DISORDERS AND DRUGS: THE CONFUSION OF CROSSOVER
The DSM-HI, published in 1980, provides 25 different diagnostic labels for patients with anxiety; because some anxiety disorders may coexist, a total of 138 different diagnostic combinations is possible. This multiplicity of disorders together with a host of new medications, many of which have "crossover" ability, have served to confuse rather than to clarify treatment protocol for the primary care physician. Some of the confusion may be alleviated by differentiating anxiety or depressive disorders as exogenous or endogenous. Exogenous refers to a normal response to threat, and it usually can be treated successfully with behavior therapy. Only failures in this group need pharmacotherapy. Endogenous disorders, which are metabolic in nature, are both more intense and pervasive and also more physically and psychologically disruptive. Therapeutic intervention is indicated in the majority of such cases. Alprazolam, even within the family of benzodiazepines, is not the only effective pharmacological agent in the treatment of anxiety or anxious depression. And although the benzodiazepines are not the sole family of compounds available to the clinician for these indications, some authorities (8) believe that they are the treatment of first choice. Widespread clinical acceptance has consequently resulted in a high comparative scrutiny with other compounds in the treatment of anxiety disorders, mixed anxiety and depressive disorders, and some subtypes of pure depressive disorders. Seldom can one attend a discussion on the pharmacologic treatment of these disorders without some reference to alprazolam’s relative efficacy and side effects. The pharmacokinetic (1) and psychodynamic properties (5) of alprazolam have been extensively studied and reviewed elsewhere. In this chapter, three clinical studies using alprazolam in outpatients that were conducted in whole or part by our organization, a private psychiatric clinic in San Diego, California, will be reviewed.