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All We Have to Fear: Psychiatry's Transformation of Natural Anxieties into Mental Disorders [Hardcover]

Allan V. Horwitz PhD , Jerome C. Wakefield DSW PhD
5.0 out of 5 stars  See all reviews (2 customer reviews)

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Book Description

June 1, 2012 0199793751 978-0199793754 1
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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Editorial Reviews

Review


"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


About the Author


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.

Product Details

  • Hardcover: 320 pages
  • Publisher: Oxford University Press, USA; 1 edition (June 1, 2012)
  • Language: English
  • ISBN-10: 0199793751
  • ISBN-13: 978-0199793754
  • Product Dimensions: 6.3 x 0.8 x 9.3 inches
  • Shipping Weight: 1.3 pounds (View shipping rates and policies)
  • Average Customer Review: 5.0 out of 5 stars  See all reviews (2 customer reviews)
  • Amazon Best Sellers Rank: #116,124 in Books (See Top 100 in Books)

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1 of 1 people found the following review helpful
5.0 out of 5 stars Excellent Reframing of Anxiety in Evolutionary Terms February 26, 2013
Format:Hardcover|Amazon Verified Purchase
I'm just going to paste in my blogpost reviewing this book originally posted on [...]:

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 my book "Pack Leader Psychology."

Harper West, MA
Author of Pack Leader Psychology
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2 of 3 people found the following review helpful
5.0 out of 5 stars Excellent August 12, 2012
Format:Hardcover
This book, written by the person who brought us the DSM III, DSM3R and DSM IV is a massive indictment of what the psychiatric world has wrought. Caveat Emptor when it comes to therapy.
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