The DSM-1 Gets Anxiety Right
The reaction is the disorder.
Posted December 16, 2020
In terms of anxiety, the first DSM got it right—formulations since then have moved in the wrong direction, in my view, toward static reification. This is always a bad step since feelings are 1) dynamic and 2) not “things” in any helpful or meaningful sense. It’s also mystifying to decontextualize a mental state and to treat it as unanchored. States are embedded. They aren’t like the recently discovered desert monolith. They grow out of something.
There are no anxiety disorders in the DSM-1. Instead, there are anxiety reactions, relatively non-ideal ways of handling anxiety feelings. In fact, that’s how the DSM-1 spells it out, with refreshingly simple language: “the various ways in which the person attempts to handle this anxiety results in the various types of reactions.”
Anxiety per se isn’t the problem. The problem is what you do about it. I find this a promising approach, especially since we are talking about a feeling everyone has now and then (now more than ever). Making the feeling itself a condition strikes me as unsound and pathologizing.
There’s a Freudian tint to this approach in that anxiety feelings are called a signal. Like ceiling sprinklers, they flood the zone when things inside get hot. Again, they aren’t the issue. What they are is a sign, a kind of rudimentary red alert.
As such, they need to be interpreted. They stand for something deeper. We don’t put out smoke. Smoke is epiphenomenal. It’s valuable only in terms of the information it provides. It points to where the fire may be. It’s not the fire.
The list of reactions the DSM-1 lays out includes phobic reaction, depressive reaction, obsessive-compulsive reaction, dissociative reaction, conversion reaction (or what we now call somatization), and others (each now its own reified category). These involve flight from anxiety feelings, escape, turning anxiety into something else, transforming it. The key point is no reaction, no disorder.
Implied in this is a way out, one that, paradoxically, amounts to doing nothing. Or not exactly nothing, but noting the feeling, watching it, assessing it, exploring what it points to. In short, tolerating it. You can also simply accept it, as in radical acceptance, a model that’s deeply promising.
In any case, it’s not about making anxiety stop or deadening it somehow or having it go away. That’s not going to happen. Ever. Plus, it’s there for a reason. It’s telling you something. It’s a kind of ally, a messenger.
My experience, if you begin to peel them back, is anxiety, then anger, then sadness, so anxiety is a foil, a placeholder emotion (Xanax always makes me cry, which suggests to me that, in my case, behind anxiety lies sadness). One of anxiety’s jobs is repressing distraction, so if you make it the problem, you miss what it’s standing in for, what is actually far more fearsome, the effects you need to get to, effects it occludes.
The first DSM calls anxiety “psychoneurotic.” If you set aside the Freudian verbiage, this makes excellent sense. It is neurotic but in a personality-driven sense.
One thing we know for sure is that a particular trait predicts what my therapist friend always called the “holy trinity” of disorders: anxiety, depression, and substance abuse. The studies are clear on this. It’s a settled question. The trait is neuroticism. What neuroticism means is negative emotionality or what some term dispositional negativity. If you happen to be high in it—it’s measurable via online tests—then negative feeling is your default setting. There’s more of it for you to manage. It’s baked in.
Anxiety, therefore, isn’t some sort of separatable, stand-alone clinical entity. It’s rooted in personality. It’s a personality expression. Returning it to its roots, so to speak, puts it in a personological context, restores its dynamism.
In fact, particular disorders—feelings we’ve wrapped in names like “generalized anxiety disorder” and “persistent depressive disorder” (what used to be called “dysthymia”)—aren’t mental illnesses in any sense that’s clarifying. They are neuroticism pathologized, extreme expressions of the neuroticism trait. To take one example, the Zurich Cohort Study (n=591) indicates that a mere 1 standard deviation increase in dispositional negativity raised the odds of depression by 41 percent and of anxiety by 32 percent during a 20-year follow-up period.
A final word about the DSM in general: It keeps getting larger. The first edition is slender; the latest you could jack your car up with. More names does not necessarily equal more understanding. Probably, it equals less (think the principle of parsimony).
Feelings come and go like wind-pushed clouds. Yes, some are tough to endure. Some seem to stick around. Not always, but definitely sometimes, it may be best just to watch them. Stay where you are; see them roll by. In Zen, they call this non-reactivity or non-judgmental awareness. The disorder is the reaction. No reaction, no disorder.