Is Anxiety Overdiagnosed?

Overlooking socioeconomic conditions and jumping to a psychiatric diagnosis can prevent us from addressing the real issues behind anxiety.

RTR2Z3W6main.jpgLucy Nicholson/Reuters

The list of practical and existential worries that keep mothers up at night runs long. They worry about their children getting hurt or killed in an accident. They worry that their children will not be happy and, on a lesser scale, that they will not be socially and academically successful. They worry, I'm sure, that they stay healthy, that they do the right thing as tricky situations arise, and their children be, overall, good people. They are often more worried about many of these things than their own children are.

For poor mothers, the usual worries are necessarily compounded by life's more immediate realities. Following the families of almost 5,000 children in the earliest years of their lives, the 2011 Fragile Families and Child Wellbeing Study identified poverty not by household income, but as a manifestation of telling life events. Those included telephone service being disconnected, not being able to pay full rent or mortgage, not being able to pay utility bills, accepting free food, or having to move in with other people due to financial reasons.

When poverty is looked at as a series of problems that must continuously be solved, the worry, one would presume, is continuous. It may very well be extreme, and disruptive. It might even go so far, the data suggests, as to be pathological.

Anxiety seen in poor mothers is caused by poverty itself, not mental illness.

"If you have a genuine problem that you can't solve, that's not actually an anxiety disorder," says Margaret Wehrenberg, Psy.D., author of three books on anxiety management.

And yet, when Fragile Families administered a standard diagnostic interview for Generalized Anxiety Disorder (GAD), it found that the psychological condition was extremely common among the poorest mothers represented in its sample. This piqued the interest of Judith Baer, Ph.D., an Associate Professor of Social Work at Rutgers University. How was it, she asked, that the women having the most financial difficulty were the most likely to be diagnosed with GAD? She wondered: do these women truly have the disorder?

Baer took Fragile Families' data and subjected it to a secondary statistical analysis that looked specifically at the relationship between poverty and diagnosis. Her results indicated that mothers who received free food had a 2.5 times greater chance of being diagnosed as having the mental disorder. Odds were 2.44 times higher for mothers who had problems paying their utilities, and 1.9 who those who had, out of necessity, moved in with others.

She and her team of researchers concluded that the anxiety seen in poor mothers is caused by poverty itself, not mental illness.

GAD is defined by the Diagnostic and Statistical Manual (the soon-to-be updated DSM-IV-TR, last revised in 2000) as "excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance)." Diagnosis requires the presence of three or more symptoms from a list comprised of: restlessness, being easily fatigued, difficulty concentrating, irritability, muscle tension, and sleep disturbance.

As one public health outlet offering counsel to sufferers of GAD says it, "You may feel like your worries come from the outside -- from other people, events that stress you out, or difficult situations you're facing. But, in fact, worrying is self-generated. The trigger comes from the outside, but an internal running dialogue maintains the anxiety itself."

In a "radical conceptual shift" from the former DSM-III criteria, claims Baer's article, this definition failed to include "an evaluation of the social contextual environment in which symptoms occurred." This means that when the mothers surveyed by Fragile Families were diagnosed in accordance with the DSM standards, their social and economic backgrounds were not taken into account.

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Lindsay Abrams is an assistant editor at Salon and a former writer and producer for The Atlantic's Health Channel.

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