Anxiety: A Short History by Allan V. Horwitz (review)

This is a little gem of a book. Allan Horwitz at Rutgers University, author of the acclaimed Creating Mental Illness, sets out to write a compact history of the concept of anxiety for Charles Rosenberg’s Biographies of Disease series. There is no previous such work available, comprehensive in its knowledge of the primary and secondary English-language literature, daring in giving an overview from the ancients to the current Diagnostic and Statistical Manual( DSM) of the American Psychiatric Association—the current bible of the field of psychiatry—and critical in its assessment of medical and nonmedical sources.

The organization is chronological, first the classical texts, then a giant leap forward to the seventeenth and eighteenth centuries, when independent medical thinking resumes in the West. The story line is that anxiety as a symptom and a diagnosis is continuously subsumed under other nosological systems—melancholia, “nerves,” neurasthenia, and so forth—until we reach Sigmund Freud’s psychoanalysis, when anxiety becomes the vaulting stone of the arch. Horwitz offers an original and thoughtful chapter on such non-psychoanalytic approaches to anxiety as behaviorism and cognitive behavioral therapy. Then Horwitz plunges us into the pharmacological revolution of the 1950s with its “tranquilizers,” and the DSMseries, particularly the third edition in 1980, which created a whole new gaggle of dubious anxiety diagnoses as supposedly “independent” disorders. Throughout, Horwitz’s touch is light and ironical and his scholarship impeccable, and the book is thoroughly to be recommended as a disease biography that gives the whole trajectory and leaves little of importance out. It is a book to be savored by disease buffs in a couple of relaxed afternoons of reading.

That said, there are a couple of problems that Horwitz does not altogether successfully dodge and that will confront future scholars of anxiety as well:

First is the conflation of anxiety and fear. Horwitz continually diverts us to fearfulness as part of the anxiety picture, yet fear is a normal emotion while anxiety— dim, unfocused, and often disabling apprehension—is a pathological emotion. True, it is as difficult to disengage fear and anxiety as to untangle unhappiness and depression. But one must be aware of the problem, in a way that Horwitz is apparently not.

Second is how to treat other psychiatric symptoms that are often part of the anxiety syndrome. Anxiety is a real component of melancholic illness, not just some outdated idea the ancients had. Horwitz notes that anxiety today usually presents as part of depression (and vice versa), but he doesn’t really implement the idea that, in nonpsychotic illness, the real disorder in past times as well as today seems to have been mixed anxiety–depression, not “pure” anxiety, which is unusual. Some authors find anxiety to be a component of virtually every psychiatric illness, arguing that anxiety is not really a free-standing disorder of its own. Horwitz observes that German psychiatrist Emil Kraepelin is one of these, then marches bravely right on past him. Yet Kraepelin and his students were at the epicenter of world psychiatry before Freud, and the view that anxiety is not really a disease of its own deserves more than a few paragraphs.

Third, in discussing the treatment of anxiety, Horwitz begins with the “tranquillizing” drugs of the 1950s, thus leaving out a huge chapter: For half a century the barbiturates, launched in 1903, were the mainline treatments of anxiety, except they were called “sedatives,” not anxiolytics. One cannot omit this in a general history of anxiety any more than one could omit the hydrazine derivatives (isoniazid, etc.) in the treatment of tuberculosis, even though they are no longer used.

These points are not really quibbles, in that they get at the structure of the argument. Yet they don’t prevent the Horwitz book from being the definitive overview of the history of anxiety. But whoever takes the next whack at this (and includes non-English-language sources) will do...