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
 PANIC DISORDER
Recurrent unexpected panic attacks characterized by
four or more of the following:
-Palpitations -Sweating -Trembling
-SOB -Air Hunger -Chest pain
-Nausea -Dizziness -Derealization
-Numbness/tingling -Chills/hot flashes
-Fear of losing control -Fear of dying
Persistent concern of future attacks.
Avoidance behavior related to the attacks.
+/- Presence of Agoraphobia
 GENERALIZED ANXIETY
DISORDER
• Excessive anxiety and worry about a number of
events or activities
• Worry is difficult to control
• Worry is associated with:
-Restlessness -Fatigue -Irritability
-Difficulty concentrating -Sleep disturbance
-Muscle tension
• Anxiety/worry cause significant distress and
impairment in daily functioning.
 SOCIAL PHOBIA
• Marked and persistent fear of one or more
social or performance situations in which
the person is concerned about negative
evaluation or scrutiny by other, i.e.
-Public speaking
-Eating or drinking in public
-Initiating or maintaining conversations
• Fears humiliation or embarrassment.
• Avoids social or performance situations.
 SPECIFIC PHOBIA
• Marked and persistent fear that is excessive,
unreasonable, cued by the presence of anticipation of a
specific object or situation, for example:
Flying Enclosed spaces
Heights Storms
Animals Blood

• Provokes an immediate anxiety response.

• Recognition that the fear is excessive or unreasonable
• Avoidance, anticipatory anxiety, or distress is
significantly impairing.
 AGORAPHOBIA
• Fear of being in places or situation from
which escape might be difficult,
embarrassing, or in which help may be
unavailable in the event of a panic attack.
• Often results in avoidance of the feared
places or situation, for example:
Crowds, Stores, Traveling on bus,
train, airplane, etc.
 OBSESSIVE-COMPULSIVE
DISORDER
Obsessions--recurrent and persistent thought,
impulses, or images that are experienced as
intrusive and inappropriate, examples are:
-Contamination -Repeated doubts
-Order -Impulses
-Sexual images
• Obsessions cause marked distress, are time
consuming (more than 1 hour/day), or cause
significant impartment in social, occupational or
other daily functioning.
 OBSESSIVE-COMPULSIVE
DISORDER (cont.)
Compulsions – repetitive behaviors or
mental acts whose goal is to prevent or
reduce anxiety or distress, examples are:
-Hand washing -Ordering
-Checking -Counting
-Repeating words
• There is recognition that the fear is
excessive or unreasonable.
 POSTTRAUMATIC STRESS
DISORDER
• Onset of symptoms following exposure to
traumatic event.
• Event includes witnessing or experiencing threat
to physical integrity causing intense fear or
horror, for example:
-Combat assault -Violent accident/crime
-Natural disaster -Physical/sexual abuse
• Characterized by:
-Reexperiencing the trauma
-Avoiding stimuli associated with the trauma,
-Experiencing increased autonomic arousal
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)
 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.