Anxiety disorders clinical presentation

The clinical presentation of anxiety disorders according to the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders is siunmarized by R. Lieb. In addition, selected aspects (prevalence, correlates, risk factors and comorbidity) of epidemiological knowledge on anxiety disorders are presented. 

The development of mild forms of anxiety and neuroveg-etative and/or cognitive responses to stress may represent an adaptive evolutionary step against environmentally (external) or self-triggered (internal) threats, but maladaptive reactions have also emerged in human evolution. Thus, anxiety disorders are maladaptive conditions in which disproportionate responses to stress, or even self-evoked responses, are displayed. Anxiety disorders are one of the most frequent psychiatric illnesses, and have a lifetime prevalence of 15- 20% [1, 89]. The most common presentations are generalized anxiety disorder, with a lifetime prevalence rate of close to 5% [1, 89] social anxiety disorder, with very variable lifetime prevalence rates ranging from 2 to 14% [90] panic disorder, with rates from 2 to 4% [1,89] and post-traumatic stress disorder (PTSD), with a prevalence rate close to 8%. Specific phobias, acute stress and obsessive-compulsive behavior are other clinical presentations of anxiety disorders. 

DSM-IV specifies a total of 12 anxiety disorders, but starts by defining panic attacks. Panic attacks are defined separately but are not considered as a separate diagnostic category because they may occur in many of the other anxiety disorders. Likewise, agoraphobia and panic disorder are not considered as specific anxiety diagnoses but rather their combination. In the following, a description of the clinical presentation will be given ... 

Guidance on the clinical indications for benzodiazepine therapy is available from various sources (Task Force Report of the American Psychiatric Association 1990 Ballenger et al. 1998a Bandelow et al. 2002). Long-term therapy is most likely to present problems with discontinuation and is usually reserved for cases that have proved resistant to treatment with antidepressants alone. Patients may benefit from a 2-4 week course of a benzodiazepine whilst antidepressant therapy is initiated, as this counteracts the increased anxiety caused by some drugs (Goddard et al. 2001). A benzodiazepine maybe useful as a hypnotic in some cases of anxiety disorder, and can be used by phobic patients on an occasional basis before exposure to a feared situation. 

The commonly used classes of antidepressants are discussed in the following sections, and information about doses and half-lives is summarized in Table 2-1. The antidepressant classes are based on similarity of receptor effects and side effects. All are effective against depression when administered in therapeutic doses. The choice of antidepressant medication is based on the patient s psychiatric symptoms, his or her history of treatment response, family members history of response, medication side-effect profiles, and comorbid disorders (Tables 2-2 and 2-3). In general, SSRIs and the other newer antidepressants are better tolerated and safer than TCAs and MAOIs, although many patients benefit from treatment with these older drugs. In the following sections, clinically relevant information is presented for the antidepressant medication classes individually, and the pharmacological treatment of depression is also discussed. The use of antidepressants to treat anxiety disorders is addressed in Chapter 3. 

In this chapter, we discuss the pharmacology of medications that are classified as anxiolytic, sedative, or hypnotic—primarily the benzodiazepines, buspirone, zolpidem, eszopiclone, and zale-plon. Subsequently, we present diagnosis-specific treatment guidelines (outlined in Table 3-1). The commonly used anxiolytics and hypnotics, together with their usual doses, are shown in Table 3-2. Many antidepressant medications are also effective in the treatment of anxiety disorders. The pharmacology of antidepressants is discussed in Chapter 2 their clinical use in anxiety disorders is addressed in the diagnosis-specific sections later in this chapter. 

Finally, it is important for the clinician to keep in mind that there are myriad medical disorders capable of producing anxiety symptoms, not in response to the perception that one is suffering from a disabling or even lethal condition, but as part of one s own symptomatological picture. These disorders may involve one or more bodily systems and require a proper clinical workup by a physician so that the clinician is not treating an anxiety disorder when in fact treatment for a medical disorder is needed. Some examples of medical conditions that may present with anxiety are listed in Table 4.2. 

Humans were not untouched by this disaster. Visits to community clinics for primary care and mental health services in the affected area increased dramatically after the spill (Impact Assessments, 1990). Exposure to the incident was shown to have a profound impact on the prevalence of psychiatric disorders with increased rates of generalized anxiety disorder, posttraumatic stress disorder, and depressive symptoms present in the population (Palinkas, Petterson, Russell, Downs, 1993). 

Anxiety symptoms are an inherent part of the initial clinical presentation of several diseases, thus complicating the distinction between anxiety disorders and medical disorders. If the anxiety symptoms are secondary to a medical illness, they usually will subside as the medical situation stabilizes. However, the knowledge that one has a physical illness (e.g., cancer and diabetes) can trigger anxious feelings and further complicate therapy. Persistent anxiety subsequent to a physical illness requires further assessment for an anxiety disorder. Symptoms of anxiety frequently present in medical disorders include palpitations, tachycardia, chest pain or tightness, shortness of breath, and hyperventilation. Medical disorders most closely associated with anxiety are listed in Table 69-1. " About 50% of patients with GAD have irritable bowel syndrome. ... 

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