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This article has reviewed clinical and demographic features of the primary anxiety disorders and other psychiatric and medical disorders that often are associated with anxiety symptoms, highlighting differential diagnosis. In summary, phobic disorders (exogenous anxiety) are characterized by anxiety reliably elicited by specific environmental stimuli; the stimuli involved determine which type of phobia is diagnosed. In contrast, panic attacks and generalized anxiety (endogenous anxiety) involve symptoms of anxiety not associated only with specific eliciting stimuli. Panic disorder is differentiated from generalized anxiety disorder by the presence of discrete attacks; both disorders usually have some level of persistent anxiety. Obsessive-compulsive disorder is characterized by recurrent unwanted but irresistible thoughts and the ritualized repetitive acts resulting from these obsessions, in the absence of preexisting psychosis or depression. Finally, posttraumatic stress disorder involves various anxiety (and other) symptoms as a direct result of an obvious stressor. Depressive symptoms are frequently associated with anxiety. It is sometimes impossible to determine which is the primary disorder. Overlap of syndromes probably also occurs with other primary psychiatric disorders, especially somatoform disorders, adjustment disorder with anxious mood, and several personality disorders. Finally, primary anxiety can be confused with several medical syndromes, especially when the medical disorder has not been recognized. Nevertheless, research with patients with pheochromocytoma suggests that medical causes of anxiety may be qualitatively different from primary anxiety disorders, especially the psychic anxiety component. Attention to the clinical and demographic features listed in Table 4, as well as the use of newly-developed structured diagnostic interviews should usually lead to a correct diagnosis, as illustrated by the following examples. The onset of a fear of public speaking in mid-adolescence suggests an uncomplicated social phobia, whereas the onset in the mid-twenties of several social and other situational anxieties in a person with a previous history of panic attacks would be strongly suggestive of the panic-agoraphobia syndrome. The new onset of generalized anxiety symptoms and depression in a 45-year-old patient who has had a previous significant depression would suggest that this person's anxiety is part of, and secondary to, the affective disorder and not a primary anxiety disorder.(ABSTRACT TRUNCATED AT 400 WORDS)
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PMID:The differential diagnosis of anxiety. Psychiatric and medical disorders. 388 37

One hundred twenty-six patients presenting at an anxiety disorders research clinic were administered a structured interview. Diagnoses were made on the basis of DSM-III criteria but without regard to current exclusionary systems within DSM-III. Rather, clinicians decided whether anxiety and depressive symptoms that met DSM-III criteria for additional diagnoses were associated features of the presenting problem or represented an independent coexisting complication. Diagnoses and accompanying psychometric data delineated groups of patients with somewhat different clinical and psychometric characteristics. But additional anxiety and depressive diagnoses were required in a number of cases. Anxiety states almost always required additional diagnoses whereas for the phobic disorders additional diagnoses occurred less frequently. Simple and social phobia were the most frequent additional diagnoses, but depression was more strongly associated with some anxiety disorders, specifically obsessive-compulsive disorder. In view of the treatment implications of comorbidity, establishing the functional relationships among anxiety symptoms without regard to exclusionary systems would seem important in both clinical and research settings.
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PMID:Co-morbidity and depression among the anxiety disorders. Issues in diagnosis and classification. 394 96

Our objective was to assemble expert clinical experience and judgment in the treatment of anxiety and related disorders in a systematic, quantitative manner. This article reports on some clinical features apart from diagnosis that may affect choice of strategy in the pharmacotherapy of anxiety disorders. A panel of internationally recognized experts in treating anxiety and depression was constituted by multistage peer nomination. Ninety percent (66 of 73) completed an extensive questionnaire. This report focuses on the expert panel's responses to questions on therapeutic options, based on multi-part case vignettes of several anxiety disorders presenting clinical variations within the same diagnosis. In the presence of higher levels of functional impairment, the experts more often recommended formal psychosocial procedures for adjustment disorder; medication for agoraphobia, social phobia, obsessive-compulsive disorder, and adjustment disorder; and polypharmacy for agoraphobia. Their therapeutic recommendations were not materially affected by chronicity in the case of panic disorder. Under the condition of heavy use of alcohol in the case of generalized anxiety disorder, the experts avoided benzodiazepines in favor of various other medications. In the presence of a serious cardiac conduction defect in the case of obsessive-compulsive disorder, they less often recommended medication. Those who did recommend medication changed their preference from tricyclic antidepressants (clomipramine) to selective serotonin reuptake inhibitors. Under the condition of a more severe precipitating event in the case of adjustment disorder, the experts were more likely to recommend both formal psychosocial intervention and medication.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:International study of expert judgment on therapeutic use of benzodiazepines and other psychotherapeutic medications: III. Clinical features affecting experts' therapeutic recommendations in anxiety disorders. 749 81

The present study is a preliminary evaluation of the effectiveness of a new cognitive-behavioral group treatment protocol for social phobia in adolescents. Five adolescents with social phobia were treated in a 16-session group treatment program, with parental involvement in selected sessions. Treatment involved skills training (social skills, problem solving, assertiveness), cognitive restructuring, behavioral exposure, and homework. Self-report measures of anxiety and depression, taken throughout treatment, indicated significant improvements over a 1-year follow-up period. Behavior test measures also indicated a decrease in subjective anxiety ratings after treatment which was maintained at follow-up. Structured diagnostic interviews 1 year after treatment confirmed full remission of social phobia for four subjects, with one subject's phobia in partial remission. Overall, the present findings support the continued evaluation of this protocol for social phobic adolescents.
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PMID:Cognitive-behavioral group treatment for social phobia in adolescents. A preliminary study. 756 11

Body dysmorphic disorder (BDD) refers to preoccupation with an imagined physical defect or the exaggeration of a slight physical anomaly. Since BDD's inclusion in the DSM-III-R, there have been only a handful of reports of its cognitive-behavioral treatment. We describe one successful short-term cognitive-behavioral therapy treatment of a BDD patient whose presenting concern was small hand size. After nine sessions of therapy, the patient evidenced substantial change on indices measuring affective, cognitive, and behavioral facets of BDD. There was also clinically meaningful improvement in overall levels of depression and anxiety. It is suggested that cognitive-behavioral treatment programs for BDD should take into account comorbid conditions such as social phobia, and avoidant personality disorder.
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PMID:Cognitive-behavioral treatment of body dysmorphic disorder: a case report. 759 90

The objective of this study was to describe preliminary experience with moclobemide in the treatment of depressive disorders in the University outpatient clinic in Malaysia. Twenty patients who satisfied DSM III R criteria for depressive disorders and scored more than 16 on the Hamilton Rating Depression Score at the initial interview were recruited into this open study. The primary diagnosis of 4 patients was later ascertained to be panic disorder(2), schizophrenia(1) and social phobia(1). Patients rated themselves as improved by first follow up (7-14 days), and rated their depression as very mild to mild by the third follow up visit (ie at a mean of 46 days). Side effects were minimal and compliance good.
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PMID:Preliminary experience with moclobemide for the treatment of depressive disorders in Malaysia. 767 65

The clinically tested reversible inhibitors of monoamine oxidase A (RIMAs) include brofaromine, moclobemide and toloxatone. Moclobemide has shown unequivocal antidepressant activity against serious depressive illness in 4 placebo-controlled double-blind trials. It has been compared with amitriptyline, imipramine, clomipramine, desipramine, maprotiline, fluoxetine, fluvoxamine, tranylcypromine, toloxatone, mianserin and amineptine in the treatment of depressive disorders. Meta-analysis showed convincing evidence of moclobemide efficacy, comparable with the most potent antidepressants available. The efficacy of moclobemide has been demonstrated in psychotic and non-psychotic depression, in depression with and without melancholia, in endogenous depression (both unipolar and bipolar), in retarded depression and in agitated depression. The efficacy of moclobemide, allied to the unusually benign side effect profile, has led to exploration of its use in other disorders. Two small studies have given encouraging results in the treatment of attention-deficit hyperactivity disorder. Large placebo-controlled studies have shown the activity of moclobemide in the depression that accompanies dementia (such as senile dementia of Alzheimer type). The results also suggested that, in this patient population, cognitive ability improved in parallel. Social phobia has also been shown to improve on treatment with either moclobemide or brofaromine. Clinical trials are in progress on the effect of moclobemide in chronic fatigue syndrome. Moreover, there are encouraging results with the use of brofaromine and moclobemide in panic disorder. Other disorders in which treatment with RIMA is of interest include agoraphobia, bulimia, borderline personality disorder, post-traumatic stress disorder, compulsive hair pulling (trichotillomania), dysmorphophobia, kleptomania as well as various anxiety syndromes.
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PMID:Reversible and selective inhibitors of monoamine oxidase A in mental and other disorders. 771 94

The individualization of social phobia among other phobic disorders is very recent, although previous clinical descriptions can be found in the literature. The new classifications (DSM-III, DSM-IV and ICD-10) have provided operationalized criteria for this disorder, which have allowed researchers to conduct epidemiological studies. However, some diagnostic issues are not completely solved, namely, those with other boundary disorders. Cross-cultural prevalence and risk factors of social phobia are reviewed. Results of a French community study have found a lifetime prevalence rate of 2.1% in males and 5.4% in females. Comorbidity of social phobia with other anxiety disorders and major depression was high. Suicidal tendencies, family history and health services utilization were analyzed according to the lifetime comorbidity pattern of social phobia and depression.
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PMID:Classification and epidemiology of social phobia. 777 11

This paper reviews evidence from clinical, epidemiologic, and family studies regarding the association between social phobia and other syndromes. Social phobia is strongly associated with other anxiety disorders, substance abuse, and affective disorders in both clinical and community samples. An average of 80% of social phobics identified in community samples meet diagnostic criteria for another lifetime condition. Social phobia is most strongly associated with other subtypes of anxiety disorders, with an average of 50% of social phobics in the community reporting a concomitant anxiety disorder including another phobic disorder, generalized anxiety, or panic disorder. Approximately 20% of subjects in the community meet lifetime criteria for a major depressive disorder. The onset of social phobia generally precedes that of all other disorders, with the exception of simple phobia. Both clinical severity and treated prevalence are consistently greater among social phobics with comorbid disorders. The results of family and twin studies reveal that shared etiologic factors explain a substantial proportion of the comorbidity between social phobia and depression, whereas the association between social phobia and alcoholism derives from a nonfamilial causal relationship between the two conditions. Clinical and phenomenologic implications of these findings are discussed.
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PMID:Comorbidity and social phobia: evidence from clinical, epidemiologic, and genetic studies. 777 12

According to the National Comorbidity Survey, social phobia is the third most frequent psychiatric disorder in the United States. Its lifetime prevalence rate of 13.3% ranks behind only major depressive episode (17.1%) and alcohol dependence (14.1%). As was the case with depression 15 years ago, social phobia has often been trivialized and stigmatized. For example, some with social phobia may be dismissed as having mere "stage fright" or excessive shyness, while, in fact, social phobia is a serious mental illness associated with substantial psychosocial distress, comorbidity, and morbidity. Typical onset of social phobia is in the midteens and often continues throughout an individual's lifetime, leading to severe social and occupational impairment. Several excellent, efficacious treatments are available. Access to these treatments for social phobia may be more difficult in the future due to managed care initiatives and health care reform. Various proposals are now being considered as a part of health care reform that may have significant impact on the diagnosis and treatment of social phobia.
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PMID:The impact of health care reform on social phobia. 778 71


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