Mental health professionals do not know what anxiety disorders are
A longer post than usual. Comments and feedback appreciated!!
Anxiety disorders are under-theorized. Mental health professionals literally do not know what they are nor do they have a working theory of them.
That can’t be right! Surely you can search the internet or go to a professional and get a clear definition of the nature of an anxiety disorder?
No. You can’t.
What do I mean by that?
Let’s talk about what it looks like when we do have a clear understanding of a condition or disease.
What does it mean to understand a disease?
There are at least four things that we can state, clearly, about diseases that we actually understand:
(1) The causes of the disease
(2) The symptoms (or effects) of the disease
(3) The treatments for the disease
(4) What the disease is
When we have a disease we understand, we know all four of these things, and we don’t confuse any of the four with any of the others.
Let’s use cancer as an example.
(1) One can talk about the causes of cancer in several ways. Smoking, for instance, is a human behavior that can cause lung cancer. Radiation exposure is an environmental cause. Some types of infection (such as HPV, HIV, and Hepatitis B and C) can lead to an increased risk of cancer. Some people have a genetic predisposition to get one or another kind of cancer. All of those can be thought of as different answers to the question “what causes cancer?”
(2) The symptoms of cancer are varied and can range from pain and fatigue to weight loss, coughing, difficulty swallowing, abnormal bleeding or bruising, the appearance of lumps, and so on, all the way to the more serious medical problems, sometimes ending in death.
(3) Treatments for cancer can include surgery, radiation therapy, chemotherapy, immunotherapy, hormone therapy, stem cell transplants, etc.
(4) But none of these things are what cancer is. Cancer is defined as the abnormal growth and division of cells in the body. If you don’t have abnormal cell growth and division, you don’t have cancer.
All four of these aspects are different from each other, and we don’t get them confused.
We don’t get the cause confused with the treatment. We don’t say “my sister got cancer because she started radiation therapy.” And we don’t say “We’re treating my friend’s lung cancer with smoking.”
We don’t get the reality of the disease mixed up with the symptoms or the causes of disease. We don’t say “the doctors looked and found no evidence of abnormal cells anywhere in my body, but I have cancer because I smoked for 25 years (cause) and now I’m coughing a lot (symptom).”
We don’t get the disease itself mixed up with the treatment. “I don’t want to start hormone therapy because that might mean I have cancer.”
All of this is what I mean when I say that we know what cancer is.
Fire
Let’s take another example, one that may seem a bit strange. Let’s look at fire.
(1) What are the causes of fire? One sort of answer might include “matches” or “dry wood and a lightning storm” or “an uninsulated wire in a pile of newspaper” or “I fell asleep on the couch while smoking.” Another cause of fire might be ... fire: my house is on fire because it’s next door to your house, which was on fire an hour ago.
(2) What are the results or symptoms of fire? Heat, light, flames, and usually smoke.
(3) What do we use to treat or combat fire? Water. Foam insulation. A fire blanket. Close the oven door! Etc.
(4) What is fire? Fire is a chemical reaction that occurs when heat, oxygen, and a fuel source combine in a process called combustion.
Again, we don’t get these things mixed up. We know that smoke is smoke and fire is fire and one is the symptom of the other.
This is what I mean when I say that we know what we’re talking about when we talk about fire.
Imagine a world where we didn’t know these things
Come with me to Bizarro World, where fire professionals don’t know what fire is or why it’s a problem.
There’s a small fire on the floor in your kitchen. You’re not sure how it started. You grab a big cup, fill it with water, and throw it on the flames. They sputter a little, and now there’s a tiny bit less fire but also more smoke. You do it again. Now you see a few flames starting to lick one of the curtains. You take the curtain off the rod, throw it on the floor, and then run to the bedroom and grab a blanket, then run back to smother the curtain with the blanket ... then throw some water on top of the whole thing. Now the wall by the stove seems hotter than it should be, and there’s a hint of smoke coming from the oven. You remember there’s a fire extinguisher in the basement, run down and get it, come back up and empty the whole thing into the oven and all around the stove and the wall behind it. Now the room is a huge smoky mess and you can’t see or breathe very well. You open a window, grab a bigger cup and start throwing water everywhere. You run out to find more blankets and throw them everywhere too. You’re making progress! Will it be enough?
But the neighbors have seen the smoke coming from the house and they called the fire department. Now the professionals are here.
“Get that water cleaned up, stat! Who brought the towels?”
“Someone get out the big vacuum for the smoke!”
“Someone needs to go through the house and find all the matches and put them somewhere safe.”
“Turn on the air-conditioning!”
(Yelling at you:) “Stop throwing water! You’re going to damage the floor!”
“Someone pick up those blankets!”
“Get the dehumidifier in here!”
“Hang the curtains back up where they go!”
You ask, desperately: “Isn’t anyone going to try to do something about the fire itself?”
The answers come back:
“Don’t tell me how to do my job. I know more about this than you do.”
“Everyone experiences fire from time to time.”
“A certain level of fire is normal in a situation like this.”
“It’s important to create a sense of normalcy during a fire. People experiencing fire tend to throw blankets on the floor and take curtains off the windows. Don’t they know that people whose houses aren’t on fire don’t do those things? Put the blankets back on the bed and the curtains back on the windows and act like a normal person. You’ll feel better about the fire once you’ve done that.”
“Houses experiencing immolation tend to have water on the floor. So it’s important to clean up the water.”
“Houses experiencing immolation tend to be smoky. So it’s important to vacuum up the smoke.”
“Houses experiencing immolation are much hotter than normal houses. So it’s important to turn on the air-conditioning.”
“Fire can be caused by falling asleep smoking on the couch. Do you smoke? Are you narcoleptic? We should look into a treatment program for these problems.”
“The fire will go out by itself eventually. Until then, try to keep a positive attitude.”
Anxiety disorders: we live in Bizarro World
When it comes to anxiety disorders, mental health professionals literally do not know what they are talking about. Because of this, when you enlist mental health professionals for help, they often act very much like the firefighters in the example above.
They tell you that the illness is natural and normal, and the important thing is to learn to cope with having the illness.
They confuse the symptoms of the illness with the illness itself.
They tell you that the things you are doing to try to feel better – very natural things! and things that do, to an extent, help you feel better! – are actually part of the illness.
They look around the rest of your life, at every other bad habit you might have, and tell you that you won’t be able to cure the illness until you have first solved those other problems.
They tell you that what’s important is to act normal, to act like everything is OK. (“Fake it ‘til you make it” is still common mental health advice! Imagine telling that to someone whose house is on fire.)
Anxiety disorders: Nobody knows anything
What is an anxiety disorder? Nobody knows! That may seem crazy, but it’s true. Ask google or chatgpt or the DSM-5 what an anxiety disorder is, and this is what you get:
Mayoclinic.org:
Experiencing occasional anxiety is a normal part of life. However, people with anxiety disorders frequently have intense, excessive and persistent worry and fear about everyday situations. Often, anxiety disorders involve repeated episodes of sudden feelings of intense anxiety and fear or terror that reach a peak within minutes (panic attacks).
These feelings of anxiety and panic interfere with daily activities, are difficult to control, are out of proportion to the actual danger and can last a long time. You may avoid places or situations to prevent these feelings. Symptoms may start during childhood or the teen years and continue into adulthood.
Examples of anxiety disorders include generalized anxiety disorder, social anxiety disorder (social phobia), specific phobias and separation anxiety disorder. You can have more than one anxiety disorder. Sometimes anxiety results from a medical condition that needs treatment.
Whatever form of anxiety you have, treatment can help.
DSM-5:
Anxiety disorders include disorders that share features of excessive fear and anxiety and related behavioral disturbances. Fear is the emotional response to real or perceived imminent threat, whereas anxiety is anticipation of future threat. Obviously, these two states overlap, but they also differ, with fear more often associated with surges of autonomic arousal necessary for fight or flight, thoughts of immediate danger, and escape behaviors, and anxiety more often associated with muscle tension and vigilance in preparation for future danger and cautious or avoidant behaviors. Sometimes the level of fear or anxiety is reduced by pervasive avoidance behaviors. Panic attacks feature prominently within the anxiety disorders as a particular type of fear response. Panic attacks are not limited to anxiety disorders but rather can be seen in other mental disorders as well. ...
Anxiety disorders differ from developmentally normative fear or anxiety by being excessive or persisting beyond developmentally appropriate periods. They differ from transient fear or anxiety, often stress-induced, by being persistent (e.g., typically lasting 6 months or more), although the criterion for duration is intended as a general guide with allowance for some degree of flexibility and is sometimes of shorter duration in children (as in separation anxiety disorder and selective mutism). Since individuals with anxiety disorders typically overestimate the danger in situations they fear or avoid, the primary determination of whether the fear or anxiety is excessive or out of proportion is made by the clinician, taking cultural contextual factors into account.
Chatgpt:
Anxiety is a natural and common emotional response to stress or danger. It is characterized by feelings of unease, worry, fear, and apprehension. While it is normal to experience occasional anxiety in response to challenging or uncertain situations, excessive or prolonged anxiety that interferes with daily life may indicate an anxiety disorder.
Anxiety disorders are a group of mental health conditions that involve excessive and persistent worrying, fear, or nervousness. They can manifest in various ways, including generalized anxiety disorder (GAD), panic disorder, social anxiety disorder (SAD), specific phobias, and others. Each type of anxiety disorder has its own specific symptoms and diagnostic criteria.
Common symptoms of anxiety can include:
Excessive worry: Feeling an uncontrollable sense of impending doom or catastrophic thoughts.
Restlessness: Having difficulty sitting still or feeling constantly on edge.
Fatigue: Feeling tired or low on energy even without physical exertion.
Difficulty concentrating: Having trouble focusing or experiencing mind going blank.
Irritability: Feeling easily annoyed or having a short temper.
Muscle tension: Experiencing muscle tightness, aches, or tension headaches.
Sleep disturbances: Having trouble falling asleep, staying asleep, or having restless sleep.
It's important to note that anxiety can affect individuals differently, and symptoms may vary from person to person.
That’s a lot of text, I know.
But skim through it looking for a definition of what anxiety is, as distinct from the symptoms of anxiety.
You won’t find one.
Bizarro World - the DSM-5 for House Fires
If the above texts were telling you about house fires, they would read like this.
“A house fire is a natural phenomenon characterized by smoke, light, heat, and water on the floor. Everyone experiences house fires from time to time. But if you have constant or regularly recurring house fires that interfere with your life, you may have a house fire disorder. House fire disorders are a group of conditions that involve smoke, light, heat, and water on the floor, but also a variety of other conditions including blankets on the floor, curtains off their rods, open windows (even in winter), the evacuation from the house of pets, children, and even adults, the purchase and regular use of an excessive or unusual number of fire extinguishers, and screaming. Each type of house fire disorder has its own specific symptoms and diagnostic criteria. For instance, screaming house fire disorder is characterized by repeated screaming for help being heard during a fire, while wet floor house fire disorder is characterized by homes that typically have extremely wet floors when firefighters arrive, and smoky house fire disorder is characterized by homes with unusual amounts of smoke. You can have more than one type of house fire disorder. The specific characteristics of different house fire disorders vary significantly and it is important that your disorder be appropriately diagnosed by a trained professional.”
What mental health professionals have to say about anxiety disorders
The texts above (Mayo Clinic, DSM, chatgpt) all amount to the same thing. “Here’s a symptom of an anxiety disorder. Here’s another symptom. Here’s another symptom. Here’s some ideas that might help you decide whether this or that symptom might indicate one type of anxiety disorder versus another type of anxiety disorder.”
If all we have is a list of symptoms, we don’t really understand the disease.
Imagine if all we could say about cancer is that it has a certain set of symptoms! We would characterize different types of cancer as “coughing cancer” and “weight loss cancer” and “bruising cancer” and “lumpy cancer.” We would not be able to tell the difference between “coughing cancer” and a cold — or distinguish “weight loss cancer” from an Ozempic prescription.
That’s exactly where we are with anxiety disorders. We can talk about the symptoms, but we have no idea of the reality underlying the symptoms. Psychologists and psychiatrists have invented a huge taxonomy based on differences in symptoms. This taxonomy doesn’t actually help anyone, because they have no idea what the underlying disease is. But at least it gives the professionals the idea that they’re doing something to help.
All of this is the same for most mental illnesses
Anxiety disorders are not unique in this regard. What I have said above seems to be true of most of the mental health disorders listed in the DSM-5. They are characterized by a list of symptoms, full stop. There is no insight into the nature of the underlying problem or problems.
All right, smart ass, so what is the underlying nature of anxiety disorders?
The underlying nature of an anxiety disorder is that it is a specific type of extreme unhappiness. In particular, I would define an anxiety disorder as extreme unhappiness that is based around1 the sensations of fear, anxiety, and/or worry.
Other forms of unhappiness also exist, and in their extreme forms many of them are identified as other types of mental illness. Depression disorders, for instance, are a form of extreme unhappiness that is based around the sensations of sadness (and related sensations).
I know it seems like that is far too simple, but I’m pretty certain that it’s true.
I can’t do much here to argue for the truth of this conclusion. It would get far too long for one post. Really, this entire substack (and the book I’m writing) is an attempt to explain what unhappiness is and why it matters and how it relates to anxiety disorders and some of the other common forms of mental illness.
What do you mean by unhappiness?
I wrote an entire post about this, and really this entire substack (and my future book) is aboat this topic. I would summarize as follows.
It is my view that unhappiness is a condition in which one experiences emotions or sensations in the body which one does not wish to experience ... or what I sometimes call “hated sensations.”
What is extreme unhappiness?
It’s unhappiness that’s extreme, duh.
But what distinguishes extreme unhappiness from regular unhappiness? What’s the magical amount of unhappiness that creates anxiety (or depression, or whatever)?
On this one I’m going to defer to the professionals.
I don’t say this because I think there’s anything magical or deeply true about the mental health categories and diagnoses that the professionals have given us. For instance, it seems to be a consistent pattern in the definitions of different mental illnesses that the problem has to be something that is “persistent and excessive” and that “causes significant distress or impairment” in certain situations. But what types of fear or sadness (or whatever symptom is being assessed) counts as “persistent and excessive?” And what does it mean for distress or impairment to be significant?
The only answer is, it’s bad enough for a patient to seek treatment, and bad enough for a psychologist or psychiatrist to agree that they have a mental disorder.
How does unhappiness become extreme?
In my view, the most common way is via loops: I have a specific hated sensation, and then I realize that I am often having that sensation, and I hate it ... so I make a resolution to avoid having that sensation. But precisely by making that resolution, I tell my body to send me news (in the form of additional sensations) of when the hated sensation might be about to crop up. I then learn to associate the new sensation (which is telling me that the hated sensation is about to arrive) with the hated sensation, and the new sensation quickly becomes a new hated sensation. And so, of course, I make a resolution to avoid that sensation. Rinse and repeat. Eventually the very fact that I am having hated sensations, or thinking about having hated sensations, or wondering how long it will be until I have more hated sensations, can become an obsessive thought, and the obsessiveness of that thought in turn can cause more hated sensations.
When the loops have looped upon themselves enough times, this entire knot of unhappiness can come to consume a significant chunk of my life.
There are other ways that unhappiness can become extreme. In some cases, there is surely an underyling physical reality that causes the unhappy sensations to recur, over and over. If we repeatedly experience a sensation that we hate, it can be very difficult not to build up a knot of unhappiness around that sensation.
So, in summary…?
In summary, an anxiety disorder is the specific extreme form of unhappiness in which a massive knot of unhappiness has arisen in one’s life (through whatever means), in which the predominant hated sensations involve fear, anxiety, and/or worry.
It officially becomes an anxiety disorder when the unhappiness affects your life so much that you seek help from a professional and get your diagnosis.
Talk about the official taxonomy of anxiety disorders
The DSM-5 lists nine anxiety disorders, plus at least two other disorders that used to be anxiety disorders but have been re-categorized in the most recent DSM (these two are PTSD and OCD).
Here’s the list of 11, as well as how I would describe them.
Social Anxiety Disorder is a form of extreme unhappiness where social situations are what most reliably causes the hated sensations to arise.
Separation Anxiety Disorder: same, but for separation from a loved one (or multiple loved ones).
Agoraphobia: same, but for going outside.
General Anxiety Disorder: same, but almost anything can cause it. (This is, pretty much by definition, the worst type of anxiety disorder. At the extreme, one comes to believe that literally anything that happens may cause one to experience unhappiness ... and then, shortly afterwards, this prediction becomes true, and literally any thought and any action and any sensation begins to cause unhappiness. That is where I ended up, at the depths of my own mental health problems.)
Post-Traumatic Stress Disorder (PTSD): same, but the trigger is a anything that reminds us of the situation in which a specific traumatic situation (or situations) arose.
Specific Phobia: same, but there is only one specific thing that causes a fear cascade (spiders, or snakes, or the number 13, or whatever).
Substance/Medication-Induced Anxiety Disorder: same, but the unhappiness is triggered by controlled substances or medications.
Anxiety Disorder Due to Another Medical Condition: obvious.
Panic Disorder: this one is different. This one is not characterized by the situation that causes the symptoms, but by the type of symptom (panic). I have no idea why the psychologists think this one is worth distinguishing from the others, as panic can arise in any of the others, but whatever.
Selective Mutism: this one is like panic disorder, but the symptom is not being able to talk in certain situations.
Obsessive-Compulsive Disorder (OCD). This one is especially interesting to me because its distinguishing characteristic is what the unhappy person does in response to the unhappiness. Namely, if you have OCD, you react to your hated sensations by doing specific actions, over and over again, which have sometimes in the past had the result of making the sensation go away.
In short, the list is a weird amalgamation of different descriptions that don’t fit together very well. The logic by which the disorders are categorized is all over the place! The whole thing makes no danged sense.
Let’s compare the anxiety disorders to our Bizarro World, in which firefighters are trying to categorize different types of house fire disorder.
Social Anxiety Disorder, Separation Anxiety Disorder, Agoraphobia, General Anxiety Disorder, PTSD, and Specific Phobia are all distinguished from each other based on the cause of the anxiety. Firefighters in Bizarro World might categorize different types of house fire similarly. We might imagine “Falls Asleep Smoking on the Couch House Fire Disorder” and “Plays with Matches House Fire Disorder” and “Faulty Electrical Wiring House Fire Disorder.”
Panic Disorder and Selective Mutism are different. These two are defined based on the specific symptoms of the unhappiness. Imagine “Heavy Smoke House Fire Disorder” and “Tremendous Heat House Fire Disorder.”
OCD is distinguished from the others based on what people do in response to their unhappiness (and which, when it fails to solve the unhappiness, causes more unhappiness). This would be something like “Wet Floor House Fire Disorder.”
How can I heal an anxiety disorder?
My answer to that one is the same as always: Feel your feelings.
When your hated feelings arise, you need to react differently: you need to intentionally feel them. Pay attention to the feeling. Do everything you can to experience every nuance of the feeling. Spend hour after hour doing this. Eventually, you cut the loops and eliminate the unhappiness.
You can read more – so much more! – on this substack, and hopefully in my eventual book, about the details of how to do that.
Despite what psychologists will tell you, it does not matter at all what “type” of anxiety disorder you have. The categories are irrelevant and unnecessary, and in my view the only reason the psychological community has bothered to create the DSM and other similar resources is because they have no idea how to treat the actual problem ... because, again, they don’t know what the problem is.
Whatever “disorder” you “have,” the underlying reality is the same. You are extremely unhappy.
And the solution (or at least one solution, the one I know about) is the same as it would be for anyone else who is extremely unhappy. Feel your feelings.
A few final notes
To psychologists, the actual nature of anxiety disorders is a difficult, mysterious question with no known answers. As we have seen, they literally have no theory as to the nature of the underlying reality. They have lists of symptoms, and nothing else.
Also: everyone who has an anxiety disorder is extremely unhappy. This is literally the most obvious fact about them.
The mental health community has failed to see the nature of anxiety disorders because the answer is too obvious. Psychologists can’t take the time to notice that all their patients are unhappy, just as fish can’t take the time to notice that they are always swimming in water. The unhappiness comes through as background noise.
I said earlier that if you don’t have abnormal cell growth and division, you don’t have cancer. That’s because the correct definition of cancer is that it consists of abnormal cell growth and division.
I would also say that if you aren’t extremely unhappy, then you don’t have an anxiety disorder. That’s because the correct definition of an anxiety disorder is that consists of (a specific form of) extreme unhappiness. The unhappiness is the disorder. The disorder is the unhappiness. The two are one and the same.
Mental health professionals see the unhappiness of their patients with anxiety disorder. But they think the unhappiness is a natural reaction to the anxiety disorder. They focus all their attention on the anxiety disorder, and ignore the unhappiness. But the unhappiness is the problem. The anxiety disorder is just a symptom of the problem.
We are told, and we believe, that it’s completely normal to be unhappy when you have a serious anxiety disorder. And yes, yes it is! But that’s like believing that it’s normal to see flames when you smell smoke. It is normal! And yet, as a diagnosis, it gets the key facts backwards.
I believe that this is why we have a mental health crisis. Our professionals literally do not know how to help us, because they insist on fighting the smoke while telling us that the fire is normal.
The words “based around” are very vague and are just a placeholder. A more detailed account of the relationship between anxiety disorders and the sensations of fear is coming up in a few paragraphs.
This piece is really good and more people should comment on it. Also I wrote it.
Can’t unsee how obvious it is that the DSM is just describing symptoms and if that’s all you have, any discussion or therapy that follows is whack-a-mole. Good analogies.