Current Medical Diagnosis & Treatment in Psychiatry

Current Concepts in Anxiety


One of the major problems in therapeutic research has gone by the euphemistic label of “allegiance effect” (Klein, 1999). It has been shown repeatedly that supposed differences in therapeutic benefit and data interpretation are closely related to the antecedent beliefs of the investigators.

Comparative studies of treatment or, even supposedly more objective physiological investigations, carried out by single-minded enthusiasts are inferior to collaborations between scientists with opposing views who are willing to put them to the test.

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A stimulating therapeutic development is the complex study of panic disorder by the team of Barlow, Gorman, Shear and Woods (2000) comparing cognitive-behavioral treatment versus imipramine and their combination with placebo in panic disorder.

This is, by far, the best controlled study in this area, although, unfortunately, the sample was limited to panic patients with minimal or no agoraphobia, who have the best prognosis in any case.

Using a Clinical Global Improvement Scale, cognitive-behavioral therapy did as well as imipramine, but within these responders imipramine was superior, with regard to degree of symptomatic remission. It follows that if response had been defined by a cutting level on this symptom scale, there would have been more responders on imipramine.

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One of the charms of psychotherapy is the frequent claim for permanent benefit since the pathogenic process has been quelled. Both Barlow et al. and Heimberg et al. indicate that the benefits of psychotherapy are better maintained than those of pharmacotherapy after treatment discontinuation. This implies a prophylactic lasting benefit. However, this may not be the case as indicated by Hollon et al. (1991) who states:

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There is still much abstract (and, I think, pointless) debate about the relative merits of dimensional rather than categorical description. Torgerson (1967) argued that there are two major mathematical approaches: those which seek to identify classes (or clusters) with a data matrix and those which seek to identify dimensions of variation (or factors) within the data. Each approach has underlying assumptions that increase the likelihood of detecting patterns conforming to the method. For example, assuming a set of variables measured in a sample of patients with anxiety disorders, both dimensional factors and clusters could be imposed on even random data by the assumptions of the particular analytic procedure used. Further, multiple discrete neurobiologic abnormalities might produce a continuum of behavioral manifestations.

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An extremely confusing area is the intricate relationship between the anxieties and the depressions. I emphasize the plural since it seems clear that there are multiple discrete anxiety disorders as well as several different depressed states, which coexist in multiple combinations. This is often referred to as comorbidity, but since these so-called comorbidities are so common, that the symptomatic mix is actually due to the evolution of complex syndromes seems likely. If that were true, one would expect that the relatives of “comorbid” patients would be more likely to have symptomatically mixed conditions than simple anxious or depressive states. The literature is contradictory and the question remains unresolved (Mannuzza et al., 1994/5).

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That separation anxiety is a common antecedent of panic disorder has been noted.

The recent work by Jerome Kagan and associates indicates the frequency of behavioral inhibition in children of patients with anxiety disorders and the possibility that behavioral inhibition may be a precursor of social anxiety disorders. This emphasizes the importance of continuity of adult with childhood anxiety disorders. Investigation of childhood disorders clearly has many technical and ethical problems, but they afford a close look at the early phases of a pathogenic process before it is obscured by multiple secondary reactions and adaptations.

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The other aspect of the spontaneous panic attack that differentiates it from fear is the common feeling of shortness of breath or dyspnea accompanying the attack. Although commonly attributed to hyperventilation, the weight of the evidence is that neither hyperventilation nor acute fear produces acute dyspnea. My suggestions with regard to a su.ocation false alarm theory of panic have had the gratifying e.ect of eliciting much discussion and even a number of studies.

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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