Cumulative research with animal, normative, and clinical populations over several decades shows that the mechanisms underlying anxiety disorders differ from those of the normal emotion of anxiety. In persons with anxiety disorders, fear and tension are disproportionate to the actual threat and may be present when no real threat exists, thereby generating an expectation of danger and distorted perceptions related to danger and various types of threats. The most common anxiety disorders are social anxiety disorder (SAD), generalized anxiety disorder (GAD), and posttraumatic stress disorder (PTSD). Persons with SAD can experience a wide range of social fears as well as severe functional consequences, whereas persons with GAD tend to experience emotional, interpersonal, and somatic symptoms of high levels of chronic anxiety. Persons with PTSD have vivid memories of and thoughts about a terrifying event or ordeal that lead to the development of anxiety, depression, and functional impairment. Effective treatment options—pharmacotherapy; psychotherapy, particularly cognitive-behavioral therapy; or a combination—can be discussed openly with the patient to make a collaborative, informed decision. A variety of medications can be used to successfully manage anxiety disorders, of which SSRIs and serotonin-norepinephrine reuptake inhibitors are the most effective. When properly used, medications can enhance a patient’s own efforts to master anxiety; overcome fearful avoidance; and address troubling behaviors, patterns, or memories. (Drug Benefit Trends. 2008;20:101-113)
Anxiety disorders are among the most common behavioral health disorders, affecting thousands of persons of all ages and cultural backgrounds (Figure 1).1,2 Because the word "anxiety" now has meanings in both technical and general usage, it is often mistakenly assumed that anxiety disorders are merely extremes of normal emotions rather than conditions with qualitatively distinct syndromes, symptoms, and behaviors. Most emotion theories present "normal" anxiety as an emotion with a complex, multiple-system physiological cascade of activation that occurs in response to a realistic potential threat and prepares a person to act. Pathological anxieties, unlike normal anxiety, are syndromal states of fear, tension, and threat-related perceptions that have no apparent adaptive function, are associated with significant functional impairment, and usually appear disproportionate to the situation to both the clinician and the patient.
Early nosological psychoanalytic models assumed that all anxiety disorders—as well as depressive and psychotic disorders—were extreme forms of normal anxiety (neuroses) and indicated defensive manifestations of marked conflict. For example, persons with social anxiety disorder (SAD) were considered to have an extreme form of shyness because of conflicted assertiveness, while those with obsessive-compulsive disorder were regarded as paralyzed by obsessional conflicts of a sexual and aggressive nature.
As the scientific basis for understanding anxiety becomes more sophisticated, clinical practice can increasingly be based on an emerging, stabilizing foundation of synthetic concepts drawn from multidisciplinary work on neural networks, dynamic psychological drives, abnormal or dysregulated neural pathways, and behavioral outcomes and can move away from simplistic etiological models. For clinicians, there is persuasive proof that severe, functionally paralyzing anxiety disorders respond dramatically to pharmacotherapy as well as to effectively implemented cognitive-behavioral, interpersonal, and supportive-expressive psychotherapies.
A clinician’s confidence in the efficacy of antianxiety medications is usually a powerful means to forming a close alliance with persons who have an anxiety disorder. Once clinicians gain experience and see quantifiable results, it becomes relatively easy to communicate an optimistic understanding of a patient’s emotional condition and to identify ways to relieve the anxiety, often with dramatic improvement in the patient’s overall quality of life.
Contemporary clinical practice is based on the sophisticated skills of recognizing, diagnosing, and treating anxiety disorders. This article focuses on the 3 most common anxiety disorders: SAD, generalized anxiety disorder (GAD), and posttraumatic stress disorder (PTSD). For each disorder, there is considerable scientific literature that recommends various specialized adaptations of cognitive-behavioral therapy (CBT) principles as effective treatments, but this review focuses on the pharmacological literature.
Social Anxiety Disorder
Typically, in persons with generalized SAD, onset of symptomatic impairment occurs in their early teenage years as increasingly complex social interactions evoke severe anxiety, expectations of failure and embarrassment, and behavioral avoidance as a coping strategy.3 Behavioral inhibition, the temperament described by Kagan and colleagues4 as a generally slow, cautious, and avoidant pattern of approach to unfamiliar persons and events, is much more common in early childhood. The average time lag between onset of SAD and a person’s first contact with a behavioral health professional, if treatment is sought at all, is 10 years.1,5 In the United States today, most persons with SAD—like persons with most other behavioral health disorders—do not receive treatment.