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Anxiety Disorders: Future Directions for Research and Treatment

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Appendix 1

Lifetime Prevalence of the Anxiety Disorders (%)

Disorder	ECA Study*	NCS Study	Edmonton Study
Panic Disorder	0.9	3.5	1.2
Agoraphobia	4.2	5.3	2.9
OCD			3.0
Social Phobia	2.8	13.3	1.7
GAD		5.1
Specific Phobia	11.2	11.3	7.2
PTSD		7.8
Any AD	10.4- 25.1_*	24.9	11.2

* based on three of the five ECA sites

OCD: obsessive-compulsive disorder; GAD: generalized anxiety disorder; PTSD: post- traumatic stress disorder; ECA Study: Epidemiological Catchment Area Study (Bourdon et al., 1988; Robins et al., 1984); NCS: National Comorbidity Survey (Kessler et al., 1994); Edmonton Study: refers to the prevalence study conducted by Bland et al., 1988.

Explanatory note:

These discrepancies have been attributed to (in the ECA and Edmonton surveys) standardization of prevalence rates to the census population of each site instead of to an identical population (Bland et al., 1988), and to variation in survey questions and interviewer instructions (Robins et al., 1984). Kessler et al. (1994) indicate that the higher prevalence rates in the NCS than in the other two surveys can, in part, be attributed to a number of methodological factors including: use of a national sample, focus on a younger age range (15-54 years), use of a correction weight to adjust for nonresponse bias, and use of DSM-III-R (Diagnostic and Statistical Manual of Mental Disorders, 3rd Revised Edition)(as opposed to DSM-III) criteria. Although the instrument used in the NCS (the Composite International Diagnostic Interview or CIDI; Robins, Wing, Wittchen, and Helzer, 1988) is similar to the instrument used in the ECA study (the Diagnostic Interview Schedule or DIS; Robins, Helzer, Croughan, and Ratcliff, 1981), Kessler et al. suggest that differences in wording and depth of probing in the NCS could have contributed to higher prevalence estimates.

Appendix 2

Glossary of Medications

Generic Name	Brand Name	Type of Medication
Adinazolam	Deracyn	Benzodiazepine*²
Alprazolam	Xanax	Benzodiazepine
Amitriptyline	Elavil	Tricyclic Antidepressant
Atenolol	Tenormin	Beta Blocker
Brofaromine	Experimental	Reversible MAOI (Type A)*
Buspirone	Buspar	Azospirodecanedione
Clomipramine	Anafranil	SSRI Antidepressant
Clonazepam	Rivotril	Benzodiazepine
Desipramine	Pertofran or Norpramin	Tricyclic Antidepressant
Diazepam	Valium	Benzodiazepine
Fluoxetine	Prozac	SSRI Antidepressant
Fluvoxamine	Luvox	SSRI Antidepressant
Imipramine	Tofranil	Tricyclic Antidepressant
Lorazepam	Ativan	Benzodiazepine
Moclobemide	Manerix	Reversible MAOI (Type A)
Paroxetine	Paxil	SSRI Antidepressant
Phenelzine	Nardil	MAO Inhibitor
Sertraline	Zoloft	SSRI Antidepressant

2. * denotes unavailability of medication in Canada.

Glossary of Abbreviations

CBT	Cognitive-Behavioural Therapy
DSM-III	Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition
DSM-III-R	Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition, rev.
DSM-IV	Diagnostic and Statistical Manual of Mental Disorders, 4th Edition
EMDR	Eye Movement Desensitization and Reprocessing
GAD	Generalized Anxiety Disorder
MAOI	Monoamine Oxidase Inhibitor Antidepressant
OCD	Obsessive-Compulsive Disorder
PD	Panic Disorder
PDA	Panic Disorder with Agoraphobia
PTSD	Posttraumatic Stress Disorder
SSRI	Selective Serotonin Re-Uptake Inhibitor

Glossary of Technical Terms

*Analytic Psychotherapy*	A form of psychotherapy based on the methods described by Freud and others. Psychological problems are assumed to stem from deep rooted intrapsychic conflicts. Therapy helps the patient to develop insight into possible original causes of his or her problem, which presumably leads to improvement in symptoms.
*Applied Relaxation Training*	A form of relaxation training in which muscle relaxation is taught in the context of in vivo exposure therapy. Individuals are taught to relax their muscles while being exposed to increasingly frightening situations.
*Applied Tension*	A method of treating individuals with blood or injection phobias who tend to faint in the feared situation. Individuals are taught to tense the muscles of their body in order to raise their blood pressure and thereby prevent fainting in the presence of blood or injections. These skills are integrated with exposure to feared cues as they are practised while confronting increasingly difficult situations.
*Breathing Retraining*	A form of behavioural treatment used primarily in patients with panic disorder. Patients are taught to breathe from their diaphragm, slow down their breathing, and use meditation strategies to relax when anxious.
*Cognitive-Behavioural Therapy*	A form of psychological treatment that attempts to change the thoughts or behaviours that help to maintain a psychological disorder. Examples of cognitive therapy techniques include cognitive restructuring, hypothesis testing, and coping self-statements. Behavioural strategies include exposure therapy, relaxation training, and a variety of other techniques.
*Cognitive Restructuring*	A component of cognitive therapy in which individuals are taught to identify and change their anxious or depressive thoughts, beliefs, predictions, and interpretations. Rather than assuming their beliefs are true, individuals are taught to consider alternative beliefs and to evaluate the evidence in a systematic and realistic way.
*Exposure and Response Prevention*	A behavioural method used to treat obsessive-compulsive disorder. Individuals are exposed to feared stimuli (e.g., contaminated objects) and are prevented from engaging in compulsive rituals (e.g., washing).
*Exposure Therapy*	A form of behaviour therapy in which individuals are required to confront the object or situation that they fear. Typically, exposure is conducted in a structured and predictable manner and is repeated frequently.
*Eye Movement Desensitization and Reprocessing*	A new form of exposure therapy that has been a source of controversy in the behaviour therapy literature. While visualizing a feared image, individuals track the rapid movements of a therapist's finger back and forth across the image. Proponents of this approach believe that this is a unique therapeutic modality. Critics argue that the effects of this technique are attributable entirely to the exposure component.
*Imaginal Exposure*	A form of exposure therapy in which individuals confront feared objects and situations in imagination only.
*Interoceptive Exposure*	A component of behavioural treatment for panic disorder in which individuals conduct specific exercises designed to induce feared sensations (e.g., racing heart, dizziness, breathlessness, etc.) until the sensations are no longer feared. Typical exercises include hyperventilation, spinning, aerobic exercise, breathing through a straw, and others.
*In Vivo Exposure*	See Flooding.
*Meta-Analysis*	A statistical procedure in which the effects of particular treatments are estimated and pooled across a range of different studies.
*Non-Directive Psychotherapy*	A form of psychotherapy in which specific behavioural instructions are not given to patients. Typically, non-directive therapies do not include homework assignments and are focused on helping the individual to gain insight into his/her problem, rather than changing specific behaviours.
*Progressive Muscle Relaxation*	A method of decreasing anxiety (especially in generalized anxiety disorder) by learning to tense and relax various muscle groups.
*Self-Help*	Self-help is a form of mutual aid in which groups of individuals with common problems or experiences seek to help each other through offering emotional support and practical assistance (Romeder, 1993). Self-help can be an important supplement to professional care and is a natural extension or replacement of the support often available to individuals from close friends, family members, or members of the clergy.
*Self-Help Groups*	Voluntary self-help groups are run by and for group members. These groups provide, free of charge, educational seminars, one-to-one exchanges, informal meetings, and sharing of personal experiences.
*Social Skills Training*	A group of techniques for teaching individuals (e.g., with social phobia) to improve social skills (e.g., communication, assertiveness, eye contact, body language, etc.)
*Structured Diagnostic Interview*	An interview which asks specific questions about each symptom included in the diagnostic criteria for particular disorders. Unlike open-ended clinical interviews, the interviewer is required to read the questions verbatim.
*Supportive Counseling*	A form of psychotherapy in which the therapist does not provide specific behavioural instructions, but rather offers support and encouragement. Client-centered therapy is considered by some to be an example.
*Supportive Psychotherapy*	See Supportive Counseling.

Appendix 3

Useful References Relating to the Assessment of Anxiety Disorders

Cox, B.J., and Swinson, R.P. (1995). Assessment and measurement. In M.B. Stein (Ed.), Social phobia: Clinical and research perspectives. Washington, D.C.: American Psychiatric Press.

Davey, G.C.L., and Tallis, F. (Eds.) (1994). Worrying: Perspectives on theory, assessment, and treatment. Chichester, U.K.: John Wiley and Sons.

Elting, D.T., and Hope, D.A. (1995). Cognitive assessment. In R.G. Heimberg, M.R. Liebowitz, D.A. Hope, and F.R. Schneier (Eds.), Social phobia: Diagnosis, assessment and treatment. New York: Guilford Publications.

Greist, J.H., Kobak, K.A., Jefferson, J.W., Katzelnick, D.J., and Chene, R.L. (1995). The clinical interview. In R.G. Heimberg, M.R. Leibowitz, D.A. Hope, and F.R. Schneier (Eds.), Social phobia: Diagnosis, assessment and treatment. New York: Guilford Publications.

McNeil, D.W., Ries, B., and Turk, C.L. (1995). Behavioural assessment: Self-report, physiology, and overt behaviour. In R.G. Heimberg, M.R. Liebowitz, D.A. Hope, and F.R. Schneier (Eds.), Social phobia: Diagnosis, assessment and treatment. New York: Guilford Publications.

Shear, M.K., and Maser, J.D. (1994). Standardized assessment for panic disorder research: A conference report. Archives of General Psychiatry, 51, 346-354.

Taylor, S. (1995). Assessment of obsessions and compulsions: Reliability, validity and sensitivity to treatment effects. Clinical Psychology Review, 15, 261-296.

Watson, C.G. (1990). Psychometric posttraumatic stress disorder measurement techniques: A review. Psychological Assessment: A Journal of Consulting and Clinical Psychology, 2, 460-469.

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