If I were to assign a relationship status to my anxiety and myself, it would be “It’s complicated.” You see, I don’t know if I have an anxiety disorder or not.
I’m on an anti-anxiety medication, but this is the United States of America, year 2015, so having a prescription for a drug does not mean you have a disorder. Besides, is there even such a thing as an anxiety “disorder” in the first place?
Anxiety is natural. It’s even good, in small amounts, allowing the brain and body to respond to potentially harmful situations. Over time though, if anxiety is chronic, the constant cortisol overload can be harmful. But guess what else is harmful? Everything.
Sunlight provides vitamin D, sure, but it also sends cancer-causing UV rays straight through my porcelain-colored skin. Almost 100 people in the US die in car crashes every day, but we still hop in our death-mobiles the second we get a craving for Starbucks or Sephora. Saturated fats clog our arteries and cause heart attacks, while sodium sends our blood pressure skyrocketing, yet I still eat a bacon-egg-and-cheese sandwich nearly every day. Besides, my boyfriend tells me all the time that saturated fat is good for you; so not even something as demonized as fat can be easily labeled “good” or “bad.”
With this train of thought, it becomes easy to question whether or not mental disorders even exist in the first place. And if they do exist, where does one draw the line between “normal” and “pathological?”
The field of psychology in general and the Diagnostic and Statistical Manual of Mental Disorders (the DSM for short) specifically have received criticism for trying to put a person in one specific box. Myers-Briggs and other methods of typology have also been criticized for similar reasons. I can acknowledge these issues, even though I find validity in Myers-Briggs. I think that the problem arises from a reductionist attitude and not seeing that Myers-Briggs allows for individual variation.
People have been typing one another for thousands of years. The ancient Greek physician Hippocrates (he of “Hippocratic Oath” fame), incorporated the four humors/temperaments of Greco-Roman medicine into his own medical theories. He believed that specific bodily fluids (or humors) affected people’s personalities and behavior. The four fundamental personality types that Hippocrates and his pals recognized were the sanguine, the choleric, the melancholic, and the phlegmatic. These types were respectively associated with air, fire, earth, and water. (As a side-note, being phlegmatic does not mean being the type of person who’s always hocking up a loogie, but rather a relaxed type of person.)
Once scientists came to generally agree that most people actually contain little to no actual flame, the idea of the four humors fell by the wayside. However, the idea of basic temperaments never fell away completely. Enter the “Big Five.”
I’ve talked about the Big Five personality traits—Openness, Conscientiousness, Agreeableness, Extraversion, and Neuroticism—before on this blog, but today we’re focusing on the correlation between the Big Five traits and psychopathology, much like how Hippocrates once associated the four humors with physical and mental health problems.
- In one meta-analysis that focused on specific depressive, anxiety, and substance abuse disorders (SUD), the writers found that all of these diagnostic groups were high on neuroticism and low on conscientiousness. SUD also correlated with low levels of agreeableness in this particular study, and people with social phobias scored unsurprisingly low in extraversion.
- A different study that focused on adolescents found a relationship between self-harming behavior and emotional instability (i.e. neuroticism), low extraversion, and low conscientiousness.
In a 2001 study, Donald R. Lynam and Thomas A. Widiger hypothesized that personality disorders represent a continuum of the Five Factor Model of personality (FFM), which is a model similar to the Big Five. Lynam and Widiger objected to the notion that personality disorders represented distinct clinical syndromes and they supported a dimensional model rather than a categorical one. Rather than a person either having or not having a trait, he/she can have various levels of different traits in a dimensional model. A categorical model is based on a simple presence or absence of a trait, and Lynam and Widiger found this approach to be too reductive.
- In order to argue their point, they developed comprehensive FFM descriptions of personality disorders based on ratings that experts gave to actual cases of personality disorders. Agreement among the expert raters was high for every personality disorder except for schizoid personality disorder. (For example, most raters agreed that paranoid personality disorder presented high scores in factors related to neuroticism and conscientiousness and relatively lower scores in openness, extraversion, and agreeableness.)
- From their data, Lynam and Widiger were able to conclude that personality disorders involve extreme variants of the traits included in the more general FFM of personality. Thus, they proposed that using the FFM could help reduce the excessive overlap that appears amongst DSM diagnoses of personality disorders.
Based on the first two studies described here, it may be reasonable to expand Lynam and Widiger’s hypothesis to predict that psychopathology more generally may be a continuum of “normal” traits, just at more extreme ends of the spectrum. For example, through this lens OCD could be viewed as extreme neuroticism and conscientiousness, rather than a “disorder” in its own right.
Of course, there are also neurological and chemical underpinnings for many mental disorders. Schizophrenia is characterized by elevated dopamine transmission in parts of the brain; a certain gene may cause people with ADHD to express a hypo-dopaminergic trait. But what if some of these neurological and chemical underpinnings are just extremes of “normal” conditions?
I’m curious about those people who might get diagnosed by a psychiatrist for something like, ADHD, generalized anxiety disorder, depression, etc., while another psychiatrist concludes that those same people are perfectly fine. It’s these people, the ones who live on the edge of the spectrum, who I think can tell us a lot about psychopathology.
Going back to my own experiences with anxiety, I start to wonder whether or not my medication is even necessary. And if it is necessary for me to maintain a higher quality of life, is it still me who is living that life? If anxiety is not a distinct illness, then am I really just medicating away a part of myself? Is anxiety something to be cured, like strep throat, or is it a key part of my personality, like my introversion? And if it is a part of my personality, is my anxiety, along with the rest of my personality, a product of nature or nurture? Or both? Am I still me without my anxiety?
When I look at cases other than my own, as I do when I am trying not to be the stereotypically self-absorbed millennial that baby-boomers are biting their nails over, the situation becomes even more complicated. Because while my anxiety is moderate and I have experienced only minor changes in how I feel and act since starting my medication, not everyone has the same experiences. Many people have much more severe anxiety than I do, and many more people’s psychology affects their daily life more than mine does. Similarly, other medications affect people and alter their feelings, perceptions, and physical well-being more than mine does.
So, after all of this, the question still remains: Is there a line that can be drawn between “normal” and “pathological,” and if so, where should it be?