ANXIETY DISORDERS

Composite Diagnostic Evaluation

Thomas A. Ban, M.D.


Introduction

        Introduction of therapeutically effective psychotropic drugs (in the 1950s) and the subsequent recognition that the differential therapeutic effects of these compounds are intimately linked to their differential action on the synaptic cleft (in the 1909s), triggered fundamental changes in the conceptualization of mental illness (during the 1970s). The new neurobiologic paradigm, which rapidly emerged (during the 1980s), and virtually replaced the old psychodynamic paradigm (by the 1990s), was formulated with primary consideration to the action mechanism of psychotropic drugs.
        Within the new frame of reference, psychopathologic symptoms are perceived as expression of pathology in the processing of ideas (impulses) derived from experience; and mental illness is seen as the result of an integration of psychopathologic symptoms. Because of this intimate link between psychopathology and the neurochemistry of the synapse, it has increasingly been acknowledged that the provision of valid diagnostic end-points for research is the single, most important prerequisite of psychiatric progress.

        Introduction of therapeutically effective benzodiazepines – drugs which facilitate transmission of impulses at the synaptic cleft of gabaminergic neurons (Costa, 1985) – focused attention on the biologic heterogeneity (in terms of pharmacologic responsiveness) of neurotic (anxiety) disorders. To overcome this heterogeneity by identifying the treatment responsive population, consideration was given to the employment of a psychometric psychopharmacology approach, i.e., linear regression equations to detect common characteristics in anxiolytic benzodiazepine responsive patients. It was the failure of this approach to arrive at meaningful diagnostic concepts, i.e., diagnostic categories with predictive validity – in terms of therapeutic responsiveness to anxiolytic benzodiazepines and unresponsiveness to drugs other than anxiolytic benzodiazepines – that prompted a re-examination of the diagnostic concept of neurotic (anxiety) disorders.