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panic attack. In social phobia, on the other hand, there is an intense, irrational fear of social or performance situations in which the patient is exposed to unfamiliar people or to possible scrutiny by others and anticipates humiliation or embarrassment. Some investigators consider social phobia to be at one end of a spectrum ranging from shyness to avoidant personality disorder to generalized social phobia.

There is both a generalized and a more discrete type of social phobia. In the generalized type, the patient fears practically all social situations in which evaluation and scrutiny are possible. It is significantly more common than the discrete type, in which the individual fears a very specific social situation, usually of public speaking or public performance. Generalized social phobia is also more severe and disabling than discrete social phobia.

Estimates of the incidence of social phobia range from 1.3% to more than 10% of the population, and twice as many women as men are affected. First-degree relatives of social phobics have a greater prevalence of social phobia than the general population. Social phobia usually has an early oncet, between 11 and 15 years of age, and has a chronic, unremitting course, with significant lifelong disability. Children as young as 21 months who exhibit behavioral inhibition (intense anxiety and fear when faced with new social situations) have an increased prevalence of childhood anxiety phenomena, including social phobia-like symptoms as well as agoraphobialike symptoms by the time they are 8 years old.

Two-thirds of social phobics are single, divorced, or widowed. More than half of all patients with social phobia never completed high school. In fact, one-fifth of social phobics are unable to work and must therefore collect welfare or disability benefits.

The most common fears among social phobics are speaking in front of a small group of people, speaking to strangers, meeting new people, eating in public, or being stared at. These fears are different from the fears of people with panic disorder, who mostly wish to avoid driving, shopping, being in crowds, or using elevators. More than half of social phobics will suffer at some point in their lifetime from a specific phobia as well.

Social phobia and specific phobia can be distinguished from panic disorder by the fact that panic attacks, if present, are in response to specific situations and do not occur unexpectedly. Also, the fear in social phobia is a fear of humiliation, shame, or embarrassment instead of a fear of having a panic attack. Somatic symptoms differ between panic disorder patients with agoraphobia and with social phobia, with blushing more common among social phobics. Difficulty in breathing, dizziness, and syncope occur more frequently among the agoraphobics. The DSM-IV diagnostic criteria for social phobia are given in Table 9—10.

Biological Basis of Social Phobia

The neurobiology of social phobia remains obscure. A state of noradrenergic overactivity in social phobia is suggested by the symptoms of tremor, tachycardia, and blushing (see Fig. 9 —3). Because of these observations, in fact, the first somewhat effective treatments for social phobia were beta adrenergic blockers. Studies of neurotransmitters and neuroimaging are still not able to suggest a biological basis for social phobia, but numerous such studies are in progress.

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Table 9—10. DSM IV diagnostic criteria for social phobia

A.Social phobia is characterized by a marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing. Note: In children there must be evidence of the capacity for age-appropriate social relationships with familiar people, and the anxiety must occur in peer settings, not just in interactions with adults.

B.Exposure to the feared social situation almost invariably provokes anxiety, which may take the form of a situationally bound or situationally predisposed panic attack. Note: In children the anxiety may be expressed by crying, tantrums, freezing, or shrinking from social situations with unfamiliar people.

C.The person recognizes that the fear is excessive or unreasonable. Note: In children this feature may be absent.

D.The feared social or performance situations are voided or else are endured with intense

anxiety or distress.

E The avoidance, anxious anticipation, or distress in the feared social or performance situation interferes significantly with the person's normal routine, with occupational or academic functioning, or with social activities or relationships, or there is marked distress about having the phobia.

F.In individuals under age 18, the duration is at least 6 months.

G.The fear of avoidance is not due to the direct physiological effects of a substance or a general medical condition and is not better accounted for by another mental disorder (panic disorder with or without agoraphobia, separation anxiety disorder, body dysmorphic disorder, a pervasive developmental disorder, or schizoid personality disorder).

H.If a general medical condition or another mental disorder is present, the fear in criterion A is unrelated to it, that is, the fear is not of stuttering, trembling in Parkinson's disease, or exhibiting abnormal eating behavior in anorexia or bulimia nervosa.

Drug Treatments for Social Phobia

The earliest and unfortunately still one of the commonest treatments of social phobia is self-medication with alcohol. The behaviorally disinhibiting actions of alcohol allow many social phobics to engage in social contacts that would otherwise be impossible. Legitimate therapeutic drugs for social phobia are now being discovered at a fast pace (Fig. 9 — 7). In fact, one of the SSRIs (paroxetine) already has been formally approved for use in the treatment of social phobia, and several other SSRIs and antidepressants are rapidly accumulating evidence of their efficacies in this condition as well. Specifically, studies of all five SSRIs (paroxetine, fluvoxamine, fluox-etine, sertraline, and citalopram) have indicated their efficacy in social phobia. Currently, SSRIs are considered first-line treatments for social phobia.

In addition, several of the newer antidepressants also appear to be effective in social phobia, including venlafaxine, nefazodone, and perhaps others. Although there

FIGURE 9 — 7. Shown here are the variety of therapeutic options for treating social phobia. Combination treatments are similar to those for panic disorder, but there is less experience with them and less documentation of how they work uniquely for patients with social phobia.

is evidence of efficacy for both the irreversible and the reversible MAO inhibitors in social phobia, there is far less evidence for the usefulness of tricyclic antidepressants. Today, MAO inhibitors are secondor third-line treatments for patients resistant to treatment with SSRIs or other newer antidepressants.

Benzodiazepines, especially clonazepam, appear efficacious in social phobia, although there have been relatively few trials and small numbers of patients studied. Beta blockers may work in patients with discrete phobias, such as fear of public speaking, but are rather underwhelming as treatments for the generalized type of social phobia. Buspirone monotherapy and clonidine monotherapy have also been investigated, with no clear consensus on their therapeutic usefulness in social phobia. Augmentation strategies for the treatment of social phobia resistant to the various monotherapies mentioned here are also in their infancy and tend to follow the strategies used for severe cases of treatment-resistant depression when monotherapies are ineffective.

Psychotherapeutic Treatments

Psychotherapeutic treatments for social phobia are also in their relative infancy. Relaxation techniques, while sometimes advocated as part of anxiety management, are difficult to apply to patients with social phobia. Exposure therapy, on the other hand, can be successfully implemented if the anxiety-provoking stimuli are categorized into common themes and if the patient practices increasing the frequency of exposure to these stimuli throughout the day. Major cognitive distortions are maintained by social phobics during social situations. For example, they overestimate the scrutiny of others, attribute critical thoughts to others, underestimate their own social skills, and fear the responses of others to their anxiety. For such patients,

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cognitive restructuring can be helpful. The task is to challenge and reorganize unrealistic, emotional, and catastrophic thoughts. Cognitive and behavioral techniques in a group setting may be the best psychosocial interventions for social phobic patients, especially when combined with drug therapy.

New prospects

As social phobia is only recently becoming better recognized and researched, better documentation for the various treatments mentioned above is now evolving. This applies especially to the five SSRIs and to some of the newer antidepressants such as venlafaxine XR. Guidelines are emerging for the use of high-potency benzodiazepines, MAO inhibitors, RIMAs, beta blockers, and various drugs in combination as secondor third-line treatments for social phobia.

Under investigation at the present time is virtually every compound being studied in depression and in panic disorder. Perhaps new and effective treatments for social phobia will arise from this same pool of compounds.

Posttraumatic Stress Disorder

Clinical Description

Posttraumatic stress disorder (PTSD) is another anxiety disorder that can be characterized by attacks of anxiety or panic, but it is notably different from panic disorder or social phobia in that the initial anxiety or panic attack is in response to a real threat (being raped, for example) and subsequent attacks are usually linked to memories, thoughts, or flashbacks of the original trauma. The lifetime incidence of PTSD is about 1%. Patients have disturbed sleep and frequent sleep complaints. Comor-bidities with other psychiatric disorders, especially depression and drug and alcohol abuse, are the rule rather than the exception. The DSM-IV diagnostic criteria are given in Table 9—11.

Biological Basis

The biology of PTSD is only now beginning to be investigated. Some evidence suggests an overactive noradrenergic nervous system, with an exaggerated startle response and autonomic hyperarousal. Because of associated memory problems, some investigators are focusing on the potential role of the hippocampus. Early findings suggest that there may be a reduction in hippocampal volume, perhaps due to an abnormal stress response similar to that hypothesized for depression (see Figures 5 — 63 and 5—64 and discussion on brain derived neurotrophic factor (BDNF)).

Treatments

Drug treatments for PTSD (Fig. 9—8) have until recently focused upon treating the associated comorbidities, especially depression. Because of the high degree of concomitant drug and alcohol abuse, benzodiazepines are usually best avoided.

Just as has been the case for every other anxiety disorder subtype, the SSRIs appear to be the treatment of choice for PTSD (Fig. 9—8). Numerous trials are in

Drug Treatments for Obsessive-Compulsive, Panic, and Phobic Disorders

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Table 9 — 11 DSM IV diagnostic criteria for posttraumatic stress disorder

A.The person has been exposed to a traumatic event in which both of the following were present:

1.The person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury or a threat to the physical integrity of others.

2.The person's response involved intense fear, helplessness, or horror. Note: In children this may be expressed instead by disorganized or agitated behavior.

B.The traumatic event is persistently reexperienced in one or more of the following ways:

1.Recurrent and intrusive distressing recollections of the event including images, thoughts, or perceptions. Note: In young children, repetitive play may occur in which themes or aspects of the trauma are expressed.

2.Recurrent distressing dreams of the event. Note: In children there may be frightening dreams without recognizing conflict.

3.Acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative flashback episodes, including those that occur on awakening or when intoxicated). Note: In children trauma-specific reenactment may occur.

4.Intense psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event.

C.Persistent avoidance of stimuli associated with the trauma and numbing of general responsiveness (not present before the trauma), as indicated by three or more of the following:

1.Efforts to avoid thoughts, feelings, or conversations associated with the trauma

2.Efforts to avoid activities, places, or people that arouse recollection of the trauma

3.Inability to recall an important aspect of the trauma

4.Markedly diminished interest or participation in significant activities

5.Feeling of detachment or estrangement from others

6.Restricted range of effect (e.g., unable to have loving feelings)

7.Sense of a foreshortened future (e.g., does not expect to have a career, marriage, children, or normal life span)

D.Persistent symptoms of increased arousal, not present before the trauma, as indicated by two or more of the following:

1.Difficulty in falling or staying asleep

2.Irritability or outbursts of anger

3.Difficulty in concentrating

4.Hypervigilance

5.Exaggerated startle response

E.Duration of the disturbance (symptoms in B, C, D) is more than 1 month.

F.The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

progress with these agents and with several of the newer antidepressants as well, including nefazodone. Although there is some evidence that tricyclic antidepressants and MAO inhibitors may have some efficacy in PTSD, they are relegated to secondor third-line use. Anecdotes suggest that beta blockers and mood stabilizers may be useful for some patients. In the future, as investigations proceed at a fast pace, several antidepressants are likely to emerge as first-line treatments for PTSD.

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FIGURE 9 — 8. Shown here are the variety of therapeutic options for treating posttraumatic stress disorder (PTSD). Combination treatments for PTSD are very poorly documented but very frequently used. The PTSD combinations are similar to those for depression and for panic disorder.

Summary

In this chapter we have given clinical descriptions and have also explored the biological basis and a variety of treatments for numerous anxiety disorder subtypes, including obsessive-compulsive disorder, panic disorder, social phobia, and posttraumatic stress disorder.

Obsessive-compulsive disorder may be linked to abnormalities of the neurotransmitters serotonin and dopamine. The neuroanatomical basis of OCD may be related to dysfunction in the basal ganglia. The hallmark of treatment for OCD is use of SSRIs plus the tricyclic antidepressant clomipramine. Panic disorder is characterized by unexpected panic attacks, possibly linked to abnormalities in the neurotransmitters norepinephrine and GABA, in the sensitivity of benzodiazepine receptors, or even in the regulation of respiration. Drug treatments include SSRIs, several of the newer antidepressants, high-potency benzodiazepines, many tricyclic antidepressants, and MAO inhibitors.

Social pbobia is characterized by expected panic attacks, that is, attacks are expected in situations of public scrutiny because of the fear the patient has of that situation. The biological basis of social phobia is obscure. Treatment is with SSRIs and perhaps other antidepressants, benzodiazepines, and sometimes beta blockers. Posttraumatic stress disorder is a reaction to traumatic events, is associated with a hyperaroused autonomic nervous system, and appears to respond to SSRI treatment)

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Table 10—1. Disorders in which psychosis is a defining feature

Schizophrenia

Substance-induced (i.e., drug-induced) psychotic disorders

Schizophreniform disorder

Schizoaffective disorder

Delusional disorder

Brief psychotic disorder

Shared psychotic disorder

Psychotic disorder due to a general medical condition

average citizen worries about long-standing myths of "mental illness," including "psychotic killers," "psychotic rage," and the equivalence of "psychotic" with the pejorative term "crazy."

We have already discussed public misconceptions about mental illness in Chapter 5 on depression (Table 5 — 1). There is perhaps no area of psychiatry where misconceptions are greater than in the area of psychotic illnesses. The reader is well served to develop an expertise on the facts about the diagnosis and treatment of psychotic illnesses in order to dispel unwarranted beliefs and to help destigmatize this devastating group of illnesses. This chapter is not intended to list the diagnostic criteria for all the different mental disorders in which psychosis is either a defining feature or an associated feature. The reader is referred to standard reference sources (DSM-IV and ICD-10) for that information. Although schizophrenia will be emphasized here, we will approach psychosis as a syndrome associated with a variety of illnesses which are all targets for antipsychotic drug treatment.

Clinical Description of Psychosis

Psychosis is a syndrome, which is a mixture of symptoms that can be associated with many different psychiatric disorders but is not a specific disorder itself in diagnostic schemes such as DSM-IV or ICD-10. At a minimum, psychosis means delusions and hallucinations. It generally also includes symptoms such as disorganized speech, disorganized behavior, and gross distortions of reality testing.

Therefore, psychosis can be considered to be a set of symptoms in which a person's mental capacity, affective response, and capacity to recognize reality, communicate, and relate to others are impaired. Psychotic disorders have psychotic symptoms as their defining features, but there are other disorders in which psychotic symptoms may be present but are not necessary for the diagnosis.

Those disorders that require the presence of psychosis (Table 10—1) as a defining feature of the diagnosis include schizophrenia, substance-induced (i.e., drug-induced) psychotic disorder, schizophreniform disorder, schizoaffective disorder, delusional disorder, brief psychotic disorder, shared psychotic disorder, and psychotic disorder due to a general medical condition. Disorders that may or may not have psychotic symptoms (Table 10—2) as an associated feature include mania and depression as well as several cognitive disorders such as Alzheimer's dementia.

Psychosis itself can be paranoid, disorganized-excited, or depressive. Perceptual distortions and motor disturbances can be associated with any type of psychosis.

Table 10-2. Disorders in which psychosis is an associated feature

Mania Depression

Cognitive disorders

Alzheimer dementia

Perceptual distortions include being distressed by hallucinatory voices; hearing voices that accuse, blame, or threaten punishment; seeing visions; reporting hallucinations of touch, taste, or odor; or reporting that familiar things and people seem changed. Motor disturbances are peculiar, rigid postures; overt signs of tension; inappropriate grins or giggles; peculiar repetitive gestures; talking, muttering, or mumbling to oneself; or glancing around as if hearing voices.

Paranoid Psychosis

In paranoid psychosis, the patient has paranoid projections, hostile belligerence, and grandiose expansiveness. Paranoid projection includes preoccupation with delusional beliefs; believing that people are talking about oneself; believing one is being persecuted or conspired against; and believing people or external forces control one's actions. Hostile belligerence is verbal expression of feelings of hostility; expressing an attitude of disdain; manifesting a hostile, sullen attitude; manifesting irritability and grouchiness; tending to blame others for problems; expressing feelings of resentment; and complaining and finding fault, as well as expressing suspicion of people. Grandiose expansiveness is exhibiting an attitude of superiority; hearing voices that praise and extol; and believing one has unusual powers, is a well-known personality, or has a divine mission.

Disorganized-Excited Psychosis

In a disorganized-excited psychosis, there is conceptual disorganization, disorientation, and excitement. Conceptual disorganization can be characterized by giving answers that are irrelevant or incoherent; drifting off the subject; using neologisms; or repeating certain words or phrases. Disorientation is not knowing where one is, the season of the year, the calendar year, or one's own age. Excitement is expressing feelings without restraint; manifesting hurried speech; exhibiting an elevated mood or an attitude of superiority; dramatizing oneself or one's symptoms; manifesting loud and boisterous; speech; exhibiting overactivity or restlessness; and exhibiting excess of speech.

Depressive Psychosis

Depressive psychosis is characterized by retardation, apathy, and anxious selfpunishment and blame. Retardation and apathy are manifested by slowed speech; indifference to one's future; fixed facial expression; slowed movements; deficiencies

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in recent memory; blocking in speech; apathy toward oneself or one's problems; slovenly appearance; low or whispered speech; and failure to answer questions. Anxious self-punishment and blame involve the tendency to blame or condemn oneself; anxiety about specific matters; apprehensiveness regarding vague future events; an attitude of self-deprecation; manifesting a depressed mood; expressing feelings of guilt and remorse; preoccupation with suicidal thoughts, unwanted ideas, and specific fears; and feeling unworthy or sinful.

This discussion of clusters of psychotic symptoms does not constitute diagnostic criteria for any psychotic disorder. It is given merely as a description of several types of symptoms in psychosis to give the reader an overview of the nature of behavioral disturbances associated with the various psychotic illnesses.

Five Symptom Dimensions in Schizophrenia

Although schizophrenia is the commonest and best known psychotic illness, it is not synonymous with psychosis but is just one of many causes of psychosis. Schizophrenia affects 1% of the population, and in the United States there are over 300,000 acute schizophrenic episodes annually. Between 25 and 50% of schizophrenia patients attempt suicide, and 10% eventually succeed, contributing to a mortality rate eight times as high as that of the general population. In the United States over 20% of all Social Security benefit days are used for the care of schizophrenic patients. The direct and indirect costs of schizophrenia in the United States alone are estimated to be in the tens of billions of dollars every year.

Schizophrenia by definition is a disturbance that must last for six months or longer, including at least one month of delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, or negative symptoms. Delusions usually involve a misinterpretation of perceptions or experiences. The most common type of delusion in schizophrenia is persecutory, but the delusions may include a variety of other themes, including referential (i.e., erroneously thinking that something refers to oneself), somatic, religious, or grandiose. Hallucinations may occur in any sensory modality (e.g., auditory, visual, olfactory, gustatory, and tactile), but auditory hallucinations are by far the most common and characteristic hallucinations in schizophrenia.

Although not recognized formally as part of the diagnostic criteria for schizophrenia, numerous studies subcategorize the symptoms of this illness (as well as symptoms of some other disorders) into five dimensions: positive symptoms, negative symptoms, cognitive symptoms, aggressive/hostile symptoms, and depressive/anxious symptoms (Fig. 10—1). Several illnesses other than schizophrenia share these symptoms dimensions as well (Figs. 10 — 2 to 10 — 6).

Positive Symptoms

Positive symptoms seem to reflect an excess of normal functions (Table 10 — 3) and typically include delusions and hallucinations; they may also include distortions or exaggerations in language and communication (disorganized speech), as well as in behavioral monitoring (grossly disorganized or catatonic or agitated behavior).

Disorders in addition to schizophrenia that can have positive symptoms include bipolar disorder, schizoaffective disorder, psychotic depression, Alzheimer's disease