Overview

Thirty years ago, it was estimated that less than five percent of the population had an anxiety disorder. Today, some estimates are over fifty percent, a tenfold increase. Is this dramatic rise evidence of a real medical epidemic? In All We Have to Fear, Allan Horwitz and Jerome Wakefield argue that psychiatry itself has largely generated this epidemic by inflating many natural fears into psychiatric disorders, leading to the over-diagnosis of anxiety disorders and the over-prescription of anxiety-reducing drugs. American psychiatry currently identifies disordered anxiety as irrational anxiety disproportionate to a real threat. Horwitz and Wakefield argue, to the contrary, that it can be a perfectly normal part of our nature to fear things that are not at all dangerous--from heights to negative judgments by others to scenes that remind us of past threats (as in some forms of PTSD). Indeed, this book argues strongly against the tendency to call any distressing condition a mental disorder. To counter this trend, the authors provide an innovative and nuanced way to distinguish between anxiety conditions that are psychiatric disorders and likely require medical treatment and those that are not--the latter including anxieties that seem irrational but are the natural products of evolution. The authors show that many commonly diagnosed irrational fears--such as a fear of snakes, strangers, or social evaluation--have evolved over time in response to situations that posed serious risks to humans in the past, but are no longer dangerous today. Drawing on a wide range of disciplines including psychiatry, evolutionary psychology, sociology, anthropology, and history, the book illuminates the nature of anxiety in America, making a major contribution to our understanding of mental health.

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<br> Finally, a book about anxiety disorders that is based on a deep understanding of normal anxiety! I wish every mental health clinician would read it. Its spectacularly clear prose reveals the landscape of normal anxiety like an airplane's radar reveals the ground beneath the fog. -- Randolph M. Nesse, MD, Department of Psychiatry, The University of Michigan, Ann Arbor, MI <br><p><br> The area of anxiety disorders has needed a thorough review and a shake-up for a long time. In this bold and thought-provoking work, Allan Horwitz and Jerome Wakefield have relied mainly on the insights from the evolutionary theory to provide a critical and powerful analysis of the modern concept of anxiety disorders. Regardless of whether or to what extent one agrees with them, their book rightly challenges the prevailing notions and is likely to perturb current thinking about fear, anxiety and anxiety disorders. It will certainly add more substance to much-needed discussions and debates about the nature of these conditions, psychiatric diagnoses, and an often-imperceptible boundary between normality and psychopathology. -- Vladan Starcevic, MD, PHD, Department of Psychiatry, Sydney Medical School, University of Sydney, Australia <br><p><br> In their new book, Horwitz and Wakefield offer the same incisive analysis that they brought to psychiatry's medicalization of sadness in their first book, The Loss of Sadness, to explain the reasons for the soaring prevalence of anxiety disorders over the past 20 years, namely that psychiatry has been mislabeling normal anxiety and fear reactions as disorder... Most importantly, they bring their analysis to bear on the actual definitions of anxiety disorders that are enshrined in the American Psychiatric Association's manual of mental disorders, pointing out the various weaknesses and flaws with regard to construction of definitions of anxiety disorders that effectively delineate normal anxiety and fear from abnormal anxiety and fear. -- Mich

<br> Finally, a book about anxiety disorders that is based on a deep understanding of normal anxiety! I wish every mental health clinician would read it. Its spectacularly clear prose reveals the landscape of normal anxiety like an airplane's radar reveals the ground beneath the fog. -- Randolph M. Nesse, MD, Department of Psychiatry, The University of Michigan, Ann Arbor, MI <br><p><br> The area of anxiety disorders has needed a thorough review and a shake-up for a long time. In this bold and thought-provoking work, Allan Horwitz and Jerome Wakefield have relied mainly on the insights from the evolutionary theory to provide a critical and powerful analysis of the modern concept of anxiety disorders. Regardless of whether or to what extent one agrees with them, their book rightly challenges the prevailing notions and is likely to perturb current thinking about fear, anxiety and anxiety disorders. It will certainly add more substance to much-needed discussions and debates about the nature of these conditions, psychiatric diagnoses, and an often-imperceptible boundary between normality and psychopathology. -- Vladan Starcevic, MD, PHD, Department of Psychiatry, Sydney Medical School, University of Sydney, Australia <br><p><br> does an excellent job at explaining the history and calling into question the present state of anxiety diagnosing. San Francisco Book Review<p><br> The most intriguing aspect, though, is the authors' discussion of how anxiety and social judgments can and have been so easily intertwined and what the implications might be from labeling and medicating anxieties instead of seeking to alter their underlying causes. San Francisco Book Review.<p><br> In their new book, Horwitz and Wakefield offer the same incisive analysis that they brought to psychiatry's medicalization of sadness in their first book, The Loss of Sadness, to explain the reasons for the soaring prevalence of anxiety disorders over the past 20 years, namely that psychiatry has been

Finally, a book about anxiety disorders that is based on a deep understanding of normal anxiety! I wish every mental health clinician would read it. Its spectacularly clear prose reveals the landscape of normal anxiety like an airplane's radar reveals the ground beneath the fog. -- Randolph M. Nesse, MD, Department of Psychiatry, The University of Michigan, Ann Arbor, MI The area of anxiety disorders has needed a thorough review and a shake-up for a long time. In this bold and thought-provoking work, Allan Horwitz and Jerome Wakefield have relied mainly on the insights from the evolutionary theory to provide a critical and powerful analysis of the modern concept of anxiety disorders. Regardless of whether or to what extent one agrees with them, their book rightly challenges the prevailing notions and is likely to perturb current thinking about fear, anxiety and anxiety disorders. It will certainly add more substance to much-needed discussions and debates about the nature of these conditions, psychiatric diagnoses, and an often-imperceptible boundary between normality and psychopathology. -- Vladan Starcevic, MD, PHD, Department of Psychiatry, Sydney Medical School, University of Sydney, Australia Horwitz and Wakefield illuminate the field of psychiatry's monumental failure to understand and classify human nature-at least insofar as the experience of anxiety is concerned. This, I believe, is the main value in their book. -- Jonathan Abramowitz, PsychCRITIQUES The most intriguing aspect, though, is the authors' discussion of how anxiety and social judgments can and have been so easily intertwined and what the implications might be from labeling and medicating anxieties instead of seeking to alter their underlying causes. -- San Francisco Book Review. In their new book, Horwitz and Wakefield offer the same incisive analysis that they brought to psychiatry's medicalization of sadness in their first book, The Loss of Sadness, to explain the reasons for the soaring prevalence of anxiety disorders over the past 20 years, namely that psychiatry has been mislabeling normal anxiety and fear reactions as disorder... Most importantly, they bring their analysis to bear on the actual definitions of anxiety disorders that are enshrined in the American Psychiatric Association's manual of mental disorders, pointing out the various weaknesses and flaws with regard to construction of definitions of anxiety disorders that effectively delineate normal anxiety and fear from abnormal anxiety and fear. -- Michael B. First, MD, Department of Psychiatry, Columbia University, New York, NY does an excellent job at explaining the history and calling into question the present state of anxiety diagnosing. -- Journal of Psychosocial Nursing ''Horwitz and Wakefield manage to make a strong case for the prosecution -- LA Review of Books This book presents some excellent arguments about the overdiagnosis of anxiety disorders and the pathologizing of normal anxiety states...There certainly has been an explosion of the diagnosis of anxiety and depression and a concurrent massive increase in the use of medications such as the SSRIs - and the authors explore that thoroughly in the second section. They propose a harmful dysfunction (HD) model of diagnosis that incorporates both the degree of harm and degree of dysfunction that has some potential. Overall this book is worth the read for anyone in interested in mental health, particularly as it relates to the diagnosis and treatment of anxiety disorders. -- Brett C. Plyler, M.D., Northwestern Memorial Hospital, Doody's The most intriguing aspect is the authors' discussion of how anxiety and social judgments can and have been so easily intertwined and what the implications might be from labeling and medicating anxieties instead of seeking to alter their underlying causes... it does an excellent job at explaining the history and calling into question the present state of anxiety diagnosing. -- Evelyn McDonald, Sacramento Book Review Also reviewed by Simon Wessely in The Lancet As a non-specialist in anxiety disorders, I found this book informative and illuminating...I would recommend it to any psychiatrist as a provocative survey of this difficult area. -- Philip Timms, The British Journal of Psychiatry ...a coherent, well-argued and thoughtful view about the boundaries we should set for mental disorder. Furthermore, I cannot suggest a much better approach...While we have our formal definition at the front of DSM, as a field we are actually in the uncomfortable position of not having a clear, philosophically coherent and easily implemented definition of a mental disorder. It is a devilishly hard problem. For those interested in the fascinating problem of trying to define the boundaries of our disorders, reading this book will be time well spent. Indeed, in our mature moments, we should be glad that our field has attracted critics of such quality. -- Kenneth S. Kendler, M.D., American Journal of Psychiatry

Author Information

Allan V. Horwitz is Board of Governors Professor of Sociology at Rutgers University. His books include The Social Control of Mental Illness and Creating Mental Illness. He is the recipient of the Pearlin Award for lifetime Achievement in the Sociology of Mental Health from the American Sociological Association. Jerome C. Wakefield is University Professor, Professor of Social Work, and Professor of Psychiatry at New York University. He is the author, with Allan V. Horwitz, of The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder--named Best Psychology Book of 2007 by the Association of American Publishers.

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