Chapter 19

### Essentials of Diagnosis

Anxiety disorders range in severity from common, mild phobias (e.g., fear of insects, heights, or storms) to chronic, disabling conditions such as panic disorder or obsessive–compulsive disorder (OCD). Anxiety diagnoses are made according to the specific symptomatic manifestation of each disorder. Table 19–1 lists the anxiety disorder diagnoses included in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, Text Revision (DSM-IV-TR). Posttraumatic stress disorder and acute stress disorder are covered in Chapter 20, and OCD is covered in Chapter 21.

Table 19–1. DSM-IV-TR Anxiety Disorders

Anxiety is characterized by heightened arousal (i.e., physical symptoms such as tension, tachycardia, tachypnea, tremor) accompanied by apprehension, fear, obsessions, or the like. Anxiety disorders are different from normal fears, although the symptoms can be similar. Generally speaking, normal fears represent emotional reactions to real, external threats, and the emotional response is appropriately related to the actual danger. In contrast, the symptoms of anxiety disorders occur either without obvious external threat or when the response to the threat is excessive. When an extreme or inappropriate fear or worry is present and is coupled with some degree of life impairment, the diagnosis of anxiety disorder should be considered.

### General Considerations

#### Epidemiology

Anxiety disorders are among the most common of psychiatric disorders, affecting up to 15% of the general population at any time. Individual anxiety disorders occur frequently. Phobic disorders (i.e., specific or social phobia) may affect as much as 8–10% of the population, generalized anxiety disorder (GAD) about 5%, and OCD and panic disorder each about 1–3%. Although posttraumatic stress disorder appears common, its specific frequency is unknown (see Chapter 20). The comorbidity of anxiety disorders with other psychiatric disorders is high. For example, about 40% of patients with primary anxiety disorders will have a lifetime history of a DSM-IV-TR depressive disorder. Further, in patients who have other psychiatric disorders, significant anxiety symptoms often are associated with those disorders. Therefore, clinically significant anxiety symptoms will occur frequently in patients seen in clinical practice.

#### Etiology

##### Psychodynamic Theory

Traditional psychoanalytic theory describes anxiety disorders as being rooted in unconscious conflict. Freud originally used the term “Angst” (literally, “fear”) to describe the simple intrapsychic response to either internal or external threat. He later derived the concept of the pleasure principle, which describes the tendency of the psychic apparatus to seek immediate discharge of impulses. In his earliest organized theory of anxiety, Freud postulated that conflicts or inhibitions result in the failure to dissipate libidinal (i.e., sexual) drives. These restrictions on ...

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