating disorders, addictions, explosive personality traits, etc.
Rather than labeling this situation "bipolar," why not address the underlying anxiety (elevated stress hormones) separately and help the person pull out of the various disruptive behaviors? It is a much more compassionate and potentially more effective approach.
Anxiety is the driving force–not one of the diagnoses
A more precise and compassionate way of considering the DSM system is to completely remove anxiety as a diagnosis. More accurately, anxiety is a core neurochemical state that allows us to stay alive. But it creates many challenging behaviors in dealing with these deeply unpleasant sensations. Anxiety is not a mental health diagnosis; it is the driving force behind them.
The key to minimizing anxiety is learning methods to lower stress hormones. There are many ways of accomplishing this with the guiding principle being training your brain to dampen the stress response with relaxation strategies. Then disruptive coping behaviors could be addressed more effectively as anxiety drops.
Treatment could consistently be divided into two parts. One arm would be focused on learning methods to calm the nervous system regardless of the situation. The other aspect of care would address becoming aware of the disruptive nature of maladaptive coping strategies and implementing more functional behaviors. This is where support and guidance in working through specific situational problems is important.
Drop the labels
By considering current diagnoses as descriptions of coping behaviors, labels drop, and the details of a given person’s situation can come to life. For example, in one of my workshops, one of the participants was a woman who had suffered from years of pelvic floor pain.
Halfway into the week, she revealed that she had suffered a miscarriage and had been carrying the guilt for years. Her pelvis had not been able to support the fetus and she hadn’t been able to forgive herself.
Though she had no structural problems with her pelvis, her life was agony. Her doctor said that she had "inadequate female structures" and she labeled herself as "not good enough." Additionally, she was now a "pain patient" with no hope of recovery. Ever since that moment, she experienced extreme pelvic floor pain. She was also never allowed to hold her near-term baby.
The first day of the workshop focused on the role of anger and frustration exacerbating pain. The next day, she was walking down a path where many people had written notes to loved ones on small rocks. She stopped and created a poem to her baby. It allowed her to let go, forgive herself, and make peace with her body.
Her pain resolved almost instantly and we were all in tears as she shared her story with the group that evening. She moved on and five years later is still thriving. There is no amount of medicine or physical therapy that would have helped her. I needed to know what was driving her symptoms and help her to find a way to process it.
There is a big difference between calling a person a “drunk” versus “someone who drinks too much"—the former is a label and the latter is a description. This concept was laid out over 2000 years ago by Epictetus, a Stoic philosopher. (2) No one likes to be labeled, especially when one of them might be “a chronic patient.” A better way to conceptualize your situation would be, "you are person who is suffering from chronic pain." What is the actual criteria for being a “pain patient?" It is a pejorative term that doesn’t enhance your relationship with your health care provider.
In 2019, Dr. Allsop published a paper that looks closely at the randomness of the DSM coding system. In her view, it is not only inaccurate but damaging. One of her key messages is that each person is unique and it is critical to understand the details of a given person’s life in order to help them move forward. (3) Labels cover up the details. Treatments are often irrelevant to a patient’s situation and just address symptoms. Again, the driving force of anxiety is frequently not considered.
Anthony DeMello was a Jesuit Priest and mystic. He was highly regarded for his observations about approaching life with clarity. His writings centered around awareness and attachment. The Way to Love is a compilation of his last memoirs where love is defined as awareness. (4)
One of the many blocks to awareness is being judgmental—whether it is positive or negative. When you have placed a judgment on someone, you have simply projected your view of yourself onto that person; or that person triggered a deep unconscious response in you. Once a label is placed on someone else or yourself, you have lost awareness of the details of what is actually happening. Continually projecting our past onto the present becomes increasingly tedious. It is infinitely more interesting and productive to remain open to possibilities and observe the world through different perspectives.
Your version of reality
The problem is even deeper than you might imagine in that research on human consciousness has shown that thoughts, ideas, and concepts become embedded in our brain the same way any concrete object does. (5)
The table I am sitting at is a table because my unconscious brain is interpreting 11 million bits of information per second and my conscious brain that is processing only 40 bits per second is calling it a table. There is nothing located in the receptors in my eyes that says this should be a table. My cat has her interpretation of a table and somehow feels free to jump up on it when she is sensing that there is something on it that is appetizing. But she doesn’t have the language to call it a table.
So, we are all programmed by our prior experiences and ongoing interpretation of the present through this filter of the past. That is why our ingrained belief systems create so much havoc in our attempts to get along. If I have a story that a given co-worker is a “jerk," then it will become more deeply embedded as my “reality” over time. Also, the ongoing interactions will be interpreted through this paradigm. You don’t necessarily have to like this person, but it would be easier for everyone to wonder what is going on in this person’s life that is causing him or her to act this way. Dr. DeMello points out that the only way to work past judgments is to become aware that they are there.
The DSM coding system takes this problem to an extreme, as I pointed out in an earlier article, “The DSM Coding System: More Harmful than Helpful?” Not only can the diagnoses be grossly inaccurate, but they can also cover up the details of that person, and the filter created by the diagnosis changes almost everything. You are treated differently, but more disturbingly, people become their own diagnoses. It is the way the brain works and you have no choice. None of this is conducive to a healing relationship.
A New Paradigm
By considering anxiety as the driving force and considering the other diagnoses as descriptions of the efforts to cope with it, a more effective approach to care would emerge. Learning skills to calm the nervous system is an essential skillset and should be taught regardless of other issues. Disruptive behaviors and environmental factors can then be specifically addressed.
All human beings struggle with anxiety. Some of us have better tools and many of us are better at hiding the pain. It is time to drop the labels and instead acknowledge our unique, individual circumstances on our road to healing.
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5(TM)) 5th Edition. Published by the American Psychiatric Association, 2013.
2. Lebell, Sharon. The Art of Living: The Classical Manual on Virtue, Happiness, and Effectiveness. Harper Collins, New York, NY, 1995.
3. Allsop, K, et al. Heterogeneity in psychiatric diagnostic classification. Psychiatry Research (2019); 279:15-22.
4. DeMello, Anthony. The Way to Love. Bantam Double Day Dell. New York, NY, 1992.
5. Feldman-Barrett, Lisa. How Emotions are Made. Houghton, Mifflin, Harcourt. Boston, MA, 2017.