Download Anxiety Disorders in the DSM-5 - Mood and Anxiety Disorders Rounds

2 0 13
VOLUME 2, ISSUE 3
V O L U M E 1 , I S S U EV O L U M E
1,
ISSUE 1
CURRENT CLINICAL TOPICS FROM LEADING RA SPECIALISTS ACROSS CANADA AND AROUND THE
AWPHYSICIAN
O R L D I N V I TLEARNING
E D B Y T H RESOURCE
E R E B E C C A FROM
M A C D THE
O N A LCANADIAN
D C E N T R E NETWORK
F O R A R T HFOR
R I T IMOOD
S A N D AND
A U T ANXIETY
O I M M U N ETREATMENTS
DISEASE
Anxiety Disorders in the DSM-5:
New Rules on Diagnosis and Treatment
By Cara Katz, BSc, Murray B. Stein, MD, FRCPC, and Jitender Sareen, MD, FRCPC
Anxiety disorders are among the most common mental disorders, with a lifetime prevalence of
16%–29%.1,2 In addition to provoking substantial disability, anxiety disorders are highly
comorbid with other mental and physical disorders, thus complicating the treatment of both
types of disorders. This issue of Mood and Anxiety Disorders Rounds highlights changes to the
diagnostic category of anxiety disorders reflected in the recently published fifth edition of the
Diagnostic and Statistical Manual of Mental Disorders and outlines evidence-based treatments
for individuals with anxiety disorders.
Anxiety disorders are common in clinical practice and are highly comorbid and disabling.3
Among the anxiety disorders, specific phobia and social anxiety disorder are the most common,
with lifetime prevalence rates of 18.4% and 13.0%, respectively.4 Panic disorder, generalized
anxiety disorder (GAD), agoraphobia, and separation anxiety disorder each have lifetime prevalence
rates of 2%–7%.
While all anxiety disorders share the core features of excessive fear, anxiety, and avoidance,
they differ in the specific object or situation of concern.5 They also differ from normal fear or
anxiety in terms of duration; symptoms related to an anxiety disorder typically persist for
>6 months. Anxiety disorders can only be diagnosed when the physiological effects of substances,
other medications, or other medical diagnoses have been ruled out or when the symptoms cannot be better explained by the diagnosis of another mental disorder.5 Thus, thorough patient
assessment should include a review of systems, medication history (including over-the-counter
medications), substance use, a complete evaluation of anxiety symptoms, a focused physical
examination of symptomatic areas, and a functional assessment. Inquiries about substance use
should include questions about illicit drugs (particularly stimulants), alcohol, and caffeine.
Further investigations should follow based on the results of the initial assessment (Table 1).6
What’s New in the DSM-5 for Anxiety Disorders?
Several important changes were made to the diagnostic category of Anxiety Disorders in the
fifth edition of the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of
Mental Disorders (DSM-5), including “cleaving” certain disorders into multiple new chapters,
regrouping, adding new conditions, and refining criteria for some disorders. For example, obsessive compulsive disorder (OCD) has moved into its own chapter that includes the new entity of
“hoarding disorder,” while posttraumatic stress disorder (PTSD) has shifted into a new chapter
that includes acute stress and adjustment disorders. Anxiety disorders in childhood are no longer
in a separate chapter. Within Anxiety Disorders, panic disorder and agoraphobia have been
declared separate disorders since each can occur alone. In order to distinguish the diagnosis of
agoraphobia from that of specific phobia, the criteria for the former require the endorsement of
fears from ≥2 agoraphobic situations. Additionally, a panic attack specifier has been added to the
DSM-5 that can be applied across all mental disorders. Panic attacks outside of panic disorder –
but associated with other disorders – are frequently noted and may have value in predicting psychopathology, severity, and outcome.7
Regarding agoraphobia, specific phobia, and social anxiety disorder, the criteria no longer
include age >18 years in order to recognize that patients’ anxiety is excessive or unreasonable; the
rationale is that individuals typically overestimate their risk in “phobic” situations. In addition,
Available online at
www.moodandanxietyrounds.ca
CANMAT Advisory Board Executive
Sagar V. Parikh, MD, FRCPC
Education Chair, Toronto
Editor, Mood and Anxiety Disorders Rounds
[email protected]
Raymond W. Lam, MD, FRCPC
Executive Chair, Vancouver
Sidney H. Kennedy, MD, FRCPC
Depression Group Chair, Toronto
Lakshmi N. Yatham, MBBS, FRCPC,
MRCPsych (UK)
Bipolar Group Chair, Vancouver
Jitender Sareen, MD, FRCPC
Anxiety Group Chair, Winnipeg
Roger S. McIntyre, MD, FRCPC
Business & Research Development Chair,
Toronto
Roumen Milev, MD, PhD, FRCPsych, FRCPC
International Conference Chair, Kingston
CANMAT Board of Directors
Serge Beaulieu, MD, PhD, FRCPC
Montréal
Glenda MacQueen, MD, PhD, FRCPC
Calgary
Diane McIntosh, MD, FRCPC
Vancouver
Arun V. Ravindran, MB, PhD, FRCPC
Toronto
Canadian Network for
Mood and Anxiety Treatments
Education Office
Room 9M-329, Toronto Western Hospital
399 Bathurst St, Toronto, On
CANADA M5T 2S8
CANMAT – or the Canadian Network for Mood and
Anxiety Treatments – is a federally incorporated
academically based not-for-profit research
organization with representation from multiple
Canadian universities. The ultimate goal of
CANMAT is to improve the quality of life of
persons suffering from mood and anxiety
disorders, through conduct of innovative research
projects and registries, development of evidence
based and best practice educational programs
and guideline/policy development.
Table 1: Baseline investigations in patients with anxiety
disorders6
• Complete blood count
• Fasting glucose
• Fasting lipid profile (total, LDL, very LDL, and HDL
cholesterol, and triglycerides)
• Electrolytes
• Liver enzymes
• Serum bilirubin
• Serum creatinine
• Urinalysis
• Urine toxicology for substance use
• 24-hour creatinine clearance (if history of renal disease)
• Thyroid-stimulating hormone
• Electrocardiogram (if age >40 years or if indicated)
• Pregnancy test (if relevant)
• Prolactin
LDL = low-density lipoprotein; HDL = high-density lipoprotein
Reproduced with permission from Canadian Psychiatric Association
Clinical Practice Guidelines. Management of anxiety disorders. Can J
Psychiatry 2006;51(8 Suppl 2):9S-91S. Copyright © 2006, Canadian
Psychiatric Association.
older adults tend to incorrectly attribute their phobia to aging
and may, therefore, not report it. While there is evidence to
support this change, the boundary between “routine” and
“excessive” anxiety may still require clarification.8,9 According
to the DSM-5, it is primarily the clinician who can determine
whether the anxiety is excessive, taking into account the
patient’s report of his symptoms and cultural factors.
Additionally, the criterion of a 6-month duration of symptoms is now extended to all ages.
Another controversial change in the diagnosis of social
anxiety disorder is that the “generalized” specifier has been
removed and replaced with a “performance only” specifier,
noting that this group tends to be distinct in etiology, age of
onset, and physiological and treatment response.5 However, a
study by Kearns et al10 called this new criterion into question,
as none of a sample of 204 anxious youth exhibited a discrete
“performance” fear without fear in other social circumstances.
Clinical and research experience with this new DSM-5 specifier will, in the coming year, determine whether this change
was well founded.
Separation anxiety disorder, previously considered in the
Disorders Usually First Diagnosed in Infancy, Childhood, or
Adolescence section, is now listed under Anxiety Disorders,
consistent with evidence that the disorder may persist from
childhood into adulthood and, in some instances (although
this remains controversial), may have onset in adulthood.11
Selective mutism has likewise been added to the Anxiety
Disorders category. A summary of these changes by disorder
can be found in Table 2.
OCD, PTSD, and acute stress disorder are no longer included in the Anxiety Disorders chapter, but are now included in the
OCD and Related Disorders and Trauma- and Stressor-related
Disorders chapters, respectively.5 These category changes are
controversial in that they emphasize how these disorders differ
from one another in terms of biological mechanism and treatment approach. On the other hand, these changes may underemphasize the similarities in these conditions.12 Furthermore, it
is unclear if these individuals require a separate or different
treatment than what was previously provided.
The decision to create a distinct category for OCD is based
on research showing that OCD is related to both anxiety and
other disorders, including Cluster C, tic, somatoform, grooming, and mood disorders.13 Additionally, hoarding – previously categorized within the diagnosis of OCD – has become its
own disorder. Similarly, evidence suggests that PTSD and
acute stress disorder be classified as a distinct category, recognizing their common etiology of trauma.14
A new “anxious distressed” specifier has also been added
to the Depressive Disorders and Bipolar and Related Disorders
categories in the DSM-5. The anxious-distressed feature has
been noted to be a major feature of bipolar and major depressive disorder, and high levels of anxiety are associated with
increased suicidality and burden of illness. Therefore, identifying this specifier can help with treatment and management.
This specifier is applied to individuals with ≥2 anxious symptoms as specified in the DSM-5.5 This new criterion, however,
does not come with a clause indicating not to diagnose if there
is a comorbid anxiety disorder. This has the potential for individuals with a comorbid mood and anxiety disorder to be
labeled with the “anxious-distressed” specifier, rather than a
separate (comorbid) anxiety disorder, which may lead to
undertreatment of the anxiety disorder.
One of the major implications of the DSM-5 may be its
impact on research, particularly in terms of childhood anxiety
disorders. For example, these changes have encouraged the
development of child-specific assessment tools (eg, Picture
Anxiety Tests)15 and disorder-specific treatment (eg, the TAFF
program for Separation Anxiety Disorder).16 Currently, the
DSM-5 changes to the Anxiety Disorders category can be considered a necessary step towards increased evidence-based
diagnosis, assessment, and treatment of childhood anxiety disorders that, to this date, has been lacking.17 However, in the
authors’ opinion, these changes will have a less immediate
impact on clinical practice.
CASE STUDY 18
A 35-year-old Asian-Canadian woman was referred to a
psychiatrist for assessment of anxiety and avoidance. Two
years earlier, she was awakened one night by chest pain that
she believed was due to a heart attack. Accompanying
symptoms were shortness of breath, rapid pulse, sweating,
and dizziness. Her family took her to the Emergency
Department, where a thorough medical work-up ruled out
any cardiac problems. After this event, however, she stopped
driving and was unable to attend her children’s sports
events, go on buses, or to her church for fear of recurrence of
the chest pain. Although she could not define a specific
stressor prior to the onset, a number of stressful life events
had occurred, including the death of a close friend from
cancer and her husband losing his job. There was no prior
history of emotional problems; however, she had a history
of asthma. As well, when the patient was 12 years old, her
father had suddenly died of a heart attack.
When considering treatment for the patient in this case,
an algorithm (Figure 1) can be helpful. She presented with
physiological symptoms of panic attacks and subsequent
avoidance of situations that she believed were the cause of her
Table 2: Highlights of DSM-5 Changes
DSM-5 anxiety disorder
Panic Disorder (PD)
DSM-IV
diagnosis
PD with or
without
Agoraphobia
Panic Attack – Specifier (can be
added to any of the DSM-5
disorders)
Changes in diagnosis
• Requires presence of recurrent panic attacks AND worry about possibility
of future attacks, development of phobic avoidance OR other change in
behaviour due to attacks
• Decoupled from agoraphobia
• Types of panic attacks described as “unexpected” versus “expected”
Social Anxiety Disorder (SAD)
Social Phobia
• Removal of “generalized social phobia”
• Newly defined “performance only” specifier
• No longer a requirement for individuals aged >18 years to recognize fear
as excessive; instead, anxiety must be out of proportion to actual danger
or threat in the situation, after taking cultural context into accounta
• 6-month duration extended to all ages (not just to those aged <18 years)
Agoraphobia
Agoraphobia
without a
history of
panic
disorder
• Decoupled from PD
• No longer a requirement for individuals aged >18 years to recognize fear
as excessive (Instead, anxiety must be out of proportion to actual danger
or threat in the situation after taking cultural context into account)a
• 6-month duration extended to all ages (not just to those aged <18 years)
• Endorsement of fears from ≥2 agoraphobia situations required (in order
to distinguish it from specific phobia)
Specific Phobia
No change
• Includes specifiers for different types of situations or objects involved
(ie., animal, natural environment, blood-injection-injury, situational, and
others)
• No longer a requirement for individuals aged >18 years to recognize fear
as excessive (Instead, anxiety must be out of proportion to actual danger
or threat in the situation, after taking cultural context into account)a
• 6-month duration extended to all ages (not just to those aged <18 years)
Generalized Anxiety Disorder (GAD)
No change
No change
• Now considered an anxiety disorder, (formerly in the Disorders Usually
First Diagnosed in Infancy, Childhood, or Adolescence category)
• No longer specifies that age of onset must be before age 18 years
• Duration criterion of ≥6 months added
Separation Anxiety Disorder
Selective Mutism
No change
• Now considered an anxiety disorder (formerly in the Disorders Usually
First Diagnosed in Infancy, Childhood, or Adolescence category
a
Also new in DSM-5, this judgment of fear or anxiety being excessive is made by the clinician
DSM = Diagnostic and Statistical Manual of Mental Disorders
episodes. In keeping with the algorithm, medical causes were
ruled out in the Emergency Room. After a complete assessment, this patient would likely be diagnosed with panic disorder. General treatment options for anxiety disorders are
presented in the following section and an update to this case
report is presented later in this issue.18
access to evidence-based psychotherapies is important.
Measuring symptoms using panic or “worry” diaries or the use
of self-reported standardized scales (eg, the Overall Anxiety
Severity and Interference Scale [OASIS])22 can help both
patients and therapists track the course and severity of anxiety
problems and are indisputable aids to treatment.
Evidence-based Treatment of Anxiety Disorders
The impact of comorbidity
Treatments are derived from studies using DSM-IV criteria and so may need adjustment in view of DSM-5 changes.
The presence of a current comorbidity with a mental disorder (ie, mood, substance use, or a personality disorder) significantly affects management. If an individual is severely depressed,
treatment of the depression – usually with a combination of
medication(s) and therapy, and attention to anxiety symptoms –
is a priority. If a bipolar disorder is comorbid with an anxiety
disorder(s), it may affect the type of medications used (eg, choice
of a mood stabilizer or gabapentin). Self-medication with alcohol and drugs to reduce tension and anxiety is common and is
associated with an increased risk of substance-use disorders.23 It
is important for both patients and clinicians to understand that
a vicious cycle can develop when anxiety symptoms lead to self-
General approach
The treatment of anxiety disorders can be extremely gratifying for clinicians because patients tend to respond well to
psychological and pharmacological therapies. Several practice
guidelines can be referenced for the treatment of anxiety disorders, specifically, panic disorder and social anxiety disorder.6,19-21 A careful, comprehensive assessment of anxiety
symptoms, disabilities, the presence of comorbid mental and
physical conditions, patient preferences for treatment, and
Figure 1: Algorithm for the Treatment and Management of Anxiety Disorders
Identify Anxiety Symptoms
1. Assess impact on function
2. Assess suicide risk
Differential Diagnosis
1. Rule out medical or substance induced anxiety
2. Consider comorbidity with another medical or psychiatric condition
3. Conduct physical and laboratory examinations
Comorbid Medical Condition
1. Consider risks and benefits of
medication for anxiety
disorder and consider impact
of untreated anxiety
Identify Specific Anxiety Disorder
Specific phobia, social anxiety
disorder, panic disorder, generalized
anxiety disorder, agoraphobia,
separation anxiety disorder
Treatment
1. Consider patient preference
2. Provide psychoeducation to patient and
family
3. Consider comorbid mental and physical
disorder(s) in management of the
anxiety disorder
Comorbid Mental Disorder
1. If substance abuse: prescribe
benzodiazepines with caution
2. If another anxiety disorder:
use therapies that are first-line
for both disorders
3. If mood disorder: use
therapies that are effective for
both disorders
Treatment by Disorder Type
Specific Phobia
1. Cognitive behaviour therapy (CBT)
2. Benzodiazepines PRN
Social anxiety disorder, panic disorder, generalized
anxiety disorder, agoraphobia, separation anxiety disorder
1. CBT
2. Antidepressants
3. Consider addition of benzodiazepines, atypical antipsychotics
Adapted from Canadian Psychiatric Association Clinical Practice Guidelines. Management of anxiety disorders. Can J Psychiatry
2006;51(8 Suppl 2):9S-91S, and Stein MB, Sareen J. Anxiety disorders. In: Hales R, Yudofsky S, Gabbard G, eds. The American Psychiatric
Publishing Textbook of Psychiatry. 6th ed. In press.
medication with alcohol and drugs, resulting in rebound
anxiety. Past recommendations insisted on abstinence
before treating comorbid anxiety and substance use disorders; however, current thinking favours concurrent treatment of both disorders whenever feasible.
Most patients prefer treating anxiety with psychotherapy alone or in combination with medication.24
However, evidence-based psychotherapy may not be
readily accessible to all patients. Thus, medication often
becomes the de facto treatment of anxiety disorders. Even
in such circumstances, it should be possible to optimize
patient care with appropriate educational, motivational,
and behavioural instructions and resources.
Psychotherapy
Among the interventions for anxiety disorders, cognitive behavioural therapy (CBT) has the most robust evi-
dence for efficacy.19,21,24 It can be delivered via a variety of
formats, including individual, group, bibliotherapy, telephone, and the computer. Although there have been few
changes in the treatment of anxiety disorders since the
Canadian Psychiatric Association’s 2006 clinical practice
guidelines,6 Internet-based CBT (iCBT) has become a
well-established treatment for depression, panic disorder,
and social anxiety disorder, with the potential to reduce
comorbidity.25,26 Mobile CBT applications are increasingly available but have not been evaluated. CBT for the various anxiety disorders differ somewhat in focus and
content, but are similar in underlying principles and
approaches.27 Core components include psychoeducation,
relaxation training, cognitive restructuring, and exposure
therapy. Over the course of CBT, patients slowly face their
anxiety-provoking situations and learn that if they stay in
the situation long enough, their anxiety resolves.
While other psychotherapies – eg, psychodynamic
psychotherapy, acceptance and commitment therapy,
mindfulness-based stress reduction, or other therapies
that target emotion regulation – are promising, further
research is necessary to establish both efficacy and linkage to patient preferences. Acceptability and response to
CBT for anxiety disorders is high; however, there is ample
room for new treatments to meet the needs of patients
who fail standard therapies.
Pharmacotherapy
Pharmacotherapy is an important option for many
patients with anxiety disorders, either in combination
with CBT or as stand-alone treatment.28 Pharmacotherapy
should never be prescribed without additional educational
materials. These can be provided at low or no cost online by
accessing unbiased sources of high-quality information,
including the National Institutes of Health, the Anxiety and
Depression Association of America (ADAA), UpToDateTM
(written expressly for consumers), or anxieties.com.
Several classes of medications are indicated by Health
Canada and similar regulatory agencies in other countries
for the treatment of specific anxiety disorders. Although
adherence to approved medications guarantees that a certain level of evidence has been attained in granting their
approval, any licensed practitioner can choose to prescribe
off-label, provided the marketed medication has a base of
solid, peer-reviewed, published evidence for efficacy and
safety in the particular clinical condition and specific to
patient circumstances. The classes of medications with the
best evidence of safety (when used appropriately) and efficacy for the treatment of anxiety disorders (with the
exception of specific phobias) are the antidepressants,
including selective serotonin reuptake inhibitors (SSRIs),
serotonin-norepinephrine reuptake inhibitors (SNRIs),
tricyclic antidepressants (TCAs), monoamine oxidase
inhibitors (MAOIs), and the benzodiazepine anxiolytics.
TCAs and MAOIs have been rarely used since the
advent of the SSRIs because they are less well-tolerated.
Some experts, however, believe that MAOIs may be efficacious for patients whose symptoms do not respond to
other treatments, particularly in the treatment of social
anxiety disorder. There is also evidence that several nonbenzodiazepine anxiolytics (eg, buspirone and pregabalin) can play a role and, for refractory anxiety, possibly
the atypical antipsychotics can help.
SSRIs and SNRIs. There are currently 6 SSRIs (fluoxetine, sertraline, paroxetine, fluvoxamine, citalopram,
and escitalopram) and 3 SNRIs (extended-release venlafaxine, desvenlafaxine, and duloxetine) available in
Canada. Although the SSRIs have different indications
for particular anxiety disorders, clinicians tend to treat
them as having equal efficacy since there is no evidence to
the contrary. As a class, the SSRIs are considered first-line
agents for each of the anxiety disorders (with the notable
exception of specific phobia) due to their overall levels of
efficacy, safety, and tolerability.6
It is recommended to begin a treatment trial with the
lowest available dose of an SSRI. Follow-up should occur
after the first week to assess medication tolerability and
patient compliance. The dose is then gradually increased
until a therapeutic dose is reached. An initial response is
typically seen in 4–6 weeks and an optimal response
achieved in 12–16 weeks. Follow-up should occur
biweekly for the first 6 weeks and then monthly thereafter. There is a misconception that patients with anxiety
disorders respond to lower doses of antidepressants than
patients with depression. In fact, average doses for treating anxiety disorders are as high or higher than for
depression.6,18 In addition, many patients presenting with
anxiety also have major depression, necessitating the use
of a full antidepressant dose. Clinicians may take an extra
1–2 weeks to reach these doses in patients with anxiety
disorders, comorbid or otherwise. Progress can be measured at each appointment with clinician-rated tools (eg,
the Clinical Global Impression scale) or self-report scales
(eg, the Depression Anxiety Stress scale).6
In patients who fail to respond to an SSRI, the next
step is to try a different SSRI or to switch to an SNRI.
Patients who experience a partial response to an SSRI or
SNRI may be considered for adjunctive treatment with a
benzodiazepine or another anti-anxiety agent. Pharmacotherapy may be needed for 1–2 years, or longer.
Benzodiazepines are among the best tolerated and
most efficacious of all the anti-anxiety agents, with broadspectrum efficacy across the anxiety disorders, including
specific phobia. They can be used as first-line agents for
treating anxiety and are the best-established pharmacotherapy for treating anxiety that is predictable and limited to particular situations (eg, a specific phobia such as
flying or social phobia such as public speaking) as they
can be prescribed on an as-needed (prn) basis.29 However,
benzodiazepines need to be prescribed with caution due
to the potential for abuse. They should only be prescribed
with great care and strict supervision to patients with a
history of alcohol or other substance abuse.
Prescription of prn benzodiazepines for unpredictable anxieties (eg, panic disorder) or chronic anxiety
(eg, GAD) is not recommended. Benzodiazepines should
generally be prescribed for anxiety on a regular schedule
(ie, 1–4 times daily depending on the pharmacokinetic
and pharmacodynamic properties of the particular benzodiazepine), with prn use for occasionally recurring,
predictable specific phobias.
Nonbenzodiazepine anxiolytics. Buspirone is a nonbenzodiazepine anxiolytic with efficacy limited to the
treatment of GAD. Gabapentin and pregabalin have limited evidence for efficacy in treating anxiety disorders,
although they are sometimes used as an alternative to the
benzodiazepines, often as an adjunct to antidepressants.
Atypical antipsychotics. There is very limited evidence
that ayptical antipsychotics may be efficacious as
monotherapy or as an adjunct to antidepressants for
treatment-resistant anxiety disorders.30
Combining psychotherapy and pharmacotherapy
Several studies suggest, albeit with few data, that
combining CBT and pharmacotherapy for anxiety disorders is superior to either one alone, particularly in children.31,32 However, the efficacy of either treatment
modality is sufficiently high that clinicians may choose one or
the other as initial therapy, based primarily on patient preference, and subsequently add the other option in patients who
fail to respond adequately to a therapeutic trial.
CASE STUDY (cont.)
Our patient, after being diagnosed with panic disorder, was
taught about the panic model. The therapist asked her to
keep a diary of her panic attacks, including details such as
where the attack occurred, her symptoms during the attack,
and what she did to manage her anxiety. During treatment
sessions, she learned how to identify the “hot” thoughts that
increased her anxiety and ways to challenge this thinking by
considering the evidence for and against her fear of having
a heart attack. Along with CBT, she was offered a trial of an
SSRI. She started on 50 mg/day of sertraline that was titrated up until an optimal therapeutic dose was achieved. After
6 weeks, the patient did not demonstrate a meaningful clinical response and the panic attacks continued. The treating
physician then decided to switch her to paroxetine, another
SSRI. After 6 weeks, the patient reported benefit with the
paroxetine, and was maintained on this medication.
Conclusion
Anxiety disorders are highly prevalent and frequently disabling conditions that often begin in childhood and persist
into adulthood. They are generally very responsive to CBT
and/or pharmacotherapy. All patients should receive education regarding their anxiety disorder, options for treatment,
prognosis, triggering factors, and signs of relapse.
Ms. Katz is a graduate student in the Department of Psychiatry and
member of the Manitoba Population Mental Health Research
Group, University of Manitoba, Winnipeg, Manitoba. Dr. Stein is a
Professor of Psychiatry and Family & Preventive Medicine,
University of California San Diego. Dr. Sareen is a Professor of
Psychiatry, Psychology and Community Health Sciences, and Group
Leader of the Manitoba Population Mental Health Research Group,
University of Manitoba, Winnipeg, Manitoba.
References
1. Kessler RC, Aguilar-Gaxiola S, Alonso J, et al. The global burden of mental disorders: an
update from the WHO World Mental Health (WMH) Surveys. Epidemiol Psichiatr Soc.
2009;18(1):23-33.
2. Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence
and age-of-onset distributions of DSM-IV disorders in the National Comorbidity
Survey Replication. Arch Gen Psychiatry. 2005;62(6):593-602.
3. Sareen J, Jacobi F, Cox BJ, Belik SL, Clara I, Stein MB. Disability and poor quality of life
associated with comorbid anxiety disorders and physical conditions. Arch Intern Med.
2006;166(19):2109-2116.
4. Kessler RC, Petukhova M, Sampson NA, Zaslavsky AM, Wittchen HU. Twelve-month
and lifetime prevalence and lifetime morbid risk of anxiety and mood disorders in the
United States. Int J Methods Psychiatr Res. 2012;21(3):169-184.
5. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders.
5th ed. Arlington (VA): American Psychiatric Publishing; 2013.
6. Canadian Psychiatric Association. Clinical practice guidelines. Management of anxiety
disorders. Can J Psychiatry 2006;51(8 Suppl 2):9S-91S.
7. Batelaan NM, Rhebergen D, de Graaf R, Spijker J, Beekman AT, Penninx BW. Panic attacks
as a dimension of psychopathology: evidence for associations with onset and course of
mental disorders and level of functioning. J Clin Psychiatry. 2012;73(9):1195-1202.
8. Zimmerman M, Dalrymple K, Chelminski I, Young D, Galione JN. Recognition of irrationality of fear and the diagnosis of social anxiety disorder and specific phobia in adults:
implications for criteria revision in DSM-5. Depress Anxiety. 2010;27(11):1044-1049.
9. Frances AJ, Nardo JM. ICD-11 should not repeat the mistakes made by DSM-5. Br J
Psychiatry. 2013;203(1):1-2.
10. Kerns CE, Comer JS, Pincus DB, Hofmann SG. Evaluation of the proposed social anxiety disorder specifier change for DSM-5 in a treatment-seeking sample of anxious youth.
Depress Anxiety. 2013;30(8):709-715.
11. Bogels SM, Knappe S, Clark LA. Adult separation anxiety disorder in DSM-5. Clin
Psychol Rev. 2013;33(5):663-674.
12. Stein DJ, Craske MG, Friedman MJ, Phillips KA. Meta-structure issues for the DSM-5: how
do anxiety disorders, obsessive-compulsive and related disorders, post-traumatic disorders, and dissociative disorders fit together? Curr Psychiatry Rep. 2011;13(4):248-250.
13. Bienvenu OJ, Samuels JF, Wuyek LA, et al. Is obsessive-compulsive disorder an anxiety
disorder, and what, if any, are spectrum conditions? A family study perspective. Psychol
Med. 2012;42(1):1-13.
14. Friedman MJ, Resick PA, Bryant RA, Strain J, Horowitz M, Spiegel D. Classification of
trauma and stressor-related disorders in DSM-5. Depress Anxiety. 2011;28(9):737-749.
15. Dubi K, Schneider S. The Picture Anxiety Test (PAT): a new pictorial assessment of anxiety symptoms in young children. J Anxiety Disord. 2009;23(8):1148-1157.
16. Schneider S, Blatter-Meunier J, Herren C, et al. The efficacy of a family-based cognitivebehavioral treatment for separation anxiety disorder in children aged 8-13: a randomized comparison with a general anxiety program. J Consult Clin Psychol. 2013 Apr 22.
[Epub ahead of print]
17. Mohr C, Schneider S. Anxiety disorders. Eur Child Adolesc Psychiatry. 2013;22 Suppl
1:S17-S22.
18. Stein MB, Sareen J. Anxiety disorders. In: Hales R, Yudofsky S, Gabbard G, eds. The
American Psychiatric Publishing Textbook of Psychiatry. 6th ed. (In press).
19. American Psychiatric Association. Practice Guidelines for the Treatment of Patients with
Panic Disorder. 2nd ed. Washington (DC): American Psychiatric Publishing; 2009.
20. Roy-Byrne P, Stein M, Bystrisky A, Katon W. Pharmacotherapy of panic disorder: proposed guidelines for the family physician. J Am Board Fam Pract. 1998;11(4):282-290.
21. Stein MB, Stein DJ. Social anxiety disorder. Lancet. 2008;371(9618):1115-1125.
22. Campbell-Sills L, Norman SB, Craske MG, et al. Validation of a brief measure of anxiety-related severity and impairment: the Overall Anxiety Severity and Impairment Scale
(OASIS). J Affect Disord. 2009;112(1-3):92-101.
23. Robinson J, Sareen J, Cox BJ, Bolton JM. Role of self-medication in the development of
comorbid anxiety and substance use disorders: a longitudinal investigation. Arch Gen
Psychiatry. 2011;68(8):800-807.
24. Roy-Byrne P, Craske MG, Sullivan G, et al. Delivery of evidence-based treatment for
multiple anxiety disorders in primary care: a randomized controlled trial. JAMA.
2010;303(19):1921-1928.
25. Hedman E, Ljotsson B, Lindefors N. Cognitive behavior therapy via the Internet: a systematic review of applications, clinical efficacy and cost-effectiveness. Expert Rev
Pharmacoecon Outcomes Res. 2012;12(6):745-764.
26. Johnston L, Titov N, Andrews G, Dear BF, Spence J. Comorbidity and internet-delivered
transdiagnostic cognitive behavioural therapy for anxiety disorders. Cogn Behav Ther.
2013;42(3):180-192.
27. Craske MG, Stein MB, Sullivan G, et al. Disorder-specific impact of coordinated anxiety
learning and management treatment for anxiety disorders in primary care. Arch Gen
Psychiatry. 2011;68(4):378-388.
28. Ravindran LN, Stein MB. The pharmacologic treatment of anxiety disorders: a review of
progress. J Clin Psychiatry. 2010;71(7):839-854.
29. el-Guebaly N, Sareen J, Stein MB. Are there guidelines for the responsible prescription of
benzodiazepines? Can J Psychiatry. 2010;55(11):709-714.
30. Depping AM, Komossa K, Kissling W, Leucht S. Second-generation antipsychotics for
anxiety disorders. Cochrane Database Syst Rev. 2010;12:CD008120.
31. Blanco C, Heimberg RG, Schneier FR, et al. A placebo-controlled trial of phenelzine, cognitive behavioral group therapy, and their combination for social anxiety disorder. Arch
Gen Psychiatry. 2010;67(3):286-295.
32. Walkup JT, Albano AM, Piacentini J, et al. Cognitive behavioral therapy, sertraline, or a
combination in childhood anxiety. N Engl J Med. 2008;359(26):2753-2766.
The authors stated that they have no disclosures to report in association with the contents of this issue.
Change of address notices and requests for subscriptions to
Mood and Anxiety Disorders Rounds are to be sent by mail to
P.O. Box 310, Station H, Montreal, Quebec H3G 2K8 or by
fax to (514) 932-5114 or by e-mail to [email protected].
Please reference Mood and Anxiety Disorders Rounds in your
correspondence. Undeliverable copies are to be sent to the
address above. Publications Post #40032303
A PARTNERSHIP FOR INDEPENDENT MEDICAL EDUCATION
Mood and Anxiety Disorders Rounds is made possible through independent sponsorships from
Lundbeck Canada Inc.
AstraZeneca Canada Inc. • Bristol-Myers Squibb Canada • Pfizer Canada Inc.
© 2013 CANMAT or the Canadian Network for Mood and Anxiety Treatments, which is solely responsible for the contents. Publisher: SNELL Medical Communication Inc. in cooperation with CANMAT. Mood and Anxiety Disorders Rounds is a trademark of SNELL Medical Communication Inc. All rights reserved. The administration of any therapies discussed
or referred to in Mood and Anxiety Disorders Rounds should always be consistent with the recognized prescribing information in Canada. SNELL Medical Communication Inc. is
committed to the development of superior Continuing Medical Education.
144-010E