12 anxiety disorders

The American Psychiatric Publishing Textbook of Psychiatry, Fifth Edition. Edited by Hales RE, Yudofsky SC, Gabbard GO. © 2008 American Psychiatric Publishing, Inc. All rights reserved. www.appi.org

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Slide show includes…

Topic Headings

Tables and Figures

Key Points

Anxiety Disorders

Eric Hollander, M.D.,Daphne Simeon, M.D.

The American Psychiatric Publishing

TEXTBOOK OF PSYCHIATRYFifth EditionEdited by Robert E. Hales, M.D., M.B.A., Stuart C. Yudofsky, M.D., Glen O. Gabbard, M.D.

© 2008 American Psychiatric Publishing, Inc. All rights reserved. www.appi.org

CHAPTER 12


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CHAPTER 12 • Topic Headings

PANIC DISORDERDefinitionClinical Description

OnsetSymptomsCharacter Traits

EpidemiologyEtiology

Biological TheoriesPsychodynamic TheoriesLearning TheoriesTraumatic Antecedents

Course, Prognosis, Morbidity, and MortalityDiagnosis

Physical Signs and BehaviorDifferential Diagnosis

TreatmentPharmacotherapyPsychotherapy

GENERALIZED ANXIETY DISORDERDefinition and Clinical DescriptionEpidemiology and ComorbidityEtiology

Biological TheoriesPsychological Theories

Course and PrognosisDifferential Diagnosis

(continued)

TreatmentBenzodiazepinesBuspironeAntidepressantsOther Medications

PsychotherapyCombined Pharmacotherapy and Psychotherapy

SOCIAL PHOBIA (SOCIAL ANXIETY DISORDER)Definition and Clinical DescriptionEpidemiology and ComorbidityEtiology

Psychosocial TheoriesBiological Theories

Course and PrognosisDiagnosis and Differential DiagnosisTreatment

Pharmacological TreatmentCognitive and Behavioral TherapiesOther Types of PsychotherapyCombination Treatment

SPECIFIC PHOBIASDefinition and Clinical DescriptionEpidemiologyEtiology

Psychodynamic TheoryBehavioral TheoriesBiological Theories

Course and PrognosisTreatment


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CHAPTER 12 • Topic Headings (continued)

POSTTRAUMATIC STRESS DISORDERDefinitionClinical DescriptionEpidemiologyEtiologyRisk Factors and PredictorsCognitive and Behavioral TheoriesBiological Theories

Sympathetic SystemEndogenous Opioid SystemSerotonergic SystemHypothalamic-Pituitary-Adrenal AxisNeuropeptidesBrain Neuroanatomy and NeurocircuitryGenetics

Course and PrognosisDiagnosisDifferential Diagnosis

Organic Mental DisordersMood and Anxiety Disorders

TreatmentPharmacotherapyPsychotherapyCognitive and Behavioral Therapies

Other Psychotherapies

OBSESSIVE-COMPULSIVE DISORDERDefinitionClinical Description

OnsetSymptomsCharacter Traits

EpidemiologyEtiology

Psychodynamic TheoryCognitive and Behavioral TheoriesBiological Theories

Neuroanatomy and Functional NeurocircuitryNeurochemistryGeneticsCourse and PrognosisDiagnosis

Differential DiagnosisTreatment

PharmacotherapyCognitive-Behavioral TherapyCombination Pharmacotherapy and PsychotherapyOther Psychotherapy


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CHAPTER 12 • Tables and Figures

Table 12–1. Approximate lifetime prevalence, gender ratio, and common comorbidities for the major

anxiety disorders

Figure 12–1. Diagnostic decision tree for anxiety disorders.

Table 12–2. DSM-IV-TR diagnostic criteria for panic attacks

Table 12–3. DSM-IV-TR diagnostic criteria for panic disorder with or without agoraphobia

Figure 12–2. Development of agoraphobia.

Table 12–4. Biological models of panic disorder

Table 12–5. Course and prognosis of panic disorder

Table 12–6. Differential diagnosis of panic disorder

Table 12–7. Comparison of symptoms of mitral valve prolapse and panic disorder

Table 12–8. Pharmacological treatment of panic disorder

Table 12–9. Cognitive and behavioral approaches to treating panic disorder

Table 12–10. DSM-IV-TR diagnostic criteria for generalized anxiety disorder

Table 12–11. Biological models of generalized anxiety disorder

Table 12–12. Differential diagnosis of generalized anxiety disorder

Table 12–13. Pharmacological treatment of generalized anxiety disorder

Table 12–14. Cognitive and behavioral approaches to treating generalized anxiety disorder

Table 12–15. DSM-IV-TR diagnostic criteria for social phobia

Table 12–16. Risk factors for social anxiety

Table 12–17. Biological models of social anxiety disorder

Table 12–18. Course and prognosis of social anxiety disorder (continued)


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CHAPTER 12 • Tables and Figures (continued)

Table 12–19. Differential diagnosis of social anxiety disorder

Table 12–20. Pharmacological treatment of social anxiety disorder

Table 12–21. Cognitive and behavioral approaches to treating social anxiety disorder

Table 12–22. DSM-IV-TR diagnostic criteria for specific phobia

Table 12–23. DSM-IV-TR diagnostic criteria for obsessive-compulsive disorder

Table 12–24. Biological models of obsessive-compulsive disorder

Table 12–25. Course and prognosis of obsessive-compulsive disorder

Table 12–26. Differential diagnosis of obsessive-compulsive disorder

Table 12–27. Pharmacological treatment of obsessive-compulsive disorder

Table 12–28. Cognitive and behavioral approaches to treating obsessive-compulsive disorder

Table 12–29. DSM-IV-TR diagnostic criteria for posttraumatic stress disorder

Table 12–30. Risk factors for posttraumatic stress disorder (PTSD)

Table 12–31. Biological models of posttraumatic stress disorder

Table 12–32. Course and prognosis of posttraumatic stress disorder (PTSD)

Table 12–33. Differential diagnosis of posttraumatic stress disorder (PTSD)

Table 12–34. Pharmacotherapy of posttraumatic stress disorder (PTSD)

Table 12–35. Cognitive and behavioral approaches to treating posttraumatic stress disorder

Summary Key Points


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TABLE 12–1. Approximate lifetime prevalence, gender ratio, and common comorbidities for the major anxiety disorders

Anxiety disorders are the most common of all psychiatric illnesses and result in considerable functional impairment and distress. Table 12–1 presents a summary overview of the prevalence, gender ratio, and comorbidities of the major anxiety disorders.


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FIGURE 12–1. Diagnostic decision tree for anxiety disorders.

A diagnostic decision tree of the anxiety disorders is presented in Figure 12–1.

Patients may have more than one disorder and thus must be evaluated for each disorder.

(continued)


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FIGURE 12–1. (continued)


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TABLE 12–2. DSM-IV-TR diagnostic criteria for panic attacks

The DSM-IV-TR definition of a panic attack is presented in Table 12–2.


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TABLE 12–3. DSM-IV-TR diagnostic criteria for panic disorder with or without agoraphobia

Panic disorder is subdivided into panic disorder with and without agoraphobia, as in DSM-III-R, depending on whether there is any secondary phobic avoidance (Table 12–3).

(continued)


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TABLE 12–3. (continued)


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FIGURE 12–2. Development of agoraphobia.

Many patients will causally relate their panic attacks to the particular situation in which the attacks have occurred. They then avoid these situations in an attempt to prevent further panic attacks (Figure 12–2).

After onset of unexpected panic attacks (solid bars), patient develops acute help-seeking behavior (X), then apprehension culminating in chronic anxiety (shaded areas), and finally agoraphobic behavior (black blocks).


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TABLE 12–4. Biological models of panic disorder

There are a number of biological theories of panic disorder that figure prominently in the psychiatric literature (Table 12–4).


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TABLE 12–5. Course and prognosis of panic disorder

The course of panic disorder without treatment is highly variable and is summarized in Table 12–5.


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TABLE 12–6. Differential diagnosis of panic disorder

The diagnosis of panic disorder is not always obvious, and a number of other psychiatric and medical disorders may mimic this condition (Table 12–6).


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TABLE 12–7. Comparison of symptoms of mitral valve prolapse and panic disorder

Although patients with mitral valve prolapse occasionally complain of palpitations, chest pain, lightheadedness, and fatigue, symptoms of a full-blown panic attack are rare. A comparison of symptoms in mitral valve prolapse and panic disorder is provided in Table 12–7.


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TABLE 12–8. Pharmacological treatment of panic disorder

Several classes of medications have been shown to be effective in accomplishing blockade of spontaneous panic attacks; a summary of the pharmacological treatment of panic disorder is presented in Table 12–8.

(continued)


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TABLE 12–9. Cognitive and behavioral approaches to treating panic disorder

In recent years, interest in cognitive-behavioral therapy for panic has surged, and it has become firmly established as a first-line treatment for this disorder and found to be comparable in effectiveness to first-line medication treatments (Table 12–9).


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TABLE 12–10. DSM-IV-TR diagnostic criteria for generalized anxiety disorder

DSM-IV-TR sharpened the distinction of GAD from “normal” anxiety by specifying that in GAD the worry must be clearly excessive, pervasive, difficult to control, and associated with marked distress or impairment (Table 12–10).


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TABLE 12–11. Biological models of generalized anxiety disorder

Although the neurobiology of GAD is among the least investigated in the anxiety disorders, advances are now being made (a summary is presented in Table 12–11).


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TABLE 12–12. Differential diagnosis of generalized anxiety disorder

The differential diagnosis of GAD is summarized in Table 12–12.


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TABLE 12–13. Pharmacological treatment of generalized anxiety disorder

The pharmacological treatment of GAD is summarized in Table 12–13.


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TABLE 12–14. Cognitive and behavioral approaches to treating generalized anxiety disorder

Research into the psychotherapy of GAD has not been as extensive as for other anxiety disorders. Still, a number of studies exist that clearly show that a variety of psychotherapies are helpful in treating GAD (Table 12–14).


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TABLE 12–15. DSM-IV-TR diagnostic criteria for social phobia

The central feature of social phobia is a marked, persistent fear of social situations in which public humiliation or embarrassment is possible (Table 12–15).


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TABLE 12–16. Risk factors for social anxiety

A number of mechanisms are proposed in learning theories as contributors to the pathogenesis of social phobia (Stemberger et al. 1995), and risk factors for social anxiety are summarized in Table 12–16.


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TABLE 12–17. Biological models of social anxiety disorder

Biological theories of social phobia are summarized in Table 12–17.


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TABLE 12–18. Course and prognosis of social anxiety disorder

Social phobia is clearly a chronic and potentially highly impairing condition; course and prognosis are summarized in Table 12–18.


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TABLE 12–19. Differential diagnosis of social anxiety disorder

Differential diagnosis of social anxiety disorder is summarized in Table 12–19.


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TABLE 12–20. Pharmacological treatment of social anxiety disorder

The pharmacological treatment of social anxiety disorder is summarized in Table 12–20. There are a number of medication options that are clearly helpful.


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TABLE 12–21. Cognitive and behavioral approaches to treating social anxiety disorder

Three major cognitive-behavioral techniques are used in the treatment of social phobia: exposure, cognitive restructuring, and social skills training (Table 12–21).


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TABLE 12–22. DSM-IV-TR diagnostic criteria for specific phobia

The DSM-IV-TR diagnostic criteria for specific phobia are presented in Table 12–22.


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TABLE 12–23. DSM-IV-TR diagnostic criteria for obsessive-compulsive disorder

The essential features of obsessive-compulsive disorder are obsessions or compulsions. DSM-IV-TR criteria for OCD are presented in Table 12–23.


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TABLE 12–24. Biological models of obsessive-compulsive disorder

Although OCD used to be viewed as having a psychological etiology, a wealth of biological findings that have emerged over the past few decades have rendered OCD one of the most elegantly elaborated psychiatric disorders from a biological standpoint (Table 12–24).


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TABLE 12–25. Course and prognosis of obsessive-compulsive disorder

Studies of the natural course of the illness suggest that 24%–33% of patients have a fluctuating course, 11%–14% have a phasic course with periods of complete remission, and 54%–61% have a constant or progressive course (A. Black 1974; Table 12–25).


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TABLE 12–26. Differential diagnosis of obsessive-compulsive disorder

The differential diagnosis of OCD is summarized in Table 12–26.


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TABLE 12–27. Pharmacological treatment of obsessive-compulsive disorder

Advances in recent decades in the pharmacotherapy of OCD have been quite dramatic and have generated a great deal of excitement for successful treatment of this disorder. The pharmacological approach to treatment of OCD is summarized in Table 12–27.


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TABLE 12–28. Cognitive and behavioral approaches to treating obsessive-compulsive disorder

Behavioral treatments of OCD (Table 12–28) can be highly effective and involve two main components: 1) exposure procedures that aim to decrease the anxiety associated with obsessions and 2) response prevention techniques that aim to decrease the frequency of rituals or obsessive thoughts.


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TABLE 12–29. DSM-IV-TR diagnostic criteria for posttraumatic stress disorder

The current DSM-IV-TR diagnostic criteria for PTSD are presented in Table 12–29.

(continued)


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TABLE 12–30. Risk factors for posttraumatic stress disorder (PTSD)

There is agreement that a variety of premorbid risk factors predispose to the development of PTSD (Table 12–30).


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TABLE 12–31. Biological models of posttraumatic stress disorder

Biological theories related to trauma are listed in Table 12–31.


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TABLE 12–32. Course and prognosis of posttraumatic stress disorder (PTSD)

The course and prognosis of PTSD are summarized in Table 12–32.


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TABLE 12–33. Differential diagnosis of posttraumatic stress disorder (PTSD)

The differential diagnosis of PTSD is described in Table 12–33.


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TABLE 12–34. Pharmacotherapy of posttraumatic stress disorder (PTSD)

In recent years, SSRIs and other serotonergic agents have emerged as the first-line pharmacological treatment of PTSD (Table 12–34).


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TABLE 12–35. Cognitive and behavioral approaches to treating posttraumatic stress disorder

A variety of cognitive and behavioral techniques have gained increasing popularity and validation in the treatment of PTSD (Table 12–35).


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CHAPTER 12 • Key Points

Anxiety disorders are prevalent in the general population, with lifetime prevalence ranging from about 2%–3% for panic disorder and OCD to 15% for social anxiety disorder.

Anxiety disorders are highly treatable: medication and CBT constitute first-line treatments for all these disorders.

The “neurocircuitry of fear” has been implicated in all anxiety disorders except for OCD, in which there is evidence of a hyperactive orbitofrontal-limbic-basal ganglia-thalamic circuitry.

Serotonin reuptake inhibitors are the first-line treatment for all anxiety disorders.

Exposure, relaxation, and cognitive restructuring are the main types of psychotherapies helpful in treating the anxiety disorders.

12 anxiety disorders

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