Anxiety Disorders, 1986 Psychological and Biological Perspectives

Anxiety is one of those entltles which everyone "knows", but which ultimately resists simple objective description. The essence of the phenomenon is its subjectivity. True it has its well documented associated physiological events: the increased pulse rate and blood pressure, sweating, and so on, but each of these phenomena may also be part of physical exertion, fear, or even pleasurable excitement. They cannot fully define the sense of threat, danger, collapse, malignancy in greater or smaller amount, in greater or lesser locali­ sation, with more or less objective evidence for its validity that characterises the particular psychological pain we all recognize as anxiety. It is precisely the essential subjectivity of anxiety and its association with an enormous range of experience that makes it difficult to assign to it well-defined diagnostic labels of the kinds so carefully described by Dr. Spitzer in his chapter on classification. His chapter ranges from the extreme dread of "Panic Disorders", to the diffuse terror of the environment which used to be labelled "Agoraphobia" (and is still so called in the day to day pragmatic usage of many clinics) and is not assimilated to the class of phobias with the label "Social Phobias". He also addresses the "Simple Phobias" which are perhaps the most readily labelled of the many varieties of anxiety.

Section I: Classification and Nosology.- Proposed Revisions in the DSM-III Classification of Anxiety Disorders Based on Research and Clinical Experience.- Background.- Overview of the DSM-III Anxiety Disorders.- Phobic Disorders.- Anxiety States.- Obsessive-Compulsive Disorders.- Post-Traumatic Stress Disorder (PTSD).- Problems and Proposed Solutions for Defining the Disorders.- Hierarchic Structure of the Classification.- Problems Defining the Individual Disorders.- Agoraphobia.- Agoraphobia without Panic Attacks.- Social Phobia.- Simple Phobia.- Panic Disorder.- Generalized Anxiety Disorder.- Obsessive Compulsive Disorder.- Post-Traumatic Stress Disorder.- Anxiety Syndromes Due to Known Organic Factors.- Conclusion.- References.- Appendix: Proposed Diagnostic Criteria for the Anxiety Disorders Section of DSM-III-R.- Anxiety Disorders.- Panic Disorder.- Limited Sympton Attacks with Phobic Avoidance (Agoraphobia Without Panic Attacks).- Social Phobia.- Simple Phobia.- Obsessive-Compulsive Disorder.- Generalized Anxiety Disorder.- Anxiety Disorder Not Otherwise Specified (NOS).- Post Traumatic Stress Disorder.- The Differentiation of Anxiety and Depressive Syndromes.- Differentiation of Anxiety from Depression at the Symptom Level.- Distinction Between Anxiety and Depressive Disorders.- Epidemiology of Anxiety and Affective Disorders.- Anxiety and Depression as Separate Disorders.- Factor Analytic Studies.- Anxiety and Depression as Part of a Single Disorder.- Life Events, Anxiety and Depression.- Conclusions.- References.- Section 2: Basic Science Studies of Anxiety.- The Neurobiology of Anxiety: A Tale of Two Systems.- The Benzodiazepine Receptor and Anxiety.- Molecular Perspective.- From Pharmacology to Pathophysiology.- Anatomic Perspective.- The Biology of Anxiety — Clinical Perspective.- Panic Disorder.- Genetic Factors and Panic Disorder.- Panic Disorder and Mitral Valve Prolapse.- Pharmacology of Panic Disorders.- A Noradrenergic Hypothesis of Panic Disorder.- Summary.- References.- The Psychophysiology of Anxiety and Hedonic Affect: Motivational Specificity.- A Theory of Motivation.- Gray’s Model.- Implications of Psychophysiology.- Further Research on Motivation and Psychophysiology.- Heart Rate.- Electrodermal Activity.- State and Trait Anxiety.- References.- Anxiety and Memory.- Do Emotions Cue Memories?.- Is Emotional Memory a Semantic Network?.- What Responses Cue Pleasant and Unpleasant Memories?.- Is Arousal a Cue for Memory Retrieval?.- Does Emotional Excitation Transfer from One Emotional State to Another?.- The Information Taxonomy of Emotional Memory.- Response Information.- Stimulus and Meaning Information.- An Information Processing View of Fear and Anxiety.- Imagery, Emotion and Action.- Matching Concepts in Memory.- Summary and Conclusions.- References.- Section 3: Psychological Treatment.- A Psychological Model of Panic.- What is Panic.- Are Panic Attacks Limited to Panic Disorder or Agoraphobia with Panic?.- Phenomenology of Panic Attacks.- Is There a Difference Between Predictable and Unpredictable Panic?.- Treatment Implications.- Conclusions.- References.- Cognitive Approaches to Anxiety Disorders.- Legacies from the Past.- Flight-Freeze-Faint Axis.- Prolongation of Juvenile Patterns.- The “Internal Saboteur”.- The Mechanisms of Anxiety.- Subjective Anxiety as a “Danger Signal”.- The Appraisal of Vulnerability.- The Vicious Cycles.- The Anxiety Disorders and Vulnerabilities.- Panic Disorders.- Agoraphobia.- Simple Phobias.- Susceptibility to Anxiety Disorders.- Treatment of Anxiety Disorders.- Cognitive Analysis and Therapy.- Hypothesis Testing.- Cognitive Restructuring.- Automatic Thoughts.- Reality Testing.- Hypothesis Testing.- Dysfunctional Attitudes.- Exposure Therapy.- Controlled Studies of Anxiety.- Summary.- References.- Exposure-Based Treatments for Anxiety Disorders.- Selection of Anxiety Disorders for Exposure Treatment.- Method and Outcome of Behavioral Treatment: Exposure.- Side Effects of Exposure Requiring Treatment.- Durability of Outcome After Exposure.- Prevention of Phobias by Pre-Exposure.- How Do Exposure and Drug Treatment Relate in Phobic and Obsessive-Compulsive Disorders.- Anxiety Disorders without Situational Anxiety (Non-Phobic, Non-Obessive-Compulsive).- References.- Psychosocial Treatment of Anxiety Disorders.- The Importance of Being Theoretical.- Theoretical Mechanisms in Exposure Treatment.- A Social Learning Analysis.- Some Treatment Guidelines.- Cognitive Processes Versus Procedures.- Conditioning Verus a Social Learning Formulation of In Vivo Exposure.- Concluding Comments.- References.- Self-Control Skills for the Treatment of Anxiety Disorders.- Perceived Control.- Self-Efficacy.- Systematic Desensitization as a Coping Skill.- Relaxation as a Coping Skill.- Cognitive Restructuring as a Coping Skill.- Control and its Impact on Anxiety.- Reconsideration of Cognition and Coping in Anxiety.- Summary.- References.- Section 4: Pharmacological Treatment.- New Perspectives on the Treatment of Panic and Phobic Disorders.- Relationship Between Panic Disorder and Phobias.- Treatment Studies.- First Treatment Study.- Drug Sensitivity.- Second Treatment Study.- Third Treatment Study.- Use of Benzodiazepines.- Imipramine as Sole Treatment.- Summary.- References.- The Use of Benzodiazepines in Anxiety Disorders.- The Benzodiazepines.- Clinical Uses.- Arguments Against Benzodiazepine Use.- Benzodiazepines in Anxiety Disorders.- Long-Term Use of Benzodiazepines in Anxiety Disorders.- Conclusions.- References.- New Approaches to the Pharmacological Treatment of Anxiety and Depression.- Anxiety.- Panic Disorder and Anxiety.- New Anti-anxiety Drugs.- Depression.- Neuroendocrine Approaches.- Therapeutic Advances.- Mechanisms of Action of Antidepressants.- Ad junct Treatment with Precursors.- Potentiators of Antidepressant Therapy.- Lithium.- Thyroid Extracts.- Methylphenidate.- Estrogen.- Second Generation Antidepressants.- Conclusion.- References.- Section 5: Summary.- Anxiety Disorders: Future Directions and Closing Comments.- Issues in the Conceptualization and Assessment of Anxiety Disorders.- Reclassification of Diagnostic Criteria.- Outstanding Assessment Issues.- Functional Assessment.- Assessment of Response Modes.- Issues in the Treatment of Anxiety Disorders.- Process vs. Outcome Research.- Alternative Treatments.- Integration.- References.- Contributors.