Anxiety Disorders: Textbook of Psychiatry

The American Psychiatric Publishing
TEXTBOOK OF PSYCHIATRY
Fifth Edition
Edited 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
Anxiety Disorders
Eric Hollander, M.D.,
Daphne Simeon, M.D.
Slide show includes…

Topic Headings
Tables and Figures
Key Points
The American Psychiatric Publishing Textbook of Psychiatry, Fifth Edition. Edited by Hales RE, Yudofsky SC, 1
Gabbard GO. © 2008 American Psychiatric Publishing, Inc. All rights reserved. www.appi.org
CHAPTER 12 • Topic Headings
PANIC DISORDER Treatment

Definition Benzodiazepines
Clinical Description Buspirone
Onset Antidepressants
Symptoms Other Medications
Character Traits Psychotherapy
Epidemiology Combined Pharmacotherapy and Psychotherapy
Etiology
SOCIAL PHOBIA (SOCIAL ANXIETY DISORDER)
Biological Theories
Definition and Clinical Description
Psychodynamic Theories
Epidemiology and Comorbidity
Learning Theories
Etiology
Traumatic Antecedents
Psychosocial Theories
Course, Prognosis, Morbidity, and Mortality
Biological Theories
Diagnosis
Course and Prognosis
Physical Signs and Behavior
Diagnosis and Differential Diagnosis
Differential Diagnosis
Treatment
Treatment
Pharmacological Treatment
Pharmacotherapy
Cognitive and Behavioral Therapies
Psychotherapy
Other Types of Psychotherapy
GENERALIZED ANXIETY DISORDER Combination Treatment
SPECIFIC PHOBIAS
Epidemiology and Comorbidity
Etiology
Epidemiology
Biological Theories
Etiology
Psychological Theories
Psychodynamic Theory
Behavioral Theories
Differential Diagnosis
Biological Theories
Treatment
(continued)
CHAPTER 12 • Topic Headings (continued)
OBSESSIVE-COMPULSIVE DISORDER POSTTRAUMATIC STRESS DISORDER

Definition Definition
Clinical Description Clinical Description
Onset Epidemiology
Symptoms Etiology
Character Traits Risk Factors and Predictors
Epidemiology Cognitive and Behavioral Theories
Etiology Biological Theories
Psychodynamic Theory Sympathetic System
Cognitive and Behavioral Theories Endogenous Opioid System
Biological Theories Serotonergic System
Neuroanatomy and Functional Neurocircuitry Hypothalamic-Pituitary-Adrenal Axis
Neurochemistry Neuropeptides
Genetics Brain Neuroanatomy and Neurocircuitry
Course and Prognosis Genetics
Diagnosis Course and Prognosis
Differential Diagnosis Diagnosis
Treatment Differential Diagnosis
Pharmacotherapy Organic Mental Disorders
Cognitive-Behavioral Therapy Mood and Anxiety Disorders
Combination Pharmacotherapy and Psychotherapy Treatment
Other Psychotherapy Pharmacotherapy
Psychotherapy
Cognitive and Behavioral Therapies
Other Psychotherapies
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)
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
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.
TABLE 12–1. Approximate lifetime prevalence, gender ratio, and common

comorbidities for the major anxiety disorders
A diagnostic decision tree of the
anxiety disorders is presented in
Figure 12–1.
FIGURE 12–1. Diagnostic

decision tree for anxiety
disorders.
Patients may have more than one

disorder and thus must be evaluated
for each disorder.
(continued)
FIGURE 12–1. (continued)
The DSM-IV-TR definition of a panic
attack is presented in Table 12–2.
TABLE 12–2. DSM-IV-TR

diagnostic criteria for panic
attacks
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).
TABLE 12–3. DSM-IV-TR diagnostic criteria for

panic disorder with or without agoraphobia
(continued)
TABLE 12–3. (continued)
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).
FIGURE 12–2. Development of agoraphobia.
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).
There are a number of biological theories of panic disorder that figure prominently in the
psychiatric literature (Table 12–4).
TABLE 12–4. Biological models of panic disorder
The course of panic disorder without treatment is highly variable and is summarized in Table 12–5.
TABLE 12–5. Course and prognosis 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).
TABLE 12–6. Differential

diagnosis of 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.
TABLE 12–7. Comparison of

symptoms of mitral valve prolapse
and 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.
TABLE 12–8. Pharmacological treatment of

panic disorder
(continued)
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).
TABLE 12–9. Cognitive and behavioral approaches to treating panic 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).
TABLE 12–10. DSM-IV-TR diagnostic criteria for 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).
TABLE 12–11. Biological models of generalized anxiety disorder
The differential diagnosis of GAD is summarized in Table 12–12.
TABLE 12–12. Differential diagnosis of generalized anxiety disorder
The pharmacological treatment of GAD is summarized in Table 12–13.
TABLE 12–13. Pharmacological treatment of 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).
TABLE 12–14. Cognitive and behavioral approaches to treating generalized anxiety disorder
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).
TABLE 12–15. DSM-IV-TR diagnostic

criteria for social phobia
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.
TABLE 12–16. Risk factors for social anxiety
Biological theories of social phobia are summarized in Table 12–17.
TABLE 12–17. Biological models of social anxiety disorder
Social phobia is clearly a chronic and potentially highly impairing condition; course and prognosis
are summarized in Table 12–18.
TABLE 12–18. Course and prognosis of social anxiety disorder
Differential diagnosis of social anxiety disorder is summarized in Table 12–19.
TABLE 12–19. Differential diagnosis 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.
TABLE 12–20. Pharmacological treatment of 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).
TABLE 12–21. Cognitive and behavioral approaches to treating social anxiety disorder
The DSM-IV-TR diagnostic criteria for specific phobia are presented in Table 12–22.
TABLE 12–22. DSM-IV-TR diagnostic criteria for specific phobia
The essential features of
obsessive-compulsive
disorder are obsessions or
compulsions. DSM-IV-TR
criteria for OCD are
presented in Table 12–23.
TABLE 12–23.
DSM-IV-TR diagnostic
criteria for 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).
TABLE 12–24. Biological models 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).
TABLE 12–25. Course and prognosis of obsessive-compulsive disorder
The differential diagnosis of OCD is summarized in Table 12–26.
TABLE 12–26. Differential diagnosis 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.
TABLE 12–27. Pharmacological treatment of 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.
TABLE 12–28. Cognitive and behavioral approaches to treating obsessive-compulsive

disorder
The current DSM-IV-TR diagnostic criteria for PTSD are presented in Table 12–29.
TABLE 12–29. DSM-IV-TR diagnostic criteria for posttraumatic stress disorder
(continued)
There is agreement that a variety of premorbid risk factors predispose to the development of PTSD
(Table 12–30).
TABLE 12–30. Risk factors for posttraumatic stress disorder (PTSD)
Biological theories related to trauma are listed in Table 12–31.
TABLE 12–31. Biological models of posttraumatic stress disorder
The course and prognosis of PTSD are summarized in Table 12–32.
TABLE 12–32. Course and prognosis of posttraumatic stress disorder (PTSD)
The differential diagnosis of PTSD is described in Table 12–33.
TABLE 12–33. Differential diagnosis 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).
TABLE 12–34. Pharmacotherapy of

posttraumatic stress disorder (PTSD)
A variety of cognitive and behavioral techniques have gained increasing popularity and validation
in the treatment of PTSD (Table 12–35).
TABLE 12–35. Cognitive and behavioral approaches to treating posttraumatic stress

disorder
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.

Anxiety Disorders: Textbook of Psychiatry

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The American Psychiatric Publishing

Slide show includes…

PANIC DISORDER Treatment

OBSESSIVE-COMPULSIVE DISORDER POSTTRAUMATIC STRESS DISORDER

TABLE 12–1. Approximate lifetime prevalence, gender ratio, and common

FIGURE 12–1. Diagnostic

Patients may have more than one

TABLE 12–2. DSM-IV-TR

TABLE 12–3. DSM-IV-TR diagnostic criteria for

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

TABLE 12–7. Comparison of

TABLE 12–8. Pharmacological treatment of

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 12–15. DSM-IV-TR diagnostic

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

TABLE 12–19. Differential diagnosis of social anxiety disorder

TABLE 12–20. Pharmacological treatment of social anxiety disorder

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

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

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

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

 Anxiety disorders are prevalent in the general population, with lifetime

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