All We Have to Fear: Psychiatry's Transformation of Natural Anxieties into Mental Disorders By Allan V. Horwitz & Jerome C. Wakefield. Oxford University Press. 2012. £18.99 (hb). 288 pp. ISBN: 9780199793754

How do we account for the apparently inexorable rise in the prevalence of anxiety disorders in the Western world? What part are psychiatrists playing in this process? And who stands to benefit from it?

The authors propose that our current ways of classifying anxiety disorders are responsible. Although clinicians tend only to see people with problems, research instruments can lead us to define, as diseases, states that should be viewed as ‘normal’ anxiety. Hence the apparent increase of these states and the potential bonanza for Big Pharma. Evolutionary psychology is proposed as the prism to achieve the clarity we currently lack.

This is a well-written critique of different ways of classifying anxiety disorders. I particularly liked the historical review of thinking about anxiety, spanning classical authors, the age of neurasthenia and Freud. The authors write, of course, in the shadow of the American health system, with its coupling ofdiagnosis and reimbursement. It grates, at times, that the authors refer to DSM as though it were the only way that psychiatrists think about anxiety. However, their critique could apply equally to ICD. It is also curious that the authors use the word ‘design’ when discussing the outcome of unplanned effects of natural selection. Although I am sure they do not mean it, it suggests that there is an ‘ideal’ evolutionary solution to every predicament. The very range of characteristics within a ‘normal’ population suggests a more scattergun process.

The central idea is that many anxiety problems should not be labelled as disorders because, at one time in our evolutionary history, these characteristics were adaptive. The problem is that evolutionary psychology offers plausible explanations that are not falsifiable. So, the idea that we can clearly identify characteristics that have had evolutionary survival value, and so should be seen as normal, is not as clear-cut as the authors propose. Indeed, the mismatch between the current environment and certain characteristics surely suggests that these characteristics have become maladaptive.

As a non-specialist in anxiety disorders, I found this book informative and illuminating, if not finally convincing. I would, though, recommend it to any psychiatrist as a provocative survey of this difficult area.