Do the words we use to talk about different psychiatric disorders, such as anxiety and schizophrenia, have an influence on how we view them? Does the fact that we all have days when we are anxious make us feel that anxiety disorders are less severe, less important than other disorders that relate less obviously to everyday life? If so, we should think again.
I was struck recently in a conversation with a colleague that some of the words we use to describe psychiatric disorders may actually alter how we view such conditions. The two words that made me consider this were anxiety and schizophrenia. These words differ in a very specific way. The word anxiety can be used to describe a wide range of levels of severity from the mild anxiety you might feel when you think you will be late for an important appointment, to the debilitating anxiety that leaves an individual unable to leave their home. In contrast, the word schizophrenia relates specifically to a disorder, you would not commonly hear someone say they felt a bit schizophrenic today. What also came out of this conversation was that the way in which mental health researchers think about these disorders is, to an extent, in keeping with these differences in the usage of these words.
“An anxiety disorder is something distinct from being the end of the range of anxiety severity; it also requires this degree of impairment, or impact on daily life:
It has been common for decades for researchers studying anxiety disorders to see them as severe expressions, or the extreme end, of anxiety. And indeed those with a clinically diagnosed anxiety disorder usually have very severe levels of fear or anxiety. However, they also have a high level of impairment. So, you could be very scared of social interactions, but manage to get through those activities that are essential for you to conduct your day-to-day life. On the other hand, your anxiety could develop to such a degree that you fear leaving your home and having to enter any kind of social situation. As a result, an anxiety disorder is something distinct from being the end of the range of anxiety severity; it also requires this degree of impairment, or impact on daily life. To distinguish this level of impairment from other, more manageable levels of high anxiety, we add words such as “clinical” or “disorder” (i.e. clinical anxiety or anxiety disorder).
In contrast, the word schizophrenia means a distinct disorder made up of groups of related symptoms such as paranoia, delusional thinking and hallucinations. Unlike researchers in the anxiety field, those working on schizophrenia appear to differ considerably in whether they consider the disorder to be a distinct entity that is quite different from the presence of absence of any related symptoms, versus those who see the disorder as the extreme end of a continuum of symptoms such as paranoia. The fact that some see the disorder as something separate and removed from variation in, for example, symptoms of paranoia in the population, may be because the word has always been taken to refer to a disorder that is qualitatively distinct from normal variation. And yet almost all of us would recognise that levels of paranoia vary amongst our colleagues, as do levels of, for example, delusional thinking. Some might say that some types of superstition are delusional thoughts, but they remain common.
“Those who experience a psychiatric disorder, be it anxiety, schizophrenia, or something else, are likely to have higher than average levels of both genetic and environmental risk”
Results from the latest genetic approaches suggest that individual genes each account for only a minute level of risk for psychiatric disorders. However, by adding the effects of many hundreds of genes together you get a genetic distribution that approaches normality. Similarly, aspects of the environment found to place individuals at risk for mental health problems do not work alone, but act to increase risk. Those who experience a psychiatric disorder, be it anxiety, schizophrenia, or something else, are likely to have higher than average levels of both genetic and environmental risk. They are simply further along some of these distributions than other individuals. In my view, psychiatric disorders of all kinds are simply the combination of being at the high end of several normal distributions. In anxiety disorders it could be anxiety/fear symptoms and also impairment. In schizophrenia it could be paranoia and delusional thinking.
Another difference between these two words is that anxiety is seen as familiar, because almost all of us experience it at sometime, whereas schizophrenia is not. This again makes the disorders seem more different than they are, suggesting that schizophrenia is somehow more severe, perhaps partly because it is so much less familiar. And yet clinically diagnosed severe anxiety can be every bit as debilitating as schizophrenia. It also affects far more people, and accounts for a large burden on our society.
As well as being of central importance to making sure our research asks the right questions, we owe it to those suffering these disorders to remember that we all differ on a huge number of these continua, and that those who have to deal with being at the extreme end are the same as the rest of us; they just have a heavier weight to bear.