16

Anxiety Disorders

Anxiety disorders are among the most prevalent mental disorders these disorders can be correspondingly complex. Understanding
in the general population. Nearly 30 million persons are affected the neuroanatomy and molecular biology of anxiety promises
in the United States. Anxiety disorders are associated with signif- new insights into the etiology and more effective treatments in
icant morbidity and often are chronic and resistant to treatment. the future. An array of treatment approaches is currently avail-
The text revision of the fourth edition of the Diagnostic and able, including psychoanalytic, cognitive, behavioral, and psy-
Statistical Manual of Mental Disorders (DSM-IV-TR) contains chopharmacologic treatments. Many times, a combination of
eight anxiety disorders: (1) panic disorder with or without ago- these treatments is used to best address the multiplicity of etio-
raphobia, (2) agoraphobia with or without panic disorder, (3) logic forces.
specific phobia, (4) social phobia, (5) obsessive-compulsive dis- Another aspect of anxiety disorders is the exquisite interplay
order (OCD), (6) posttraumatic stress disorder (PTSD), (7) acute of genetic and experiential factors. Students should also be aware
stress disorder, and (8) generalized anxiety disorder (GAD). of the role of specific neurotransmitters in the development of
Anxiety disorders, similar to most psychiatric disorders, are anxiety and the mechanisms of anxiolytic medications.
usually the result of a complex interplay of biological, psycho- Students should study the questions and answers below for a
logical, and psychosocial elements. Treatment of patients with useful review of these disorders.

HELPFUL HINTS

Students should know the following names, cases, terms, and acronyms related to anxiety disorders.

acute stress disorder Sigmund Freud MHPG propranolol (Inderal)

▲ ▲ ▲ ▲ ▲ ▲ ▲

▲ ▲ ▲

▲ ▲ ▲ ▲ ▲

▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲

anticipatory anxiety GABA mitral valve prolapse reaction formation

anxiety generalized anxiety norepinephrine repression
Aplysia disorder numbing secondary gain
aversive conditioning hypnosis obsessive-compulsive serotonin
▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲

benzodiazepines imipramine (Tofranil) disorder (OCD) shell shock

clomipramine implosion panic attack sleep EEG studies
▲ ▲ ▲ ▲

(Anafranil) intrapsychic conflict panic disorder soldier’s heart

counterphobic attitude isolation panicogens systematic
▲ ▲ ▲ ▲ ▲ ▲ ▲

Jacob M. DaCosta lactate infusion phobias desensitization

Charles Darwin limbic system ◦ agoraphobia thought stopping
▲ ▲ ▲ ▲

ego dystonic Little Albert ◦ social undoing

fear Little Hans ◦ specific John B. Watson
Otto Fenichel locus ceruleus and raphe posttraumatic stress Joseph Wolpe
▲

flooding nuclei disorder (PTSD)

QUESTIONS
A. acute stress disorder occurs earlier than PTSD
Directions B. PTSD is associated with at least three dissociative
Each of the questions or incomplete statements below is followed symptoms
by five suggested responses or completions. Select the one that C. reexperiencing the trauma is not found in acute stress
is best in each case. disorder
D. avoidance of stimuli associated with the trauma is
16.1. Posttraumatic stress disorder (PTSD) differs from acute only found in PTSD
stress disorder in that E. PTSD lasts less than 1 month after a trauma
156
 16. Anxiety Disorders 157

16.2. The risk of developing anxiety disorders is enhanced by 16.8. Generalized anxiety disorder
A. eating disorders A. is least likely to coexist with another mental disorder
B. depression B. has a female-to-male ratio of 1:2
C. substance abuse C. is a mild condition
D. allergies D. has about a 50 percent chance of a recurrence after
E. all of the above recovery
E. has a low prevalence in primary care settings
16.3. Which of the following is not a sign of poor prognosis in
obsessive-compulsive disorder (OCD)? 16.9. Physiological activity associated with PTSD include all
except
A. Childhood onset
B. Coexisting major depression A. decreased parasympathetic tone
C. Good social adjustment B. elevated baseline heart rate
D. Bizarre compulsions C. excessive sweating
E. Delusional beliefs D. increased circulating thyroxine
E. increased blood pressure

16.4. Which of the following statements regarding anxiety and

gender differences is true? 16.10. Unexpected panic attacks are required for the diagnosis
of
A. Women have greater rates of almost all anxiety dis-
orders. A. generalized anxiety disorder
B. Gender ratios are nearly equal with OCD. B. panic disorder
C. No significant difference exists in average age of C. social phobia
anxiety onset. D. specific phobia
D. Women have a twofold greater lifetime rate of agora- E. all of the above
phobia than men.
E. All of the above 16.11. Isolated panic attacks without functional disturbances
A. usually involves anticipatory anxiety or are phobic
16.5. Which of the following epidemiological statements is B. are part of the criteria for diagnostic panic disorder
true regarding anxiety disorders? C. occur in less than 2 percent of the population
D. rarely involve avoidance
A. Panic disorder has the lowest heritability. E. none of the above
B. The mean age of onset is higher in girls.
C. The age of onset is earlier than that of mood dis-
orders. 16.12. Which of the following is not a component of the DSM-
D. Rates in males peak in the fourth and fifth decades of IV-TR diagnostic criteria for OCD?
life. A. Children need not recognize that their obsessions are
E. All of the above unreasonable.
B. Obsessions are acknowledged as excessive or unrea-
16.6. Sigmund Freud postulated that the defense mechanisms sonable.
necessary in phobias are C. Obsessions or compulsions are time consuming and
take more than 1 hour a day.
A. regression, condensation, and dissociation D. The person recognized the obsessional thoughts as a
B. regression, condensation, and projection product of outside him- or herself.
C. regression, repression, and isolation E. The person attempts to ignore or suppress compulsive
D. repression, displacement, and avoidance thoughts or impulses.
E. repression, projection, and displacement
16.13. All of the following are true for the course of panic dis-
16.7. Anxiety disorders order except
A. are greater among people at lower socioeconomic A. patients become concerned after the first one or two
levels panic attacks
B. are highest among those with higher levels of educa- B. excessive caffeine intake can exacerbate symptoms
tion C. comorbid depression increases risk for committing
C. are lowest among homemakers suicide
D. have shown different prevalences with regard to social D. the overall course is variable
class but not ethnicity E. patients without comorbid agoraphobia have a higher
E. all of the above recovery rate
158 16. Anxiety Disorders

16.14. Tourette’s disorder has been shown to possibly have a 16.19. Which of the following medical disorders are not as-
familial and genetic relationship with sociated with panic disorder due to a general medical
condition?
A. generalized anxiety disorder
B. obsessive-compulsive disorder A. Cardiomyopathy
C. panic disorder B. Parkinson’s disease
D. social phobia C. Epilepsy
E. none of the above D. Sjögren’s syndrome
E. Chronic obstructive pulmonary disease (COPD)
16.15. All of the following have been noted through brain imag-
16.20. Which of the following disorders is rarely confused
ing in patients with panic disorder except
with anxiety that stems primarily from medical dis-
A. magnetic resonance imaging (MRI) studies have orders?
shown pathological involvement of both temporal
A. Panic disorder
lobes
B. Specific phobia
B. generalized cerebral vasoconstriction
C. Obsessive-compulsive disorder
C. right temporal cortical atrophy
D. Posttraumatic stress disorder
D. increased blood flow to the basal ganglia
E. Generalized anxiety disorder
E. positron emission tomography scans have implicated
dysregulation of blood flow in panic disorder
16.21. Induction of panic attacks in patients with panic disorder
can occur with
16.16. A patient with OCD might exhibit all of the following
brain imaging findings except A. carbon dioxide
B. cholecystokinin
A. longer mean T1 relaxation times in the frontal cortex C. doxapram
than normal control subjects D. yohimbine
B. significantly more gray matter and less white matter E. all of the above
than normal control subjects
C. abnormalities in the frontal lobes, cingulum, and 16.22. First-line medication treatments of anxiety disorders may
basal ganglia generally include all of the following except
D. decreased caudate volumes bilaterally compared with
A. diazepam (Valium)
normal control subjects
B. fluoxetine (Prozac)
E. lower metabolic rates in basal ganglia and white
C. fluvoxamine (Luvox)
matter than in normal control subjects
D. nefazodone (Serzone)
E. venlafaxine (Effexor)
16.17. Buspirone (Buspar) acts as a
16.23. Therapy for phobias may include all of the following
A. dopamine partial agonist useful in the treatment of
except
OCD
B. serotonin partial agonist useful in the treatment of A. counterphobic attitudes
OCD B. flooding
C. dopamine partial agonist useful in the treatment of C. phenelzine (Nardil)
generalized anxiety disorder D. propranolol (Inderal)
D. serotonin partial agonist useful in treatment of gen- E. systematic desensitization
eralized anxiety disorder
E. none of the above 16.24. Mr. A was a successful businessman who presented for
treatment after a change in his business schedule. Al-
though he had formerly worked largely from an office
16.18. Which of the following choices most accurately describes
near his home, a promotion led to a schedule of frequent
the role of serotonin in OCD?
out-of-town meetings requiring weekly flights. Mr. A re-
A. Serotonergic drugs are an ineffective treatment. ported being “deathly afraid” of flying. Even the thought
B. Dysregulation of serotonin is involved in the symp- of getting on an airplane led to thoughts of impending
tom formation. doom in which he envisioned his airplane crashing to the
C. Measures of platelet binding sites of titrated ground. These thoughts were associated with intense fear,
imipramine are abnormally low. palpitations, sweating, clamminess, and stomach upset.
D. Measures of serotonin metabolites in cerebrospinal Although the thought of flying was terrifying enough,
fluid are abnormally high. Mr. A became nearly incapacitated when he went to the
E. None of the above airport. Immediately before boarding, Mr. A would often
 16. Anxiety Disorders 159

have to turn back from the plane, running to the bathroom C. Obsessive-compulsive personality disorder
to vomit. Which of the following is the most appropriate D. Generalized anxiety disorder
treatment for this patient who has another flight sched- E. None of the above
uled tomorrow?
A. β-agonists
B. Exposure therapy Directions
C. Lorazepam
D. Paroxetine Each set of lettered headings below is followed by a list of num-
E. None of the above bered words or phrases. For each numbered word or phrase,
select
16.25. Ms. K was referred for psychiatric evaluation by her gen- A. if the item is associated with A only
eral practitioner. On interview, Ms. K described a long B. if the item is associated with B only
history of checking rituals that had caused her to lose C. if the item is associated with both A and B
several jobs and had damaged numerous relationships. D. if the item is associated with neither A nor B
She reported, for example, that because she often had the
thought that she had not locked the door to her car, it was Questions 16.27–16.31
difficult for her to leave the car until she had checked
repeatedly that it was secure. She had broken several car A. Social phobia
door handles with the vigor of her checking and had been B. Agoraphobia
up to an hour late to work because she spent so much
time checking her car door. Similarly, she had recurrent 16.27. Symptoms include blushing and muscle twitching
thoughts that she had left the door to her apartment un- 16.28. Is associated with a sense of suffocation
locked, and she returned several times daily to check the 16.29. Is chronic without a history of panic disorder
door before she left for work. She reported that check- 16.30. May be associated with panic attacks
ing doors decreased her anxiety about security. Although 16.31. Patients are comforted by the presence of another
Ms. K reported that she had occasionally tried to leave her person
car or apartment without checking the door (e.g., when
she was already late for work), she found that she became Questions 16.32–16.36
so worried about her car being stolen or her apartment A. Generalized anxiety disorder
being broken into that she had difficulty going anywhere. B. Panic disorder
Ms. K reported that her obsessions about security had be-
come so extreme over the past 3 months that she had lost 16.32. Response rates between 60 and 80 percent have been
her job because of recurrent tardiness. She recognized reported to buspirone
the irrational nature of her obsessive concerns but could 16.33. Patients with the disorder may still be responsive to bus-
not bring herself to ignore them. pirone after being exposed to benzodiazepine
Which of the following symptom patterns of OCD 16.34. Buspirone’s use is limited to potentiating the effects of
does Mrs. K present? other antidepressants and counteracting the adverse sex-
A. Intrusive thoughts ual effects of selective serotonin reuptake inhibitors
B. Symmetry 16.35. Relapse rates are generally high after discontinuation of
C. Pathological doubt medication
D. Contamination 16.36. Tricyclic drugs have been reported to worsen anxiety
E. None of the above symptoms in patients in whom the first symptoms were
precipitated by cocaine
16.26. A 23-year-old woman presents to clinic with a chief com-
plaint of “difficulty concentrating because I worry about Questions 16.37–16.40
my child.” She had recently gone back to teaching after
A. Cognitive behavioral therapy
having her third child. The patient states she is constantly
B. Psychodynamic therapy
wondering about other things as well. For example, she
is going to help her sister-in-law throw a goodbye party
16.37. Produces 80 to 90 percent panic-free status in panic dis-
and finds herself constantly going over what she needs
order within at least 6 months of treatment
to do to prepare for the party. At the end of the day, her
16.38. May be nearly twice as effective in the treatment of social
husband claims she is irritable and tired. At night, she is
phobia as a more educational-supportive approach
unable to sleep and keeps thinking about her tasks for the
16.39. Goals are more ambitious and require more time to
next day. What is the most likely diagnosis?
achieve
A. Avoidant personality disorder 16.40. Combining treatment with medication may be superior
B. Obsessive-compulsive disorder to either treatment alone
160 16. Anxiety Disorders

Directions ANSWERS
Each group of questions below consists of lettered headings fol- 16.1. The answer is A
lowed by a list of numbered phrases or statements. For each Acute stress disorder is a disorder that is similar to posttraumatic
numbered phrase or statement, select the one lettered heading stress disorder (PTSD), but acute stress disorder occurs earlier
that is most associated with it. Each lettered heading may be than PTSD (within 4 weeks of the traumatic event) and remits
selected once, more than once, or not at all. within 2 days to 1 month after a trauma (not PTSD).
PTSD shows three domains of symptoms: reexperiencing the
Questions 16.41–16.45 trauma; avoiding stimuli associated with the trauma; and expe-
riencing symptoms of increased autonomic arousal, such as en-
A. Panic disorder
hanced startle. Flashbacks, in which the individual may act and
B. Generalized social phobia
feel as if the trauma is recurring, represent a classic form of re-
C. Posttraumatic stress disorder
experiencing. Other forms of reexperiencing symptoms include
D. Generalized anxiety disorder
distressing recollections or dreams and either physiological or
E. Acute stress disorder
psychological stress reactions on exposure to stimuli that are
linked to the trauma. Symptoms of avoidance associated with
16.41. Is associated with depersonalization
PTSD include efforts to avoid thoughts or activities related to
16.42. Must include at least two spontaneous panic attacks
trauma, anhedonia, reduced capacity to remember events related
16.43. Symptoms must persist at least 1 month after the trauma
to trauma, blunted effect, feelings of detachment or derealization,
16.44. Must include three somatic or cognitive symptoms asso-
and a sense of a foreshortened future. Symptoms of increased
ciated with worry
arousal include insomnia, irritability, hypervigilance, and ex-
16.45. Difficult to distinguish from avoidant personality disor-
aggerated startle. The diagnosis of PTSD is only made when
der
symptoms persist for at least 1 month; the diagnosis of acute
stress disorder is made in the interim.
Questions 16.46–16.49
Acute stress disorder is characterized by reexperiencing,
A. Imaginal exposure avoidance, and increased arousal, similar to PTSD. Acute stress
B. Interoceptive exposure disorder (not PTSD) is also associated with at least three disso-
C. In vivo exposure ciative symptoms.
D. Systematic desensitization
16.2. The answer is E (all)
16.46. A patient is presented with photographs of snakes while Disorders that may enhance the risk for the development of anxi-
practicing various relaxation techniques to overcome ety disorders include eating disorders, depression, and substance
fear; gradually, he practices relaxation while in the pres- use and abuse. In contrast, anxiety disorders have been shown
ence of live snakes. to elevate the risk of subsequent substance use disorders and
16.47. A patient with OCD attempts to use public telephones and may comprise a mediator of the link between depression and the
doorknobs while intentionally refraining from washing subsequent development of substance use disorders in a clinical
her hands afterward. sample.
16.48. A patient is asked to imagine his wartime experiences as Several studies have also suggested that there is an associ-
vividly as possible to confront his memory of the trau- ation between anxiety disorders and allergies, high fever, im-
matic events. munological diseases and infections, epilepsy, and connective
16.49. A patient breathes through a thin straw to produce the tissue diseases. Likewise, prospective studies have revealed that
sensation of not getting enough air; this activity produces the anxiety disorders may comprise risk factors for the develop-
a similar sensation to the distressing feeling of getting on ment of some cardiovascular and neurological diseases, such as
an airplane. ischemic heart disease and migraine.

Questions 16.50–16.54 16.3. The answer is C

A. Acrophobia A good prognosis for people with obsessive-compulsive disorder
B. Ailurophobia (OCD) is indicated by good social and occupational adjustment,
C. Cynophobia the presence of a precipitating event, and an episodic nature of
D. Mysophobia symptoms. About one-third of patients with OCD have major
E. Xenophobia depressive disorder, and suicide is a risk for all patients with
OCD. A poor prognosis is indicated by yielding to (rather than
16.50. Fear of dirt and germs resisting) compulsions, childhood onset, bizarre compulsions,
16.51. Fear of heights the need for hospitalization, a coexisting major depressive dis-
16.52. Fear of strangers order, delusional beliefs, the presence of overvalued ideas (i.e.,
16.53. Fear of dogs some acceptance of obsessions and compulsions), and the pres-
16.54. Fear of cats ence of a personality disorder (especially schizotypal personality
 16. Anxiety Disorders 161

disorder). The obsessional content does not seem to be related Table 16.1
to the prognosis. Psychodynamic Themes in Phobias

16.4. The answer is E (all) Principal defense mechanisms include displacement, projection,
The results of community studies reveal that women have greater and avoidance.
rates of almost all of the anxiety disorders. Despite differences Environmental stressors, including humiliation and criticism from
in the magnitude of the rates of specific anxiety disorders across an older sibling, parental fights, or loss and separation from
parents, interact with a genetic constitutional diathesis.
studies, the gender ratio is strikingly similar. Women have an A characteristic pattern of internal object relations is externalized
approximately twofold elevation in lifetime rates of panic, gen- in social situations in the case of social phobia.
eralized anxiety disorder, agoraphobia, and simple phobia com- Anticipation of humiliation, criticism, and ridicule is projected
pared with men in nearly all of the studies. The only exception onto individuals in the environment.
is the nearly equal gender ratio in the rates of OCD and social Shame and embarrassment are the principal affect states.
Family members may encourage phobic behavior and serve as
phobia. obstacles to any treatment plan.
Studies of youth report similar differences in the magnitude Self-exposure to the feared situation is a basic principle of all
of anxiety disorders among girls and boys. Similar to the gender treatment.
ratio for adults, girls tend to have more of all subtypes of anxi-
ety disorders irrespective of the age composition of the sample.
However, it has also been reported that despite the greater rates of or situation, which has the power to elicit anxiety. The phobic ob-
anxiety in girls across all ages, there is no significant difference ject or situation selected has a direct associative connection with
between boys and girls in the average age at onset of anxiety. the primary source of the conflict and has thus come naturally
to symbolize it. Furthermore, the situation or object is usually
16.5. The answer is C such that the patient is able to keep out of its way and by the
Anxiety disorders have been shown to have the earliest age of additional defense mechanism of avoidance to escape suffering
onset of all major classes of mental and behavioral disorders from serious anxiety.
with a median onset by the age of 12 years. This is far earlier Regression is an unconscious defense mechanism in which
than the onset of mood disorders or substance use disorders and a person undergoes a partial or total return to early patterns of
comparable to that of impulse control disorders. Women have adaptation. Condensation is a mental process in which one sym-
greater rates of anxiety disorders than men. This difference in bol stands for a number of components. Projection is an uncon-
gender rates can be seen as early as 6 years of age. Despite the scious defense mechanism in which persons attribute to another
far more rapid increase in anxiety disorders with age in girls than person generally unconscious ideas, thoughts, feelings, and im-
in boys, there are no gender differences in the mean age at onset pulses that are undesirable or unacceptable in themselves. In
of anxiety disorders (not higher in girls) or in their duration. psychoanalysis, isolation is a defense mechanism involving the
Female preponderance of anxiety disorders is present across all separation of an idea or memory from its attached feeling tone.
stages of life but is most pronounced throughout early and mid- Dissociation is an unconscious defense mechanism involving the
adulthood. The rates of anxiety disorders in men are also rather segregation of any group of mental or behavioral processes from
constant throughout adult life, but the rates in women peak in the rest of the person’s psychic activity. Table 16.1 describes
the fourth and fifth decades of life and decrease thereafter. a more current view of seven of the psychodynamic themes in
Studies show a three- to fivefold increased risk of anxiety phobias.
disorders among first-degree relatives of persons with anxiety
disorders. Twin studies reveal that panic disorder has the highest 16.7. The answer is A
heritability and has been shown to have the strongest degree of Community studies have consistently found that rates of anxi-
familial aggregation, with an almost sevenfold elevation in risk. ety disorders in general are greater among those at lower levels
of socioeconomic status and education level. Anxiety disorders
16.6. The answer is D are negatively associated with income and education levels. For
Sigmund Freud viewed phobias as resulting from conflicts cen- example, there is almost a twofold difference between rates of
tered on an unresolved childhood oedipal situation. In adults, anxiety disorders in individuals in the highest income bracket and
because the sexual drive continues to have a strong incestuous those in the lowest and between those who completed more than
coloring, its arousal tends to create anxiety that is characteristi- 16 years of school and those who completed less than 11 years of
cally a fear of castration. The anxiety then alerts the ego to exert school. In addition, certain anxiety disorders seem to be elevated
repression to keep the drive away from conscious representation in specific occupations. Anxiety disorders are higher in home-
and discharge. Because repression is not entirely successful in makers and those who are unemployed or have a disability. Sev-
its function, the ego must call on auxiliary defenses. In phobic eral community studies have also yielded greater rates of anxiety
patients, the defenses, arising genetically from an earlier pho- disorders, particularly phobic disorders, among African Ameri-
bic response during the initial childhood period of the oedipal cans. The reasons for ethnic and social class differences have not
conflict, involves primarily the use of displacement—that is, the yet been evaluated systematically; however, both methodolog-
sexual conflict is transposed or displaced from the person who ical factors and differences in exposure to stressors have been
evoked the conflict to a seemingly unimportant, irrelevant object advanced as possible explanations.
162 16. Anxiety Disorders

16.8. The answer is D in a specific period of time to meet criteria for panic disorder.
Generalized anxiety disorder (GAD) is a chronic (not mild) con- Rather, the attacks must be recurrent, and at least one attack
dition, and nearly half of patients who eventually recover experi- must be followed by at least 1 month of anticipatory anxiety or
ence a later recurrence. GAD is characterized by frequent, per- phobic avoidance. This recognizes for the first time that although
sistent worry and anxiety that is disproportionate to the impact of the panic attack is obviously the seminal event for diagnosing
the events or circumstances on which the worry focuses. The dis- panic disorder, the syndrome involves a number of disturbances
tinction between GAD and normal anxiety is emphasized by the that go beyond the attack itself. Isolated panic attacks without
use of the words “excessive” and “difficult to control” in the cri- functional disturbances are not diagnosed as panic disorder.
teria and by the specification that the symptoms cause significant Furthermore, isolated panic attacks without functional distur-
impairment or distress. The anxiety and worry are accompanied bance are common, occurring in approximately 15 percent of
by a number of physiological symptoms, including motor tension the population.
(i.e., shakiness, restlessness, headache), autonomic hyperactiv-
ity (i.e., shortness of breath, excessive sweating, palpitations), 16.12. The answer is D
and cognitive vigilance (i.e., irritability). The ratio of women to Obsessions and compulsions are the essential features of OCD.
men with the disorder is about 2:1 (not 1:2). The disorder usu- An individual must exhibit either obsessions or compulsions to
ally has its onset in late adolescence or early adulthood, although meet DSM-IV-TR criteria. The DSM-IV-TR recognizes obses-
cases are commonly seen in older adults. Also, some evidence sions as “persistent ideas, thoughts, impulses, or images that
suggests that the prevalence is particularly high (not low) in pri- are experienced as intrusive and inappropriate,” causing distress.
mary care settings. This is because patients with GAD usually Obsessions provoke anxiety, which accounts for the categoriza-
seek out a general practitioner or internist for help with a somatic tion of OCD as an anxiety disorder. However, they must be differ-
symptom. GAD is probably the disorder that most (not least) of- entiated from excessive worries about real-life problems and as-
ten coexist with another mental disorder, usually social phobia, sociated with efforts to either ignore or suppress the obsessions.
specific phobia, panic disorder, or a depressive disorder. The DSM-IV-TR diagnostic criteria for OCD indicate that the
obsessions must be acknowledged as excessive or unreasonable
16.9. The answer is D (with the exception that children need not acknowledge this fact),
According to current conceptualizations, PTSD is associated there must be attempts to suppress these intrusive thoughts, and
with objective measures of physiological arousal. This includes the obsessions or compulsions are time consuming to the point of
elevated baselines heart rate, increased blood pressure, and ex- requiring at least 1 hour a day, among other diagnostic criteria.
cessive sweating. Furthermore, evidence from studies of baseline As part of the criteria, however, is not that the thoughts are a
cardiovascular activity revealed a positive association between product of outside the person, as in thought insertion, but that
heart rate and PTSD. the person recognizes that the thoughts are a product of his or
The finding of elevated baseline heart rate activity is con- her own mind.
sistent with the hypothesis of tonic sympathetic nervous system
arousal in PTSD. Disturbance in autonomic nervous system ac- 16.13. The answer is A
tivity in individuals with PTSD is characterized by increased After the first one or two panic attacks, patients may be relatively
sympathetic and decreased parasympathetic tone. Preliminary unconcerned about their condition. With repeated attacks, how-
evidence suggests that this autonomic imbalance can be normal- ever, the symptoms may become a major concern. Patients may
ized with selective serotonin reuptake inhibitor treatment. There attempt to keep the panic attacks secret and thereby cause their
is no change in blood level of thyroxine in those with PTSD. families and friends concern about unexplained changes in be-
havior. Panic disorder, in general, is a chronic disorder, although
16.10. The answer is B its course is variable, both among patients and within a single
Unexpected panic attacks are required for the diagnosis of panic patient. The frequency and severity of the attacks can fluctuate.
disorder, but panic attacks can occur in several anxiety disor- Panic attacks can occur several times a day or less than once a
ders. The clinician must consider the context of the panic attack month. Excessive intake of caffeine or nicotine can exacerbate
when making a diagnosis. Panic attacks can be divided into two the symptoms. Depression can complicate the symptom picture
types: (1) unexpected panic attacks, which are not associated in anywhere from 40 to 80 percent of all patients. Although the
with a situational trigger, and (2) situationally bound panic at- patients do not tend to talk about suicidal ideation, they are at
tacks, which occur immediately after exposure in a situational increased risk for committing suicide. Recovery rates appear
trigger or in anticipation of the situational trigger. Situationally to be higher in patients without comorbid agoraphobia than in
bound panic attacks are most characteristic of social phobia and those who meet criteria for both conditions. Family interactions
specific phobia. In generalized anxiety disorder, the anxiety can- and performance in school and at work commonly suffer. Pa-
not be about having a panic attack. tients with good premorbid functioning and symptoms of brief
duration tend to have a good prognosis.
16.11. The answer is A
Some differences between the DSM-IV-TR and earlier versions 16.14. The answer is B
in the diagnostic criteria of panic disorder are interesting. For ex- An interesting set of findings concerns the possible relationship
ample, no longer is a specific number of panic attacks necessary between a subset of cases of OCD and certain types of motor tic
 16. Anxiety Disorders 163

syndromes (i.e., Tourette’s disorder and chronic motor tics). In- obsessions and compulsions. Data show that serotonergic drugs
creased rates of OCD, Tourette’s disorder, and chronic motor tics are an effective treatment, but it is unclear whether serotonin is
were found in the relatives of Tourette’s disorder patients com- involved in the cause of OCD.
pared with relatives of control subjects whether or not the patient Clinical studies have shown that measures of platelet binding
had OCD. However, most family studies of probands with OCD sites of imipramine and of serotonin metabolites in cerebrospinal
have found elevated rates of Tourette’s disorder and chronic mo- fluid are variable, neither consistently abnormally low nor ab-
tor tics only among the relatives of probands with OCD who also normally high.
have some form of tic disorder. Taken together, these data suggest
that there is a familial and perhaps genetic relationship between 16.19. The answer is D
Tourette’s disorder and chronic motor tics and some cases of A high prevalence of generalized anxiety disorder (not panic
OCD. Cases of the latter in which the individual also manifests disorder) symptoms has been reported in patients with Sjögren’s
tics are the most likely to be related to Tourette’s disorder and syndrome. Sjögren’s syndrome is a chronic autoimmune dis-
chronic motor tics. Because there is considerable evidence of ease in which a person’s white blood cells attack their moisture-
a genetic contribution to Tourette’s disorder, this finding also producing glands. The hallmark symptoms are dry eyes and
supports a genetic role in a subset of cases of OCDs. dry mouth; however, it may also cause dysfunction of other
organs.
16.15. The answer is D The symptoms of anxiety disorder caused by a general med-
Structural brain imaging studies, such as magnetic resonance ical condition can be identical to those of the primary anxiety
imaging (MRI), in patients with panic disorder have implicated disorders. A syndrome similar to panic disorder is the most com-
pathological involvement in the temporal lobes, particularly the mon clinical picture. Patients who have cardiomyopathy may
hippocampus. One MRI study reported abnormalities, especially have the highest incidence of panic disorder secondary to a gen-
cortical atrophy, in the right temporal lobes of these patients. eral medical condition. Cardiomyopathy is a disease of the heart
Functional brain imaging studies, such as positron emission muscle (myocardium). One study reported that 83 percent of pa-
tomography (PET), have implicated dysregulation of cerebral tients with cardiomyopathy awaiting cardiac transplantation had
blood flow. Specifically, anxiety disorders and panic attacks are panic disorder symptoms. Increased noradrenergic tone in these
associated with cerebral vasoconstriction, which may result in patients may be the provoking stimulus for the panic attacks.
central nervous system symptoms such as dizziness and in pe- In some studies, about 25 percent of patients with Parkinson’s
ripheral nervous system symptoms that may be induced by hy- disease and chronic obstructive pulmonary disease have symp-
perventilation and hypocapnia. Increased blood flow to the basal toms of panic disorder. Other medical disorders associated with
ganglia has not been noted in patients with panic disorder. panic disorder include chronic pain; primary biliary cirrhosis (an
autoimmune disease of the liver); and epilepsy (a chronic dis-
16.16. The answer is E order characterized by paroxysmal brain dysfunction caused by
Brain imaging studies of patients with OCD using PET scans excessive neuronal discharge), particularly when focus is in the
have found abnormalities in frontal lobes, cingulum, and basal right parahippocampal gyrus.
ganglia. PET scans have shown higher (not lower) levels of
metabolism and blood flows to those areas in OCD patients than 16.20. The answer is B
in control subjects. Volumetric computed tomography scans have Specific phobia is usually easily distinguished from anxiety stem-
shown decreased caudate volumes bilaterally in OCD patients ming from primary medical problems by the focused nature of
compared with normal control subjects. Morphometric MRI has the anxiety. Such specificity is not typical of anxiety disorders
revealed that OCD patients have significantly more gray matter related to medical problems.
and less white matter than normal control subjects. MRI has also Panic disorder with or without agoraphobia must be dif-
shown longer mean T1 relaxation times in the frontal cortex in ferentiated from a number of medical conditions that produce
OCD patients than is seen in normal control subjects. similar symptomatology. Panic attacks are associated with a va-
riety of endocrinologic disorders, including hypo- and hyper-
16.17. The answer is D thyroid states, hyperparathyroidism, and pheochromocytomas.
Buspirone (Buspar) is a serotonin receptor partial agonist and Episodic hypoglycemia associated with insulinomas can also
is most likely effective in 60 to 80 percent of patients with gen- produce panic-like states, as can primary neuropathologic pro-
eralized anxiety disorder (GAD). Data indicate that buspirone cesses. These include seizure disorders, vestibular dysfunction,
is more effective in reducing the cognitive symptoms of GAD neoplasms, and the effects of both prescribed and illicit sub-
than in reducing the somatic symptoms. The major disadvantage stances on the central nervous system. Finally, disorders of the
of buspirone is that its effects take 2 to 3 weeks to become evi- cardiac and pulmonary systems, including arrhythmias, chronic
dent in contrast to the almost immediate anxiolytic effects of the obstructive disease, and asthma, can produce autonomic symp-
benzodiazepines. toms and accompanying crescendo anxiety that can be difficult
to distinguish from panic disorder.
16.18. The answer is B A number of primary medical disorders can produce syn-
Clinical trials of drugs have supported the hypothesis that dys- dromes that bear a striking resemblance to obsessive-compulsive
regulation of serotonin is involved in the symptom formation of disorder (OCD). In fact, the current conceptualization of OCD
164 16. Anxiety Disorders

as a disorder of the basal ganglia derives from the phenomeno- as clinician and patient wait for the effects of antidepressants
logical similarity between idiopathic OCD and OCD-like dis- to take hold. Longer-term administration of benzodiazepines is
orders that are associated with basal ganglia diseases, such as reserved for patients who do not respond to or cannot tolerate
Sydenham’s chorea and Huntington’s disease. It should be noted antidepressants.
that OCD frequently develops before age 30 years, and new-onset
OCD in an older individual should raise questions about potential 16.23. The answer is A
neurological contributions to the disorder. Also, among children A counterphobic attitude is not a therapy for phobias, although it
with pediatric autoimmune neuropsychiatric disorder associated may lead to counterphobic behavior. Many activities may mask
with streptococcus (PANDAS), the syndrome appears to emerge phobic anxiety, which can be hidden behind attitudes and be-
relatively acutely, in contrast to the more insidious onset of child- havior patterns that represent a denial, either that the dreaded
hood OCD in the absence of infection. Hence, children with acute object or situation is dangerous or that one is afraid of it. Basic
presentations, the role of such an infectious process should be to this phenomenon is a reversal of the situation in which one
considered. is the passive victim of external circumstances to a position of
It is particularly important to recognize potentially treatable attempting actively to confront and master what one fears. The
contributors to posttraumatic symptomatology in the differential counterphobic person seeks out situations of danger and rushes
for posttraumatic stress disorder (PTSD). For example, neuro- enthusiastically toward them. The devotee of dangerous sports,
logical injury after head trauma can contribute to the clinical such as parachute jumping, rock climbing, bungee jumping, and
picture, as can psychoactive substance use disorders or with- parasailing, may be exhibiting counterphobic behavior.
drawal syndromes, either in the period immediately surrounding Both behavioral and pharmacological techniques have been
the trauma or many weeks after the trauma. Medical contribu- used in treating phobias. The most common behavioral technique
tors can usually be detected through careful history and physical is systematic desensitization, in which the patient is exposed se-
examination. rially to a predetermined list of anxiety-provoking stimuli graded
Generalized anxiety disorder (GAD) must be differentiated in a hierarchy from least to most frightening. Patients are taught
from both medical and other psychiatric disorders. Similar to self-induce a state of relaxation in the face of each anxiety-
neurological, endocrinologic, metabolic, and medication-related provoking stimulus. In flooding, patients are exposed to the pho-
disorders to those considered in the differential diagnosis of panic bic stimulus (actually [in vivo] or through imagery) for as long
disorder are relevant to the differential diagnosis of GAD. as they can tolerate the fear until they reach a point at which
they can no longer feel it. The social phobia of stage fright in
16.21. The answer is E (all) performers has been effectively treated with such β-adrenergic
Since the original finding that sodium lactate infusion can induce antagonists as propranolol (Inderal), which blocks the physio-
panic attacks in patients with panic disorder, many substances logical signs of anxiety (e.g., tachycardia). Phenelzine (Nardil),
have shown similar panicogenic properties, including the no- a monoamine oxidase inhibitor, is also useful in treating social
radrenergic stimulant yohimbine (Yocon), carbon dioxide, the phobia.
respiratory stimulant doxapram (Dopram), and cholecystokinin.
Disordered serotonergic, noradrenergic, and respiratory systems 16.24. The answer is C
are doubtless implicated in panic disorder, and the condition ap- Patients with specific phobias are often treated with as-needed
pears to be caused both by a genetic predisposition and some benzodiazepines, such as lorazepam (Ativan). In the clinical case
type of traumatic distress. More recently, neuroimaging stud- described, this is the most appropriate choice of treatment given
ies revealed that patients with panic disorder have abnormally their high safety margin (e.g., in overdose) and their overall ex-
brisk cerebrovascular responses to stress, showing greater vaso- cellent efficacy and rapid onset of action. β-adrenergic receptor
constriction during hypocapnic respiration than normal control antagonists (not agonists) may be useful in the treatment of spe-
subjects. cific phobia, especially when the phobia is associated with panic
attacks. The most commonly used treatment for specific pho-
16.22. The answer is A bia is exposure therapy. In this method, therapists desensitize
Antidepressant medication is increasingly seen as the medica- patients by using a series of gradual, self-paced exposures to
tion treatment of choice for the anxiety disorders. More specifi- the phobic stimulus; thus, this method would not be appropriate
cally, drugs with primary effects on the serotonin neurotrans- when immediate relief is required. Paroxetine, an SSRI, is not
mission system have become first-line recommendations for indicated for the immediate treatment of phobias.
panic disorder, social phobia, OCD, and PTSD. Evidence now
exists that such medications are also effective for generalized 16.25. The answer is C
anxiety disorder. Although they typically take longer to work The symptoms of an individual patient with OCD can overlap and
than benzodiazepines, the selective serotonin reuptake inhibitors change with time, but OCD has four major symptoms patterns. In
(SSRIs) such as fluoxetine (Prozac), sertraline (Zoloft), paroxe- this case, Mrs. K presents the symptom pattern of pathological
tine (Paxil), fluvoxamine (Luvox), and citalopram (Celexa), as doubt followed by a compulsion of checking. It is the second
well as venlafaxine (Effexor) and nefazodone (Serzone), are most common symptom pattern. The obsession often implies
probably more effective than benzodiazepines and easier to dis- some danger of violence, in this case forgetting to lock the car
continue. Increasingly, benzodiazepines such as diazepam (Val- door or the door to the apartment. The checking may involve
ium) are used only for the temporary relief of extreme anxiety multiple trips back into the house to check the stove, for example.
 16. Anxiety Disorders 165

For Mrs. K, checking involves trips back to her car and her ated with panic attacks, agoraphobia more so than social phobia.
apartment to make sure both are secure, thereby making her Whereas patients with agoraphobia are often comforted by the
constantly late for work. The patients have an obsessional self- presence of another person in an anxiety-provoking situation, pa-
doubt and always feel guilty about having forgotten or committed tients with social phobia are made more anxious than before by
something. the presence of other persons. Breathlessness, dizziness, a sense
The most common symptom pattern in OCD is an obsession of suffocation, and fear of dying are common with panic disorder
of contamination followed by washing or accompanied by com- and agoraphobia; however, the symptoms associated with social
pulsive avoidance of the presumably contaminated object. The phobia usually involve blushing, muscle twitching, and anxi-
feared object is often hard to avoid (e.g., feces, urine, dust, or ety about scrutiny. Most cases of agoraphobia are thought to be
germs). Patients with contamination obsessions usually believe caused by panic disorder. When the panic disorder is treated, the
that the contamination is spread from object to object or person agoraphobia often improves with time. Agoraphobia without a
to person by the slightest contact. history of panic disorder is often incapacitating and chronic, and
In the third most common pattern, there are intrusive ob- depressive disorders and alcohol dependence often complicate
sessional thoughts without a compulsion. Such obsessions are its course.
usually repetitious thoughts without a compulsion. Such obses-
sions are usually repetitious thoughts of a sexual or aggressive Answers 16.32–16.36
act that are reprehensible to the patient. Patients obsessed with
thoughts or aggressive or sexual acts may report themselves to 16.32. The answer is A
the police or confess to a priest.
The fourth most common pattern is the need for symmetry or 16.33. The answer is A
precision, which can lead to a compulsion of slowness. Patients
can literally take hours to eat a meal or shave their faces. 16.34. The answer is D

16.26. The answer is D 16.35. The answer is C

Excessive and uncontrollable worry characterized by irritability,
insomnia, and fatigue is the most likely attributable to gener- 16.36. The answer is B
alized anxiety disorder. The patient’s worries typically include Buspirone was promoted as a less sedating alternative to ben-
various aspects of the patient’s life and cause functional impair- zodiazepines in the treatment of panic disorder. Buspirone has
ment. These symptoms must persist for at least 6 months. Patients lower potential for abuse and dependence than benzodiazepines
with avoidant personality disorder have a long-standing pattern and produces relatively few adverse effects and no withdrawal
of avoiding activities because they fear judgment and feel in- syndrome. Buspirone does not alter cognitive or psychomotor
adequate. These symptoms are part of a lifelong pattern rather function, does not interact with alcohol, and is not a muscle re-
than new onset. Obsessive-compulsive disorder involves intru- laxant or an anticonvulsant. However, the efficacy of buspirone in
sive thoughts that result in compulsive activity to relieve anxiety. patients with panic disorder is disappointing, and with its further
These patients’ symptoms are ego dystonic in that they are able drawback of delayed onset of action and the need for multiple
to recognize their problematic compulsions and obsessions. Pa- dosings, its use is limited to potentiating the efficacy of other
tients with obsessive-compulsive personality disorder often seek antidepressants and counteracting the adverse sexual effects of
perfection and organization to a degree that it causes functional SSRIs.
impairment. Their symptoms are ego syntonic in that they do not Although the short-term efficacy of antipanic medications has
recognize the unreasonable nature of their behaviors. been established, the question of how long to treat a panic patient
who responds to treatment remains open. The results of follow-
Answers 16.27–16.31 up studies are mixed. Several reports indicate that most panic
patients relapse within 2 months to 2 years after the medication is
16.27. The answer is A discontinued. Following medication discontinuation, only about
30 to 45 percent of the patients remain well, and even remitted
16.28. The answer is B patients rarely revert back to significant phobic avoidance or se-
rious vocational or social disability. Improvement may continue
16.29. The answer is A for years after a single course of medication treatment. Given
the uncertainty about the optimal duration of treatment, the cur-
16.30. The answer is C rent recommendation is to continue full-dosage medication for
panic-free patients for at least 1 year. Medication taper should be
16.31. The answer is B slow, with careful monitoring of symptoms. Distinction should
Social phobia is the excessive fear of humiliation or embarrass- be made among return symptoms, withdrawal, and rebound
ment in various social setting, such as speaking in public, urinat- anxiety.
ing in a public rest room (also called shy bladder), or speaking Atypical responses to medications have been reported in
to a date. It can sometimes be difficult to differentiate from ago- panic patients whose first panic attacks were precipitated by
raphobia, which is the fear of or anxiety regarding places from cocaine use. These patients respond preferentially to benzodi-
which escape may be difficult. Both disorders can be associ- azepines and anticonvulsants, but tricyclic drugs seem to worsen
166 16. Anxiety Disorders

their anxiety symptoms. This pattern of medication response sug- Psychodynamic psychotherapy is based on the concept that
gests that cocaine-induced panic attacks may be related to a symptoms result from mental processes that may be outside of
kindling-like phenomenon. the patient’s conscious awareness and that elucidating these pro-
Tolerance to the sedative effects of benzodiazepines devel- cesses can lead to remission of symptoms. Moreover, to lessen
ops quickly, but the antianxiety effect of a given dosage is well the patient’s vulnerability to panic, the psychodynamic thera-
maintained over time in those with generalized anxiety disor- pist considers it necessary to identify and alter core conflicts.
der (GAD). However, the relapse rate upon discontinuation of The goals of psychodynamic psychotherapy are more ambitious
benzodiazepines is high, as is the risk for dependency. and require more time to achieve than those of a more symptom-
Buspirone is a potential alternative to benzodiazepine treat- focused treatment approach. Thus, these therapies are inherently
ment in GAD. Response rates between 60 and 80 percent have more difficult to study than more concrete, focused, manual-
been reported at levels ranging from 30 to 60 mg a day in three based therapies.
divided doses. Although response rates seem comparable, more Investigators have examined use of the combination of med-
patients drop out of buspirone trials than benzodiazepine tri- ication and cognitive behavioral therapy for patients with panic
als. The relative merits of buspirone and benzodiazepines are disorder and agoraphobia. Several short-term treatment studies
further detailed under panic disorder. One notable exception is have shown that the combination of the tricyclic medication
that patients with GAD exposed to benzodiazepines may still be imipramine (Tofranil) with one component of cognitive behav-
responsive to buspirone, unlike panic patients. ioral therapy, behavioral exposure, may be superior to either
treatment alone. Another study showed that selective serotonin
Answers 16.37–16.40 reuptake inhibitors, such as paroxetine (Paxil), plus cognitive
therapy worked significantly better for patients with panic disor-
16.37. The answer is A der than cognitive therapy plus placebo. There has been one study
of the combination of psychodynamic psychotherapy with med-
16.38. The answer is A ication. This study suggested that psychodynamic psychother-
apy may improve the long-term outcome of medication-treated
16.39. The answer is B patients.

16.40. The answer is C Answers 16.41–16.45

Some studies have shown that cognitive-behavioral treatment
of panic disorder, or panic control therapy, produces 80 to 16.41. The answer is E
90 percent panic-free status within at least 6 months of treat-
ment. Two-year follow-up indicates that more than 50 percent of 16.42. The answer is A
patients who originally responded to panic control therapy have
occasional panic attacks, and more 25 percent seek additional 16.43. The answer is C
treatment. Nonetheless, these treatment responders do tend to
have a significant decline in panic-related symptoms and most 16.44. The answer is D
maintain many of their treatment gains.
16.45. The answer is B
As with panic disorder, considerable progress in the psycholog- To meet the criteria for panic disorder, an individual must have
ical treatment of social anxiety or social phobia is linked to the experienced at least two spontaneous panic attacks in the absence
application of cognitive-behavioral methods. Unlike more tradi-
of any trigger or environmental cue. Furthermore, at least one of
tional psychotherapies, cognitive-behavioral approaches do not
these attacks must be associated with concern about additional
focus on the origins of social anxiety but instead focus on the
use of coping strategies that can be implemented in current fear- attacks, worry about attacks, or changes in behavior. A panic
ful situations. The most thoroughly studied form of cognitive- attack is defined as an episode of abrupt intense fear accompanied
behavioral therapy for social phobia is a group therapy consist- by at least four autonomic or cognitive symptoms (i.e., sweating,
ing of several discrete entities, including (1) presentation of a palpitations, fear of dying).
three-system (cognitive-behavioral-physiological) model of so- A generalized social phobia is a chronic and disabling con-
cial anxiety, (2) training in identification and restructuring of dition characterized by a phobic avoidance of most social situa-
irrational beliefs regarding social performance, (3) in-session tions. It can be difficult to distinguish from avoidant personality
exposure to feared social situations via group role-playing sce- disorder. Both disorders include avoidance; however, in general-
narios, and (4) homework assignments directing patients to use
ized social phobia, the patient has a desire and capacity to inter-
cognitive and exposure techniques in vivo. Groups are partic-
act, but with avoidant personality disorder, the patient appears
ularly amenable to the treatment of social phobia in that they
provide natural opportunities for patients to practice feared be- to have given up.
haviors in a supportive and informative context. Posttraumatic stress disorder (PTSD) is a condition marked
by the development of symptoms after exposure to traumatic life
Outcome research is somewhat limited, but one study showed events (e.g., war, natural disaster). The person reacts to this expe-
that cognitive-behavioral group therapy was nearly twice as rience with fear and helplessness, persistently relives the event,
effective as standard educational-supportive group psychother- and tries to avoid being reminded of it. To make the diagnosis,
apy. the symptoms must last for more than 1 month after the event and
 16. Anxiety Disorders 167

must significantly affect important areas of life, such as family Imaginal exposure typically involves having the patient close
and work. Acute stress disorder is similar to PTSD but occurs his or her eyes and imagine feared stimuli as vividly as possible.
earlier than PTSD (within 4 weeks of the traumatic event) and The primary use of this type of exposure is to help patients
remits within 2 days to 4 weeks. Acute stress disorder is also confront feared thoughts, images, and memories. For example,
associated with at least three of the following dissociative symp- individuals with OCD may experience obsessional thoughts and
toms: (1) a subjective sense of numbing, detachment, or absence images about causing harm to people they love.
of emotional responsiveness; (2) a reduction in awareness of his Interoceptive exposure is the most recent form of exposure
or her surroundings; (3) derealization; (4) depersonalization; and therapy to be introduced. This procedure is designed to induce
(5) dissociative amnesia. feared physiological sensations under controlled circumstances.
Generalized anxiety disorder (GAD) is characterized by a A number of specific exercises have been developed to induce
pattern of frequent, persistent worry and anxiety that is dispro- specific panic-like sensations. For example, the step-up exercise,
portionate to the impact of the events or circumstances on which in which the patient repeatedly steps up and down on a single step
the worry focuses. Patients with GAD do not necessarily ac- as rapidly as possible, produces rapid heart rate and shortness of
knowledge the excessive nature of their worries, but they must breath.
be bothered by their degree of worry. This pattern must occur Systematic desensitization requires initial training in progres-
“more days than not” for at least 6 months. Patients must find sive muscle relaxation and the development of one or more care-
it difficult to control their worry and must report three or more fully constructed hierarchies of feared stimuli. Treatment then
of six somatic or cognitive symptoms, which include feeling involves the pairing of mental images of the lowest items on the
restlessness, fatigue, muscle tension, or insomnia. Worry can be hierarchy with relaxation until the image can be held in mind
commonplace in many other anxiety disorders, but the worries without it producing significant distress.
in GAD must exceed in the breadth or scope the worries charac-
terized in other anxiety disorders. Answers 16.50–16.54

Answers 16.46–16.49 16.50. The answer is D

16.46. The answer is D 16.51. The answer is A

16.47. The answer is C 16.52. The answer is E

16.48. The answer is A
16.53. The answer is C
16.49. The answer is B
16.54. The answer is B
Exposure therapy involves intentionally confronting feared, but
Specific phobia is divided into four subtypes (animal type, natu-
otherwise not dangerous, objects, situations, thoughts, memo-
ral environment type, blood injury type, and situational type) in
ries, and physical sensations for the purpose of reducing fear
addition to a residual category for phobias that do not clearly fall
reactions associated with the same or similar stimuli. System-
into any of these four categories. The key feature in each type of
atic desensitization was the first exposure therapy technique to
phobia is that the fear is circumscribed to a specific object, both
undergo scientific investigation. Although an effective treatment
temporally and with respect to other objects. Phobias have tradi-
for some anxiety disorders, it has generally fallen out of use
tionally been classified according to the specific fear by means
among researchers and cognitive-behavioral therapists. The con-
of Greek or Latin prefixes, as indicted by the examples below.
temporary use of exposure therapy may be usefully divided into
three classes of procedures: in vivo exposure, imaginal exposure, Acrophobia: fear of heights
and interoceptive exposure. Agoraphobia: fear of open places
In vivo exposure involves helping patients to directly confront Ailurophobia: fear of cats
feared objects, activities, and situations. It is usually conducted in Claustrophobia: fear of closed spaces
a graduated fashion according to a mutually agreed-on (between Cynophobia: fear of dogs
patient and therapist) hierarchy. For example, a hierarchy for a Hydrophobia: fear of water
specific animal phobia, such as a snakes or spiders, may begin Mysophobia: fear of dirt and germs
with looking at pictures and other representations of the feared Pyrophobia: fear of fire
animal followed by looking at the actual animal kept in a cage, Xenophobia: fear of strangers
first at a distance and then gradually moving closer. Zoophobia: fear of animals
 17
Somatoform Disorders

Six somatoform disorders are currently listed in the Diagnostic does not usually account for the symptoms described by the
and Statistical Manual of Mental Disorders (DSM): somatiza- patient. The disorders may be chronic or episodic, they may
tion disorder, conversion disorder, hypochondriasis, body dys- be associated with other mental disorders, and the symptoms
morphic disorder, pain disorder, and undifferentiated somato- described are always worsened by psychological stress.
form disorder not otherwise specified. Treatment is often very difficult because the symptoms tend
The term somatoform is derived from the Greek word soma, to have deeply rooted and unconscious psychological meanings
which means body. Somatoform disorders are a broad group of for most patients, and these are patients who do not or cannot
illnesses that have bodily signs and symptoms as a major com- express their feelings verbally. Unconscious conflicts are ex-
ponent. These disorders encompass mind-body interactions in pressed somatically and seem to have a particular tenaciousness
which the brain, in ways still not well understood, sends vari- and resistance to psychological treatment.
ous signals that impinge on the patient’s awareness, indicating Treatment involves both biological and psychological strate-
a serious problem in the body. Additionally, minor or as yet gies, including cognitive-behavioral treatments, psychodynamic
undetectable changes in neurochemistry, neurophysiology, and therapies, and psychopharmacologic approaches. If other psy-
neuroimmunology may result from unknown mental or brain chiatric disorders, such as depression or anxiety disorders, are
mechanisms that cause illness. also present, they must be treated concomitantly. Different med-
Before a somatoform disorder is diagnosed, the clinician must ications are effective with the range of disorders, and students
initiate a thorough medical evaluation to rule out the presence of should be knowledgeable about this.
actual medical pathology. A certain percentage of these patients Students should study the questions and answers below for a
will turn out to have real underlying medical pathology, but it useful review of these disorders.

HELPFUL HINTS

Students should be able to define the terms listed below.

amobarbital (Amytal) Briquet’s syndrome pain disorder stocking-and-glove

▲

▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲

▲ ▲ ▲

interview conversion disorder pimozide (Orap) anesthesia

anorexia nervosa dysmorphophobia primary gain and symbolization and
▲ ▲

antisocial personality endorphins secondary gain projection

disorder hemianesthesia pseudocyesis undifferentiated
▲ ▲ ▲ ▲ ▲

astasia-abasia hypochondriasis pseudoseizures somatoform disorder

▲ ▲

autonomic arousal hysteria secondary symptoms undoing

▲

disorder identification somatization disorder

biofeedback instinctual impulse somatoform disorder not
▲ ▲

body dysmorphic la belle indifférence otherwise specified

disorder malingering somatosensory input
▲

QUESTIONS 17.1. Which of the following features are helpful in deciding

whether idiopathic physical symptoms may have a psy-
Directions chiatric basis?
Each of the questions or incomplete statements below is followed A. Symptoms have comorbid major psychiatric disor-
by five suggested responses or completions. Select the one that ders such as depression.
is best in each case. B. Symptoms closely follow traumatic events.
168
 17. Somatoform Disorders 169

C. Symptoms lead to psychological “gratification.” B. somatization disorder begins early in life

D. Symptoms represent predictable personality traits. C. complaints are limited to pain in conversion disorder
E. All of the above D. complaints are not limited to neurological symptoms
in conversion disorder
17.2. Conversion disorder E. conversion disorder involves a particular disease
A. usually has a chronic course rather than a symptom
B. is associated with antisocial personality disorder
C. is commonly comorbid with a schizoid personality 17.8. A patient with somatization disorder
disorder A. has had physical symptoms for only 3 months
D. responds well to a confrontation of the “false nature” B. usually experiences minimal impairment in social or
of the symptoms occupational functioning
E. is associated with symptoms that conform to known C. may have a false belief of being pregnant with objec-
anatomical pathways tive signs of pregnancy, such as decreased menstrual
flow or amenorrhea
17.3. Which of the following statements regarding conversion D. presents the initial physical complaints after age
disorder and gender differences is true? 30 years
A. Women are often involved in occupational accidents. E. has complained of symptoms not explained by a
B. Symptoms are more common on the right side than known medical condition
the left side of the body in women.
C. The ratio of women to men among adult patients is 17.9. All of the following mental disorders are frequently seen
as high as 10:1. in patients with somatization disorder (relative to the
D. In children, there is a higher predominance in boys. general population) except
E. There is an association with borderline personality A. bipolar I disorder
disorder in men. B. generalized anxiety disorder
C. major depressive disorder
17.4. Conversion reactions D. obsessive-compulsive personality disorder
A. seem to change the psychic energy of acute conflict E. schizophrenia
into a personally meaningful metaphor of bodily dys-
function 17.10. The most frequently occurring of the somatoform disor-
B. conform to usual dermatomal distribution of under- ders is
lying peripheral nerves A. somatization disorder
C. are invariably sensorimotor as opposed to autonomic B. pain disorder
D. are always transient C. hypochondriasis
E. all of the above D. conversion disorder
E. body dysmorphic disorder
17.5. Characteristic signs of conversion disorder include all of
the following except 17.11. Medical disorders to be considered in a differential diag-
A. astasia-abasia nosis of somatization disorder include
B. cogwheel rigidity A. multiple sclerosis
C. hemianesthesia of the body beginning precisely at the B. systemic lupus erythematosus
midline C. acute intermittent porphyria
D. normal reflexes D. hyperparathyroidism
E. stocking-and-glove anesthesia E. all of the above
17.6. Which of the following diseases is part of the differential 17.12. Which of the following is not a recommended treatment
diagnosis for conversion disorder? strategy for a patient with somatization disorder?
A. Multiple sclerosis A. Increasing the patient’s awareness that psychological
B. Guillain-Barré syndrome factors may be involved
C. Acquired immunodeficiency syndrome (AIDS) B. Having several different clinicians involved in caring
D. Dementia for the patient
E. All of the above C. Avoiding additional laboratory and diagnostic proce-
dures
17.7. Conversion disorder differs from somatization disorder
D. Seeing patients during regularly scheduled visits at
in that
regular intervals
A. conversion disorder includes symptoms in many or- E. Listening to somatic complaints as emotional expres-
gan systems sions rather than medical complaints
170 17. Somatoform Disorders

17.13. Chronic pain disorder is most frequently associated with C. Hypochondriasis is a chronic and somewhat disabling
disorder.
A. substance-related disorders
D. Recent estimates are that 4 to 6 percent of the general
B. anxiety disorder
medical population meets the specific criteria for the
C. dementia
disorder.
D. depressive disorder
E. Significant numbers of patients with hypochondri-
E. schizophrenia
asis report traumatic sexual contacts, physical vio-
lence, and major parental upheaval before the age of
17.14. All of the following depressive symptoms are most
17 years.
prominent in patients with pain disorder except
A. decreased libido 17.19. Body dysmorphic disorder is associated with
B. insomnia
C. weight loss A. a family history of substance abuse
D. anhedonia B. major depressive disorder
E. anergia C. obsessive-compulsive disorder
D. social phobia
E. all of the above
17.15. The most accurate statement regarding pain disorder is
A. It is diagnosed equally among men and women. 17.20. In body dysmorphic disorder,
B. Peak ages of onset are in the second and third decades.
C. It is least common in persons with blue-collar occu- A. plastic surgery is usually beneficial
pations. B. a comorbid diagnosis is unusual
D. First-degree relatives of patients have an increased C. anorexia nervosa may also be diagnosed
likelihood of having the same disorder. D. about 50 percent of patients may attempt suicide
E. Depressive disorders are no more common in patients E. serotonin-specific drugs are effective in reducing the
with pain disorder than in the general public. symptoms

17.16. People with hypochondriasis 17.21. A 34-year-old woman presented with chronic and inter-
mittent dizziness, paresthesias, pain in multiple areas of
A. are usually women her body, and intermittent nausea and diarrhea. She re-
B. are often thanatophobic ported that these symptoms had been present most of the
C. do not respond to reassurance time, although they had been undulating since she was
D. seek treatment more than explanations approximately 24 years old. In addition, she complained
E. in postmortem examinations, have a greater degree of mild depression; was disinterested in many things in
of upper gastrointestinal (GI) inflammation and con- life, including sexual activity; and had been to many doc-
gestion than normal control subjects tors to try to find out what was wrong with her. Physical
examination, including a neurological examination, was
17.17. Which of the following is a theory for the cause of normal. There were no abnormalities on laboratory test-
hypochondriasis? ing. Her doctor diagnoses somatization disorder. Which
A. Symptoms are viewed as a request for admission to of the following about this disorder is true?
the sick role made by a person facing challenges in A. It occurs more commonly in men.
his or her life. B. It is more common in urban populations.
B. Persons with hypochondriasis have low thresholds for C. These patients are no more likely to develop another
and low tolerance of physical discomfort. medical illness than people without the disorder.
C. Aggressive and hostile wishes toward others are trans- D. The symptoms typically begin in middle age.
ferred (through repression and displacement) into E. These patients usually give a very thorough and com-
physical complaints. plete report of their symptoms.
D. Hypochondriasis is a variant form of other mental
disorders, such as depressive or anxiety disorders.
17.22. Mr. J is a 28-year-old single man who is employed in a
E. All of the above
factory. He was brought to an emergency department by
his father, complaining that he had lost his vision while
17.18. True statements about hypochondriasis include all of the
sitting in the back seat on the way home from a family
following except
gathering. He had been playing volleyball at the gath-
A. Depression accounts for a major part of the total pic- ering but had sustained no significant injury except for
ture in hypochondriasis. the volleyball hitting him in the head a few times. As
B. Hypochondriasis symptoms can be part of dysthymic was usual for this man, he had been reluctant to play
disorders, generalized anxiety disorder, or adjustment volleyball because of his lack athletic skills, and he was
disorder. placed on a team at the last moment. He recalls having