Panic Disorder in the Age of Anxiety
Anxiety is by far the most-common psychiatric complaint in the U.S.
Posted Jan 19, 2012
"According to the National Institute of Mental Health," Daniel Smith noted in the New York Times last Sunday, "anxiety disorders now affect 18 percent of the adult population of the United States, or about 40 million people. By comparison," he continued, "mood disorders—depression and bipolar illness, primarily—affect 9.5 percent. That makes anxiety the most common psychiatric complaint by a wide margin, and one for which we are increasingly well-medicated."
Smith's interesting Opinionator column, also reprinted in the paper's Sunday Review, was called "It's Still the ‘Age of Anxiety.' Or Is It?," a clever and timely nod to both Auden's famous post-Second World War poem and the scale of worries currently besetting us, from the eurozone crisis pushing several countries to the brink of insolvency and default, to seemingly interminable claims that 2012 represents the end of the Mayan calendar and thus, allegedly, the end of the world. (Can we all consider that the Mayans merely stopped counting beyond 2012, perhaps with a view to starting a new calendar? Also, note of those predicting "Judgement Day" last May: "Doomsday Ministry Scrubs End of World Predictions from Website." If only their doing so had garnered quite as much press as the original prediction...)
But since it's Smith's recent column about anxiety that concerns us, let's review his argument, particularly the suggestion that "we are increasingly well-medicated" for anxiety, since the addition of "well-" there turns a straightforward fact (as a country we are indeed highly medicated for anxiety) into a dubious and tendentious claim. That's because Xanax, the drug Smith considers so favorable to the treatment of anxiety, has been at the center of a medical storm in Britain, in particular, over its litany of side effects, acute withdrawal syndrome, and, most alarming of all, its increasingly well-noted link to brain shrinkage—a serious problem among all the benzodiazepines, the class of drugs to which Xanax (alprazolam) belongs.
"Last spring," Smith writes, "the drug research firm IMS Health released its annual report on pharmaceutical use in the United States. The anti-anxiety drug Xanax was the top psychiatric drug on the list, clocking in at 46.3 million prescriptions in 2010." An editorial note clarified that the drug was indeed "prescribed 46.3 million times in the United States in 2010," rather than to "46 million people," as some had assumed, but that is still eye-popping news, placing Xanax, Times editors note, as "the only psychiatric medication among the top 15 prescription drugs in the United States in 2010."
The scandal embroiling Xanax in Britain has so far been more muted on this side of the Atlantic, but it's surely only a matter of time before the controversy hits home, not least because of the scale of the drug's popularity.
But there's also another controversy surrounding the makers of Xanax, Upjohn Pharmaceuticals, that goes unnoted in Smith's article: They are very much on record as having paid for a key DSM conference on anxiety and panic back in the late 1970s. At that landmark event in Boston, experts debated whether panic should be split off from then-existing anxiety neurosis and turned into a separate disorder. According to Isaac Marks, an expert on the phenomenon whom I interviewed for my book Shyness: How Normal Behavior Became a Sickness, the conference "began with the chief executive of Upjohn saying unashamedly, ‘Look, there are three reasons why Upjohn is here taking an interest in these diagnoses. The first is money. The second is money. And the third is money.'"
"They were quite upfront about it," Marks marveled, "and exceedingly successful at it for at least the first six years" after DSM-III appeared—roughly, 1980-86.
Nor was it a secret among DSM participants that Upjohn had paid for the conference because it hoped the experts attending would endorse Xanax, its drug, as the preferred treatment for panic disorder. Some (including Marks) demurred. Details about panic disorder were sketchy at best, as distinct from panic itself, which few could mistake and everyone attending was committed to treating. As Marks explained to Robert Spitzer (editor of DSM-III) at the time, "The presence of panic per se is not the hallmark of any particular anxiety syndrome.... There is thus ... little point in separating panic syndromes from anxiety syndromes" (qtd. p.74 of Shyness).
As the differences here aren't trivial, you might think those seeking to clarify them for the DSM would have wanted all available input and expertise. Yet as Marks explained of a strategy that soon became a pattern marking the approval of other disorders, "The consensus was arranged by leaving out the dissenters." Those, like him, who wouldn't toe the line were quietly dropped from future meetings. Marks even reports that Spitzer relayed the news to him as they took a pee at the Boston conference. "Isaac, you're not going to win," Spitzer told him in the men's room. Panic [disorder] is in. That's it."
When I asked Spitzer about this, in a follow-up interview, he admitted that having Upjohn pay for the conference "was a mistake on our parts... We should never have done that. But they had no influence on any criteria or the name."
Perhaps no direct influence, but it's tough to eliminate the disturbing appearance of a massive conflict of interest there, to say nothing of the chief executive of Upjohn openly bragging about the three main reasons his company was paying for the conference in the first place. I report in my book, based on details in the American Psychiatric Association's own archival record, how Spitzer sometimes devised criteria for major disorders. One incident, reported in the New Yorker (Jan. 2005), also has witnesses describing that during a 40-minute conversation about hysterical psychoses, Spitzer all-of-a-sudden asked for a typewriter, then "banged out criteria sets for factitious disorder and for brief reactive psychosis." One of the startled witnesses told the magazine, "It struck me that this was a productive fellow! He comes in to talk about an issue and walks aways with diagnostic criteria for two different mental disorders!" (qtd. p.51 of Shyness).
None of this backstory to Xanax's serious withdrawal syndrome appears in Smith's Opinionator column, unfortunately, but if it had one wonders if he'd continue to claim that we are "well-medicated" in our anxiety, where the adjective "well-" slips between assertions of quantity and quality.
At the same time, Smith makes several good points, including by reminding us why Freud spoke of anxiety as a "riddle" split between biology and psychology, not as a component of biology alone (as many today continue mistakenly to assume). "Just because our anxiety is heavily diagnosed and medicated," Smith adds, "doesn't mean that we are more anxious than our forebears. It might simply mean that we are better treated—that we are, as individuals and a culture, more cognizant of the mind's tendency to spin out of control."
Those aren't the same thing at all, of course, but ... "better treated"? Not according to a raft of books casting doubt on the long-term efficacy of anxiolytics and antidepressants, including Anatomy of an Epidemic, Crazy Like Us, Side Effects, The Emperor's New Drugs, and my own Shyness: How Normal Behavior Became a Sickness, particularly its chapter "Why Drug Treatments Fail."
But "more cognizant of the mind's tendency to spin out of control"? Certainly, we are doubtless so. Still, when all the facts are considered, the ironic but unavoidable conclusion to Smith's column is that anti-anxiety medication must itself be considered one the factors heightening our anxiety, not diminishing it. Unfortunately, despite all the newspaper exposés, that message isn't getting through to writers still insisting—against the evidence—that we are "well-medicated" in our anxiety.