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Shorn of the psychologic components of apprehension and fear, the anxiety attack consists essentially of an excessive autonomic discharge Some of the autonomic symptoms are duplicated by chromaf n tumors, hyperthyroidism, and the menopause The prominence of chest discomfort and respiratory distress during an acute anxiety attack may be mistaken for myocardial ischemia, in which case the patient is often subjected to a series of studies of cardiac function Another form of the illness in which dizziness, a vague dif culty with visual clarity, and fear of losing consciousness are the most prominent features may be mistaken for a neuro-otologic problem ( panic-vertigo, page 258) In contrast, numerous other symptoms such as headache are relatively infrequent, and the diagnosis should be suspect if headache is a prominent feature (Chronic headache may be part of chronic anxiety state or anxious depression) Loss of consciousness, incontinence, and clonic or myoclonic movements do not occur Other medical diseases that are brought to mind by particular elements of an anxiety state are pulmonary embolism, cardiac arrhythmias, hypoglycemia, hypoparathyroidism, alcohol, drug, and nicotine withdrawal, and especially complex partial seizures Strict adherence to the diagnostic criteria of these disease states readily permits their differentiation from acute anxiety, but diagnosis may be dif cult if the symptoms of anxiety are very brief or persist for hours or days on end Of greater importance is the relationship of anxiety neurosis to other psychiatric illnesses, particularly to depression Symptoms of depression are frequently added to those of anxiety neurosis, and the majority of patients with depression have symptoms of anxiety Indeed, some psychiatrists believe that anxiety neurosis is accounted for mainly by a variant of depression As has been mentioned, an anxiety state appearing for the rst time after the fortieth year usually proves to be primarily a depression The uncovering of paranoid symptoms in a patient with an anxiety state should always raise the question of depression, as should the presence of symptoms such as overwhelming fatigue, self-depreciation, and feelings of hopelessness and, of course, ideas of self-destruction As mentioned, a very small number of patients with a condition diagnosed as pure anxiety neurosis by competent psychiatrists have committed suicide Schizophrenia may also begin with prominent anxiety symptoms Here the diagnosis rests on nding the characteristic thought disorder of schizophrenia, which may emerge only after several interviews Hysteria may include anxiety symptoms, though they are seldom prominent, as do also phobic and obsessive-compulsive neuroses, but each has other distinguishing attributes.

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Certain medications, particularly anxiolytics and antidepressants, are highly effective in suppressing panic attacks and creating a sense of well-being Among these, the benzodiazepine alprazolam (2 to 6 mg/day) is currently favored, but lorazepam and clonazepam are almost as effective and are considered slightly less likely to cause dependence They are all effective within hours In mild cases, the benzodiazepines may be used intermittently rather than several times daily, but they tend to be less useful once a panic attack has become established The panic attacks tend to recur when the medications are discontinued, even after prolonged (6 to 12 months) administration Attempts to reduce the amount of these medications should be gradual Tricyclic antidepressants and drugs

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that putatively raise serotonin concentrations in the nervous system (selective serotonin reuptake inhibitors, or SSRIs) are also effective to some degree in the prevention of panic attacks and agoraphobia but their onset of action is delayed for weeks They become useful for symptoms of anxiety that persist for more than several months The doses are similar to those used to treat depression (see Chap 57) Buspirone, a speci c serotonin 5-HT2 agonist, has been promoted as effective in the treatment of anxiety and as a surrogate for benzodiazepines, but its bene t has seemed to us to be slight It is important to point out that during the initial weeks of administration of antidepressants, the underlying anxiety symptoms may worsen and an anxiolytic is usually required until the antidepressant becomes effective Propranolol, 10 to 20 mg three times daily, or a long-acting form of adrenergic blocker, reduces many of the autonomic accompaniments of anxiety and is useful to many patients, but its effects on the other symptoms are uncertain For true anxiety neurosis with panic attacks, psychiatric consultation is valuable With regard to psychotherapy, behavioral therapy (progressive exposure of the patient to panic-provoking situations) is said to be bene cial, particularly if agoraphobia is a major symptom Relaxation activities, including biofeedback and meditation, help many patients, although persistence is required in performing these at least once daily and they are less helpful once a panic attack has begun So-called cognitive-behavioral psychotherapy, which is discussed in relation to the treatment of depression (page 1315), also appears to be useful in the treatment of panic disorder according to Andreasen and Black A cardiac consultation and some simple tests (electrocardiogram, chest lms) may be needed to reinforce the benign nature of the cardiac and respiratory symptoms and to alleviate the patient s fear of heart disease These and other current concepts of the treatment of anxiety are discussed by Goodwin and Guze Anxiety symptoms arising in relation to a particular threatening event in a nonneurotic individual carry the best prognosis.

of open (agoraphobia), closed, or high places, dogs, cats, insects, dirt, sprays and other contaminants, air travel, acquired immunode ciency syndrome (AIDS), cancer, insanity, and death Feelings of helplessness, pessimism, and despondency, the hallmarks of a depressive illness, result after years of phobic suffering Often there are obsessive-compulsive tendencies as well, and some patients are hypochondriacal Phobias are essentially obsessive fears and are somehow allied with this latter category of neurosis The present authors have observed a number of patients whose phobic (or obsessive-compulsive) neurosis became greatly exaggerated as an endogenous depression developed Recovery from the depression returned them to their earlier and milder phobic state All of these features suggest a linkage between neuroses and depression

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