Abstract
In 1894, Sigmund Freud caricatured the archetypal anxious patient: a woman (perhaps it had to be a woman), who imagined that her husband was dying from influenza every time he coughed or who feared that, if the front door bell rang, bad news would follow. Reading these words in Allan V Horwitz’s concise history of anxiety, it struck me that they aptly described my wife, who is always cautiously apprehensive about imagined future distress. Yet my wife is the most balanced, sane and grounded person that I have ever met, someone who is capable of coping effectively with either good or bad fortune and of managing the perils of life with stoic equanimity. So, is my wife suffering from an anxiety neurosis or is she simply one of the (appropriately) worried well? Is anxiety an entirely normal emotion in the face of the stress of life or is it a pathological state devoid of any concrete connection to the world in which we live? Is anxiety primarily a psychosocial or somatic phenomenon? And how have these distinctions been variably drawn across time?
These are questions that are neatly raised, but perhaps not fully answered, by Horwitz’s study. The book is structured in a conventional, if satisfyingly confident, way. Having set the scene in an introductory chapter that reflects on how historians might address shifting symptoms, categories, explanations and responses, Horwitz explores the etymological roots, symptomatic dimensions, and treatments of anxiety in the ancient world and particularly its association with melancholy in the writings of Greek and Roman physicians and philosophers. The discussion is strong on the Western tradition, but would have benefited from comparison with Egyptian, Chinese and Indian formulations of anxiety. Did the Chinese experience, or have a distinct word for, anxiety?
Chapter Two focuses particularly on accounts of melancholy and anxiety during the sixteenth, seventeenth and eighteenth centuries, charting the changing contours of anxiety and nervousness in the works of Robert Burton, Richard Napier, David Hume, Thomas Willis, George Cheyne, William Battie and others. The discussion treads familiar ground fairly well, but too readily dismisses attitudes to anxiety during the Middle Ages and focuses too conveniently on accessible British sources rather than on North American, European and Eastern writings. The following chapter traces the formulation of somatic, and particularly nervous, readings of anxiety in the nineteenth century. Horwitz’s analysis is instructive, effectively highlighting the manner in which anxiety emerged as a middle- and upper-class phenomenon, responding to and fuelling the professionalization of alienists or nerve doctors. Here, as elsewhere in the book, it would have been useful to have had stronger reflections on the impact of gender and race, as well as class, on clinical and popular understandings of anxiety.
The pivotal chapter of the book examines the contributions of Freud to modern psychodynamic accounts of anxiety as the primary cause of all other psychological difficulties or, as Freud put it in 1926, ‘the fundamental phenomenon and main problem of neurosis’. Horwitz’s analysis of Freud is sensitive and balanced, recognizing both the idiosyncratic elements of his theories that were subsequently discarded and the impact of Freud’s insights on later approaches to the aetiology and treatment of anxious individuals. In the following chapter, Horwitz suggests that psychoanalytical formulations of anxiety became less persuasive on both sides of the Atlantic in the light of the rise of behavioural and cognitive psychology and the growing importance of biological psychiatry, which was founded partly on the production of psychoactive medications and partly on the demise of asylums for the mentally ill. This theme is pursued in more depth in the penultimate chapter, which convincingly charts the rising production, prescription and consumption of anxiolytics and antidepressants during the second half of the twentieth century as modern populations appeared to be drowning in a sea of stress-induced depression and anxiety. Of particular interest to both medical historians and practitioners, partly because Horwitz’s analysis is more expansive and assured in this section, is the changing definition and place of anxiety in the various incarnations of the Diagnostic and Statistical Manual of Mental Disorders.
The final chapter leads us, perhaps appropriately, to reflect on a conundrum. In spite of the comfort, security and safety in which many modern populations live, we exhibit greater signs of anxiety and tension than previous generations. Anxiety is now apparently the most common class of mental illness. Of course, this begs the question with which I began this review: is anxiety normal or pathological? Is anxiety a mental illness or merely a flexible and quite healthy means of displaying and communicating the human predicament, as Sartre and his existential colleagues claimed? Are some forms of anxiety pathological (those that inhibit and paralyse or render people unhappy), while others provide a platform for the construction of effective coping strategies? In the end, Horwitz’s answer is quite rightly cautious: although advances in psychiatry, psychology, neurology and medical imaging seem to promise more refined understandings of neurological and mental processes, the boundaries between the normal and the pathological, between anxiety and other conditions, between my wife and her less well-adjusted husband, will always remain as indistinct, culturally determined and contested as in previous eras.