Generalized anxiety disorder (GAD) has a lifetime prevalence in the US population of about 5.7%. Typically, GAD begins in early adulthood and tends to have a chronic and persistent course. The disorder frequently presents comorbidly with other conditions, and about 90% of patients with GAD have at least 1 comorbid lifetime psychiatric disorder. Patients with GAD tend to be high users of medical services; the disorder is associated with significant physical as well as psychological symptomatology and impacts health, family relationships, and employment. Pharmacologic and psychosocial treatments are available for GAD. Different side effect profiles, speed of onset of action, and discontinuation requirements of individual drugs need to be taken into account when selecting treatment. Treatment selection should include consideration of comorbidity, psychological function, social impairment, and refractoriness, as well as the need for ongoing intervention for many individuals. Innovative treatments, including anticonvulsants, atypical antipsychotics, and others, as well as treatment targeting concomitant insomnia, may help improve outcomes for affected individuals.

This article reviews typical anxiety presentations in Asia, and among Asian refugees. In Asia, there are multiple functional somatic syndromes that are common anxiety presentations. These distress syndromes often produce catastrophic cognitions about anxiety‐type somatic and psychological symptoms. These functional somatic syndromes should be understood, and specifically assessed and addressed, in order to optimize the evaluation and treatment of anxiety disorders among Asian individuals.

Chapter 10 discusses how to deal with difficult clinical situations using example vignettes. The vignettes presented in this chapter are not intended to fully describe any one case, but rather to highlight how to deal with some issues that commonly arise within cognitive remediation programs.

Objectives: To examine the relationship of sleep disturbance with complicated grief (CG) in patients with bipolar disorder (BD).Methods: Adults with DSM‐IV BD were asked if they ever experienced significant loss and, if so, completed the Inventory of Complicated Grief. Subjective sleep disturbance was assessed with the Pittsburgh Sleep Quality Index (PSQI). The association of CG with sleep disturbance was assessed in univariate t‐tests, and in multivariate analyses controlling for the presence of anxiety disorder comorbidity and current bipolar recovery status.Results: Individuals with CG had significantly higher mean PSQI scores (10.9 versus 7.9, p = 0.003) than those without CG. Further, within the group of BD participants who had experienced a significant loss, those with CG had significantly poorer sleep (p = 0.01). CG remained significantly associated with greater sleep impairment after adjustment for comorbid anxiety disorder and bipolar mood state. This additive impairment in sleep with CG comorbidity was evident for four of the PSQI component scales: sleep quality, sleep duration, sleep efficiency and sleep disturbance.Conclusions: Our data indicate a significant association of CG with poor sleep in individuals with BD. Disturbed sleep may be a mechanism by which CG increases the burden of illness in BD.

Cognitive behavioral therapy (CBT) is an effective treatment for many but not all patients with panic disorder. This raises the question of whether there are types of panic disorder for which CBT is effective, and other types for which it is ineffective. Klein's (1993) suffocation alarm theory suggests two types of panic disordered patient: those with intense dyspnea as a frequent panic symptom (suffocation panickers) and those with little or no dyspnea (nonsuffocation panickers). Klein's theory suggests CBT will be less effective for suffocation panickers compared to nonsuffocation panickers. To test this prediction, 22 unmedicated panic-disordered patients were classified as suffocation panickers (n = 13) or nonsuffocation panickers (n = 9) and received 10 sessions of CBT. Both groups had significant reductions in symptoms from pre- to posttreatment, and gains were maintained at 3-month followup. Groups did not differ in treatment response. At 3-month followup 75% of suffocation panickers, and 50% of nonsuffocation panickers were panic-free, and 75% of suffocation panickers and 63% of nonsuffocation panickers were classified as treatment responders. These results fail to support the prediction from Klein's theory and suggest that panic disorder with intense dyspnea can be successfully treated with CBT.

There are a number of unmet needs in the treatment of anxiety disorders including the need for more effective, rapidly acting, and better tolerated medications; early identification of nonresponse; effective treatments for refractory disorders; prevention of relapse; and promotion of resilience and long-lasting response. Rates of response to contemporary antidepressants and other anxiolytics are often less robust than might be hoped, and remission rates, which have until recently been infrequently measured, are even lower. A small number of mostly uncontrolled studies suggest a role for augmentation of initial therapy with a second modality in patients who do not fully remit to treatment. There also is a small but growing literature which suggests the use of novel anticonvulsants and atypical antipsychotics in the treatment of anxiety disorders should be further studied. However, a definitive place for these newer therapeutic strategies in the anxiety disorder treatment armamentarium awaits evidence from large, controlled studies. Psychopharmacology Bulletin. 2004;38(Suppl 1): 31-37.

OBJECTIVES:In this article, we review the evidence for, and implications of, a high rate of comorbid posttraumatic stress disorder (PTSD) in individuals with bipolar disorder.METHODS:We reviewed studies providing comorbidity data on patients with bipolar disorder, and also examined the PTSD literature for risk factors and empirically supported treatment options for PTSD.RESULTS:Studies of bipolar patients have documented elevated rates of PTSD. Based on our review, representing 1214 bipolar patients, the mean prevalence of PTSD in bipolar patients is 16.0% (95% CI: 14-18%), a rate that is roughly double the lifetime prevalence for PTSD in the general population. Risk factors for PTSD that are also characteristic of bipolar samples include the presence of multiple axis I disorders, greater trauma exposure, elevated neuroticism and lower extraversion, and lower social support and socio-economic status.CONCLUSIONS:These findings are discussed in relation to the cost of PTSD symptoms to the course of bipolar disorder. Pharmacological and cognitive-behavioral treatment options are reviewed, with discussion of modifications to current cognitive-behavioral protocols for addressing PTSD in individuals at risk for mood episodes.

Insomnia and major depressive disorder (MDD) can coexist. This study evaluated the effect of adding eszopiclone to fluoxetine.Patients who met DSM-IV criteria for both MDD and insomnia (n = 545) received morning fluoxetine and were randomized to nightly eszopiclone 3 mg (ESZ+FLX) or placebo (PBO+FLX) for 8 weeks. Subjective sleep and daytime function were assessed weekly. Depression was assessed with the 17-item Hamilton Rating Scale for Depression (HAM-D-17) and the Clinical Global Impression Improvement (CGI-I) and Severity items (CGI-S).Patients in the ESZ+FLX group had significantly decreased sleep latency, wake time after sleep onset (WASO), increased total sleep time (TST), sleep quality, and depth of sleep at all double-blind time points (all p < .05). Eszopiclone co-therapy also resulted in: significantly greater changes in HAM-D-17 scores at Week 4 (p = .01) with progressive improvement at Week 8 (p = .002); significantly improved CGI-I and CGI-S scores at all time points beyond Week 1 (p < .05); and significantly more responders (59% vs. 48%; p = .009) and remitters (42% vs. 33%; p = .03) at Week 8. Treatment was well tolerated, with similar adverse event and dropout rates.In this study, eszopiclone/fluoxetine co-therapy was relatively well tolerated and associated with rapid, substantial, and sustained sleep improvement, a faster onset of antidepressant response on the basis of CGI, and a greater magnitude of the antidepressant effect.

Background. Discontinuation of benzodiazepine (BZ) treatment results in a well-characterized withdrawal syndrome in 40–50% of anxious patients. While numerous studies have established the role of BZ dose, treatment duration, half-life, potency, rate of withdrawal and severity of underlying anxiety disorder in predicting severity of withdrawal symptoms, fewer studies have examined the role of psychological and personality factors. Method. In 123 panic disorder patients undergoing gradual tapered discontinuation of alprazolam in conjunction with pre-treatment with carbamazepine or placebo, the relationship between measures of ‘symptom sensitivity’ and ‘harm avoidance’, and severity of withdrawal symptoms measured as peak severity of symptoms, time before taper needed to be slowed due to symptoms, and ability to complete taper, was examined. Results. After controlling for the less substantial effects of dose, treatment duration, pre-taper anxiety and panic attack frequency, measures of symptom sensitivity and harm avoidance accounted for an additional 3–6% of withdrawal variance. Conclusions. These results show an effect of symptom sensitivity and harm avoidance on BZ withdrawal symptoms, comparable to prior findings linking dependent personality characteristics to withdrawal severity. Failure to show the expected effect on ability to complete taper may be due to either the more symptomatic nature of the patients in this study.

The authors examined the prevalence of self-reported childhood physical or sexual abuse in a sample of adult patients presenting for treatment of panic disorder, social phobia, or generalized anxiety disorder. Regardless of the presence of comorbid anxiety disorders or comorbid depression, patients with panic disorder had significantly higher rates of past childhood physical or sexual abuse than patients with social phobia. Patients with generalized anxiety disorder had intermediate rates of past physical or sexual abuse that were not significantly different from the other two diagnostic groups. Anxiety disorder patients with a history of childhood abuse were also more likely to have comorbid major depression than those without. These findings are discussed in terms of biological and behavioral factors that may influence the development of anxiety disorders after the experience of a traumatic event.