Anxiety Disorders, Dissociative Disorders, and Adjustment Disorders

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Franklin R. Schneier, Lisa A. Mellman, David Spiegel: Anxiety Disorders, Dissociative Disorders, and Adjustment

Disorders, in Gabbard’s Treatments of Psychiatric Disorders, 4th Edition. Edited by Glen O. Gabbard. Copyright ©2009

American Psychiatric Publishing, Inc. DOI: 10.1176/appi.books.9781585622986.265186. Printed 5/10/2009 from

www.psychiatryonline.com

Gabbard’s Treatments of Psychiatric Disorders > Part VI. Anxiety Disorders, Dissociative Disorders, and Adjustment

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Anxiety Disorders, Dissociative Disorders, and Adjustment Disorders

INTRODUCTION

Anxiety Disorders

Anxiety disorders are the most common mental disorders among adults in the United States, with

lifetime and 12-month prevalences of 29% and 18%, respectively (Kessler et al. 2005a). Most

persons with anxiety disorders experience significant impairment in role functioning (Kessler et al.

2005b), and costs have been estimated at more than $42 billion per year, including lost

productivity, mortality, and treatment costs (Greenberg et al. 1999). Increasing numbers of people

with anxiety disorders are seeking treatment (Olfson et al. 2004), although first treatment contact

is still typically delayed more than 10 years after onset of the disorder (Wang et al. 2005).

Empirical support for the effectiveness of treatments for specific anxiety disorders has grown

tremendously in recent years. In particular, numerous studies have clarified the efficacy of specific

forms of cognitive-behavioral therapy (CBT) for each of the anxiety disorders, and selective

serotonin reuptake inhibitor (SSRI) efficacy has been well established in panic disorder, social

anxiety disorder, obsessive-compulsive disorder (OCD), posttraumatic stress disorder (PTSD), and

generalized anxiety disorder (GAD). A small but growing literature addresses alternative

psychotherapies and medications, combined approaches, treatment-refractory conditions, and

treatment of comorbid syndromes.

In Chapter 29, “Panic Disorder,” Murray Stein and Laura Campbell-Sills review treatments for panic

disorder. They note that SSRIs have emerged as the first-line pharmacotherapy, and

benzodiazepines also have a role in treatment of many patients. Effective cognitive-behavioral

treatments for panic incorporate psychoeducation, identification and modification of panic-related

cognitions, exposure to feared sensations and situations, and relapse prevention.

Social anxiety disorder and specific phobias are reviewed in Chapter 30. Franklin Schneier, Brigette

Erwin, Richard Heimberg, Randall Marshall, and Lisa Mellman describe established CBTs for social

anxiety disorder that utilize cognitive restructuring and exposure to feared situations through

role-playing and homework assignments. SSRIs are a first-line pharmacotherapy, with

benzodiazepines and monoamine oxidase inhibitors among the other established options. Specific

phobias are best treated with exposure.

John Greist and James Jefferson review data on treatments for OCD in Chapter 31,

“Obsessive-Compulsive Disorder.” SSRIs and clomipramine remain the mainstays of

pharmacotherapy for OCD, although their limited efficacy has prompted a search for augmenting

agents, such as antipsychotics. Exposure in vivo and ritual prevention constitute the

well-established core of CBT for OCD.

Treatments for PTSD and acute stress disorder (ASD) are discussed in Chapter 32. Charles Marmar

and David Spiegel note that CBT incorporating prolonged imaginal or in vivo exposure is widely

considered the first-line modality of treatment. SSRIs are the best-established pharmacotherapy,

and use of anti-adrenergic agents in the early stages of treatment holds promise for inhibiting the

consolidation of PTSD symptoms.

In Chapter 33, “Generalized Anxiety Disorder,” Rudolph Hoehn-Saric, Thomas Borkovec, and

Kenneth Belzer discuss supportive psychotherapy and CBT for GAD that emphasize relaxation inPrint: Anxiety Disorders, Dissociative Disorders, and Adjustment Diso… http://www.psychiatryonline.com/popup.aspx?aID=265190&print=yes…

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addition to cognitive and exposure elements. SSRIs and short-term use of benzodiazepines are

common adjunctive pharmacotherapies.

These chapters recognize what is now a wealth of data supporting effective treatments for specific

anxiety disorders. Clinical experience suggests that supportive and psychodynamic therapies and a

variety of lesser-studied medications may also be useful. Much remains to be learned about

optimizing treatment for the individual patient, including selection of initial treatment, augmenting

partial responses, and maintaining responses in the long term.

Dissociative and Adjustment Disorders

Today, the treatments for dissociative and adjustment disorders are benefiting from clearer

rationales, methods, and bodies of evidence. Like ASD and PTSD, these disorders largely originate

in stressful or traumatic experience and represent a spectrum of maladaptive responses to such

events. Disruptions in cognition, emotion, and social relationships are common features, with

underlying dysfunction in noradrenergic, serotonergic, dopaminergic, and other neurotransmitter

systems as well as the hypothalamic-pituitary-adrenal (HPA) axis.

In Chapter 34, Richard Kluft and Richard Loewenstein discuss the diagnosis and treatment of

dissociative disorders, including depersonalization. They note that the more serious of the

dissociative and adjustment disorders can be thought of as poorly modulated responses to

overwhelming input. Apparent inconsistencies in symptom patterns over time and across

individuals can be understood as reflecting excessive trauma-related activation of the cortex, limbic

system, locus coeruleus, autonomic nervous system, and HPA axis, associated with intrusion and

hyperarousal symptoms, and deactivation, associated with avoidance and dissociation. The

intensity and perceived lack of controllability of such symptoms allow symptoms of one type to

reinforce the development of the other.

Effective treatments for dissociative and adjustment disorders involve combining psychotherapy

and pharmacotherapy. The psychotherapies shown to be effective involve establishment of trust,

management of physiological hyperarousal, controlled exposure to traumatic memories, working

through and cognitive restructuring of these memories, teaching access to and control over

dissociative symptoms using techniques such as hypnosis, and gradual modulation of associated

physiological and emotional hyperarousal. Pharmacological approaches are still adjunctive but

include antidepressants, particularly those affecting the serotonergic system. Results from the use

of antianxiety medications have been disappointing.

Adjustment disorders, discussed in Chapter 35 by James Strain and Kimberly Klipstein, constitute a

milder and broader range of dysfunctional responses to an array of stressors. While by definition

they are transitory, they are not uncommonly associated with more serious psychiatric comorbidity,

such as anxiety or depressive disorders. About half of the time they are treated pharmacologically,

and they often require considerable supportive psychotherapeutic input as well.

REFERENCES

Greenberg PE, Sisitsky T, Kessler RC, et al: The economic burden of anxiety disorders in the 1990s. J Clin

Psychiatry 60:427–435, 1999 [PubMed]

Kessler RC, Berglund P, Demler O, et al: Lifetime prevalence and age-of-onset distributions of DSM-IV

disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 62:693–602, 2005a

Kessler RC, Tat Chiu W, Demler O, et al: Prevalence, severity, and comorbidity of 12-month DSM-IV disorders

in the National Comorbidity Survey Replication. Arch Gen Psychiatry 62:617–627, 2005b

Olfson M, Marcus SC, Wan GJ, et al: National trends in the outpatient treatment of anxiety disorders. J Clin

Psychiatry 65:1166–1173, 2004 [PubMed]

Wang PS, Berglund P, Olfson M, et al: Failure and delay in initial treatment contact after first onset of mental

disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 62:603–613, 2005 [PubMed]Print: Anxiety Disorders, Dissociative Disorders, and Adjustment Diso… http://www.psychiatryonline.com/popup.aspx?aID=265190&print=yes…

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