1 . António Egas Moniz was awarded the 1949 Nobel Prize for treating mental disorders with leukotomy.
In 1949, the Nobel Prize in Medicine was awarded to António
Egas Moniz for his discovery of "a simple operation, always safe, [and] which may prove to be
an effective surgical treatment in certain cases of mental disorder" [11]. Specifically, Moniz
discovered the prefrontal leukotomy as a treatment for mental disorders, including anxiety
disorders [12]. Since then, studies have found that damage to the ventromedial prefrontal
cortex produces resistance against anxiety and depression [13; 14; 15; 16]. Despite the
effective reduction of anxiety in these patients, it took many decades until research began to
address the harms imposed by damage to the prefrontal cortex. For example, in addition to
reducing anxiety, damage to the ventromedial prefrontal cortex also impairs self-regulation
and decision-making and can induce sociopathic behaviors [17; 18; 19; 20; 21]. Similar
patterns of anxiety reduction were also observed in one patient with focal bilateral lesions
to the amygdalae who showed a similar pattern of impairment in her daily life as those with
damage to the prefrontal cortex [22]. Although the prefrontal cortex and amygdala are critical
structures in a neural network that is necessary for anxiety, these findings highlight the
fact that damage to these structures comes with unintended consequences. These findings also
highlight the more general point that, in treating anxiety disorders, it is also important to
not abolish otherwise useful traits as it is to reduce the anxiety to a manageable
level.
2 . Two neural structures that are necessary for anxiety responses are the temporal pole and amygdala.
In 1949, the Nobel Prize in Medicine was awarded to António
Egas Moniz for his discovery of "a simple operation, always safe, [and] which may prove to be
an effective surgical treatment in certain cases of mental disorder" [11]. Specifically, Moniz
discovered the prefrontal leukotomy as a treatment for mental disorders, including anxiety
disorders [12]. Since then, studies have found that damage to the ventromedial prefrontal
cortex produces resistance against anxiety and depression [13; 14; 15; 16]. Despite the
effective reduction of anxiety in these patients, it took many decades until research began to
address the harms imposed by damage to the prefrontal cortex. For example, in addition to
reducing anxiety, damage to the ventromedial prefrontal cortex also impairs self-regulation
and decision-making and can induce sociopathic behaviors [17; 18; 19; 20; 21]. Similar
patterns of anxiety reduction were also observed in one patient with focal bilateral lesions
to the amygdalae who showed a similar pattern of impairment in her daily life as those with
damage to the prefrontal cortex [22]. Although the prefrontal cortex and amygdala are critical
structures in a neural network that is necessary for anxiety, these findings highlight the
fact that damage to these structures comes with unintended consequences. These findings also
highlight the more general point that, in treating anxiety disorders, it is also important to
not abolish otherwise useful traits as it is to reduce the anxiety to a manageable
level.
3 . The standard for anxiety disorder assessment is the structured interview.
The standard procedure for anxiety disorder assessment is the
structured diagnostic interview, which is administered by a trained professional. The
structured interview consists of pre-determined questions that assess for relevant symptoms
based on diagnostic criteria. For example, an interview for GAD would start by asking the
individual questions about the presence of worry symptoms over the past six months. If the
interviewee answers this question affirmatively, the interviewer would then ask the
individual about the presence of secondary symptoms associated with the worry (e.g., sleep,
irritability). If the individual responds affirmatively to the minimum number of secondary
symptoms required for a diagnosis of GAD, the individual would then be queried about the
presence of distress or impairment due to the worry. The key advantage of the structured
interview is its standardized administration, procedure, and scoring, which minimize bias
and error in assessment. Two commonly used structured interviews for the assessment of
mental disorders are the Diagnostic Interview Schedule (DIS) and the Composite International
Diagnostic Interview (CIDI) [56,57]. In addition, the Anxiety Disorders
Interview Schedule (ADIS) is a structured diagnostic interview that was developed
specifically for anxiety disorder assessment [58]. These interviews are regularly updated along with diagnostic criteria,
as for example with new editions of the DSM. Structured interviews rely essentially on
self-report; in addition to being administered by clinicians, they may also be conducted by
trained lay persons and/or computer-assisted technology (as in epidemiologic
surveys).
4 . The Overall Anxiety Severity and Impairment Scale (OASIS) consists of two items.
The Overall Anxiety Severity and Impairment Scale (OASIS)
is a brief, transdiagnostic screening tool designed to assess for the severity of anxiety
in the past week of the individual's life [69]. There are five items, each rated on a five-point scale (0 to 4),
yielding a total possible score of 20. A raw score of 8 or greater indicates the presence
of anxiety disorder based on validation against anxiety disorder diagnosis using the
psychiatrist-administered SCID [70]. Raw
scores of 10 and 12 indicate the presence of marked and severe anxiety, respectively,
based on validation against the clinician-rated Clinical Global Impression-Severity
(CGI-S) scale in a sample of individuals with any anxiety disorder ascertained using the
Mini International Neuropsychiatric Interview (MINI) [71].
5 . The most prevalent anxiety disorder subtype in older adults is specific phobia.
Anxiety disorders are the most prevalent mental disorders in
older adults [54,84]. The most prevalent subtypes are, in
descending order, specific phobia, GAD, social anxiety disorder, and panic disorder.
Table 5 displays the one-year prevalence of anxiety
disorders, both overall and by subtype, in the NESARC and the Collaborative Psychiatric
Epidemiology Surveys (CPES) of the United States. The prevalence of anxiety disorders is
higher among women relative to men, and the prevalence of all anxiety subtypes decreases
among persons 75 years of age or older. Previous studies have also reported ethnic
differences in prevalence, such that Native and White Americans have the highest prevalence,
and Hispanic and Asian Americans have the lowest prevalence of anxiety disorders [85]. Black Americans have a higher or lower
prevalence of anxiety disorders depending on subtype; specific phobias and GAD are more
prevalent, comparable to Native and White Americans, whereas panic disorder and social
anxiety disorder are less prevalent, closer to levels observed in Hispanic and Asian
Americans. The prevalence of anxiety disorders does not vary substantially by educational
attainment or marital status.
6 . Women 55 years of age or older have the highest prevalence of any anxiety disorder according to data from the NESARC.
ONE-YEAR PREVALENCE OF ANXIETY DISORDER AMONG ADULTS 55 YEARS OF AGE AND OLDER IN TWO
NATIONAL SAMPLES
| Population | Specific Phobia | Social Anxiety Disorder | Generalized Anxiety Disorder | Panic Disorder | Any Anxiety Disorder |
|---|
| NESARC | CPESa | NESARC | CPES | NESARC | CPES | NESARC | CPES | NESARC | CPESb |
|---|
| Total | 5% | 6% | 2% | 3% | 1% | 3% | 1% | 2% | 9% | 6% |
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| Education | | Less than high school | | Completed high school | | Some college | | Bachelor's degree |
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| Marital status | | Married or cohabiting | | Widowed, divorced or separated | | Never married |
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| aSpecific phobia was assessed in a sub-sample
of 9,282 respondents from the NCS-R. | | bSpecific phobia was not included in the
overall anxiety disorder estimate for the CPES. |
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7 . The most persistent anxiety disorder subtype in older adults is generalized anxiety disorder.
The chronicity of a disease refers to its persistence.
Persistence is defined here as the percentage of respondents who meet diagnostic criteria
for an anxiety disorder at baseline and who then meet criteria again at follow-up. Data from
the NESARC indicate that approximately 30% of older adults (55 years of age and older) have
persistent cases of anxiety disorder, or chronicity, assessed over a three-year follow-up
period. The most persistent subtypes were specific phobia (25%) and GAD (20%), followed by
social anxiety disorder (16%) and panic disorder (10%) [31].
8 . The most significant modifiable risk factor for anxiety disorder is cigarette smoking.
The two strongest risk factors for anxiety disorders among
older adults are female sex and younger age [84,108,109]. However, other risk factors have also
been identified. Cigarette smoking is shown to be a major risk factor of anxiety disorder
onset, while smoking cessation is associated with reduced anxiety, suggesting that smoking
interventions would have a significant effect on anxiety disorder onset [110,111]. Another important risk factor of anxiety disorder onset in longitudinal
studies is the occurrence of adverse life events, such as the ending of a relationship or
the injury, illness, or death of a loved one [112,113,114].
9 . SSRIs and SNRIs are the most effective in the treatment of social anxiety disorder.
Individual CBT was found to be effective for acute treatment
compared with waitlist control groups. Pharmacologic interventions included anticonvulsants,
benzodiazepines, monoamine oxidase inhibitors (MAOIs), noradrenergic and serotonergic
antidepressants, selective serotonin reuptake inhibitors (SSRIs), and selective
norepinephrine reuptake inhibitors (SNRIs). SSRIs and SNRIs were found to be the most
effective class of pharmacological treatment compared with placebo control groups [133].
10 . The treatment of choice for specific phobias is exposure therapy.
Exposure therapy is the treatment of choice for specific
phobias [139,140]. This includes in vivo (real-life) and
virtual reality exposure to phobic stimuli or situations. Virtual reality exposure therapy
was introduced in the 1990s, and although it may have some treatment benefit, it has not
been found to have strong efficacy [141]. A
one-session exposure therapy treatment for specific phobias was pioneered more than 30 years
ago with a suggested duration of two hours and was subsequently used to treat various
specific phobia subtypes [142,143,144,145]. More recent
studies suggest that one session does not always turn out to be adequate and that multiple
sessions are generally more efficacious [140,146]. However, there may be some cases
where the single-session approach is viable.
