Is It Anxiety, Or Just Not Getting Your Way?
Believe it or not, there are important differences
In a slew of recent evaluations I’ve received for review, I’ve noticed a semantic pattern in almost all of them: “anxiety” is listed as the primary motive for engaging in dangerous or inappropriate behavior. When anxiety entered our culture’s treasured lexicon, it gained almost immediate traction with Millennial and Gen-Z aged populations. Routine nervousness in typically nerve-wracking situations was recast as ADHD-induced anxiety, whereas dreading a social event, like most normal people would, suddenly masqueraded as clinical social anxiety. For my clients with severe mental illnesses, their psychiatric symptoms are evident, as they legitimately exhibit and report symptoms aligned with those in the DSM-5. The criteria for anxiety disorders are as follows: excessive worry occurring more days than not for at least 6 months, difficulty in controlling worry, exaggerated responding to minor stimuli, and/or persistent irritability resulting from a chronic “on-edge” sensation. Needless to say, hating your boss and believing you’re a victim of the patriarchy do not qualify as symptoms worthy of intervention. At least not a therapeutic intervention.
For individuals with disabilities, specifically those with severe deficits in language, I’ve thought frequently about their experience of anxiety. To illustrate my skepticism, we look to the case of a 55-year-old nonverbal male we’ll refer to as Frank. Frank, who has lived in residential settings away from his family since age 5 because of highly destructive and dangerous behavior, meets the criteria for a severe to profound intellectual disability. Without vocal or verbal speech and challenges across decades in teaching even basic sign language, his most effective means of communicating tends to wax and wane. When calm, he relies on gesturing, smiling, and clapping. When provoked, he pulls hair, rips doors off of hinges, throws rocks at staff, and flips them over by tackling them below the knees. But yes, disability activists, please go on about how Frank’s mode of communication is a superpower that affords him an enlightened understanding of this place we call Earth.
One of Frank’s reports was one that more than 10 times referred to his behavior being symptomatic of “anxiety”; “Giving Frank a schedule to plan his day will help him be more proactive in managing his anxiety”, “Whenever possible, let Frank know when the schedule is about the change, as he gets fixated on dates which further increases his anxiety”, “Frank experiences a lot of anxiety around plans and calendars”. I want to make one thing crystal clear: I am not making the argument, in any stretch of the imagination, that people with disabilities do not experience anxiety. Humans, regardless of condition, disability, or disorder, are hardwired to experience symptoms of anxiousness. We evolved from the well-known fight-or-flight response, which protected us in situations when we were cavemen being chased down by a tiger or even approaching an unfamiliar berry on a tree that we were unsure was poisonous. Skepticism and even impending dread has served us for more centuries than are documented in history textbooks. With this said, we have to consider modern society’s understanding of anxiety, as well as our threshold for tolerating potentially anxiety-provoking situations.
Our use of such labels has bastardized the true experiences of psychiatric problems, as well as resulted in clinical recommendations no better than socially-influenced guesswork or contagion. In the case of Frank, who does not have a concept of time, does not recognize what day or month it is, requires maximal physical assistance to feed himself, clean himself, use the bathroom, get dressed and undressed, and conduct basic hygiene routines, I’m not entirely sold on the notion that clinical symptoms of anxiety have plagued his existence. His behavior is more than likely habitual and conditioned, at this point; for nearly 6 decades, Frank has found a means of getting his way through destruction and physical attacks. If you had minimal other means of communication and linebacker-tackling people got you what you wanted, you would likely sustain a similar routine as Frank’s. With this, then, is his hair-pulling a coping mechanism for the persistent worry of being alive? Or is it because the basketball court was closed and he was denied immediate, gratifying access to a basketball? In ripping a door off its hinges, was this to channel chronic tension, or because the staff member withholding reinforcement hid behind the door for her own safety and he couldn’t reach her? Sure, it is plausible that both can occur: he could be angry about basketball and anxious as to the reasons for the rejection. But for my developmentally-minded people, perhaps child therapists and teachers: feelings of more vague, complex emotions like “rejection” do not form, in typically developing children, until at least school-age. For the adult with the functioning level of an infant… how much more likely is an angered tantrum than guilt, shame, or the sadness of rejection?
I’m certain I’ll receive messages essentially saying, “tomato, tomato… who cares?” The clinical outcomes of guesswork are the reasons why I consider this a crucial issue to address. Nervousness is not necessarily anxiety, as mentioned. It’s an inborn mechanism impossible to rid ourselves of. Feeling “anxious” also doesn’t guarantee a clinical anxiety diagnosis. Today’s “anxiety” is a symptom of a disease of civilization, one in which we’re so dependent on limitless access and luxury that we instead tie ourselves into knots over things less-privileged countries--- or severely impaired individuals--- might find laughable. For the individual with disabilities, the one who knows their own name but requires maximal assistance with most everything else like feeding, toileting, showering, and dressing--- is it possible to experience the ruminative, almost trivial anxiety, that many of today’s millennials and Gen-Z claim to experience? I’m interested in different perspectives on this, as the research available is quite limited and tends to cluster around more popular diagnoses like autism or ADHD.
Anxiety is characterized by dwelling and ruminating over the past, as well as discontentment and brewing uncertainty about upcoming events. It is a looming feeling of fear and unpredictability that often results in maladaptive avoidance behavior, such as excessive use of Klonopin or Xanax, avoiding stimuli that trigger panic, and evading circumstances that we believe may increase anxiety symptoms. Considering dwelling on the past and attempts to predict how we’ll feel rely almost exclusively on language, and the ability to recount experience, we have to ask ourselves: are we assigning a pathology to this individual because of observed or reported symptoms, or because it’s popular and easy? Severely disabled or even severely mentally ill individuals are usually made to manage problems more relevant to their current level of functioning. That is, they’re unconcerned with being “stigmatized” if they’re unable to even feed themselves and keep themselves alive. For Frank, who is unsure about what day it is or what time it is or how much money it costs for a Mint Chip Frappuccino from Starbucks, I do not believe that he is “anxious” about his “schedule”. I think he’s bored out of his mind but also highly deficient in effective communication, resulting from his dangerous behavior being rewarded more often than not for many, many decades.
It’s imperative we address the various issues in assuming pathologies. Firstly, the assumption leads to faulty treatment planning and potential writing of interventions that fail to address the true problem. A highly contentious example is that of “trauma-informed practice”: it assumes everyone is traumatized, and therefore proceeds to treat people under the assumption that they’re internally damaged and require a unique approach. These individuals would have otherwise fared just fine had they been treated based on observable and socially significant problems, versus the TikTok-diagnosis offered by a 25-year-old therapist who recently learned about trauma-responsive practice from an autistic advocate. The resulting therapy now looks quite similar to how a mother would coddle a newborn baby, in that most every instance of crying immediately contacts Mommy and a nap. I’ve seen such depraved interventions proposed primarily by activists and clout-chasing behavior analysts, such as those claiming eye contact to be painfully uncomfortable to the degree of causing post-traumatic symptoms, or an individual being allowed to streak naked through Walmart, as it’s his own form of “authenticity”. God forbid anyone feel uncomfortable!
Let’s indulge the theory that our clientele are a conglomerate of traumatized, anxious people. If we assumed such behaviors were all symptoms of anxiety, the intervention would look exactly nothing like what our field suggests. The gold standard in treating anxiety and Post-Traumatic Stress Disorder (PTSD) is exposure. Exposure, as in continually facing the stimuli that trigger symptoms of anxiety. It is addressing the problem at its root, a clinical baptism by fire. It is unbelievably difficult, as I’ve independently weaned myself off of Klonopin following a 10-year physical and psychological dependence and managed to completely eliminate panic attacks that used to occur 4-5 times per day for consecutive months at a time. For a decade I relied on the powerful pull of avoidance, as the effects of facing my panic attack symptoms were excruciating. Klonopin melted them entirely, and the warm tingle that washed over following an episode was truly incomparable to any non-medical intervention I’d already attempted. This only expanded and heightened my fear, making every waking moment that of anticipating when another panic attack would arise and if I’d be capable of tolerating it. Believe me when I say: I understand the treatment is grueling, it is long, and it is soul-crushing.
With that, though, I’m no longer stricken by fear in my car or in public places where panic attacks would typically strike. My attention isn’t arrested by a slight physiological change that my mind has registered as a threat. And my quality of life has substantially improved as a result of the work I put in toward improving upon my clinical symptoms and diagnoses. To assume disabled individuals cannot handle similar challenges is stigmatization in and of itself; it is the soft bigotry of low expectations.
This chronic activism has made it where they want to argue with you about your own diagnosis, or your child's. My teen was dx with anxiety at a young age, because it goes hand in hand with arfid. He's been on meds, in therapy, sees specialists and is being recommended for in home services 2 hours a week. We have to interrupt his panic stricken catastrophizing with things like "you're fine. It's just a muscle spasm. Go lay down or do something else." It interrupts his day. His rating scales remain the same. It's present at school, at home, at therapy etc. But these internet activists talk about anxiety in the form of "I couldn't find a parking spot." My son picked at his nails (receptive behavior) until he got a cuticle infection, and then freaked out for days over having to slowly drain it and is it still infected and is my finger okay, and still tries to mess with his nails. 🤦♀️ We are going to have to start exposure therapy during feeding therapy so he can get SHOTS AND BLOOD DRAWS. The line between an actual disabling condition and internet symptoms are so far apart it makes me angry. Sorry for the rant.