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General Considerations

A. Epidemiology

Anxiety disorders are among the most common of psychiatric disorders, affecting up to 15% of the general population at any time (Table 18–1). 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 obsessive–compulsive disorder (OCD) and panic disorder each about 1–3%. Although posttraumatic stress disorder appears common, its specific frequency is unknown (see Chapter 19). 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-5 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.

Table 18–1Anxiety Disorders

B. Etiology

1. 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 sexual expression could occur because of external threat and would subsequently result in a fear of the loss of control of the drive. The damming up of the impulses, along with the fear of loss of control, would result in anxiety.

Freud soon began to see the limitations of this theory and later proposed that anxiety was central to the concept of neurosis. He acknowledged that anxiety was a natural, biologically derived response mechanism required for survival. He abandoned the concept of the transformation of sexual drive (energy) into anxiety and accepted the prevailing notion of the time: anxiety was a result of threat. He recognized two sources of such threat. The first, termed traumatic situations, involved stimuli that were too severe for the person to manage effectively and could be considered the common or natural fear response. The second, called danger situations, resulted from the recognition or anticipation of upcoming trauma, whether internal (by loss of control of drives) or external. The response to these threats resulted in what was called signal anxiety, which was an attenuated and therefore more manageable anxiety ...

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