Psychiatry, Anxiety Disorders, and Existential Angst

Is there a relationship between clinical anxiety and existential angst? If so, what existential role do psychiatrists play in treating anxiety disorders? I’ll address these and related questions in what follows.

Anxiety Disorders

“Anxiety,” meaning a displeasing feeling of fear and concern that causes worry, uneasiness, or dread as well as physical symptoms like fatigue and concentration problems is a blanket term in psychiatry covering a number of mental disorders, including phobias, panic disorder, obsessive-compulsive disorder, posttraumatic stress disorder, and social anxiety disorder. According to Wikipedia, general anxiety disorder “is characterized by excessive, uncontrollable and often irrational worry about everyday things that is disproportionate to the actual source of worry” and “often interferes with daily functioning, as individuals suffering GAD typically anticipate disaster, and are overly concerned about everyday matters [as opposed to more specific ones, as in the other anxiety disorders like PTSD or SAD] such as health issues, money, death, family problems, friendship problems, interpersonal relationship problems, or work difficulties.” Anxiety disorders have physiological causes as well as treatments in the forms of cognitive behavioural therapy and pharmaceutical drugs.

Let’s turn to the more specific anxiety disorder, OCD, which Wikipedia says is “characterized by intrusive thoughts that produce uneasiness, apprehension, fear, or worry; by repetitive behaviors aimed at reducing the associated anxiety; or by a combination of such obsessions and compulsions.” The article goes on to say, “Obsessions are thoughts that recur and persist despite efforts to ignore or confront them. People with OCD frequently perform tasks, or compulsions, to seek relief from obsession-related anxiety.” For example, someone with OCD may fear that she’ll leave the lights on after she leaves a room, and even though she can see herself flip the switch and watch the lights go out, she won’t trust her eyes, because she’ll entertain extreme doubts about what she sees or won’t trust her memories. So to allay the fear she may perform an elaborate ritual, by flipping the light switch off and on several times, perhaps attaching some magical significance to the number. People with OCD feel the ritual “somehow either will prevent a dreaded event from occurring, or will push the event from their thoughts.” The compulsions are irrational and people with OCD even know that they’re irrational on an intellectual level, in that there’s no well-supported theory explaining any causal link between the rituals performed and the desired outcome. If a person with OCD turns the lights off and on six times, there’s no scientific significance of that number; faith in the number is just a superstition. And even if the ritual successfully pushes the fear away, this is only temporary so the compulsion is irrational also in the sense of being relatively ineffective as a treatment.

As the Wikipedia article points out, normal people also have irrational fears and even obsessions, but “people with OCD may attach extraordinary significance to the thoughts.” Moreover, “Whether or not behaviors are compulsions or mere habit depends on the context in which the behaviors are performed. For example, arranging and ordering DVDs for eight hours a day would be expected of one who works in a video store, but would seem abnormal in other situations. In other words, habits tend to bring efficiency to one's life, while compulsions tend to disrupt it.” Indeed, the DSM-IV definition of GAD says that to count as a disorder, the anxiety must “cause clinically significant distress or impairment in social, occupational, or other important areas of functioning,” besides meeting certain other conditions.

According to the Wikipedia article on GAD, cognitive behavioural therapy assumes a person with GAD has at least some of the following defects: “cognitive avoidance, positive worry beliefs, ineffective problem-solving and emotional processing, interpersonal issues, previous trauma, intolerance of uncertainty, negative problem orientation, ineffective coping, emotional hyperarousal, poor understanding of emotions, negative cognitive reactions to emotions, maladaptive emotion management and regulation, experiential avoidance, and behavioral restriction.” To correct these defects, the therapy might involve these components: “self-monitoring, relaxation techniques, self-control desensitization, gradual stimulus control, cognitive restructuring, worry outcome monitoring, present-moment focus, expectancy-free living, problem-solving techniques, processing of core fears, socialization, discussion and reframing of worry beliefs, emotional skills training, experiential exposure, psychoeducation, mindfulness and acceptance exercises.”

For OCD, one behavioural treatment is to train the person to tolerate the anxiety by weaning her off of the ritual. Another treatment is called “associative splitting,” meaning that the person imagines neutral or positive associations to change her thought patterns so that she’ll lose interest in the behaviour.
 

Clinical Anxiety and Existential Angst

Now, besides clinical anxiety, there’s what I’ll called existential angst. Whereas the worries felt by someone with a so-called anxiety disorder are about things over which we have at least some control, even if the person resorts to performing magic rituals to deal with the imagined threats, angst pertains to more fundamental conditions of human life. For example, an angst-ridden person feels horror about having a finite body which is doomed to die, about our animal nature as evidenced by our sexuality, about the universe’s apparent godlessness, and about the existence of evil and of nature’s indifference to our plights. Existential philosophers and theologians maintain that because this angst is both fundamental to human experience and intolerable to us, we avoid the fear and the horror by distracting ourselves, by preferring delusions to reality-based worldviews, and so by becoming existentially inauthentic: we cope with the unpleasant structural truths of our existence by developing vices of avoidance rather than virtues of sublimation.

I wonder whether there’s a relationship between the so-called anxiety disorders and existential angst. Could the general and specific anxieties be unconscious substitutes for angst, as though angst were filtered for conscious consumption and turned into more manageable fears? If so, this would explain the paradoxical nature of clinical anxiety: on the one hand, anxiety is intolerable and inescapable, meaning that the fear is severely unpleasant and at best delayed by the rituals; on the other hand, the fear is localized even in GAD to something less fundamental than the finitude of organic life. Anxieties seem like more manageable forms of angst. Even if clinical anxieties have physiological causes, they may effectively provide means of coping with angst, by distracting the person with more superficial fears.

It’s important here to understand the scientific perspective of psychiatry. Although psychiatric discourse drips with normative presumptions and implications, there is an unbridgeable abyss between psychiatric theories themselves and normative discourse, which is to say that the theories must be solely about facts rather than any normative evaluation of them. So although the raison d’etre of psychiatry and of all medical sciences is to do good for the patient, as opposed to merely discovering how the body or the mind works with no thought to practical applications, psychiatrists must avoid normative discourse as much as possible. Only in that way can psychiatrists be perceived as having mastered the scientific skills of objectivity, neutrality, professional detachment, rigorous handling of quantifications, and so forth.

Thus, the DSM doesn’t say that anxiety is bad and must be cured for that normative reason, but employs the euphemism that anxiety “impairs important areas of functioning.” What is a function, in this context? In psychiatry, this word is used as an equivocation to maintain psychiatry’s Janus-faced position. In common parlance, the word refers to the intended purpose of something that’s been intelligently designed as a means to achieving a goal. Thus, all technologies have functions, which are just the works the technologies are meant to carry out to be useful. A telephone’s traditional function is to permit people to communicate even across long distances. A gun’s function is to serve as a deadly weapon. When a telephone or a gun breaks and can no longer perform those desired ends, the users regard those malfunctions as bad because they interpret the desired ends as good. People want to communicate or to defend themselves, and although we may be unwise in the work we think ought to be performed, the context of technological functions is normative, because the functions are intended by designers or consumers whose values motivate them to build or to purchase the technologies.

Psychiatrists presuppose that sense of “function” but they also lean on the word’s biological sense. A biological function is just a naturally selected effect. For example, the heart’s function is to circulate blood in an organism, and although the organism may prefer that that end be carried out, the effect’s subjective rightness is irrelevant to the process of natural selection. This is because, whereas humans create technologies, there is no intelligent designer of organisms, according to modern biology. So if you think of human health from the biological perspective, you must put aside your thoughts about what we think is good or bad, because the genes and the environment have no such thoughts and they’re the main biological causes of our health.

If pressed on this equivocation, the psychiatrist will say that she borrows her normative judgments from society. Thus, if someone’s anxiety is so severe that it prevents her from being socially productive, the anxiety will be bad in the cryptonormative sense of being disordered and dysfunctional. The rightness of human health depends on social standards of normality, and when someone doesn’t fit well into her society, doctors look for causes of that conflict and seek to change not society but the patient. This is because the psychiatrist’s sole source of normative judgment, which motivates the entire medical endeavour to help the patient, is the social convention about what’s right or wrong.

As the Wikipedia article puts it, distinguishing between (dysfunctional) compulsions and (normal) habits, “habits tend to bring efficiency to one's life, while compulsions tend to disrupt it.” This presupposes that efficiency is a social good. And what is efficiency? Efficiency is the effectiveness of your selected means of achieving your desired end. For example, if you want to build a bridge to support cars, but you choose to build the bridge out of marshmallows, you’re not being efficient. Thus, “efficiency” is virtually synonymous with “instrumental rationality,” in this context. And the assumption is that we ought to try to achieve what we desire, thus “maximizing out utility.” But what if our desires were bad? In that case, efficiency would also be bad. Indeed, the psychiatrist assumes that someone with a mental illness may have the wrong desires, in which case the ill person shouldn’t strive to be efficient in satisfying them. Mental illness could still disrupt a person’s overall efficiency, by preventing her from pursuing some of her priorities since she must waste time dealing with the illness. But this presupposes that efficiency isn’t the ultimate ideal and that some desires are better than others.

Notice that when the psychiatrist sides with social convention and tradition, she chooses to ignore the existential perspective. When the existentialist is horrified by human norms, she’s reacting to the majority’s consensus about how we should live, since the majority tends to be existentially inauthentic, and so existential horror requires a social outsider’s perspective. The existentialist is alienated from society, just as the scientist is alienated from her personal preoccupations when she thinks objectively about the mysteries in nature. The existentialist rejects much of what society regards as normal, not because of some personal quirk, but because she puts herself in nature’s alien shoes, as it were, looking on all of us as we would be seen were the atoms and the stars to have eyes to see and a mind to judge. And the existentialist concludes that human norms themselves are absurd (objectively meaningless). This is because the atoms and the stars have no eyes or mind, and the existentialist’s alienation is self-destructive. What you appreciate when you detach from social myths and traditions and nevertheless think about social goings-on is that even our normal, much beloved practices are ridiculous games. Just as we laugh at clowns when we’re outside the circus, so too existentialists laugh at society generally when they detach from a culture’s assumptions about what’s normal or good.

So the psychiatrist assumes that clinical anxiety is bad and ought to be cured, because this anxiety prevents the person from fulfilling her social functions--to use the quasi-scientific euphemism. In plain language, someone with an anxiety disorder doesn’t do what society thinks she ought to be doing, because she’s incapable of doing so without help. But from the existential perspective, which is also the mystical perspective in the esoteric traditions of most major religions as well as the perspective of most introverts, social omegas, and modern artists, that very assessment of what’s functional/good is suspect. The psychiatrist stands with society and condemns those who would be social outsiders if left to their own devices, while the existentialist stands with horrible nature and condemns the norms of human societies for being engines of existential inauthenticity. These engines are ethically and aesthetically graceless means of dealing with the primary facts of life. And in so far as a society is especially deluded and hostile to existential virtues, the psychiatrist exacerbates the greater sin of existential inauthenticity by reversing those people’s antisocial tendencies. By “curing” someone of her inability to fit into society, she knocks down a barrier that would have helped prevent society from indoctrinating the outsider with its delusions and distractions.

The psychiatrist’s duplicity is especially apparent in her double standard regarding OCD and mainstream religion. There is obviously no way for the psychiatrist to condemn OCD and to give mainstream monotheism a pass, without special pleading for the latter. Both the monotheist and the person with OCD have obsessive fears which they alleviate with irrational rituals. In the case of monotheism, these rituals include prayer, attending Church, and studying an obsolete text that’s supposedly inspired by God. Indeed, the Wikipedia article on OCD says that one of the common obsessions is “the possibility that someone or something other than oneself--such as God, the Devil, or disease--will harm either the person with OCD or the people or things that the person cares about.” As quoted above, the article tries to allay concerns that the obsessions of so-called normal people must likewise be dysfunctional, thus undermining the psychiatric distinction, by saying that dysfunctional obsessions are those to which “extraordinary significance” is attached. Well now, how much significance should be attached to the belief that there are all-seeing gods as well as demons tempting people into sin so that our immortal spirits are damned to hell for eternity? Surely, the religious fundamentalist’s obsession with these theistic ideas is extraordinary compared to the religious moderate’s, but this in itself is hardly a defect of fundamentalism. Some ideas call for extreme actions, so just because a belief is common or ordinary doesn’t mean it’s well-justified. This is why appealing to popularity can be fallacious.

But the reason the psychiatrist condemns OCD and not mainstream religion is that the latter has been socially integrated. To be sure, the psychiatrist’s quasi-scientific theory of OCD implies that most monotheists ever born have suffered from “dysfunctional” anxiety in the form of OCD. But psychiatry isn’t a pure science, because medical science has a normative purpose, which is to say that medicine was technoscientific from its inception, as opposed to being abstract theorizing with no regard to social utility. The psychiatrist is supposed to act for the good, and she chooses the ideals that are normal within her society, rather than thinking through ethical matters on her own or siding with the antisocial findings of existentialists, mystics, introverts, and so on. So if one form of OCD is integral to a society, as it is in the case of manifestly irrational monotheism, the psychiatrist can only resort to mental gymnastics when defending the ideals she borrows from that sick society while condemning antisocial forms of OCD. The psychiatrist borrows ideals that derive from one form of mental illness (mainstream religion), to condemn a mental illness (OCD) that inoculates social outsiders so that they won’t be subjected to the more prevalent illnesses and delusions. This situation is just extravagantly absurd enough to be natural.

Some Red Herrings

Some red herrings need to be tossed aside here. You might think that because anxiety disorders have physiological causes as opposed to being voluntary, these behaviours must indeed be bad. It should take only a moment of reflection to realize, though, that normal behaviours too have physiological causes. Indeed, all behaviours are caused by brain states. Now, if you want to say that mental disorders are caused by brains that are biologically dysfunctional, you’ve got the following problem on your hands: our brains evolved to optimize our ancestors for life in natural environments that no longer obtain for most people. Thus, behaviours that are biologically functional, which is just to say naturally selected, aren’t necessarily ideal. For example, we’re naturally selected to prefer to eat sugar, to be violent, and to care more about our families or races than about foreigners. Rape is common in the animal kingdom, so we should think twice before assuming that what’s biologically normal is normatively best.

Likewise, then, the fact that people with anxiety disorders can be cured is neither here nor there, as far as my discussion is concerned. Normal, healthy, socially acceptable people can also be “cured” of their normality, if they’re brainwashed to accept a crazy belief system or if they’re convinced to take mind-altering drugs. Abnormal people can be made normal and normal people can be made abnormal, if certain steps are taken. This is a matter of there being physical mechanisms operating in either direction, as it were, so we don’t learn the normative status of something just because we know how to physically change the thing into something else.

As for the insufferable pomposity of cognitive behavioural therapists, we should keep in mind that this therapy combines behaviourism and the cognitive revolution in psychology, and thus contemporary practitioners inherit the arrogance of behaviourists who, decades ago, abstracted away the mind so they could imagine they were reducing people and animals to machines that could be trained. Since each behaviourist enjoyed a first-person perspective only on her own thoughts, she came to feel superior to the animals and people she studied in her lab, since she could more easily dehumanize bodies whose internal states she couldn’t access more directly by introspection. As Horkheimer and Adorno point out in Dialectic of Enlightenment, it’s the Marquis de Sade who brings ultrarationality to fruition. When you’re dealing with machines, the proper course is to modify them by forceful programming or to use them as slaves. Behaviorists reduced all creatures to machines simply by ignoring their minds and focusing on their observable behaviours (stimulus and response patterns, and so on).

And so we shouldn’t be surprised to find the intellectual descendants of those pretentious wannabe ultrarationalists saying in Wikipedia that CBT’s premise is “that changing maladaptive thinking leads to change in affect and in behavior.” The word “maladaptive” here is a technical term in CBT and means unproductive or counterproductive. Adaptive responses constructively deal with disruptive behaviour. Thus, compulsive rituals in OCD are maladaptive since they’re inefficient and disruptive, and so forth. However, from the existential perspective, antisocial behaviour can be constructive if the society is in decline and the culture robs you of your authenticity. Of course, changing thoughts can change behaviour, assuming thoughts can cause behaviour. But the phony objectivity in the use of “maladaptive” masks the CB therapist’s conservatism, since she sides with social conventions and thus gives no credit to mental illnesses as adaptive/effective inoculators against cultural nonsense (delusions, distractions, games, collective disorders, and obsolete myths and other dogmas).

Again, quoting a medical article, Wikipedia says CB therapists ‘help individuals challenge their patterns and beliefs and replace "errors in thinking such as overgeneralizing, magnifying negatives, minimizing positives and catastrophizing" with "more realistic and effective thoughts, thus decreasing emotional distress and self-defeating behavior.” ’ This talk of “errors in thinking” is straight out of the behaviourist tradition of dehumanization, which in turn was foreshadowed by the Marquis de Sade. Whatever mentally ill people do wrong, according to society, that wrongness isn’t confined to any mere error of reasoning. On the contrary, as I’ve argued elsewhere, the mentally ill are monstrous for calling attention to the arbitrariness of social conventions. And whatever the physiological causes of mental disorders, those who prefer not to be treated may console themselves by reaping the benefits of being social outsiders. So there may be a choice involved rather than just some error in computation. I suspect that if you look into the CB theory behind this talk of errors in thinking, you’ll find a great deal of subjective, philosophical or even quasi-religious normative presuppositions. Like the rest of us, wannabe ultrarationalists are mere mammals, after all. Likewise, the talk of replacing those “errors” with “more realistic and effective” thoughts is so much balderdash. CB therapists receive their authority from social conventions which establish the norms against which the abnormal behaviours of the mentally ill are judged bad. But social conventions are rarely realistic; on the contrary, cultures are filled with delusions that distract the majority from appreciating the natural, cosmicist reality which defines our existential predicament.

Society Versus the Individual

I want to clarify what I think we are entitled to conclude from the above. I’m not saying that people with anxiety disorders should be left alone. Within the law, people are free to choose their goals, and if some genetic quirk causes certain people to act in a way that prevents them from achieving those goals, including the goal of fitting into society, those people should seek treatment. Moreover, not every case of fitting into society is bad even in existential terms. This depends on the society and on the degree of conformity. My point, then, isn’t to condemn all psychiatry. Rather, what interests me is the big picture in which psychiatry is caught up in the process of serving the majority’s collective interests. Whether psychiatric practices are noble in the grand scheme depends on whether the society itself is healthy or in decline. I suggested that clinical anxiety may be a means of coping with existential angst, but even if there’s no such connection, psychiatry looks different from a perspective that acknowledges our dire existential situation. Psychiatrists typically defend social norms and offer treatment for antisocial behaviours. But even when these behaviours cause suffering, they’re also blessings in disguise if they compel the person to detach from a society so she’s spared the downside of being fully integrated into an existentially-flawed population.

The question that’s ignored by the psychiatrist’s talk of “functioning” is whether a particular set of social norms is good or bad. If you think all normative judgments derive from mass opinion, you’ll think this question is unanswerable. But existentialists, mystics, artists, introverts, romantics, and omegas disagree. They think the individual can envision her personal ideals and that even if she’s influenced by her society, her vision stands as a more or less original work of ideological art. So even if an anxiety disorder causes suffering, that suffering should be balanced against the good done when the disorder detaches the person from a potentially inferior culture. Siding always with the social norms, as is the psychiatrist’s wont and as though all societies were equally good, is philosophically very dubious. The complete assessment of a mental disorder will consider both the social perspective, and thus the psychiatric one which takes social norms/functions for granted, but also the antisocial perspective as it’s found in philosophical and religious traditions.

Psychiatrists and social workers suspect that those suffering from anxiety disorders (and from mental disorders generally) underreport their conditions. One explanation of this is that there’s a social stigma attached to the disorders, but I think this explanation is insufficient. Assuming that mental disorders ostracize those who have them, these people are forced to look at society anew (given that their critical faculties are left intact by the disorder). Just as a game looks different depending on whether you’re a player or a spectator, society looks different depending on whether you take social conventions for granted or study them as an outsider. The mentally ill tend to be social outsiders and so they’re well-positioned to appreciate the absurdity of many social practices. Understandably, an ill person will prefer not to suffer, and to that extent mainly the stigma would prevent her from seeking treatment. But the mental illness may have the upside of bestowing greater objectivity and that may help explain why mental illnesses are underreported: the suffering outsiders don’t want to be accepted by a culture they come to regard as ridiculous. In some cases, antisocial attitudes may be the poisoned fruits of a deranged mind, but in others the illness may force the person to look objectively at society and at human nature, and as is apparent from the history of modern science, objectivity is toxic to dogmas. 

PostScript: Evolution and the Self-Destruction of Omegas

An article summarizing a number of recent books on the widely-reported anxiety epidemic in the US concludes, “American anxiety seems like a cultural chimera created by, yes, social and economic problems, and by personal crises, but also by media attention.” The summarized books point to specific causes of anxiety in the US, such as the pressures of academia and the invention of Prozac-like drugs by Big Pharma. Certainly, the existential predicament I talk about doesn’t explain all kinds of anxiety, although some social and economic factors are related to our intense modern awareness of that predicament.

But I’d like to talk about an evolutionary explanation of melancholic depression by Jeffrey Kahn, summarized in the article. The explanation is that depression could have evolved as a means of weeding out unproductive members of a group, to conserve the group’s scarce resources. The old and infirm members would withdraw from society, sacrificing themselves for the good of the group and giving the stronger, more promising members a larger share of the food, weapons, and other goods. Howard Blum offers a similar explanation of self-destruction in The Lucifer Principle. However, there’s a better evolutionary explanation, which is that a dominance hierarchy forms not because the omegas direct how the group is structured, but because they’re not strong enough to compete with the alphas and betas, and the stronger members bully their way to a greater share of the resources. Genetically, the result is the same since the resources are reserved for the group’s stronger members, but the social mechanism is different: the omegas don’t choose to sacrifice themselves for the good of the majority, but are naturally pushed out by the stronger members in a competition.

Kahn’s explanation looks to me like it takes on the perspective not just of the genes, but of society’s winners. The winners and the best guardians and proliferators of the gene pool might prefer to think that the omegas withdraw because the losers recognize the superiority of the other members and bow out by suffering from sort of anxiety or depression. The anxiety becomes a physiological mechanism that eliminates those who are no longer socially useful, but the point is that this is supposed to be an active self-withdrawal for the good of the group. I think this reverses cause and effect. Anxiety and depression don’t cause the social withdrawal of omegas; rather, the cause is the omegas’ relative weakness or introversion which in turn causes them to lose in competition with stronger group members, so that the pecking order forms in an organic way. Anxiety and depression are effects of being on the outside of a society. When you’re alienated from a society, you can afford to look on it objectively, in which case you recognize the arbitrariness and absurdity of its rules and practices; you lack a social network and the distractions of cultural games, giving you time to ruminate and philosophize, which leads to skepticism, atheism, a greater sensitivity to suffering, and a general appreciation of our existential plight.