Is Anxiety Overdiagnosed?
Overlooking socioeconomic conditions and jumping to a psychiatric diagnosis can prevent us from addressing the real issues behind anxiety.
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.
Others, Baer claims, have looked at the survey's results and responded that, well, of course these women are anxious. "That's the point," she said, "That psychiatry has gone so far... that they're confusing what's happening in every day life with mental disorder."
Baer works with her colleague Jerome Wakefield's definition of a mental disorder, which says that for something to qualify as pathological it must both be harmful to the person and be due to the failure of some internal mechanism in the mind -- in other words, a dysfunction.
"The 'dysfunction' requirement," he wrote in his seminal critique of the DSM-III, "is necessary to distinguish disorders from many other types of negative conditions that are part of normal functioning, such as ignorance, grief, and normal reactions to stressful environments."
"We have to be careful if we suggest to people, 'Oh you're disordered because you're feeling anxious,'" said Baer.
She gives the example of her own reaction to driving on the New Jersey Turnpike. The road is huge, busy, and crowded with 18-wheelers. She often becomes anxious. And because she is anxious, she drives more carefully than she otherwise might. Anxiety can go so far as to cause paralysis, and were it to prevent one from being able to do what it takes to get from point A to point B, that would make it a disorder.
But, insists Baer, "It's not as if these things are nefarious mechanisms that are in us." A normal amount of anxiety serves innate purposes in terms of our survival.
"Psychiatry has gone so far that they're confusing what's happening in every day life with mental disorder."
The claim that poor mothers are more likely to suffer from GAD, then, is in Baer's opinion the diagnostic equivalent of a therapist talking to someone behind the wheel and, ignoring the high speeds and the trucks blaring past. Then concluding that there's something wrong with them because they seem distressed. The danger of pathologization - calling something a disease when it may not be - is, in this case, that we end up mistakenly ignoring treatable context. With psychiatrists increasingly shifting away from talk therapy, that may mean an increase in prescriptions for poor women when what they really need is social support.
"A therapist would say that a real problem needs real help," says Wehrenberg. She suggests that a diagnosis can be a way of directing attention toward a patient that can lead to help through counseling and perhaps broader social services. But going about things in this way keeps the conversation in medicalized terms instead of focusing it on the social and economic roots of anxiety.
Baer also cautions that insurance coverage and rates often depend on a diagnosis. When people are incorrectly labeled as having a mental disorder, the data about legitimate "failures of an internal mechanism" becomes confounded.
When the fifth edition of psychiatry's Diagnostic and Statistical Manual is released next year, it plans to include a revised definition of generalized anxiety disorder that further broadens its parameters. Patients will only have to exhibit one of two symptoms -- restlessness or muscle tension -- for 3 months in order to be diagnosed as having an anxiety disorder. Baer believes that, like the controversial classification of bereavement as disorder, is going to contribute to more and more people receiving diagnoses.
"Just because somebody's feeling anxious doesn't mean they're mentally ill or something's inherently wrong with them."