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Anxiety Disorders (Modern Trends in Pharmacopsychiatry Series, Vol. 29)

Richard Balon, MD

Wayne State University, Detroit, Michigan, USA

Edited by David S. Baldwin and Brian E. Leonard. Basel, Switzerland: S. Karger AG; 2013; ISBN 978-3-318-02463-0; pp 184; $115 (hardcover).

As pointed out in the Preface to this slender volume, “Anxiety disorders are common, usually have an early onset, often take a prolonged course, cause much personal distress, impair everyday function, lower quality of life, and carry a considerable economic burden” (p VII). Better understanding of these disorders and their treatment certainly could help all clinicians managing patients with an anxiety disorder. Thus, the editors of this book, Drs. Baldwin and Leonard, drew a group of experts from the Anxiety Disorders Research Network to help put together updates on a range of anxiety disorder topics, from “the nature and origin of anxiety and related symptoms and insights from genetic and neuroimaging research…” (p VIII) to “provide succinct but comprehensive accounts of the evidence-based pharmacological treatment…” (p VIII) of various anxiety disorders.

The book contains 13 chapters: “On the nature of obsessions and compulsions”; “The origin of anxiety disorders—an evolutionary approach”; “Genetic factors in anxiety disorders”; “Neuroimaging in anxiety disorders”; “Potential neuroimmunological targets in the treatment of anxiety disorders”; “Anxiety and cardiovascular disease”; “The early phases of anxiety disorders: from prevention to treatment”; “Duration of untreated illness and duration of illness in anxiety disorders: assessment and influence on outcome”; “Pharmacotherapy of generalized anxiety disorder”; “Pharmacological treatment of panic disorder”; “Pharmacological treatment of social anxiety disorder”; “Pharmacotherapy of posttraumatic stress disorder”; and “Evidence-based treatment pathways for translational studies in obsessive-compulsive disorder.” I list the chapter titles to illustrate the intended broad scope of this book, which contrasts—as the reader will realize fairly soon—with rather meager and not so broad or useful results.

The chapter “On the nature of obsessions and compulsions” presents an overview of the history of thinking about obsessions and compulsions and poses an interesting question about obsessive-compulsive disorder (OCD): “Is it a disorder of the will, of emotions, or rather the course of thinking?” (p 9). The authors also point out OCD patients’ need for absolute certainty and the lack of trust underlying this need; and that, based on insights from Wittgenstein, this “kind of certainty is unattainable in principle via the acquisition of factual knowledge” (p 14). The chapter also includes a detailed discussion of DSM-IV diagnostic criteria for OCD. This is a bit unfortunate because DSM-5 was published in the meantime, and it would be more useful to include a discussion of DSM-5 criteria.

The chapter on the origin of anxiety discusses the evolutionary process of fear and anxiety, “both emotional processes that help organisms cope with threats of danger” (p 16) and that 3 responses to threat occur: freezing (to distract threat’s attention), flight (to increase distance to a threat), and fight (to defeat the threat). There are 2 interesting questions in regards to pathological anxiety raised here: “Why do fear and anxiety manifest even when not needed?” and “What is the optimal ‘set-point’ for fear and anxiety?” (p 17). The chapter then delves into imaging findings in anxiety disorders regarding neurocircuitry and argues that anxiety disorders are heterogeneous, “the brain mechanism involved in PTSD [posttraumatic stress disorder], PD [panic disorder], and phobias can arguably be distinguished from those which mediate GAD [generalized anxiety disorder] and OCD” (p 20). This might be an additional argument for separating OCD from anxiety disorder as has happened in DSM-5. As interesting as this chapter is, its final message was lost on me. The chapter on genetic factors in anxiety disorders is a thorough review of all genetics data. It was unclear to me why the linkage studies data were included, because their approach has not been found to be useful. I also was disappointed that the discussion of challenge studies in anxiety disorders does not mention lactate infusions at all. The chapter ends on a cautionary note worth remembering, “However, to date the identified genetic risk factors are of no diagnostic or predictive value, as the field is far from having identified the entirety of all genetic and epigenetic risk factors interdependent with environmental factors” (p 34). The chapter on neuroimaging also is disappointing and demonstrates a lack of detailed editing, because it discusses the etiology of anxiety disorders again (why here?) and refers to what will most likely be included in various DSM-5 categories, while the DSM-5 has already has been published. The chapter on potential neuroimmunological targets discusses the “pivotal roles of cytokines in signaling to the brain and leading to behavioural changes” (p 67) followed by a review of neuroimmunological changes in depression and neuroimmunomodulation effects of antidepressants. The rest of the chapter is filled with hypotheses on neuroimmunology of anxiety disorders. In all fairness, it is known that a chronic anxious state may have a deleterious effect on the immunological function (p 73). However, the findings and conclusions about the inflammatory response in anxiety disorders are limited by “reliance on cross-sectional study design, small sample sizes, the lack of standard measurements, and high comorbidity with depression” (p 75).

The chapter on anxiety and cardiovascular disease, again, does not contribute much. The chapter on the early phases of anxiety disorders introduces an interesting model of preventive intervention adapted from Patrick McGorry’s model on early manifestation of psychosis. There are 3 new levels of prevention: universal (focused on the whole population or general public), selective (focused at asymptomatic population with a higher risk of a particular disorder), and indicated (targeted at high-risk individuals with minimal but detectable signs or symptoms foreshadowing a particular mental illness, but not meeting its diagnostic criteria) (p 99). This seems like a useful model for developing treatment algorithms. The problem is that we know even less about predictors and prodromes of anxiety disorders than we know about the prodromes and predictors of psychotic illness. In addition, similar to the situation in psychosis, we do not know when to start and how long to continue the intervention. Related to this topic, the following chapter focuses on the duration of untreated illness and duration of illness in anxiety and its influence on outcome. The main omission of this chapter is the lack of a definition of remission of anxiety disorders because the duration of illness is defined as the time elapsing between illness onset and remission.

The 5 “purely” treatment chapters (on GAD, PD, social anxiety disorder, PTSD, and OCD) are mostly disappointing. They are brief reviews of the topic, with no new information or clinically useful tips, which are expected from experts. The chapter on pharmacological treatment of PD is probably the only useful one, because at least it discusses the length of treatment and treatment of anxiety in special populations. In view of the difficulties treating children and adolescents with antidepressants (maturity of the neurotransmitter systems, suicidal ideation with antidepressants), I hoped for some suggestions on the use of benzodiazepines in children and adolescents, but no luck. The chapter on social anxiety disorder makes a point that this disorder may be difficult to distinguish from avoidant personality disorder, which may be a more severe form of the same condition; however, the authors do not relate this observation to any treatment recommendations. The last chapter on OCD suggests that “Overall, the evidence is not strong enough to support the superior efficacy or tolerability of any one SSRI [selective serotonin reuptake inhibitor] in OCD” (p 171). Although this probably is true, referencing this statement with one’s own article, which has not been accepted for publication, is a bad practice.

As the reader can guess, I am not really enthusiastic about this volume. I expected much more from a book written by experts. Clinicians would not be able to learn much from this text. Some theoretical chapters are interesting, but not useful. The treatment chapters are not useful. The main weakness of this volume is its poor editing (including the fact that the publishers did not wait for the publication of DSM-5 to have the criteria included in this volume). Thus, in spite of the Preface title—“Concerned efforts to improve the understanding and treatment of anxiety disorders”—one’s understanding and treatment probably does not get better after reading this volume. I have to admit that I enjoyed more the recently published article “My anxious, twitchy, phobic (somehow successful) life”1 by Scott Stossel, editor of The Atlantic (including the fact that Hugh Grant, Mahatma Gandhi, and Thomas Jefferson were all afflicted by fear of public speaking).


  1. Stossel S. My anxious, twitchy, phobic (somehow successful) life. The Atlantic. 2014;313:75–92.