Current Medical Diagnosis & Treatment in Psychiatry

Introduction: Current Concepts in Anxiety

Donald F. Klein
New York State Psychiatry Institute, New York

Introducing an up-to-date book covering a broad range of anxiety-related topics presents a problem. It seems in the nature of scientific activity that investment in one’s conclusions may lead to a less than balanced consideration or relevant evidence and analyses. Of course, this truism applies to our views of this controversial area. We hope to contribute to this dialectical process so that those who remain open-minded may arrive at their conclusions reflectively. I will emphasize issues about the anxiety disorders that seem salient to me and promising with regard to research and treatment, however, space limitations force neglect of many real advances.

The Current State of Psychiatric Understanding

The state of patient-orientated research in psychiatry is affected by several problematic facts. Psychiatric diagnosis is almost entirely at a descriptive syndromal level.

Objective, specific, diagnostic tests are not available for almost all psychiatric diseases.

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One clear advance has been the increase in direct, physiologically sophisticated investigations of real anxious patients (rather than surrogate sophomores) compared with each other and with normals. The past 20 years have demonstrated that systematic perturbations (challenges) provide fascinating data indicating, at physiological and genetic levels, that the anxiety disorders are distinct from each other and normal controls. Splitting rather than lumping seems to pay off.

Cognitive theorists deny that spontaneous panics are qualitatively unique. They posit that people with enduring catastrophizing attitudes misconstrue harmless endogenous sensations as dangerous, eliciting fear-associated autonomic responses which then increases these sensations. This confirms the erroneous cognition of imminent peril, sparking a psychophysiological vicious circle that culminates in panic, i.e., the apprehension of immediate total disaster.

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