Current concepts in clinical therapeutics: anxiety disorders, Part 1

The diagnosis, epidemiology, classification and clinical presentation, pathophysiology, and treatment of anxiety disorders are reviewed. Anxiety disorders, among the most common mental disorders, must be differentiated from medical diseases with anxious symptoms. A complete physical and mental status examination, as well as a thorough knowledge of the patient's medical, psychiatric, and drug history are required. Epidemiologic studies indicate an incidence of 4-8% in the United States. There are four categories of anxiety disorders: phobic disorders, anxiety states, posttraumatic stress disorders, and atypical anxiety disorders. Several psychoanalytic, behavioral, and cognitive theories have been advanced to explain the pathophysiologic mechanisms causing anxiety disorders. Of most interest are the biological theories involving the catecholamine neurotransmitter norepinephrine and the benzodiazepine receptor. Proper treatment for anxiety disorders involves nonpharmacologic and pharmacologic approaches. The benzodiazepines are widely used and are the mainstay of drug treatment for patients with situational anxiety and generalized anxiety disorder. However, problems with sedation, complications of drug withdrawal, and patients' fear of drug dependency may limit clinical usefulness. Buspirone is the first nonbenzodiazepine anxiolytic to be introduced in the United States in more than 25 years. Its unique role in treating anxiety, compared with the benzodiazepines, may include less sedation, minimal drug abuse potential, and fewer withdrawal symptoms upon drug discontinuation. Nonpharmacologic therapy is used extensively in the treatment of phobic disorders (simple and social phobia). Important advances in the diagnosis and treatment of anxiety disorders have been made. An accurate diagnosis is essential for optimal management. Unfortunately, many anxious patients do not seek treatment and some do not receive the most appropriate treatment.