Vitamin Information Center

Anxiety Disorders
MICHAEL LINGEN
University of Göttingen, Göttingen, Germany
mlingen@gwdg.de
Synonyms
Panic disorder; Agoraphobia; Social phobia; Specific
phobia; Simple phobia; General anxiety disorder
(GAD); Obsessive-compulsive disorder (OCD); Acute
and post-traumatic stress disorder (PTSD); Hypochondria;
Health anxiety; Health phobia
Definition
Fear and anxiety are not primarily pathological, but
ubiquitous phenomena necessary for life and survival.
It is only in its extreme form that anxiety becomes
problematic. Anxiety is a feeling of apprehension
and fear characterized by physical symptoms such as
palpitations, sweating, and feelings of stress. Anxiety
disorders are a cover term for a variety of mental
disorders in which severe anxiety is a salient symptom.
Unlike the relatively mild, brief anxiety caused
by a stressful event such as an exam or a business presentation,
anxiety disorders are chronic, or can become
chronic, or grow progressively worse if not treated, and
are pathologically associated with other mental disorders.
Basic Characteristics
Epidemiology
Anxiety disorders rank among the most frequent psychological
diseases. 1–2% of the total population are
affected by an anxiety disorder in need of treatment.
Epidemiological studies concluded that the lifetime
prevalence of anxiety disorders is 14% (Regier 1998).
The 12-month prevalence of anxiety disorders is 12.0%,
 specific phobias are most frequent (7.8%), followed
by  panic disorders (12-month prevalence: 2.3%;
Wittchen and Jacobi 2005). The lifetime prevalence of
panic disorders is estimated to be 3–5 percent (Faravelli
et al. 2005). General anxiety disorder (GAD)
shows a lifetime prevalence of 5% in adults (Ballenger
et al. 2001). Prevalence rates of GAD are highest in
middle-aged women (> 45 years).
Aetiology
In a general model, anxieties can be explained as a consequence
of a dysfunctional interpretation of events,
which go hand in hand with a behavior that more
and more strengthens the dysfunction (e. g. avoidance).
According to this model, the ill-making interpretations
are the result of individual, relatively stable convictions
and doctrines. These are triggered by specific situations,
physical reactions or thoughts that influence the
(consequently very selective) processing and interpretation
of information. Most patients, for example, over
estimate dangers and underestimate their own capacity
to deal with them. As soon as a perceived danger
is assessed, a number of negative, automatic thoughts
build up (e. g. self-doubt, sceptic predictions). This process
of building up can be described as a vicious circle:
signs of an assumed dysfunction enhance the perception
of violability and influence the situational cognitions
and the dysfunctional attempts to cope with it;
these consist mainly in avoidance and safety-seeking
behavior. Consequently, the person is convinced that
only this behavior will avert the dreaded catastrophe.
Experiencing that the catastrophe did not occur or perceiving
that the situation could only be managed with
this behavior, suppresses the development of functional
assessments and behaviors. The term “safety-seeking
behaviors” (Salkowskisk 1991) refers to every behavior
used to avoid the dreaded event (e. g. diction or voice
modulation of socially insecure people, always carrying
a mobile phone or medication by people with panic disorders).
Cognitive-behavioral therapy therefore stresses
the need to modify this safety-seeking behavior;
the behavioral-therapeutic approach also distinguishes
between risk-factors (genetic precondition, life story),
triggering or releasing factors (stages or events of life
that were particularly stressful) and maintaining conditions
(e. g. self-energizing processes based on self-evaluation
and assessment of events as catastrophic, leading
to avoidance).
From a psycho-dynamic point of view, in contrast,
the symptoms of anxiety are seen as a result of inner
conflicts or of deficits of the so-called self-structure,
depending on the underlying concept. According to the
conflict model, the psychological defense of unacceptable
emotions (e. g. aggressive or egoistic impulses)
leads to a massive inner conflict which in turn “is frightening”
in the original sense. According to this model,
people would rather suffer from anxiety than have
a conflict with their consciences, an external authority
or other images of themselves; they, however, are not
aware of this inner conflict. The deficit model, on the
other hand, assumes that the anxiety cannot be fought
efficiently because of a weak ego, which then leads to
increasingly strong appearances of anxiety in the form
of symptoms. The continuous failure of psychological
defenses in the face of increasingly trivial stimuli therefore
leads to frequent and massive bouts of anxiety.
Consequences
In most anxiety disorders spontaneous remission is very
rare. On the contrary, these disorders tend to become
chronic at an early stage and sufferers have a high probability
of developing a second anxiety disorder (up to
50%) or a depression (up to 50%). A common combination
is anxiety disorder and substance abuse (up to
40%); this, however, in most cases, has to be regarded
as an unsuccessful attempt by sufferers to treat their
anxiety themselves. It is quite common that an anxiety
disorder finds its expression in somatic symptoms
(e. g. stomach ache) which are mistaken for symptoms
of a physical disease and consequently wrongly
treated. This in turn can lead to feelings of insecurity
in the patient and in extreme cases result in a kind
of vicious circle of increasing anxiety and increasing
somatic symptoms.
Treatment
Until a few years ago, anxiety disorders had been
regarded as difficult to treat. In recent years, however,
newer and more effective therapeutic strategies have
been developed. For all forms of anxiety disorders, psychotherapy
is the method of choice. The benefit or lack
of an additional treatment with medication is still under
debate. The benefit of a pharmaco-therapy as an interim
solution before the onset of psychotherapeutic measures
is undisputed. A permanent therapy with medication
(e. g. antidepressants, benzodiazepines), however,
is not always appropriate, as it prevents the establishment
of functional interpretations and coping strategies
and is also probably not quite harmless because of
potential addictions (as in the case of benzodiazepines).
The general objective of psychotherapy for anxiety disorders
is an adequate reduction of symptoms, a general psychological and physical improvement and, at the
same time, an increase in the quality of life.
Behavioral-therapeutic measures for the treatment of
anxiety disorders are based on the realization that anxieties
aremainly influenced by learning processes,maintaining
conditions (e. g. morbid gain in the form of
social care) and distorted interpretations. Consequently,
the specific therapeutic approach focuses on changing
these conditions, e. g. confrontation with anxietyeliciting
stimulus, relaxation techniques, etc.
A decisive focus in which the psychoanalytical therapy
differs from cognitive-behavioral approaches is the
psychoanalytical handling of the therapeutic relationship
with its specific interactions that are governed by
the patient’s unconscious conflicts. The objective is
that these unconscious conflicts, which are inextricably
linked to previous relationships, can be experienced and
dealt with in the present relationship with the analyst.
Cross-References
 Acute and Post-Traumatic Stress Disorder (PTSD)
 Agoraphobia
 Dissociation
 General Anxiety Disorder (GAD)
 Hypochondria
 Obsessive-Compulsive Disorder (OCD)
 Panic Disorder
 Social Phobia
 Specific Phobia
References
Ballenger JC, Davidson JRT, Lecrubier Y, Nutt DJ, Lydiart RD,
Mayer EA, International Consensus Group on Depression
and Anxiety (2001) Consensus statement on depression, anxiety,
and functional gastrointestinal disorders. J Clin Psychiatr
62:53–58
Barlow DH (2002) Anxiety and its disorders: The nature and
treatment of anxiety and panic, 2nd edn. Guilford, New York
Brunello N, Davidson JR, Deahl M, Kessler RC, Mendlewicz J,
Racagni G, Shalev AY, Zohar J (2001) Posttraumatic stress
disorder: Diagnosis and epidemiology, comorbidity and
social consequences, biology and treatment. Neuropsychobiology
43:150–162
Davey GCL (ed) (1997) Phobias: A handbook of theory, research
and treatment. Wiley, Chichester
Goodman WK, Rudorfer M, Maser JD (2000) Obsessive-compulsive
disorder. Contemporary issues in treatment. Erlbaum,
Mahwah
Goodwin RD, Faravelli C, Rosi C, Cosci F, Truglia E, De
Graaf R, Wittchen HU (2005) The epidemiology of panic
disorder and agoraphobia in Europe. Eur Neuropsychopharmacol
15:435–43
Wittchen HU, Jacobi F (2005) Size and burden of mental disorders
in Europe: A critical review and appraisal for studies.
Eur Neuropsychopharmacol 15:357–76

Affective Disorders
UWE RUHL
Institut für Psychologie, Universität Göttingen,
Göttingen, Germany
uruhl@uni-goettingen.de
Definition
In affective disorders, the fundamental disturbance is
a change in mood to depression (with or without associated
anxiety) or to elation (mania). The mood change
is usually accompanied by a change in the overall level
of activity; most of the other symptoms are either secondary
to, or easily understood in the context of, the
change in mood and activity. Most of these disorders
tend to be recurrent ( recurrent depressive disorder)
and the onset of individual episodes is often related to
stressful events or situations.
Basic Characteristics
Introduction
Hippocrates was one of the first to use the term “melancholy”,
literally meaning “black bile”, to describe
depressive symptoms. Usually, sadness accompanies
tragic situations; for example, the death of a loved one
or loss of employment. Everyone will experience such
sad phases during their lifespan and everyonewill experience
other common symptoms of depressive disorders
during times of stress; for example, problems with concentration,
sleep disturbances, and changes in appetite.
However, a depressive disorder differs both qualitatively
(e. g., much more pervasive) and quantitatively
(i. e., longer duration) from “normal” sadness or reactions
to stress. Thus, actual definitions of depressive
disorders (e. g. according to DSM-IV, ICD-10) define
a severity threshold (depending upon a specific number
of symptoms) and a minimum duration (2 weeks).
Major depression is associated with female gender,
lower social status, and stressful life events (e. g., hospitalization
for a serious illness, pregnancy, death of
a close relative, divorce). Depression can strike a person
at any age (Cave: even small children!). Major
Depressive Disorder (MDD) is very highly associated
with potential morbidity and mortality (suicide, medical
illness, disruption in interpersonal relationships,
substance abuse, and lost work time).
 Dysthymia is a “chronic” form of depression. It is
defined by its subsyndromal nature (i. e., fewer than the
five persistent symptoms required to diagnose a major
depressive episode are present) and a protracted duration
of at least 2 years for adults. The symptoms of dysthymia
alone do not meet the criteria for Major Depression
and low mood is the primary symptom.
Patients with bipolar disorders ( bipolar affective disorder)
suffer from depressive episodes and/or manic/
hypomanic episodes (i. e., bipolar I and bipolar II disorders).
A manic syndrome is defined as a period of
unusual and extreme good mood or extreme irritability.
Manic patients often show a decreased need to sleep
and strong hyperactivity. Episodes of  hypomania are
typical. Bipolar disorders are associated with significant
morbidity and mortality rates.
 Cyclothymia is also marked by manic and depressive
states. Oscillation of high and lowmoods is typical.
However, those phases are neither of sufficient intensity
nor duration to merit a diagnosis of bipolar disorder or
MDD.
Epidemiology
Depressive disorders are more common in women than
in men (female/male ratio = 1.5–2/1). One year prevalence
rates of depression in European countries are estimated
between 1.9% (Netherlands and Great Britain;
Bijl et al. 1998; Jenkins et al. 1997) and 8.3% (Germany
Jacobi et al. 2004). Dysthymia affects about 2% of the
adult population per year; women seem to be slightly
more affected than men. The one year prevalence estimate
of bipolar disorders in adults is 0.9% (Pini et al.
2005). Almost 2% of the adult population suffers from
bipolar disorders (i. e., lifetime prevalence, Kessler et
al. 1994). Because the costs in existing economic studies
are based on a top-down approach (and depend on
assumptions in terms of resource use), it is impossible
to assess the exact economic burden. Depressive disorders
have a high economic burden due to their high
prevalence and their association with high disability in
acute depressive phases (e. g., lost workdays, reduced
working capacity). Unipolar major depression is one
of the 10 leading diseases of the global disease burden
(Lopez et al. 2006).
Pathophysiology/Etiology
The pathophysiology of MDD has not been clearly
defined. Different studies have suggested a disturbance
in CNS serotonin (i. e., 5-HT). Norepinephrine (NE)
and dopamine (DA) are other important neurotransmitters
forMDD (“monoamine hypothesis”). However,
this hypothesis is not sufficient to explain the complex
symptoms of depression. One problem is that many
other neurotransmitter systems are altered in depressive
disorders (e. g., GABA and acetylcholine). Another
problem is that improvement of monoamine neurotransmission
with medication and lifting of the clinical
signs of depression do not prove that depression is actually
caused by defective monoamine neurotransmission.
Accordingly, in different studies, no objective biological
markers exist that correspond definitively with
the disease states of bipolar disorder ( bipolar affective
disorder),  dysthymia, and  cyclothymia. Overall,
the etiology of affective disorders is multimodal
(e. g., biological factors, psychosocial factors, stressful
life events) with a strong genetic component.
Consequences
The relationship between depressive disorders and
comorbidity of other mental disorders (especially anxiety
disorders, i. e.  generalized anxiety disorders, panic,  agoraphobia, and  post-traumatic stress
disorders) as well as physical illness is well established.
Patients suffering from bipolar disorders frequently
showcomorbid anxiety disorders and substance use disorders.
Accordingly, dysthymic disorders are associated
with higher rates of comorbid substance abuse. Suicide
is the most severe complication of major depression.
Depressive disorders account for about 20 to 35%
of all deaths by suicide (Angst et al. 1999). Men are
much more likely to succeed in committing suicide than
women (ratio about 4:1). However, women  attempt
suicide about four times more often than men.
Treatment
Antidepressant medication and/or cognitive-behavioral
psychotherapy have the strongest evidence for the
treatment of depressive disorders. In severe depressions
(with or without psychotic symptoms), patients
are mostly treated with antidepressants and cognitivebehavioral
psychotherapy. Antidepressants should be
changed if there is no clear effect (after an additional
attempt of dose increase) within 4 to 6 weeks.
Accordingly, revisions to a psychotherapeutic treatment
plan should be considered, including the addition of
antidepressant medication, if there is no symptomatic
improvement within 3 or 4 months of therapy. Further,
to reduce relapse rates, anti-depressive medication
should be used routinely for at least 6 months after
remission (i. e., continuation phase therapy). Cognitivebehavioral
psychotherapy is also important for relapse
prophylaxis. In recurrent depressive patients ( recurrent
depressive disorder), either antidepressants or special
medication for relapse prophylaxis and mood stabilization,
respectively (e. g., lithium, valproate), may
be used for years (i. e., maintenance phase therapy).
Such maintenance pharmacotherapy is typically recommended
for individuals with a history of three or more
 depressive episodes, chronic depression, or bipolar
disorder.
Cross-References
 Depressive Episode
 Dysthymia
 Hypomania
 Mania
 Recurrent Depressive Disorder
References
Angst J, Angst F, Stassen HH (1999) Suicide risk in patients with
major depressive disorder. J Clin Psychiatry 60:57–62
Bijl RV, van Zessen G, Ravelli A (1998) Prevalence of psychiatric
disorder in the general population: results of the Netherlands
Mental Halth Survey and incidence Study (NEMESIS). Soc
Psychiatry Psychiatr Epidemiol 33:587–95
Jacobi F, Wittchen HU, Hölting C, Höfler M, Pfister H, Müller
N, Lieb R (2004) Prevalence, comorbidity and correlates of
mental disorders in the general population: results from the
German Health Interview and Examination Survey (GHS).
Psychol Med 27:775–789
Jenkins R, Leweis G, Bebbington P, Brugha T, Farrell M, Gill B,
Meltzer H (1997) The national psychiatric morbidity surveys
of Great Britain: initial findings from the household survey.
Psychol Med 27:775–89
Kessler RC, McGonagle KA, Zhao S, Nelson CB, Hughes M,
Eshleman S, Wittchen HU, Kendler KS (1994) Lifetime and
12-month prevalence of DSM-III-R psychiatric disorders in
the United States. Results from the National Comorbidity
Survey. Arch Gen Psychiatry 51:8–19
Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray CJ
(2006) Global and regional burden of disease and risk factors
2001: systematic analysis of population health data. Lancet
367:1747–57
Pini S, de Queiroz V, Pagnin D, Pezawas L, Angst J, Cassano
GB, Wittchen HU (2005) Prevalence and burden of bipolar
disorders in European countries. Eur J Neuropsychopharmacol
15:425–34