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Chapter 12. Anxiety Disorders

Murray Stein, M.D., M.P.H., F.R.C.P.C.; Jitender Sareen, M.D., F.R.C.P.C.
DOI: 10.1176/appi.books.9781585625031.346502

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The authors are grateful to Sarah Marie Raposo and Cara Katz for assistance in the preparation of this manuscript.

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Proposed neural circuitry of panic.The amygdala has a crucial role as an anxiety way-station that mediates incoming stimuli from the environment (thalamus and sensory cortex) and stored experience (frontal cortex and hippocampus; dark arrows), thereby affecting the anxiety and panic response by stimulating various brain areas responsible for key panic symptoms (lighter arrows). The periaqeductal gray in the midbrain could be especially important for mediating panic-anxiety. Drug treatments can target all parts of this system, affecting amygdala and frontal-lobe interpretation of stimuli, or output effects. Cognitive-behavioral treatment affects the frontal-lobe areas, especially in the medial prefrontal cortex, which is known to inhibit input to the amygdala by using a braking action.Source. Reprinted from Roy-Byrne PP, Craske MG, Stein MB: “Panic Disorder.” Lancet 368(9540):1023–1032, 2006. Copyright 2006, Elsevier Ltd. (available at: www.sciencedirect.com/science/article/pii/S014067360669418X). Used with permission.

Clusters in which significant hyperactivation or hypoactivation was found in patients with posttraumatic stress disorder (PTSD), social anxiety disorder, and specific phobia relative to comparison subjects and in healthy subjects undergoing fear conditioning.Results are shown for the amygdalae (A) and insular cortices (B). Note that within the left amygdala there were two distinct clusters for PTSD, a ventral anterior hyperactivation cluster and a dorsal posterior hypoactivation cluster. The right side of the image corresponds to the right side of the brain.Source. Reprinted from Etkin A, Wager TD: “Functional Neuroimaging of Anxiety: A Meta-Analysis of Emotional Processing in PTSD, Social Anxiety Disorder, and Specific Phobia.” American Journal of Psychiatry 164(10):1476–1488, 2007. Copyright 2007, American Psychiatric Association. Used with permission.

Cognitive and behavioral factors in panic disorder.Source. Adapted from Roy-Byrne PP, Craske MG, Stein MB: “Panic Disorder.” Lancet 368(9540):1023–1032, 2006. Used with permission.

Algorithm for the treatment and management of anxiety disorders.
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Approximate lifetime and 12-month prevalence, gender ratio, and median age at onset for anxiety disorders in the U.S. general population

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