ANXIETY DISORDERS

Composite Diagnostic Evaluation

Thomas A. Ban, M.D.

 

Concluding Remarks

In this presentation the transformation of the diagnostic concept of neurotic disorders, based in a psychological frame of reference, into the diagnostic concept of anxiety disorders, based on a psychopathologic frame of reference, was outlined; and recent developments in the conceptualization of anxiety disorders, triggered by the introduction of anxiolytic-benzodiazepines, were discussed. It was emphasized that a valid classification of anxiety disorders cannot be attained based on psychopathologic symptoms alone, because in the organization of anxiety disorders factors other than pathology in the processing of ideas (impulses) derived from experience, such as temporality, spatiality and totality, also play an important role.

The shift of emphasis from one conceptual framework to another has far reaching practical and heuristic implications in psychiatry. Thus, replacement of the psychopathologic with the biologic conceptualization of mental illness resulted in a shift of emphasis from phenomenologic explorations to biochemical and neurophysiologic measures; and replacement of the psychopathologic approach in diagnosis and classification with a holistic-nosologic approach may result in a shift of emphasis from the spatial to the temporal organization of mental illness and a shift in priorities of biologic research from the detection of the biologic correlates of the disease to the recognition of its genetic pattern. Furthermore, in clinical investigations with psychotropic drugs replacement of the psychopathologic with a nosologic approach may result in a shift of emphasis from establishing clinical efficacy to the identification of the treatment responsive population; and in the methodology of clinical investigation the replacement of dimensional rating scale measures of improvement, i.e., decrease of scores, with categorical nosologic endpoints, i.e., resolution of nosologic pattern(s).

To ascertain that the different disorders identified represent meaningful categories of disease validation studies employing statistical approaches and external correlates, are in progress. To facilitate this process a composite diagnostic evaluation of anxiety disorders – CODE–AD – was developed which can provide the clinician – as well as the epidemiologist – a simple screening procedure for anxiety disorders; the researcher with a suitable assessment instrument to ascertain that the disorder identified fits criteria of the same disorder in both major consensus based classifications, i.e., the ICD-10 and DSM.III.R and the educator with a means to provide an understanding how the different nosologic entities were derived in anxiety disease.