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.

 !"!  !"  #$!  #

%
 &&& '' #



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

Slide show includes

|' !
 #
|
O #

)
" 

|

 
  
  |
 
   O
    
 


  
 ! "!  !"  # $!  #

%
  &&& '' #


 
  
PANIC DISORDER
Definition
Clinical Description


 ' 
!
| 
Epidemiology
Etiology
* # !|


"! !|


+
 #|


|  !
!


Course, Prognosis, Morbidity, and Mortality
Diagnosis
" ! #*
% 
,



 , # 
Treatment
" !
'
"!
'
GENERALIZED ANXIETY DISORDER
Definition and Clinical Description
Epidemiology and Comorbidity
Etiology
* # !|


"!# !|


Course and Prognosis
Differential Diagnosis

Treatment
*
- -
' 

*' 

 
'


.
 ! 
Psychotherapy
Combined Pharmacotherapy and Psychotherapy
SOCIAL PHOBIA (SOCIAL ANXIETY DISORDER)
Definition and Clinical Description
Epidemiology and Comorbidity
Etiology
"!! |


* # !|


Course and Prognosis
Diagnosis and Differential Diagnosis
Treatment
" !# !|


#  %
*
% |
'


|'

"!
'
   |


SPECIFIC PHOBIAS
Definition and Clinical Description
Epidemiology
Etiology
"! !|

*
% |


* # !|


Course and Prognosis
Treatment

|

 
  
  |
 
   O
    
 


  
 ! "!  !"  # $!  #

%
  &&& '' #





 
  

OBSESSIVE-COMPULSIVE DISORDER
Definition
Clinical Description


 ' 
!
| 
Epidemiology
Etiology
"! !|

#  %
*
% |


* # !|


Neuroanatomy and Functional Neurocircuitry
Neurochemistry
Genetics
Course and Prognosis
Diagnosis
,



 , # 
Treatment
" !
'
#  %
0*
% |
'
   " !
'"!
'

"!
'

POSTTRAUMATIC STRESS DISORDER

Definition
Clinical Description
Epidemiology
Etiology
Risk Factors and Predictors
Cognitive and Behavioral Theories
Biological Theories
 '
 !

#
'  



# !

' !0"  0

1 
2
'
' 

* 2
 2
! ! 


 !
Course and Prognosis
Diagnosis
Differential Diagnosis
# !.
, 

.1
, 

Treatment
" !
'
"!
'
#  %
*
% |
'

Other Psychotherapies

|

 
  
  |
 
   O
    
 


  
 ! "!  !"  # $!  #

%
  &&& '' #


 

Table 121.

''1 



'
%
!
#

 !
1
 


!   


 4

Figure 121.

, # !
!  


1
 


Table 122.

,.0$50| # !! 

 
' !!

Table 123.

,.0$50| # !! 

 
' ! 
& & #' 

Figure 122.

,
%
'

#' 

Table 124.

* # ! 

' ! 


Table 125.


'# 
' ! 


Table 126.

,



  # 
' ! 


Table 127.

 ' 
 ' 


Table 128.

" !# !



' ! 


Table 129.

#  %

% ''!

 #' ! 


Table 1210.

,.0$50| # !! 

 
#

 -
1
 


Table 1211.

* # ! 

#

 -
1
 


Table 1212.

,



  # 
#

 -
1
 


Table 1213.

" !# !



#

 -
1
 


Table 1214.

#  %

% ''!

 ##

 -
1
 


Table 1215.

,.0$50| # !! 

 
! ' 

Table 1216.

 
!
! 1


Table 1217.

* # ! 

! 1
 


Table 1218.


'# 
! 1
 


%%
''
' ! 



|

 
  
  |
 
   O
    
 


  
 ! "!  !"  # $!  #

%
  &&& '' #


 


Table 1219.

,



  # 
! 1
 


Table 1220.

" !# !



! 1
 


Table 1221.

#  %

% ''!

 #! 1
 


Table 1222.

,.0$50| # !! 

 
'
!
!' 

Table 1223.

,.0$50| # !! 

 

 %
0! ' %
 


Table 1224.

* # ! 


 %
0! ' %
 


Table 1225.


'# 

 %
0! ' %
 


Table 1226.

,



  # 

 %
0! ' %
 


Table 1227.

" !# !




 %
0! ' %
 


Table 1228.

#  %

% ''!

 #
 %
0! ' %
 


Table 1229.

,.0$50| # !! 

 
'  !
 


Table 1230.

 
!
'  !
 
7"|,8

Table 1231.

* # ! 

'  !
 


Table 1232.


'# 
'  !
 
7"|,8

Table 1233.

,



  # 
'  !
 
7"|,8

Table 1234.

" !
'
'  !
 
7"|,8

Table 1235.

#  %

% ''!

 #'  !
 


Summary

)
" 

|

 
  
  |
 
   O
    
 


  
 ! "!  !"  # $!  #

%
  &&& '' #

Anxiety disorders are the most common of all psychiatric illnesses and result in considerable functional
impairment and distress. Table 121 presents a summary overview of the prevalence, gender ratio, and
comorbidities of the major anxiety disorders.

TABLE 121. Approximate lifetime prevalence, gender ratio, and common comorbidities
for the major anxiety disorders

|

 
  
  |
 
   O
    
 


  
 ! "!  !"  # $!  #

%
  &&& '' #

A diagnostic decision tree of the

anxiety disorders is presented in
Figure 121.

FIGURE 121. Diagnostic

decision tree for anxiety
disorders.
"
 %
 


 
 

%



! 



|

 
  
  |
 
   O
    
 


  
 ! "!  !"  # $!  #

%
  &&& '' #

FIGURE 121. (continued)

|

 
  
  |
 
   O
    
 


  
 ! "!  !"  # $!  #

%
  &&& '' #

The DSM-IV-TR definition of a _


  is presented in Table 122.

TABLE 122. DSM-IV-TR

diagnostic criteria for panic
attacks

|

 
  
  |
 
   O
    
 


  
 ! "!  !"  # $!  #

%
  &&& '' #

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 123).

TABLE 123. DSM-IV-TR diagnostic criteria for

panic disorder with or without agoraphobia


|

 
  
  |
 
   O
    
 


  
 ! "!  !"  # $!  #

%
  &&& '' #

(

TABLE 123. (continued)

|

 
  
  |
 
   O
    
 


  
 ! "!  !"  # $!  #

%
  &&& '' #

((

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 122).

FIGURE 122. Development of agoraphobia.







1'
!
' !
!
'

%
'!


'0

 #
% 
 
''

 
!  # ! !
1
 


 

#' !
% 


|

 
  
  |
 
   O
    
 


  
 ! "!  !"  # $!  #

%
  &&& '' #

(

There are a number of biological theories of panic disorder that figure prominently in the
psychiatric literature (Table 124).

TABLE 124. Biological models of panic disorder

|

 
  
  |
 
   O
    
 


  
 ! "!  !"  # $!  #

%
  &&& '' #

(/

The course of panic disorder without treatment is highly variable and is summarized in Table 125.

TABLE 125. Course and prognosis of panic disorder

|

 
  
  |
 
   O
    
 


  
 ! "!  !"  # $!  #

%
  &&& '' #

(3

The diagnosis of panic disorder is not always obvious, and a number of other psychiatric and medical
disorders may mimic this condition (Table 126).

TABLE 126. Differential

diagnosis of panic disorder

|

 
  
  |
 
   O
    
 


  
 ! "!  !"  # $!  #

%
  &&& '' #

(6

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 127.

TABLE 127. Comparison of

symptoms of mitral valve prolapse
and panic disorder

|

 
  
  |
 
   O
    
 


  
 ! "!  !"  # $!  #

%
  &&& '' #

(9

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 128.

TABLE 128. Pharmacological treatment of

panic disorder


|

 
  
  |
 
   O
    
 


  
 ! "!  !"  # $!  #

%
  &&& '' #

(:

TABLE 128. (continued)

|

 
  
  |
 
   O
    
 


  
 ! "!  !"  # $!  #

%
  &&& '' #

(

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 129).

TABLE 129. Cognitive and behavioral approaches to treating panic disorder

|

 
  
  |
 
   O
    
 


  
 ! "!  !"  # $!  #

%
  &&& '' #

(;

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 1210).

TABLE 1210. DSM-IV-TR diagnostic criteria for generalized anxiety disorder

|

 
  
  |
 
   O
    
 


  
 ! "!  !"  # $!  #

%
  &&& '' #



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 1211).

TABLE 1211. Biological models of generalized anxiety disorder

|

 
  
  |
 
   O
    
 


  
 ! "!  !"  # $!  #

%
  &&& '' #

(

The differential diagnosis of GAD is summarized in Table 1212.

TABLE 1212. Differential diagnosis of generalized anxiety disorder

|

 
  
  |
 
   O
    
 


  
 ! "!  !"  # $!  #

%
  &&& '' #



The pharmacological treatment of GAD is summarized in Table 1213.

TABLE 1213. Pharmacological treatment of generalized anxiety disorder

|

 
  
  |
 
   O
    
 


  
 ! "!  !"  # $!  #

%
  &&& '' #

/

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 1214).

TABLE 1214. Cognitive and behavioral approaches to treating generalized anxiety disorder

|

 
  
  |
 
   O
    
 


  
 ! "!  !"  # $!  #

%
  &&& '' #

3

The central feature of social phobia is a marked, persistent fear of social situations in which public
humiliation or embarrassment is possible (Table 1215).

TABLE 1215. DSM-IV-TR diagnostic

criteria for social phobia

|

 
  
  |
 
   O
    
 


  
 ! "!  !"  # $!  #

%
  &&& '' #

6

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 1216.

TABLE 1216. Risk factors for social anxiety

|

 
  
  |
 
   O
    
 


  
 ! "!  !"  # $!  #

%
  &&& '' #

9

Biological theories of social phobia are summarized in Table 1217.

TABLE 1217. Biological models of social anxiety disorder

|

 
  
  |
 
   O
    
 


  
 ! "!  !"  # $!  #

%
  &&& '' #

:

Social phobia is clearly a chronic and potentially highly impairing condition; course and prognosis
are summarized in Table 1218.

TABLE 1218. Course and prognosis of social anxiety disorder

|

 
  
  |
 
   O
    
 


  
 ! "!  !"  # $!  #

%
  &&& '' #



Differential diagnosis of social anxiety disorder is summarized in Table 1219.

TABLE 1219. Differential diagnosis of social anxiety disorder

|

 
  
  |
 
   O
    
 


  
 ! "!  !"  # $!  #

%
  &&& '' #

;

The pharmacological treatment of social anxiety disorder is summarized in Table 1220. There are a number
of medication options that are clearly helpful.

TABLE 1220. Pharmacological treatment of social anxiety disorder

|

 
  
  |
 
   O
    
 


  
 ! "!  !"  # $!  #

%
  &&& '' #

/

Three major cognitive-behavioral techniques are used in the treatment of social phobia: exposure,
cognitive restructuring, and social skills training (Table 1221).

TABLE 1221. Cognitive and behavioral approaches to treating social anxiety disorder

|

 
  
  |
 
   O
    
 


  
 ! "!  !"  # $!  #

%
  &&& '' #

/(

The DSM-IV-TR diagnostic criteria for specific phobia are presented in Table 1222.

TABLE 1222. DSM-IV-TR diagnostic criteria for specific phobia

|

 
  
  |
 
   O
    
 


  
 ! "!  !"  # $!  #

%
  &&& '' #

/

The essential features of

obsessive-compulsive
disorder are obsessions or
compulsions. DSM-IV-TR
criteria for OCD are
presented in Table 1223.

TABLE 1223.
DSM-IV-TR diagnostic
criteria for obsessivecompulsive disorder

|

 
  
  |
 
   O
    
 


  
 ! "!  !"  # $!  #

%
  &&& '' #

//

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 1224).

TABLE 1224. Biological models of obsessive-compulsive disorder

|

 
  
  |
 
   O
    
 


  
 ! "!  !"  # $!  #

%
  &&& '' #

/3

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 1225).

TABLE 1225. Course and prognosis of obsessive-compulsive disorder

|

 
  
  |
 
   O
    
 


  
 ! "!  !"  # $!  #

%
  &&& '' #

/6

The differential diagnosis of OCD is summarized in Table 1226.

TABLE 1226. Differential diagnosis of obsessive-compulsive disorder

|

 
  
  |
 
   O
    
 


  
 ! "!  !"  # $!  #

%
  &&& '' #

/9

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 1227.

TABLE 1227. Pharmacological treatment of obsessive-compulsive disorder

|

 
  
  |
 
   O
    
 


  
 ! "!  !"  # $!  #

%
  &&& '' #

/:

Behavioral treatments of OCD (Table 1228) 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 1228. Cognitive and behavioral approaches to treating obsessive-compulsive

disorder

|

 
  
  |
 
   O
    
 


  
 ! "!  !"  # $!  #

%
  &&& '' #

/

The current DSM-IV-TR diagnostic criteria for PTSD are presented in Table 1229.

TABLE 1229. DSM-IV-TR diagnostic criteria for posttraumatic stress disorder


|

 
  
  |
 
   O
    
 


  
 ! "!  !"  # $!  #

%
  &&& '' #

/;

TABLE 1229. (continued)

|

 
  
  |
 
   O
    
 


  
 ! "!  !"  # $!  #

%
  &&& '' #

3

There is agreement that a variety of premorbid risk factors predispose to the development of PTSD
(Table 1230).

TABLE 1230. Risk factors for posttraumatic stress disorder (PTSD)

|

 
  
  |
 
   O
    
 


  
 ! "!  !"  # $!  #

%
  &&& '' #

3(

Biological theories related to trauma are listed in Table 1231.

TABLE 1231. Biological models of posttraumatic stress disorder

|

 
  
  |
 
   O
    
 


  
 ! "!  !"  # $!  #

%
  &&& '' #

3

The course and prognosis of PTSD are summarized in Table 1232.

TABLE 1232. Course and prognosis of posttraumatic stress disorder (PTSD)

|

 
  
  |
 
   O
    
 


  
 ! "!  !"  # $!  #

%
  &&& '' #

3/

The differential diagnosis of PTSD is described in Table 1233.

TABLE 1233. Differential diagnosis of posttraumatic stress disorder (PTSD)

|

 
  
  |
 
   O
    
 


  
 ! "!  !"  # $!  #

%
  &&& '' #

33

In recent years, SSRIs and other serotonergic agents

have emerged as the first-line pharmacological
treatment of PTSD (Table 1234).

TABLE 1234. Pharmacotherapy of

posttraumatic stress disorder (PTSD)

|

 
  
  |
 
   O
    
 


  
 ! "!  !"  # $!  #

%
  &&& '' #

36

A variety of cognitive and behavioral techniques have gained increasing popularity and validation
in the treatment of PTSD (Table 1235).

TABLE 1235. Cognitive and behavioral approaches to treating posttraumatic stress

disorder

|

 
  
  |
 
   O
    
 


  
 ! "!  !"  # $!  #

%
  &&& '' #

39


 


1
 

'
%
 
#

'' & 



'
%
!
# #
 </<
' ! 
,(6<

! 1
 

1
 

 #

=
 ! *|! 

0 






 

|
>
! ! 


?

 ' !
 1
 

1!
'

, & !

 
% 
!

'
! %
 
0  !0
## 0 !! ! 

 
'
   


0 



1

 

1'

1 !#  %

! #

  '


'!
'

'
 
 #
1
 


|

 
  
  |
 
   O
    
 


  
 ! "!  !"  # $!  #

%
  &&& '' #

3: