A history of anxiety: from Hippocrates to DSM

Abstract

This article describes the history of the nosology of anxiety disorders. Greek and Latin physicians and philosophers distinguished anxiety from other types of negative affect, and identified it as a medical disorder. Ancient Epicurean and Stoic philosophers suggested techniques to reach an anxiety-free state of mind that are reminiscent of modern cognitive psychology. Between classical antiquity and the late 19^th century there was a long interval during which anxiety was not classified as a separate illness. However, typical cases of anxiety disorders kept being reported, even if under different names. In the 17^th century, Robert Burton described anxiety in The Anatomy of Melancholy. Panic attacks and generalized anxiety disorder may be recognized in the “panophobias” in the nosology published by Boissier de Sauvages in the 18^th century. Also, anxiety symptoms were an important component of new disease constructs, culminating in neurasthenia in the 19^th century. Emil Kraepelin devoted much attention to the possible presence of severe anxiety in manic-depressive illness, thereby anticipating the “anxious distress” specifier of bipolar disorders in DSM-5. A pitfall to consider is that the meaning of common medical terms, such as melancholia, evolves according to places and epochs.

Introduction

In DSM-5, ¹ anxiety (French: anxiété; German: Angst) is defined as the anticipation of future threat; it is distinguished from fear (peur; Furcht), the emotional response to real or perceived imminent threat. Further, the term worry (souci; Sorge) in DSM-5 adds an additional nuance by referring to the cognitive aspects of apprehensive expectation. Anxiety is a normal emotion. From an evolutionary viewpoint, it is adaptive since it promotes survival by inciting persons to steer clear of perilous places. Since the 20^th century, anxiety has also been a disorder in psychiatric classifications. The clinical threshold between normal adaptive anxiety in everyday life and distressing pathological anxiety requiring treatment is subject to clinical judgment.

It has often been written that the history of anxiety disorders is recent. It has been repeated that anxiety; like schizophrenia, was hardly known as an illness before the 19^th century. In contrast, mood disorders, with melancholia foremost, can boast historical roots going back to classical antiquity. However, it may not be quite true that anxiety is a relatively recent construct. There are indications that anxiety was clearly identified as a distinct negative affect and as a separate disorder by Greco-Roman philosophers and physicians. In addition, ancient philosophy suggested treatments for anxiety that are not too far removed from today's cognitive approaches.

Anxiety in Greco-Roman philosophy and medicine

The Hippocratic Corpus is a collection of Greek medical texts attributed to Hippocrates (c 460 BC to c 370 AD), or written in his name by his disciples. The phobia of a man named Nicanor is described)^2,3: “Nicanor's affection (πάθoς), when he went to a drinking party, was fear (Φόβoς) of the flute girl. Whenever he heard the voice of the flute begin to play at a symposium, masses of terrors rose up. He said that he could hardly bear it when it was night, but if he heard it in the daytime he was not affected. Such symptoms persisted over a long period of time.” In this text, a typical case of phobia is labeled as a medical disorder.

Latin Stoic philosophical writings, such as the treatises of Cicero and Seneca, prefigure many modern views concerning the clinical features and the cognitive treatment of anxiety. In the Tusculan Disputations (TD), Cicero (106 BC to 43 BC) wrote that affliction (molestia), worry (sollicitudo), and anxiety (angor) are called disorders (aegritudo), on account of the analogy between a troubled mind and a diseased body. (TD, Book III, X)⁴ This text shows that anxious affect is distinguished from sadness; also, anxiety is defined as a medical illness (aegritudo). The Latin word aegritudo is the usual word for illness in medical textbooks. Cicero makes clear that this term is used to translate the Greek term pathos (παθoς). At the time of Cicero, Roman authors were creating new terms for philosophical and medical concepts, and referred to the original Greek words to define these neologisms. Cicero offers a clinical description of the various abnormal affects: Angor (anxiety) is further characterized clinically as a “constricting” disorder (premens), whereas molestia (affliction) is described as permanent (permanens), and sollicitudo (worry) as ruminative (cum cogitatione) (TD, Book IV, VIII). Cicero makes an interesting distinction between anxietas that designates trait anxiety or the fact of being prone to anxiousness, and angor that refers to state anxiety or current anxiety (TD, Book IV, XII). This anticipates the works of Cattell and Schleier, who are often credited with having introduced the terms “state” and “trait” anxiety.⁵

Greek and Latin literature indicate means to identify pathological anxiety and to free oneself from its effects. The TD, written by Cicero after the death of his daughter Tullia in childbed, is a plea for Stoicism, a branch of philosophy that is one of the pillars of today's cognitive therapy. Seneca (4 BC to 65 AD), another Stoic philosopher, taught his contemporaries how to achieve freedom from anxiety in his book Of Peace of Mind (De tranquillitate animi [DTA]). Seneca defines (DTA, chapter 2) the ideal state of “peace of mind” (tranquillitas) as a situation where one is undisturbed (non concuti), and which is equivalent to what the Greeks called euthymia ((εύθυμíα). One should note that euthymia is used in the context of mood rather than anxiety in modern psychiatry. According to Seneca, fear of death is the main cognition preventing us from enjoying a carefree life (DTA, chapter 11. “He who fears death will never act as becomes a living man”). ^6,7 This thought anticipates the future developments by Kierkegaard, Heidegger, and existentialist philosophers about the fondamental anxiety caused by man's realization that his existence is finite. One way to escape from the clutch of anxiety is to devote one's attention to the present instead of worrying about the future. In his book On the Shortness of Life (De brevitate vitae [DBV]), Seneca's recommendation is to combine together past, present and future in only one time (DBV, chapter 15. “He makes his life long by combining ail times into one”).^8,9 Today, this focus on the present moment is one of the key objectives in techniques such as mindfulness meditation.

Even though Stoics and Epicureans were viewed as competing philosophical schools, they offered similar advice about the means to get rid of anxiety. Epicurius (341 BC Samos to 270 BC Athens),¹⁰ the philosopher who founded the school of philosophy called Epicureanism, taught that the objective (Greek: télos) of a happy life included reaching a state called ataraxia where the mind was free of worry. One path to ataraxia was to get rid of negative cognitions about the past and of fears about the future, since the only existing reality is the present moment. Epicurius' writings have been largely lost but his teaching survived through his Latin disciple, Lucretius, who wrote a very poetic book, De natura rerum (DNR - The Nature of Things). This book was rediscovered in 1417¹¹ and the French philosopher Michel de Montaigne (1533 to 1592) owned an annotated copy.¹² In De natura rerum, Lucretius praises Epicurius for being the first philosopher to discover that “men were lords in riches... and that they yet, O yet, within the home, still had the anxious heart (anxia corda) which vexed life unpausingly with torments of the mind” (DNR, Book VI, 14-16).¹³ In Lucretius' words, Epicurius put limits to the excess of desire (cupido) and to the unfounded terrors (timor), thus pointing to the path toward ataraxia (DNR, VI, 24-27).

Naming anxiety

The word anxiety derives from the Latin substantive angor and the corresponding verb ango (to constrict). A cognate word is angustus (narrow). These words derive from an Indo-European root that has produced Angst in modern German (and related words in Dutch, Danish, Norwegian, and Swedish). Interestingly, the same relationship between the idea of narrowness and anxiety is attested in Biblical Hebrew. In fact, Job expresses his anguish (Job 7:10) literally with the Hebrew expression “the narrowness (tsar) of my spirit.”

In French, as well as in other Romance languages, anxiété (anxiety; from the Latin anxiĕtas) is often differentiated from angoisse (anguish; from the Latin angŭstĭa). Sometimes, the two terms are considered synonymous by some authors. More frequently, a nuance is established: anxiety designates a psychological feeling whereas anguish designates the somatic experience. Joseph Lévy-Valensi (1879 to 1943),¹⁴ a professor of psychiatry in Paris who died at Auschwitz, defined “anxiété” in his textbook of psychiatry as a dark and distressing feeling of expectation. Anxiété was described as including the psychological and cognitive aspects of worrying. In contrast, “angoisse” was defined as the experience of spastic constriction of voluntary or involuntary muscle fibers. Angoisse (anguish) could be experienced as a constriction affecting the muscles of all systems; kaleidoscopic manifestations were mentioned in Lévy-Valensi's book: bronchial spasm, shortness of breath, intestinal cramps, vaginismus, urinary urgency, pseudo-angina pectoris, headache. In other Romance languages, as in French, anxiety and anguish may be considered more or less synonymous by some authors; if other authors do find a nuance, anxiety then bears the connotation of psychological worry whereas anguish implies a somatic feeling of constriction. A look at the reference dictionaries of various Romance languages confirms that the same nuance of meaning is reproduced in the word pairs ansiedad vs angustia in Spanish,¹⁵ ansietat vs angoixa in Catalan,¹⁶ ànsia or ansietà vs angòscia in Italian,¹⁷ and ansiedade vs angústia in Portuguese.¹⁸ The only exception is the most eastern Romance language, Romanian. Anxietate, the word used in Romanian medical articles to translate anxiety, seems to be a recent loanword from the French anxiété, first attested to in 1934.¹⁹ One of the traditional Romanian words for anxiety is nelinişte (unrest), a negation of linişte (quiet, rest), from the Latin lenis (smooth, mild).

Bridging the gap between Antiquity and modern medicine

Between classical antiquity and modem psychiatry, there was an interval of centuries when the concept of anxiety as an illness seems to have disappeared from written records. Patients with anxiety did exist, but they were diagnosed with other diagnostic terms. The last and most successful of these new diagnoses was Beard's neurasthenia.

In 1621, Robert Burton published his treatise The Anatomy of Melancholy, an encyclopedic review of the literature from Antiquity up until the 17^th century. As explained by Allan W. Horwitz,²⁰ Burton's work is generally quoted in the context of depression. However, Burton was also concerned with anxiety. At that time, the meaning of melancholia was not limited to depression but encompassed anxiety. Generally, the diagnosis of melancholia could be applied to a variety of clinical pictures with negative affect or internalizing symptoms. A key criterion of melancholia was the fact that the patient would remain quiet; an agitated patient qualified for a diagnosis of mania, in Greek, or furor, in Latin. For Burton, fear and sorrow were intimately linked. As stated by the author, “Cousin-german [first cousin] to sorrow, is fear, or rather a sister, fidus Achates, and continual companion — an assistant and a principal agent in procuring of the mischief; a cause and symptom as the other.” Fidus (ie, faithful) Achates, was a trustworthy follower of Aeneas (Virgil Aeneid, 6. 158, etc).²¹ Yet, Burton also observed that fear and sorrow could occur independently. Burton discusses social phobia, using cases from the Romans and the Greeks as examples (“...Tully [ie, Marcus Tullius Cicero] confessed of himself, that he trembled still at the beginning of his speech; and Demosthenes, that great orator of Greece, before Philippus”).

In the 18^th century, medical authors published clinical descriptions of panic attacks, but they did not label them as a separate illness. Rather, symptoms of panic attacks were often considered to be symptoms of melancholia. Coste and Granger²² analyzed more than 2000 reports of consultations of French physicians, written during the 16^th to 18^th centuries. Retrospective diagnosis was attempted on the basis of DSM-IV criteria. The authors report the typical example of a man, seen in 1743, who shows typical symptoms of panic attacks, but whose contemporary diagnosis is “vapors” and melancholia (affection vaporeuse et mélancolique).²³ According to the Oxford English Dictionary, the word “vapors” as a term for a nervous disorder was most common around 1665 to 1750. This clinical case offers one more proof that the term melancholia, in its long history, could refer to symptoms of both depression and anxiety.

Boissier de Sauvages (1706-1767) published the first significant French medical nosology. This work was the last major medical textbook to be written in Latin. It was soon followed by a posthumous French translation. This shows that Boissier de Sauvages stood at a transition between two epochs, being both an heir to classical antiquity and a precursor of modem science, proclaiming himself a disciple of the clinical observation method of Thomas Sydenham. Like Cicero, Boissier de Sauvages used the term Aegritudo for “illness” or “disorder” in the Latin edition of his book. The classification of Boissier de Sauvages listed 10 major classes of disease, which were further broken down into orders, genera, and 2400 species (individual diseases). Mental disorders, called vesaniae, belonged to the 8^th class of diseases, and were subdivided into four orders:

• Hallucinations, comprising Vertigo, Suffusion, Diplopia, Syrigmus (ie, imaginary noise perceived in the ear), Hypochondriasis, and Somnambulism;

• Morositates, including Pica, Bulimia, Polydipsia, Antipathia, Nostalgia, Panophobia (ie, panic terror), Satyriasis, Nymphomania, Tarantism (ie, immoderate craving for dance), and Hydrophobia

• Deliria, comprising Paraphrosine (ie, temporary delirium caused by a substance or a medical illness), Amentia (“universal” delirium without furor); Melancholia (“partial” and non-aggressive delirium with sadness and chronicity), Mania (“universal delirium” with furor and chronicity), Demonomania (ie, melancholia attributed to the devil)

• Folies anomales comprising Amnesia, and Agrypnia (ie, insomnia).

The disorder mainly concerned with anxiety is Panophobia,²⁴ defined as a panic terror, a fright that is experienced at night in the absence of any obvious cause. Panophobia is related to the Greek adjective pantophobos (παντoΦóβoς, afraid of everything).The first form of panophobia is little more than nocturnal terror. However, other subtypes of panophobia are reminiscent of modem anxiety disorders. In panophobia hysterica, also called “panic terror caused by vapors,” hysterical and hypochondriac subjects experience sudden fright and react dramatically with heart racing or pallor when startled by innocuous noises or sights. This was attributed to a diathesis of exacerbated sensibility. It was reported that these subjects may additionally present with the complicating symptoms of grief or worries. In panophobia phrontis (from the Greek øρoντίς: care, worry, preoccupation), also called worry (French: souci), the patients present with features evocative of GAD. These individuals are constantly extremely worried, and for this reason they avoid company, preferring to keep to themselves. They complain of pain and bodily tension.

In the late 19^th and early 20^th century, anxiety was a key component of various new diagnostic categories, from neurasthenia to neuroses. George Miller Beard first described neurasthenia in 1869. Its symptoms were manifold, ranging from general malaise, neuralgic pains, hysteria, hypochondriasis, to symptoms of anxiety and chronic depression.²⁵ Beard was the first successful American author in the field of psychiatry. Neurasthenia had a long life: it survived to our time by being retained as a category in ICD-10. Sigmund Freud and Emil Kraepelin were contemporaries, both born in 1856. Pierre Janet was born 3 years later, in 1859. Janet developed the idea that anxious manifestations could be triggered by “subconscious” fixed ideas. He coined the term “psychasthenia” for what was supposed to be one of the two major neuroses, along with hysteria. Freud separated anxiety neurosis from neurasthenia. He coined many of the terms that are used today for various anxiety disorders, even though these terms have by now largely shaken off their psychoanalytical connotations.

Emil Kraepelin gave much attention to anxiety as a symptom associated with other diagnoses, but wrote less extensively on anxiety as a separate diagnosis. In the 8^th edition of his textbook,²⁶ Kraepelin describes anxiety (Angst) as the most frequent of ail abnormal distressing affects. Anxiety is described as the association of inner tension with a kind of anhedonia (eine Verbindung von Unlust mit innerer Spannung). It completely permeates both the body and the mental state. Kraepelin admits a separate nosological category for phobias, including those that arise in social situations (Situationsphobien). However, in the 8^th edition, phobias are lumped together in the same chapter as obsessive-compulsive thoughts and fears. A major contribution of Kraepelin was his description of the possible presence of significant anxiety in manic-depressive illness, in a way that anticipates the “anxious distress” specifier for bipolar disorders that appeared in DSM-5. In Kraepelin's words, the mood in manic-depressive patients may be anxious, with a torturing tension that may culminate²⁷ in mute or helpless despair, or with an anxious restlessness that is expressed through various motor manifestations, states of excitation, or inconsiderate self-aggression. One of the criteria for the anxious distress specifier in DSM-5 is the feeling that the individual might lose control of him- or herself, and a note in DSM-5 states that high levels of anxiety have been associated with higher suicide risks.

DSM-I and DSM-II

In DSM-I (1952),²⁸ anxiety was almost synonymous with “psychoneurotic disorders.” DSM-I states that the chief characteristic of the psychoneurotic disorders was “anxiety” which might be directly felt and expressed or which might be unconsciously and automatically controlled by the utilization of various psychological defense mechanisms (depression, conversion, displacement, etc). “Anxiety” in psychoneurotic disorders was interpreted as a danger signal sent and perceived by the conscious portion of the personality. It was supposedly produced by a threat from within the personality (eg, by supercharged repressed emotions, including such aggressive impulses as hostility and resentment). The repressed impulses giving rise to the anxiety might be discharged by, or deflected into, various symptomatic expressions. According to the apparent manifestations, the diagnosis might be anxiety reaction, when the anxiety was diffuse and not restricted to different situations objects; dissociative reaction; conversion reaction, when the impulse causing the anxiety was “converted” into functional symptoms in organs or part of the body; phobic reaction, when the patient's anxiety became detached from a specific idea, object, or situation in the daily life and was displaced to some symbolic idea or situation in the form of a specific neurotic fear; obsessive-compulsive reaction, when the anxiety was associated with the persistence of unwanted ideas and of repetitive impulses to perform acts; and depressive reaction, when the anxiety was allayed and partially relieved by depression and self-deprecation.

In DSM-II, the overarching category for anxious symptomatology was called Neuroses (300).²⁹ It was stated that anxiety was the chief characteristic of the neuroses, which established anxiety and neurosis as quasi synonyms. Anxiety might be felt and expressed directly, or it might be controlled unconsciously and automatically by conversion, displacement and various other psychological mechanisms. Generally, these mechanisms produced symptoms experienced as subjective distress from which the patient desired relief. The category of neuroses included anxiety neurosis, characterized by anxious over-concern extending to panic and frequently associated with somatic symptoms; hysterical neuroses, where symptoms were symbolic of underlying conflicts and could often be modified by suggestion, including two types (conversion type, and dissociative type); phobic neuroses, in which fears were displaced to the phobic object from some other object of which the patient was unaware; obsessive-compulsive neurosis; depressive neurosis; and neurasthenic neurosis, characterized by complaints of chronic weakness, easy fatigability, and sometimes exhaustion.

From DSM-III to DSM-5

In DSM-III (1980), the chapter of anxiety disorders included (i) Phobic disorders, subdivided into Agoraphobia, with or without panic attacks, Social Phobia, and Simple Phobia; (ii) Anxiety states, subdivided into Panic disorder (PD), GAD, and Obsessive-Compulsive Disorder (OCD); and (iii) Post-traumatic Stress Disorder (PTSD). In addition, Anxiety disorders of childhood or adolescence included Separation anxiety disorder, Avoidant disorder of childhood or adolescence, and Overanxious disorder. DSM-II's anxiety neurosis was split into two newly created categories, PD and GAD, in DSM-III. This splitting was based on research showing that imipramine, a tricyclic antidepressant, blocked recurrent panic attacks³⁰ but had no effect on phobic anxiety not associated with panic attacks.³¹ PTSD was another new category.

As pointed out by Michael B. First,³² the most important change in the DSM-III-R (1987) classification of anxiety disorders was the elimination of the DSM-III hierarchy that had prevented the diagnosis of panic or any other anxiety disorder if these occurred concurrently with a depressive disorder.

“Mixed anxiety and depressive disorder” is a category in ICD-10 (F41.2) to be used when symptoms of both anxiety and depression are present, but neither set of symptoms, considered separately, is sufficiently severe to justify a diagnosis. In DSM-TV, Mixed anxiety-depressive disorder was included in Appendix B (Criteria sets and axes provided for further studies), rather than in the main body of the text because of information about potentially high rates of false positives. Another new category in DSM-IV was Acute stress disorder.

DSM-5 introduced a grouping of the anxiety disorders of DSM-IV into three spectra (ie, anxiety, OCD, and trauma- and stressor-related disorders) based on the sharing of common neurobiological, genetic, and psychological features. For the first time, the increasing knowledge about different brain circuits underlying stress, panic, obsessions, and compulsions, played a role in a classification. In addition, disorders that may be developmentally connected, whether they occur in children or adults, are grouped in the same chapters. Thus, obsessive-compulsive disorders are separated from anxiety disorders, and are grouped with other disorders characterized by repetitive thoughts or behaviors, such as body dysmorphic disorder, hoarding disorder, trichotillomania, and excoriation. Similarly, trauma- and stressor-related disorders include reactive attachment disorder, disinhibited social engagement disorder, and adjustment disorders, in addition to PTSD and acute stress disorder. Finally, selective mutism and separation anxiety disorders, previously included with the disorders diagnosed in infancy, childhood, and adolescence, are now classified with the other anxiety disorders. Mixed anxiety-depressive disorder was not retained as a category in DSM-5 because, among other reasons, that diagnosis proved too unstable over follow-up.

Conclusion

Ancient Greek and Latin authors reported cases of pathological anxiety, and identified them as medical disorders. The therapeutic techniques suggested by ancient Stoic and Epicurean philosophers would not seem out of place in today's textbooks of cognitive psychotherapy. In the centuries separating classical antiquity from the emergence of modem psychiatry in the mid-19^th century, typical cases of anxiety disorders kept being reported in medical writings, even though nosological categories were far removed from ours. Freud coined many of the terms used for various anxiety disorders in DSM-I and DSM-II. DSM-III introduced new disorders such as panic disorder, GAD, and PTSD. Major contributions of DSM-5 are (i) a grouping of the anxiety disorders into three spectra (anxiety, OCD, and trauma- and stressor-related disorders) based on the sharing of common features, and (ii) the grouping of developmentally connected disorders in the same chapters.