Anxiety Disorders: Assessment and Treatment 2 CE Hours

Learning objectives

1. Identify the DSM-5 diagnostic criteria for each type of anxiety disorder. 2. Describe the assessment tools used to identify the subcategories of anxiety disorders. 3. List the symptoms of the subcategories of anxiety disorders. 4. Discuss strategies that parents can use to assist children with anxiety disorders. 5. Explain the different classes of medications used to treat each type of anxiety disorder. 6. Discuss therapeutic treatment models used for specific anxiety disorders.

Introduction Mandy is a 52-year-old woman who has a responsible job as an accountant. To her friends and family, she appears to to “have it all together.” However, in the last three months, Mandy has been more reluctant to go to places she describes as “open”— in particular, to the mall.

Two months ago when she was at the mall, Mandy felt her legs go numb and tingle. She felt different and scared for no real reason; however, it went away after a few minutes. The next week when at the mall again, Mandy felt as if she were having a heart attack: her heart began to pound uncontrollably and she began shaking and gasping for breath. Her friend called 911; Mandy was examined by the emergency medical personnel who later determined that nothing was wrong with her heart.

Mandy felt foolish and embarrassed. As a result, she has become very reluctant to go out with friends and now frequently stays at home. She has made an appointment to go see her primary care doctor because she is sure that something is wrong with her heart. James, 29, has always described himself as a “neurotic.” He is a perfectionist who worries over every detail of his life, including his job as a nurse. He has recently begun to

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wake up in the middle of the night two or three times a week, worrying that he has forgotten to do something important at work. He calls the hospital to check on his patients, as well as any tasks that he was assigned.

His coworkers found this amusing at first— a sign of how conscientious he was as a nurse. In the last week, however, his coworkers started to laugh at him and to appease him: they tell him that they have checked on things when they really had not done so.

James also constantly worries that something will happen to his young son. He is unable to stop worrying that his son will get cancer or have an accident. When these thoughts occur, James cannot concentrate on anything else. He also forbids his son to participate in activities – such as skateboarding or playing basketball with other kids— because he is afraid the boy will get hurt.

He has also begun to worry about his wife leaving him. He asks her for daily reassurance that she will not divorce him and she is becoming increasingly annoyed by the questioning.

Jordan is a 7-year-old boy who recently witnessed his father die in a car accident. Jordan was a passenger in the car, but was unharmed. He has been having nightmares and has also started sucking his thumb and wetting the bed. His mother noted that while playing, Jordan acts out a car accident with his toys. Jordan is well behaved, but his mother is worried about his other behaviors.

All of the individuals in these vignettes are displaying symptoms consistent with some form of an anxiety disorder. Anxiety is a broad term that encompasses a broad spectrum of disorders, each with their own distinct features and courses of treatment. According to the Anxiety and Depression Association of America, (2016a): • Anxiety disorders are the most common mental illness in the U.S. and affect about 18.1 percent of the U.S. adult population, or about 42 million people. Numbers may be even higher due to untreated and unreported cases.

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• Anxiety disorders are highly treatable, yet only 36.9% of those suffering receive treatment. • People with an anxiety disorder are three to five times more likely to go to the doctor and six times more likely to be hospitalized for psychiatric disorders than those who do not suffer from anxiety disorders. • Anxiety disorders develop from a complex set of risk factors, including genetics, brain chemistry, personality, and life events. • It is not uncommon for someone with an anxiety disorder to also suffer from depression, or vice versa. Nearly one-half of those diagnosed with depression are also diagnosed with an anxiety disorder. • Many of these persons have dual diagnoses; for example, some have both PTSD and GAD, or co-occurring social phobia and OCD. • There are a large number of individuals with anxiety disorders who also experience co-occurring substance abuse issues (National Institute of Mental Health, 2016a).

The impact on society is enormous. In particular, those with anxiety disorders tend to have physical issues resulting from their anxiety which mimic a variety of physical ailments. Therefore, persons with anxiety disorders spend $42 billion dollars a year due to anxiety disorder; $22.84 billion of that is spent seeking treatment for physical problems that have mimicked anxiety symptoms, instead of seeking treatment for the real cause – underlying anxiety (Folk and Folk, 2017).

It is important, however, to differentiate between ordinary life stressors and true anxiety. For example, stress experienced as “butterflies in the stomach” before giving a speech or a presentation is normal; however, being so afraid to speak before a group that one resigns from a job rather than give a speech is a more serious form of anxiety.

Furthermore, worrying about doing a good job on a paper for school and stressing over the outcome is normal; however, being so concerned about failing that a student is unable

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to start the project and then fails the class is more in line with one who is experiencing a generalized anxiety disorder.

Most people are hesitant to go into a new social setting and may occasionally turn down an invitation because they “won’t know anyone there.” Someone who avoids social contact altogether, however, has more serious social phobia issues.

Statistics on prevalence The following statistics are from the National Institute of Mental Health, (2016a): • Generalized anxiety disorder (GAD) GAD affects 6.8 million adults, or 3.1% of the U.S. population, yet only 43.2% are receiving treatment. Women are twice as likely to be affected as men. GAD often co-occurs with major depression. • Panic disorder (PD) PD affects six million adults, or 2.7% of the U.S. population. Women are twice as likely to be affected as men. Social anxiety disorder affects 15 million adults, or 6.8% of the U.S. population. It is equally common among men and women and typically begins around age 13. According to an ADAA (2016a) survey, 36% of people with social anxiety disorder report experiencing symptoms for 10 years or more before seeking help. • Specific phobias Specific phobias affect 19 million adults, or 8.7% of the U.S. population. Women are twice as likely to be affected as men. Symptoms typically begin in childhood; the average age-of-onset is seven years old. • Obsessive-compulsive disorder (OCD) OCD affects 2.2 million adults, or 1.0% of the U.S. population. OCD is equally common among men and women. The average age of onset is 19; 25 percent of cases occur by age 14. One-third of affected adults first experienced symptoms in childhood.

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• Post-traumatic stress disorder (PTSD) PTSD affects 7.7 million adults, or 3.5% of the U.S. population. Women are more likely to be affected than men. Rape is the most likely trigger of PTSD: 65% of men and 45.9% of women who are raped will develop the disorder. Childhood sexual abuse is also a strong predictor of lifetime likelihood for developing PTSD.

Children Anxiety disorders affect 25.1% of children between 13 and 18 years old. Research shows that untreated children with anxiety disorders are at a higher risk to perform poorly in school, miss out on important social experiences, and engage in substance abuse. Anxiety disorders also often co-occur with other disorders such as depression, eating disorders, and attention-deficit/hyperactivity disorder (ADHD).

Note: All children experience a certain amount of anxiety. However, worry that interferes with daily functioning may become problem. Not all children may meet the criteria for an anxiety disorder. There are many helpful tips for parents when managing an anxious child, regardless of the child’s diagnosis.

The Anxiety and Depression Association of America (2016c) provides the following tips to help parents dealing with an anxious child: • Pay attention to the child’s feelings. • Stay calm when the child becomes anxious about a situation or an event. • Recognize and praise small accomplishments. Build on the child’s strengths. • Do not punish mistakes or lack of progress. • Be flexible and try to maintain a normal routine. • Support the child but help him/her learn to do things on his/her own. • Help children handle feelings; they need to know it is OK to feel anxious, express how they feel, and that they can cope with these feelings.

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• Do not pass fears to children. Model positive responses and strategies to handle anxiety. • Modify expectations during stressful periods. • Plan for transitions. (For example, allow extra time in the morning if getting to school is difficult.)

Parents must keep in mind that a child’s anxiety disorder diagnosis is not a sign of poor parenting. It may add stress to family life so it is helpful to build a support network of relatives and friends. It is also important that parents have the same expectations of an anxious child that they would for any other child.

The Australian Capital Territory (ACT) published a parents’ tip sheet for managing their children’s anxiety. It encourages parents to: • Monitor their children’s viewing of anxiety-provoking programs on TV, such as the news; • Spend calm, relaxing time with children; • Encourage physical activity to increase relaxation; • Encourage self-soothing activities, such as listening to calm music or bathing; and Encourage children to face— instead of avoid situations— that provoke anxiety (ACT, 2012).

Older adults Anxiety is as common among older adults as it is among younger people. Generalized anxiety disorder (GAD) is the most common anxiety disorder among older adults; anxiety disorders in this population are frequently associated with traumatic events, such as a fall or an acute illness.

Related Illnesses Many people with an anxiety disorder also have a co-occurring disorder or physical illness. This can make their symptoms worse and recovery more difficult. It’s essential to be treated for both disorders. 6

Obsessive-compulsive disorder (OCD) and post-traumatic stress disorder (PTSD) are closely related to anxiety disorders and can be experienced at the same time, along with depression.

Here are other disorders that may co-occur with anxiety disorders: • Bipolar disorder; • Eating disorders; • Headaches; • Irritable bowel syndrome (IBS); • Sleep disorders; • Substance abuse; • Adult ADHD (attention deficit/hyperactive disorder); • BDD (body dysmorphic disorder); • Chronic pain; • Fibromyalgia; or • Stress.

Anxiety disorder Anxiety becomes a disorder when the anxiety interferes with daily functioning. Understanding the correct diagnosis is critical when choosing the correct path to manage anxiety. Treatment protocols and best practices differ from one anxiety disorder to another. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM- 5) is the book used by qualified mental health professionals to make psychiatric diagnoses. The DSM-5 defines eleven subcategories of anxiety disorders. It also moved obsessive-compulsive disorders to a separate category. The DSM-5 provides the following summary (2013): Anxiety disorders include disorders that share features of excessive fear and anxiety and related behavioral disturbances. Fear is the emotional response to real or perceived imminent threat, whereas anxiety is anticipation of future threat. Obviously, these two states overlap, but they also differ, with fear more often

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associated with surges of autonomic arousal necessary for fight or flight, thoughts of immediate danger, and escape behaviors, and anxiety more often associated with muscle tension and vigilance in preparation for future danger and cautious or avoidant behaviors. Sometimes the level of fear or anxiety is reduced by pervasive avoidance behaviors. Panic attacks feature prominently within the anxiety disorders as a particular type of fear response. Panic attacks are not limited to anxiety disorders but rather can be seen in other mental disorders as well.

The DSM-5 includes sections for the following subcategories. • Separation anxiety disorder; • Selective mutism; • Specific phobia; • Social anxiety disorder (formerly social phobia); • Panic disorder/panic attack specifier; • Agoraphobia; • Generalized anxiety disorder; • Substance/medication-induced anxiety disorder; • Anxiety disorder due to another medical condition; • Other specified anxiety disorder; and • Unspecified anxiety disorder.

Assessing and diagnosing anxiety disorders

Before the correct treatment protocols for anxiety can be followed, a clinician must properly assess and diagnose whether or not a patient has an anxiety disorder and if so, which type of anxiety disorder. Correct assessments are especially important to determine the best treatment options because generalized anxiety disorder and panic attacks follow different courses of treatment, both in psychotherapy and in psychopharmacology.

Assessing for generalized anxiety disorder

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A common measure for both adults and adolescents is the Beck Anxiety Inventory (BAI) (Beck and Steer, 1993) and the Beck Youth Inventories-2 (Beck, Beck, and Jolly, 2005). These are screening tools designed to identify symptoms of anxiety that can be either self-administered or scored by a practitioner when speaking with the patient. These tools have been found to provide accurate assessments for anxiety disorders and can also be used to track progress over the course of treatment.

In a study of BAI scores published by Muntingh et al. (2011) it was determined: A significantly higher score was found for patients with panic disorder and agoraphobia compared to patients with agoraphobia only or social phobia only. BAI scores in patients with an anxiety disorder with a co-morbid anxiety disorder and in patients with an anxiety disorder with a co-morbid depressive disorder were significantly higher than BAI scores in patients with an anxiety disorder alone or patients with a depressive disorder alone. Depressed and anxious patients did not differ significantly in their mean scores.

Muntingh and fellow researchers concluded that the BAI may be used as a severity indicator of anxiety in primary care patients with different anxiety disorders. However, because the instrument seems to reflect the severity of depression as well, it is not a suitable instrument to discriminate between anxiety and depression in a primary care population. Finally, the instructions for the BAI are written at an 8.3 grade level; therefore, oral instructions should be given to those with lower reading skills.

Another popular scale is the General Anxiety Disorder Seven Item (GAD-7). The GAD-7 is free and is easily administered. A study published in 2017 by Jordan, Shedden-Mora, and Lowe concluded the following: • The (GAD-7) is one of the most frequently used diagnostic self-report scales for screening, diagnosis, and severity assessment of anxiety disorder. • The first four items discriminated better than the last three items with respect to latent anxiety; therefore, they should be weighted more heavily.

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• Estimates of anxiety corresponding with low to moderate levels of anxiety show greater variability. • The GAD-7 provides a psychometrically-sound instrument that can be incorporated as an economical and an easily applicable instrument in primary care practices. The purpose is to single out patients with anxiety disorders to properly apply treatments and to reduce long-term economic costs. • The GAD-7 does not properly discriminate in the lower spectrum of anxiety. Therefore, its usage should be restricted to the detection of anxiety disorders.

APA and DSM-5 assessment measures The following information on measurement tools for the DSM-5 is provided by the APA (2013): The APA is offering a number of “emerging measures” for further research and clinical evaluation. These patient assessment measures were developed to be administered at the initial patient interview and to monitor treatment progress. They should be used in research and evaluation as potentially useful tools to enhance clinical decision-making and not as the sole basis for making a clinical diagnosis. Instructions, scoring information, and interpretation guidelines are provided; further background information can be found in DSM-5. The APA requests that clinicians and researchers provide further data on the instruments’ usefulness in characterizing patient status and improving patient care at http://www.dsm5.org/Pages/Feedback-Form.aspx. This material can be reproduced without permission by clinicians for use with their patients. Any other use, including electronic use, requires written permission of the PROMIS Health Organization (PHO).

The assessment measures include short questionnaires (approximately ten questions) that begin with a DSM-5 Level 1 cross-cutting questionnaire. On this questionnaire, clients indicate if, in the past two weeks, they felt: • Nervous, anxious, frightened, worried, or on edge; • Panicked or being frightened; and/or 10

• They avoided situations that made them feel anxious at a mild or a greater level of severity.

From these general indicators, clients are asked to complete the next short DSM-5 Level 2 questionnaire. This questionnaire provides more detailed information and ratings of the degrees or levels of severity of the anxiety within the past seven days. Responses require only a check mark in a box to determine if the feelings occurred as follows: • 1-Never. • 2-Rarely. • 3-Sometimes. • 4-Often. • 5-Always.

The higher the score, the greater the severity. The raw scores for each item correspond to a “T” score table where a total score indicates the level of severity: • Less than 55: None to slight. • 55 to 59.9: Mild. • 60 to 69.9: Moderate. • 70 and over: Severe.

Level 2 measures include questionnaires directed to: 1. Anxiety: Adult. 2. Anxiety: Parent/Guardian of Child Ages 6-17. 3. Anxiety: Child Ages 11–17.

For children: • LEVEL 2, Somatic Symptom, Parent/Guardian of Child Age 6, 17 (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15]). • LEVEL 2, Sleep Disturbance, Parent/Guardian of Child Age 6, 17 (PROMIS, Sleep Disturbance, Short Form).

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• LEVEL 2, Inattention, Parent/Guardian of Child Age 6, 17 (Swanson, Nolan, and Pelham, version IV [SNAP-IV]). • LEVEL 2, Anxiety, Parent/Guardian of Child Age 6, 17 (Adapted from PROMIS Emotional Distress, Anxiety, Parent Item Bank). • LEVEL 2, Somatic Symptom, Child Age 11 to 17 (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15]). • LEVEL 2, Sleep Disturbance, Child Age 11 to 17 (PROMIS, Sleep Disturbance, Short Form). • LEVEL 2, Anxiety, Child Age 11 to 17 (PROMIS Emotional Distress, Anxiety, Pediatric Item Bank). • LEVEL 2, Irritability, Child Age 11 to 17 (Affective Reactivity Index [ARI]).

In addition, the DSM-5 Disorder-Specific Severity Measures are as follows:

For adults: • Severity Measure for Social Anxiety Disorder (Social Phobia), Adult. • Severity Measure for Separation Anxiety Disorder, Adult. • Severity Measure for Specific Phobia, Adult. • Severity Measure for Panic Disorder, Adult. • Severity Measure for Agoraphobia, Adult. • Severity Measure for Generalized Anxiety Disorder, Adult. • Severity of Posttraumatic Stress Symptoms, Adult (National Stressful Events Survey PTSD Short Scale [NSESS]). • Severity of Acute Stress Symptoms, Adult (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS]).

For children ages 11 to 17: • Severity Measure for Separation Anxiety Disorder, Child Age 11 to 17. • Severity Measure for Specific Phobia, Child Age 11 to 17.

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• Severity Measure for Social Anxiety Disorder (Social Phobia), Child Age 11 to 17. • Severity Measure for Agoraphobia, Child Age 11 to 17. • Severity Measure for Generalized Anxiety Disorder, Child Age 11 to 17. • Severity of Posttraumatic Stress Symptoms, Child Age 11 to 17 (National Stressful Events Survey PTSD Short Scale [NSESS]). • Severity of Acute Stress Symptoms, Child Age 11 to 17 (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS]).

The assessment measures included above are the ones most closely related to anxiety disorders. Measures have been developed for other DSM-5 disorders, as well.

CATEGORIES OF ANXIETY DISORDER

Generalized anxiety disorder (GAD) In the DSM-5, there are specific criteria detailed for a general anxiety disorder (GAD) diagnosis. The following is a summary of the required symptom characteristics to be used as a guide. However, it is important to understand that only a qualified professional, one that also relies on clinical judgment, can make an accurate diagnosis.

GAD is characterized as excessive anxiety, worry, apprehension, or expectation that occurs more days than not for at least six months. This excessive anxiety can be about a number of events or activities, such as work or school performance. In children, the worry is more likely to be either about their abilities or the quality of their performance in school, for example (Glasofer, 2017).

The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms present for more days than not for the past six months). In children, only one symptom is needed: • Restlessness, feeling “keyed up” or on edge. • Being easily fatigued. • Difficulty concentrating, mind “going blank.”

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• Irritability. • Muscle tension. • Sleep disturbance including difficulty falling or staying asleep, or restless unsatisfying sleep. Many individuals with GAD also experience symptoms such as sweating, nausea, or diarrhea.

Furthermore, the focus of the anxiety and worry is not confined to features of another Axis I disorder (such as social phobia, OCD, PTSD, etc.).

The anxiety, worry, or physical symptoms cause clinically-significant distress or impairment in social, occupational, or other important areas of functioning. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism). Additionally, it does not occur exclusively during a mood disorder, psychotic disorder, or a pervasive developmental disorder.

Assessing GAD symptoms

Standardized assessment tools In specialized care settings, like a mental health clinic, standardized assessment tools are sometimes used to evaluate symptoms. The clinician may begin with a semi-structured interview, including a standardized set of questions.

The diagnostic interviews for adults include the Structured Clinical Interview for DSM-5 Disorders (SCID-5) and the Anxiety and Related Disorders Interview Schedule for DSM- 5 (ADIS-5). These interviews are administered by a clinician, or a trained mental health professional, who is familiar with the DSM-5 classification and diagnostic criteria (APA, 2015).

There is an ADIS version for children that includes input from both the parent and the child to evaluate the child’s symptoms and the presence of co-occurring conditions, such as depression.

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Social anxiety disorder

Note: Both separation anxiety disorder and social anxiety disorder have been shortened to SAD, depending on the organization using the term. Social anxiety disorder is often shortened to SoAD. These abbreviations will not be used in this course in order to avoid confusion between the two terms.

Previously known in the DSM-IV as social phobia, social anxiety disorder was primarily diagnosed if an individual felt extreme discomfort or fear when performing in front of others. Research has shown that this definition is too narrow.

With DSM-5, social anxiety can be diagnosed due to an individual’s response in a variety of social situations. The person, for example, may be so uncomfortable carrying on a conversation that s/he is unable to talk to others, particularly someone s/he doesn’t know. A person who is anxious about being observed may be unable to go out to dinner because s/he fears being watched while eating and drinking.

Social anxiety disorder is about more than just shyness; it can be considerably disabling. A diagnosis requires that a person’s fear or anxiety is out of proportion—in frequency and/or duration—to the actual situation. The symptoms must be persistent, lasting six months or longer. In DSM-IV, the timeframe was required only for children; DSM-5 expands this criterion to include adults as well. The minimum symptom time period requirement reduces the possibility that an individual is experiencing only transient or temporary fear.

To be diagnosed with social anxiety disorder, a person must suffer from significant distress or impairment that interferes with his or her ordinary routine in social settings, at work or school, or during other everyday activities. Unlike in DSM-IV, which requires that the individual recognize that his or her response is excessive or unreasonable, the DSM-5 criteria shift that judgment to the clinician.

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According to the DSM-5 (APA, 2013), social anxiety disorder is characterized by: • Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. Examples include social interactions (e.g., having a conversation), being observed (e.g., eating or drinking), or performing in front of others (e.g., giving a speech). • The individual fears that he or she will act in a way— or show anxiety symptoms— that will be negatively evaluated (e.g., be humiliated, embarrassed, or rejected) or will offend others. • The social situation(s) almost always provokes fear or anxiety. (Note: in children, the fear or anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, or failure to speak in social situations.) • The social situation(s) are actively avoided, or are endured with marked fear or anxiety. • The fear or anxiety is out of proportion to the actual threat posed by the social situation. (Note: “Out of proportion” refers to the sociocultural context.) • The fear, anxiety, or avoidance is persistent, typically lasting six or more months. • The fear, anxiety, and avoidance cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. • The disturbance is not attributable to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition. • The disturbance is not better accounted for by another mental disorder (e.g., anxiety about having panic attacks in panic disorder, agoraphobic situations in agoraphobia, separation from attachment figures in separation anxiety disorder, public exposure to perceived physical flaws in body dysmorphic disorder, or social communication problems in autism spectrum disorder. Failure to speak is not better accounted for by stuttering or expressive language problems in communication disorders, or refusal to speak due to opposition in oppositional- defiant disorder).

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If another medical condition (e.g., stuttering, Parkinson’s disease, obesity, disfigurement from burns or injury) is present, the fear, anxiety, or avoidance is unrelated or is out of proportion to it.

Specify if: Performance only—the fear is restricted to speaking or performing in public.

Specify if: Selective mutism—the fear results in a failure to speak in specific social situations in which there is an expectation for speaking (e.g., at school), despite speaking in other situations.

The diagnosis process would begin with a review of the patient's mental health history and an interview to evaluate the person's perceptions and experiences. These steps would determine whether the fear was so severe as to interfere with the person's daily functioning, school work, employment, or relationships (Glasofer, 2017).

Characteristics of social anxiety disorders are outlined in the DSM-5, and include: • A significant and persistent fear of social (or performance) situations; will be intensely afraid of embarrassment or humiliation. • Physical symptoms of anxiety or a panic attack. Common somatic complaints include shaking, rapid heart rate, chest pain, tingling or numbness, shortness of breath, and trembling. These physical sensations may lead to a greater sense of fear and anxiety as the panic sufferer worries that s/he will lose control, embarrass him/herself, or even possibly face medical issues due to his/her symptoms (Star, 2017). • Recognition that the fear is unreasonable, yet unable to stop it. • Avoidance of any feared situations or enduring them with intense anxiety. • Symptoms that persist for at least six months.

The clinician must differentiate social anxiety disorder from other anxiety disorders, such as panic disorder, and identify any co-occurring conditions such as depression, obsessive- compulsive disorder (OCD), and post-traumatic stress disorder (PTSD). 17

While the process may seem subjective, the diagnosis of social anxiety disorder is actually more precise than some might imagine. There are certainly gray areas that require interpretation; however, the DSM-5 provides a relatively strong framework by which to make a diagnosis (Glasofer, 2017).

Assessing social anxiety disorder A commonly-used screening tool is the Liebowitz Social Anxiety Scale (LSAS), developed by Michael Liebowitz (1987). A 2010 article published by NIH found that: The major strength of the LSAS is its broad coverage of both performance and interaction-related anxiety. The total score on the LSAS is often used as an index of current impairment due to social phobia. The LSAS-SR can be utilized efficiently in pharmaceutical trials, which often rely on repeated assessment. A limitation of the measure is that it does not capture cognitive schemas or physiological complaints characterized among persons with social phobia (Letamendi, Chavira, and Stein, 2010).

Social Phobia and Anxiety Inventory (SPAI) The above-referenced NIH article mentions the Social Phobia and Anxiety Inventory (SPAI) to assess social anxiety distress across a broad range of somatic symptoms, cognitions, and behavior across fear-producing situations (Letamendi, Chavira, and Stein, 2010). The inventory includes 45 items covering social-situation anxiety, somatic symptoms, and phobic cognitions, as well as thirteen agoraphobia symptom assessments. Internal consistency and test-retest reliability are well supported and significantly differentiate patients with social phobia from those other clinic groups such as panic disorder and obsessive-compulsive disorder (Letamendi, Chavira, and Stein, 2010).

Separation anxiety disorder According to the DSM-5 (APA, 2013), separation anxiety disorder (Code 309.21/F93.0) is a fairly common anxiety disorder that occurs in youth younger than 18. It is persistent and lasts for at least four weeks; the required typical duration in adults is six months or more. Separation anxiety disorder can also be associated with panic attacks and can occur

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with comorbid panic disorder. Separation anxiety disorder consists of persistent and excessive anxiety beyond that which is expected for the child's developmental level related to separation, or impending separation, from the attachment figure such as the primary caretaker or a close family member. It is evidenced by at least three of the following criteria: • Recurrent excessive distress when anticipating or experiencing separation from home or from major attachment figures. • Persistent and excessive worry about losing major attachment figures or about possible harm to them, such as illness, injury, disasters, or death. • Persistent and excessive worry about experiencing an untoward event (e.g., getting lost, being kidnapped, having an accident, becoming ill) that causes separation from a major attachment figure. • Persistent reluctance or refusal to go out, away from home, to school, to work, or elsewhere because of fear of separation. • Persistent and excessive fear of or reluctance about being alone or without major attachment figures at home or in other settings. • Persistent reluctance or refusal to sleep away from home or to go to sleep without being near a major attachment figure. • Repeated nightmares involving the theme of separation. • Repeated complaints of physical symptoms (e.g., headaches, stomachaches, nausea, vomiting) when separation from major attachment figures occurs or is anticipated.

In order to meet criteria for this disorder, it must cause clinically significant distress or impairment in social, academic, occupational, or other important areas of functioning. It also may not be better explained by another mental disorder— such as refusing to leave home because of excessive reluctance to change (such as in an autism spectrum disorder), delusions or hallucinations concerning separation (psychotic disorders), refusal to go outside without a trusted companion (agoraphobia), worries about ill health or other harm befalling significant others (generalized anxiety disorder), or concerns about having an illness in (illness anxiety disorder). 19

Boys and girls do not significantly differ in symptom presentation.

Assessing separation anxiety The following assessment tools address separation anxiety: Self-report for childhood anxiety related disorders (SCARED) This measure is designed to screen for anxiety disorders in children ages eight and above. It consists of 41 items that measure general anxiety, separation anxiety, social phobia, school phobia, and physical symptoms of anxiety. Both child self-reporting and parental reporting versions of SCARED are available.

Spence children's anxiety scale (SCAS) The SCAS is a self-report measure of anxiety for children and adolescents. Normative data is available separately for boys and girls between the ages of seven and 18. The SCAS consists of 45 items (38 assessing anxiety, seven items assessing social desirability). The subscales include: panic/agoraphobia; social anxiety; separation anxiety; generalized anxiety; fear of physical injury and; obsessions/compulsions.

DSM-5 Severity Measure for Separation Anxiety Disorder-Children Diagnostic Interview for Children and Adolescents (DICA)

Child behavior checklist (CBCL) ASA-27 is a 27-item self-report questionnaire that purports to examine symptoms of separation anxiety experienced after 18 years of age.

DSM-5 Severity Measure for Separation Anxiety Disorder—Adult

Panic disorder

Panic disorder is commonly defined as a psychiatric disorder in which debilitating anxiety and fear arise frequently and without reasonable cause.

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The DSM-IV-TR diagnostic criteria for panic disorder requires “unexpected, recurrent panic attacks, followed in at least one instance by at least a month of a significant and related behavior change, a persistent concern of more attacks, or a worry about the attack's consequences. Diagnosis is excluded by attacks due to a drug or medical condition, or by panic attacks that are better accounted for by other mental disorders.”

The most notable change that has occurred to the diagnosis of panic disorder is the way in which it is now classified in relation to agoraphobia. In the last edition of the DSM, panic disorder was diagnosed as occurring with or without agoraphobia. In the new DSM-5, panic disorder and agoraphobia are listed as two separate and distinct mental health disorders. Some additional changes have also occurred to the types of panic attacks defined in the DSM-5: Panic disorder has remained classified as an anxiety disorder with the main symptom being the experience of persistent and typically unanticipated panic attacks. The diagnostic criteria also specifies that these panic attacks are marked by continual fear of having future attacks, shifts in one’s behaviors to avoid these attacks, or both of these issues for at least one month.

DSM-5 diagnoses a panic disorder (APA, 2013) The diagnostic criteria for panic disorder are defined in the DSM-5 as an anxiety disorder. The disorder is now based on the rates of panic attack occurrences, which are recurrent and often unexpected. At least one attack is followed by one month (or more) of the person fearing that they will have more attacks.

This causes behavior changes, which includes avoiding situations that might induce an attack.

A panic disorder diagnosis must rule out other potential causes of the attacks, such as: • The attacks are not due to the direct physiological effects of a substance such as drug use or a medication or a general medical condition. • The attacks are not better accounted for by another mental disorder

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including social phobia, other specific phobia, obsessive-compulsive disorder, post-traumatic stress disorder, or separation anxiety disorder.

Defining panic attacks with DSM-5 The previous edition of the DSM distinguished the types of panic attacks as belonging to one of three categories: situationally bound/cued, situationally predisposed, or unexpected/uncued. The DSM-5 has removed some of this jargon and has simplified the panic attack criteria. It now fits into two simplified types: expected or unexpected. Expected panic attacks are those that occur due to a specific fear, such when a person with a fear of flying and has a panic attack when on an airplane.

Unexpected panic attacks occur suddenly without any external cue that the attack is about to occur. These unanticipated attacks are the hallmark feature of panic disorder: a panic attack is defined as the abrupt onset of intense fear that reaches a peak within a few minutes.

The Anxiety and Depression Association of America (2016b) notes that other symptoms of a panic attack include a feeling of imminent danger or doom and the need to escape. According to DSM-5, a panic attack is characterized by four or more of the following symptoms: • Palpitations, pounding heart, or accelerated heart rate; • Sweating; • Trembling or shaking; • Sensations of shortness of breath or smothering; • A feeling of choking; • Chest pain or discomfort; • Nausea or abdominal distress; • Feeling dizzy, unsteady, lightheaded, or faint; • Feelings of unreality (derealization) or being detached from oneself (depersonalization); • Fear of losing control or going crazy; 22

• Fear of dying; • Numbness or tingling sensations (paresthesias); and/or • Chills or hot flushes.

The presence of fewer than four of the above symptoms may be considered a limited- symptom panic attack.

The National Institute of Mental Health (NIMH) (2016a) notes that panic attacks can occur at any time of the day or night, even during sleep. Typically, an attack will last about 10 minutes, but some last longer. Panic attacks affect about six million adults in the United States; women are two times more likely than men to suffer with the condition.

About one-third of people with panic attacks become confined to their homes, too fearful to leave. This condition is known as agoraphobia (NIMH, 2016a). Several well-known persons, including TV chef and cookbook author Paula Deen and singer Carly Simon, have publicly admitted that they struggled with agoraphobia.

Despite the public visibility of this disorder, many people with panic disorders and agoraphobia do not seek treatment and continue to suffer.

Assessing for panic disorders The Panic Disorder Severity Scale (PDSS) is one of the most commonly-used tools to screen for panic disorders. The scale was developed by Shear et al. (1997) and consists of seven items scored on a scale ranging from zero (0) to four (4). The PDSS measures the areas of panic frequency, distress during panic, panic-focused anticipatory anxiety, phobic avoidance of situations, phobic avoidance of physical sensations, impairment in work functioning, and impairment in social functioning.

Panic Disorder Severity Scale for Adolescents (PDSS-A) was modified by D. A. Spiegel and M. K. Shear from an interview-based version published by Shear et al. in 1997. For this questionnaire, a panic attack was defined as a sudden rush of fear or discomfort ac-

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companied by at least four of the symptoms listed below. In order to qualify as a sudden rush, the symptoms must peak within ten minutes. Episodes like panic attacks, but that have fewer than four of the listed symptoms, are called “limited-symptom attacks.” Here are the symptoms counted by this measure: • Rapid or pounding heartbeat; • Sweating; • Trembling or shaking; • Breathlessness; • Feeling of choking; • Chest pain or discomfort; • Nausea; • Dizziness or faintness; • Feelings of unreality; • Numbness or tingling; • Chills or hot flushes; • Fear of losing control or going crazy; and/or • Fear of dying.

The subject answers seven questions by checking the severity from none, mild/slight, moderate, substantial, severe, or extreme.

Furukawa et al. (2009) evaluated the PDSS and concluded the following: The Panic Disorder Severity Scale (PDSS) is promising to be a standard global rating scale for panic disorder. In order for a clinical scale to be useful, we need a guideline for interpreting its scores and their changes, and for defining clinical change points such as response and remission.

The evaluation concluded that the PDSS data could, “Assist clinical investigators in translating findings to be interpretable by practitioners and patients, and will also support practitioners in their use of the PDSS in management of panic disorder.”

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Selective mutism According to American Speech Language and Hearing Association (ASHA, 2017), selective mutism falls within the category of anxiety disorders (APA, 2013). The diagnostic criteria for selective mutism are as follows: • The child shows consistent failure to speak in specific social situations in which there is an expectation for speaking, at school for example, despite speaking in other situations. • The disturbance interferes with educational or occupational achievement or with social communication. • The duration of the disturbance is at least one month and is not limited to the first month of school. • The failure to speak is not attributable to a lack of knowledge of, or comfort with, the spoken language required in the social situation. • The disturbance is not better explained by a communication disorder, like child- onset fluency disorder. It also does not occur exclusively during the course of autism spectrum disorder, schizophrenia, or another psychotic disorder.

These behaviors are a method of self-protection during an experience of intense anxiety but may appear deliberately oppositional (Kotrba, 2015).

Individuals with selective mutism may present with social anxiety and social phobia. Symptoms of social anxiety and social phobias may include the following (Kearney, 2010): • Lack of eye contact; • Clinging to parents; • Hiding; • Running away; • Crying; • Freezing; • Throwing a tantrum if asked to speak publicly; • Avoidance of eating in public;

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• Anxious when having picture or video taken; and/or • Anxious to use public restrooms.

In addition to these features of social anxiety, children with selective mutism avoid initiating and participating in conversations. If they are able to express themselves, they may rely on gesturing, nodding, pointing, or whispering. They may have fears of being ignored, ridiculed, or harshly evaluated if they speak.

Assessing selective mutism screening (ASHA, 2017). Screening for selective mutism is conducted whenever selective mutism is suspected, or as part of a comprehensive speech and language evaluation for any child with communication concerns. If a parent or caregiver reports that a child is communicating successfully at home but not in one or more settings, the SLP may want to consider the diagnosis of selective mutism.

Screening typically includes: • Norm-referenced parent/caregiver and teacher report measures; • Competency-based tools such as interviews and observations; and • Hearing screening to rule out hearing loss as a possible contributing factor.

Evaluation and assessment of children with selective mutism is accomplished through a collaborative approach with an interdisciplinary team consisting of a pediatrician, psychologist or psychiatrist, SLP, teacher, school social worker or guidance counselor, and family/caregivers. During the evaluation, parents/caregivers may need to help elicit verbal output. The SLP can also involve parents/caregivers by requesting a video recording of the child's communicative behavior at home and then compare the child's behavior in a clinical or school setting. Video recordings may also be used for subsequent language sample analysis.

Agoraphobia

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In the current updated edition of the DSM-5, agoraphobia now stands apart from panic disorder as its own separate and codable diagnosis. The diagnostic criteria for agoraphobia now includes the experience of intense fear or anxiety in at least two agoraphobic situations, such as being outside the home alone, public transportation (i.e. airplanes, buses, subways, etc.), open spaces, public places (i.e. stores, theaters, or cinemas), crowds or standing in a line with other people, or a combination of two or more of these scenarios.

To be diagnosed with agoraphobia, the person must also exhibit avoidance behaviors. These avoidances occur out of a fear of experiencing a panic attack (or anxiety-related symptoms) in a situation from which it would be difficult to flee or where no help would be available. Agoraphobics are greatly affected by avoidance behaviors; these issues tremendously impair the sufferer’s quality of life and overall functioning.

Diagnostic criteria for agoraphobia DSM-5 The only essential characteristic of agoraphobia is the strong fear of the previously listed circumstances; however, the following are all evaluated and considered in order to make an adequate diagnosis: • An individual has extreme anxiety about two or more of the following situations:

o Using public transportation; o Being in open areas; o Being in closed-off areas; o Standing in line or a crowd; and o Being alone outside of the house. • He or she avoids the above situations because the individual believes s/he may become stuck or help might be unavailable in the event that the individual begins to panic. • The listed situations usually incite fear or anxiety. • The listed situations are avoided, require help from a loved one, or are endured with intense fear. • The fear that the individual has is out of proportion to the possibility of danger.

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• The fear or avoidance is persistent: it typically lasts for at least six months or longer. • The fear or avoidance causes the individual significant distress. • If another medical condition exists alongside of this disorder, the fear or avoidance is undoubtedly excessive. • The fear or avoidance is not better explained by the symptoms of another mental disorder or a situational circumstance. Assessing agoraphobia*

The PAS is a measure of the severity of illness in patients with panic disorder (with or without agoraphobia). It is available in both clinician-administered and self-rating formats. It contains five sub-scales: panic attacks, agoraphobic avoidance, anticipatory anxiety, disability, and functional avoidance (health concerns).The questionnaire is designed for people who suffer from panic attacks and agoraphobia (Bandelow, 2013). *(Review the earlier section that discusses the APA DSM-5 Severity Measure for Agoraphobia.)

Post-traumatic stress disorder

Diagnostic criteria for PTSD include a history of exposure to a traumatic event that meets specific stipulations and symptoms from each of four symptom clusters: intrusion, avoidance, negative alterations in cognitions and mood, and alterations in arousal and reactivity. The sixth criterion concerns duration of symptoms; the seventh assesses functioning; the eighth criterion clarifies symptoms as not attributable to a substance or co-occurring medical condition.

According to the DSM-5, the following criteria must exist to diagnose PTSD in an adult, adolescent, or child older than six years old:

• Exposure to actual or threatened death, serious injury, or sexual violence (any undesired sexual activity is sexual violence). • Presence of one or more specified intrusion symptoms in association with the traumatic event(s).

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• Persistent avoidance of stimuli associated with the traumatic event(s). • Negative alterations in cognition and moods associated with the traumatic event(s). • Marked alterations in arousal and reactivity associated with the traumatic events(s). • Duration of the disturbance exceeds one month. • Clinically significant distress or impairment is present in important areas of functioning. • Inability to attribute the disturbance to the physiologic effects of a substance or another medical condition.

DSM-5 criteria for PTSD in children ages six years or younger are as follows: • Directly experiencing the traumatic event, witnessing the event, or learning it occurred to a parent or caregiver. • Intrusion symptoms associated with the event (recurrent memories, distressing dreams, dissociative reactions, marked distress, or physiological reaction in response to exposure to traumatic triggers). • Avoidance of situations or things that arouse recollections of the trauma OR negative alterations in cognitions (increased negative emotions, decreased interest in significant activities, social withdrawal, decreased positive emotions). • Alterations in arousal and reactivity associated with the traumatic events (two of irritability, hypervigilance, exaggerated startle, concentration problems, sleep disturbances). • Duration of the disturbance exceeding one month. • Clinically significant distress or impairment in relationships with parents, siblings, peers, or other caregivers or in school behavior. • Inability to attribute the disturbance to the physiologic effects of a substance or another medical condition

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Two specifications are noted including delayed expression and a dissociative subtype of PTSD, the latter of which is new to DSM-5. In both specifications, the full diagnostic criteria for PTSD must be met for an application to be warranted.

Criterion A: Stressor The person was exposed to: death, threatened death, actual or threatened serious injury, or actual or threatened sexual violence, as follows (one required): 1. Direct exposure. 2. Witnessing, in person. 3. Indirectly, by learning that a close relative or close friend was exposed to trauma. If the event involved actual or threatened death, it must have been violent or accidental. 4. Repeated or extreme indirect exposure to aversive details of the event(s), usually in the course of professional duties (e.g., first responders, collecting body parts; professionals repeatedly exposed to details of child abuse). This does not include indirect non-professional exposure through electronic media, television, movies, or pictures.

Criterion B: Intrusion symptoms The traumatic event is persistently re-experienced in the following ways (one required): 1. Recurrent, involuntary, and intrusive memories. (Note: Children older than six may express this symptom in repetitive play.) 2. Traumatic nightmares. (Note: Children may have frightening dreams without content related to the trauma[s].) 3. Dissociative reactions (flashbacks) which may occur on a continuum from brief episodes to complete loss of consciousness. (Note: Children may reenact the event in play.) 4. Intense or prolonged distress after exposure to traumatic reminders. 5. Marked physiologic reactivity after exposure to trauma-related stimuli.

Criterion C: Avoidance

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Persistent avoidance of distressing trauma-related stimuli after the event (one required): 1. Trauma-related thoughts or feelings. 2. Trauma-related external reminders (e.g., people, places, conversations, activities, objects, situations).

Criterion D: Negative alterations in cognition and moods Negative alterations in cognition and moods that began, or worsened, after the traumatic event (two required): 1. Inability to recall key features of the traumatic event (usually dissociative amnesia; not due to head injury, alcohol, drugs). 2. Persistent (and often distorted) negative beliefs and expectations about oneself or the world (e.g., "I am bad," or "The world is completely dangerous"). 3. Persistent distorted blame of self or others for causing the traumatic event or for resulting consequences. 4. Persistent negative trauma-related emotions (fear, horror, anger, guilt, or shame). 5. Markedly diminished interest in (pre-traumatic) significant activities. 6. Feeling alienated from others (e.g., detachment or estrangement). 7. Constricted affect: Persistent inability to experience positive emotions.

Criterion E: Alterations in arousal and reactivity Trauma-related alterations in arousal and reactivity that began or worsened after the traumatic event (two required): 1. Irritable or aggressive behavior; 2. Self-destructive or reckless behavior; 3. Hypervigilance; 4. Exaggerated startle response; 5. Problems in concentration; and/or 6. Sleep disturbance.

Criterion F: Duration Persistence of symptoms (Criteria B, C, D, and E) for more than one month.

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Criterion G: Functional significance Significant symptom-related distress or functional impairment (e.g., social, occupational).

Criterion H: Exclusion Disturbance is not due to medication, substance use, or other illness. Specify if: With dissociative symptoms.

In addition to meeting criteria for diagnosis, an individual experiences high levels of either of the following in reaction to trauma-related stimuli: 1. Depersonalization: The experience of being an “outside observer” or detached from oneself (e.g., feeling as if "this is not happening to me" or as if one were in a dream). 2. Derealization: The experience of unreality, distance, distortion (e.g., "things are not real"). Specify if: With delayed expression. Full diagnosis is not met until at least six months after the trauma(s), although onset of symptoms may occur immediately.

Additionally, the DSM-5 updates include a new subtype of PTSD for children six years of age and younger and is referred to as “post-traumatic stress disorder in preschool children.” As the first developmental subtype of an existing disorder, this represents a significant step for the DSM taxonomy.

PTSD is often presents in individuals who have gone through a natural disaster or after an involvement in war. However, each traumatic event has individual characteristics that influence the development of PTSD.

SAHMSA (2017) notes the following symptoms in children who have experienced trauma and may be displaying symptoms of PTSD: • The child sees the event happening again, either when awake or when dreaming. • The child acts out the event while playing.

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• The child fears items or places linked with event. • The child often seems nervous or jumpy, scares easily. • The child has difficulty trusting people. • The child has trouble sleeping and concentrating. • The child often acts out in anger.

It is important to recognize the signs of traumatic stress and its short- and long-term impact.

The signs of traumatic stress may be different in each child. Young children may react differently than older children (SAHMSA, 2017).

Preschool children • Fear being separated from their parent/caregiver; • Cry or scream a lot; • Eat poorly or lose weight; • Have nightmares.

Elementary school children • Become anxious or fearful; • Feel guilt or shame; • Have a hard time concentrating; • Have difficulty sleeping.

Middle and high school children • Feel depressed or alone; • Develop eating disorders or self-harming behaviors; • Begin abusing alcohol or drugs; • Become involved in risky sexual behavior.

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Impact of trauma The impact of child traumatic stress can last well beyond childhood. In fact, research has shown that child trauma survivors may experience: • Learning problems, including lower grades and more suspensions and expulsions; • Increased use of health and mental health services; • Increase involvement with the child welfare and juvenile justice systems; and/or • Long-term health problems (e.g., diabetes, heart disease).

“The Body's Alarm System” (SAHMSA, 2017) Everyone has an alarm system in their body that is designed to keep them safe from harm. When activated, this tool prepares the body to fight or run away. The alarm can be activated at any perceived sign of trouble and leave children feeling scared, angry, irritable, or even withdrawn.

Healthy steps to help children respond to the alarm • Recognize what activates the alarm and how their body reacts; • Decide whether there is real trouble and seek help from a trusted adult; • Practice deep breathing and other relaxation method.

What parents can do to help (SAHMSA, 2017) • Assure the child that he or she is safe. • Explain that he or she is not responsible; children often blame themselves for events that are completely out of their control. • Be patient. Some children will recover quickly while others will recover more slowly. • Reassure them that they do not need to feel guilty or bad about any feelings or thoughts. • Seek the help of a trained professional. When needed, a mental health professional trained in evidence-based trauma treatment can help children and families cope and move toward recovery.

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A multidisciplinary treatment approach should include all professionals in contact with the child including pediatricians, family physicians, school counselors, teachers, social workers, therapists, clergy members, peers, and family members.

Assessing for post-traumatic stress disorder The U.S. Veteran’s Administration’s National Center for PTSD lists several instruments that are used for adults in the assessment and diagnosis of PTSD: • Clinician-Administered PTSD Scale (CAPS). • PTSD Symptom Scale – Interview version (PSS-I). • Structured Clinical Interview for DSM-IV PTSD module (SCID). • Structured Interview for PTSD (SI-PTSD).

All of these instruments assess the specific types of symptoms that are needed to meet the DSM-5 criteria for a PTSD diagnosis. “CAPS” measures not just symptoms, but also the impact of symptoms on daily functioning (VA.Gov, 2017a).

Assessing PTSD in children and adolescents There are no specific laboratory studies or specific imaging studies that establish the diagnosis of PTSD. Several psychological tests may be helpful in PTSD, including the following: • Child and Adolescent Psychiatric Assessment: Life Events Section and PTSD Module (CAPA-PTSD). • Children’s PTSD Inventory (CPTSDI). • Child PTSD Symptom Scale (CPSS). • Abbreviated UCLA PTSD Reaction Index. • Trauma Symptom Checklist for Children (TSCC). • Impact of Events Scale. • Screen for Child Anxiety Related Disorders (SCARED). • Beck Depression Inventory. • Mississippi Scale for Combat-Related PTSD. 35

Specific phobias A phobia is an anxiety disorder that involves a persistent fear of an object, place, or situation that is disproportional to the threat or danger posed by the feared object. The person who has the phobia will go to great lengths to avoid the feared object and may experience great distress if it is encountered. These irrational fears and reactions must result in interference with social and work life to meet the DSM-5 criteria. There are five subtypes of specific phobia: animal, natural environment, blood-injection-injury, situational, and other. Social phobia, which involves fear of social situations, is a separate disorder. Examples of specific phobias include fear of mice, vomiting, insects, and heights. Many of us can relate to some phobias like dental work or mathematics; however, the normal response to these fears is proportional to the threat.

Under the DSM-5, several changes have been made to prevent the over-diagnosis of specific phobias based on the overestimation of danger or occasional fears. A person no longer has to demonstrate excessive or unreasonable anxiety for a diagnosis of specific phobia. Instead, the anxiety must be “out of proportion” to the threat considering the environment and situation.

Specific phobia symptoms A person who has a specific phobia disorder experiences significant and persistent fear when in the presence of, or anticipates the presence of, the object of fear, which may be an object, place, or situation.

The DSM-5 criteria for a specific phobia are: • Marked and out-of-proportion fear within an environmental or situational context to the presence or anticipation of a specific object or situation. • Exposure to the phobic stimulus provokes an immediate anxiety response, which may take the form of a situationally bound or situationally predisposed panic attack. • The person recognizes that the fear is out of proportion.

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• The phobic situation(s) is avoided or is endured with intense anxiety or distress. • The avoidance, anxious anticipation, or distress in the feared situation(s) interferes significantly with the person's normal routine, occupational (or academic) functioning, or social activities or relationships, or there is marked distress about having the phobia.

The DSM-5 criteria state that the symptoms for all ages must have a duration of at least six months.

Assessing specific phobias See the previous section on the DSM-5 Severity Measure for Specific Phobias. The APA (2017) suggests the following measurement tools: • Acrophobia Questionnaire (AQ); • Blood-Injection Symptom Scale (BISS); • Claustrophobia General Cognitions Questionnaire (CGCQ); • Claustrophobia Situations Questionnaire (CSQ); • Claustrophobia Questionnaire (CLQ); • Dental Anxiety Inventory (DAI); • Dental Cognitions Questionnaire (DCQ); • Dental Fear Survey (DFS); • Fear of Spiders Questionnaire (FSQ); • Fear Survey Schedule (FSS); • Medical Fear Survey (MFS); • Mutilation Questionnaire (MQ); • Snake Questionnaire (SNAQ); • Spider Phobia Beliefs Questionnaire (SBQ); and • Spider Questionnaire (SPQ).

Obsessive-compulsive disorder (OCD)

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OCD is included as an anxiety disorder in the 2017/18 International Classification of Diseases (ICD)-10-CM Diagnosis Code F42, effective October 1, 2017. It was changed to a separate disorder category in the DSM-5 outside of the category of anxiety disorder. Because Medicare and Medicaid use the ICD-10 coding for reimbursement, the disorder will be reviewed in this course (WHO, 2017).

The ICD-10’s clinical information about obsessive-compulsive disorder defines it as: • A disorder characterized by the presence of persistent and recurrent irrational thoughts (obsessions), resulting in marked anxiety and repetitive excessive behaviors (compulsions) as a way to try to decrease that anxiety. • An anxiety disorder characterized by recurrent, persistent obsessions or compulsions. Obsessions are the intrusive ideas, thoughts, or images that are experienced as senseless or repugnant. Compulsions are repetitive and seemingly purposeful behaviors which the individual generally recognizes as senseless and from which the individual does not derive pleasure although it may provide a release from tension. • An anxiety disorder in which a person has intrusive ideas, thoughts, or images that occur repeatedly, and in which he or she feels driven to repeatedly perform certain behaviors. For example, a person may worry about germs and so s/he will wash his or her hands over and over again. Having an obsessive- compulsive disorder may cause a person to have trouble carrying out daily activities. • A disorder that is characterized by a recurrent obsession or compulsion that interferes with the individual's daily functioning or serve as a source of distress. • Obsessive-compulsive disorder (OCD) is a type of anxiety disorder characterized by repeated, upsetting thoughts called obsessions, often doing the same thing over and over again to try to make the thoughts go away. Those repeated actions are called compulsions. Examples of obsessions are a fear of germs or a fear of being hurt. Compulsions include washing hands, counting, checking on things or cleaning. Untreated, OCD can take over a 38

person’s life. Researchers think brain circuits may not work properly in people who have OCD. It tends to run in families and the symptoms often begin in children or teens. Treatments that combine medicines and therapy are often effective.

In this disorder, a person has obsessive, anxious thoughts, and develops rituals or compulsions to cope with those obsessive thoughts. According to the Anxiety and Depression Disorder Association of America (2016b), the common symptoms of obsessive-compulsive disorder are: • Obsessions: Unwanted, intrusive thoughts, such as:

o Constant, irrational worry about dirt, germs, or contamination. o Excessive concern with order, arrangement, or symmetry. o Fear that negative or aggressive thoughts or impulses will cause personal harm or harm to a loved one.

o Preoccupation with losing or throwing away objects with little or no value. o Excessive concern about accidentally or purposefully injuring another person.

o Feeling overly responsible for the safety of others. o Distasteful religious and sexual thoughts or images. o Doubting that is irrational or excessive. • Compulsions: Ritualistic behaviors and routines to ease anxiety or distress, such as:

o Cleaning – Repeatedly washing one’s hands, bathing, or cleaning household items, often for hours at a time.

o Checking – Checking and re-checking several (to hundreds) times a day that the doors are locked, the stove is turned off, the hairdryer is unplugged, etc.

o Repeating – Inability to stop repeating a name, phrase, or simple activity (such as going through a doorway over and over).

o Hoarding – Difficulty throwing away useless items, such as old newspapers or magazines, bottle caps, or rubber bands.

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o Touching and arranging. • Mental rituals – Endlessly reviewing conversations, counting; repetitively calling up “good” thoughts to neutralize “bad” thoughts or obsessions; excessively praying and using special words or phrases to neutralize obsessions.

Examples of obsessions and the compulsive behaviors associated with them noted published by The American Association of Family Physicians (Fenske and Petersen, 2015) are shown below:

Common Obsessions and Compulsions Type Examples Obsessions Aggressive Images of hurting a child or parent. impulses: Contamination: Becoming contaminated by shaking hands with another person. Need for order: Intense distress when objects are disordered or asymmetric. Religious: Blasphemous thoughts, concerns about unknowingly sinning. Repeated doubts: Wondering whether a door was left unlocked. Sexual imagery: Recurrent pornographic images. Compulsions Checking: Repeatedly checking locks, alarms, appliances. Cleaning: Hand-washing. Hoarding: Saving trash or unnecessary items. Mental acts: Praying, counting, repeating words silently. Ordering: Reordering objects to achieve symmetry. Reassurance- Asking others for reassurance. seeking: Repetitive actions: Walking in and out of a doorway multiple times.

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) includes a new, separate chapter for OCD and related disorders, including body dysmorphic disorder, hoarding disorder, trichotillomania, and excoriation disorder outside of the anxiety disorder category. Previously, OCD was grouped together with impulse control disorders (ICDs) not elsewhere classified. Again, it is included here

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because of the ICD-10 classifies it under the anxiety disorder category of diagnosis and that criteria is required for insurance and Medicare/Medicaid reimbursement.

The American Psychiatric Association defines OCD as the presence of obsessions, compulsions, or both. Obsessions are defined by (1) and (2) as follows: 1. Recurrent and persistent thoughts, urges, or images that are experienced at some time during the disturbance, as intrusive and unwanted, and cause marked anxiety and distress; and 2. The person attempts to suppress or ignore such thoughts, impulses, or images or to neutralize them with some other thought or action.

Compulsions are defined by (1) and (2) as follows: 1. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) in response to an obsession or according to rules that must be applied rigidly; and 2. The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a way that could realistically neutralize or prevent whatever they are meant to address, or they are clearly excessive.

Assessing for obsessive-compulsive disorders The Florida Obsessive-Compulsive Inventory is a useful tool in screening patients for obsessive-compulsive disorders. It has recently been shown to be valid and reliable in a 2016 study by Rapp, Bergman, Placentini, and McGuire. It is a self-report questionnaire with 25 items that determine both the number and severity of symptoms. There is also a version of the inventory for children.

Another scale that is frequently used by clinicians is the Yale-Brown Obsessive Compulsive-Scale (Y-BOCS) (Goodman, et al., 1989). This scale is administered by a clinician and assesses the impact of obsessions on the patient’s life, how much time the

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obsessions take from a patient’s day, and how much control the patient has over these obsessions.

Yale-Brown Obsessive-Compulsive Scale Second Edition (Y-BOCS-II) was created in response to advancements in the understanding of OCD phenomenology and in an attempt to address psychometric criticisms of the Y-BOCS (Storch et al., 2010).

Rapp et al., 2016, explains the revisions in the second edition: The Y-BOCS-II Severity Scale includes changes to the items administered including an updated “obsession-free interval” item is included in lieu of the original “resistance against obsessions” items, better incorporation of behavioral avoidance, and expansion of the rating scale to range from 0 to 5 (0 = none, to 4 = very severe, 5 = extreme. In revising the range of the Severity Scale items, these adjustments provide greater severity distinction and treatment sensitivity for individuals with high OCD severity.

The Children’s Yale–Brown Obsessive–Compulsive Scale (CY-BOCS) is a semi- structured interview that assesses the presence and the severity of OCD in children. It parallels the Y-BOCS format, scoring, and interpretation (Rapp et al., 2016).

The Y-BOCS/Y-BOCS-II/CY-BOCS represent the gold standard in clinician- administered assessment tools for OCD severity (Rapp et al., 2016).

Other anxiety-related disorders The DSM-5 lists specific diagnostic criteria that cannot be contributed to other specific anxiety or psychiatric disorders, substance use, withdrawal or other medical disease or condition. Jacofsky et al. (2017) discusses “Anxiety Due to Another Medical Condition”; “Substance/Medication Induced Anxiety Disorder” (drugs); and the catchall categories “Other Specified and Unspecified Anxiety Disorder”. These two diagnoses are used when symptoms create significant distress and/or impaired functioning, but do not seem to meet the diagnostic criteria for any of the other anxiety disorders.

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Anxiety disorders due to another medical condition Certain medical disorders or diseases can cause psychiatric symptoms. A medical evaluation should be performed by a qualified health care professional to rule out a medical condition that may be causing the symptoms. When the fear and anxiety symptoms are the direct effect of a medical condition, this would be referred to as an “anxiety disorder due to another medical condition”. This diagnosis is not used if their anxiety is due to realistic concerns about having a medical condition. For instance, someone with cancer is reasonably worried about pain: this is a normal and rational worry. It would not, therefore, be diagnosed as a mental disorder.

When a person suffers from anxiety disorder due to another medical condition, the presence of that medical condition leads directly to the anxiety experienced. The anxiety is the predominant feature and may take the form of panic attacks, obsessive-compulsive behavior, or generalized anxiety.

In order to give this diagnosis to a patient, there must be evidence that shows the anxiety, regardless of the way it is exhibited, is due to the direct physiologic effects of another medical condition (American Psychiatric Association, 2013). History, physical examination, or laboratory findings are used to establish this direct effect. Anxiety due to another medical condition is not better explained by another mental disorder and does not occur only during the course of delirium. Clinically-significant distress must be present, and the functioning of the person in social, occupational, or other areas of life must be impaired.

Careful and thorough medical evaluation must be conducted to determine the presence of the medical condition that leads to the anxiety (Gagarina, 2011). Some of the medical conditions that may be involved in this disorder are hyperthyroidism, hypothyroidism, hypoglycemia, hyperadrenocorticism, cancer, or mitral valve prolapse. Other heart-related problems may also underlie this disorder, such as congestive heart failure and arrhythmia. Breathing problems such as COPD, pneumonia, and

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hyperventilation also can initiate anxiety. Neurological conditions like encephalitis or neoplasms can also lead to anxiety (Bourne, 2014).

Substance/medication-induced anxiety disorder When anxiety symptoms are a direct result of a prescription drug, an over-the-counter drug, or a street drug, then the correct diagnosis is “substance/medication-induced anxiety disorder”. The anxiety may be caused by the proper and customary use of the drug. It may also occur because of misuse, intoxication, or withdrawal from a particular substance.

Prescription drugs that can cause anxiety as a side effect of the drug may include medications containing amphetamines such as Benzedrine®, Dexedrine®, and Ritalin®. Certain high blood pressure (hypertensive) medications can also cause anxiety (clonidine and Methyldopa®). Steroidal drugs used to treat asthma and other respiratory disorders may create anxiety symptoms (albuterol, salmeterol, and theophylline). In addition, various hormonal medications (including thyroid medications) are known to cause anxiety symptoms.

Non-prescription drugs can also cause anxiety symptoms. This would include drugs that contain caffeine (Anacin®, Empirin®, Excedrin®). Many cold and flu medications list anxiousness as a side effect (particularly decongestants and cough syrups). While not typically considered drugs by most people, excessive caffeine use (coffee, teas, certain sodas), nicotine use (cigarettes, "chew," and quit-smoking aids), and alcohol, have all been known to cause, or aggravate, a pre-existing anxiety disorder. Similarly, withdrawal from these substances can precipitate anxiety symptoms.

The use and withdrawal from several street drugs are also implicated in precipitating, or worsening, an anxiety disorder. These include cocaine, methamphetamine, and marijuana.

Diagnostic criteria

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The DSM-5 diagnostic criteria for substance/medication-induced anxiety disorder are those of the anxiety disorders, primarily anxiety and panic. Obsessions and compulsions should not be present: obsessive-compulsive disorders—which may also be precipitated by drugs or medications— now have their own category. Symptoms must develop during or within one month of use or intoxication, or within one month after withdrawal from a drug or substance known to cause anxiety. The symptoms must not be ascribable to other anxiety disorders and must not be the result of delirium caused by the drug. The responsible drug (or drugs) should be specified.

Other specified anxiety disorder Someone may not fully meet the diagnostic criteria for a particular anxiety disorder. Un- cued, unexpected panic attacks, for instance, are a diagnostic criterion for panic disorder. Individuals might meet all the diagnostic criteria for panic disorder except one. Instead of unexpected panic attacks, they experience limited symptom panic attacks. This means that they experiences less than four symptoms and do not meet the full criteria needed to diagnose a panic disorder. The most common symptom of limited-symptom panic attacks is shortness of breath due to hyperventilation.

Although they do not meet the full criteria, it may still be worthwhile to note these anxiety symptoms if they cause significant distress or impairment. In this case, they could receive a diagnosis of “other specified anxiety disorder”.

“Other unspecified anxiety disorder” is used when there are anxiety-like symptoms that cause significant distress or impaired functioning. There is, however, insufficient information to determine what particular type of anxiety disorder may be present. This situation may occur in emergency room settings where a complete history and full psychiatric evaluation are not always feasible.

Anxiety disorder treatments

Treatment of general anxiety disorders

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Establishing a diagnosis is only the beginning of treatment for any type of anxiety disorder. There are a number of pharmacological, therapeutic, relaxation, and lifestyle strategies that can be combined to meet the unique needs of the client and address the specific category of anxiety s/he may face.

When medications are prescribed for anxiety, they must be carefully discussed with patients to make them aware of the risks and benefits. These include potential short- and long-term side effects and contraindications, including other medications being taken.

All medications must be closely monitored due to the possible side effects of worsening anxiety or the occasional emergence of suicidal thoughts, especially with children and adolescents.

Cognitive behavioral therapy (CBT)—which uses education and behavior change, relaxation / breathing training, meditation, distraction strategies, and exposure therapy using stimuli that works toward systematic desensitization to stimuli— can be effective and will be later discussed in more detail.

The use of any type of therapy involves the selection of a specific treatment based upon the evidence supporting the treatment, the specific clinical features of each patient, the preference of the patient, and any co-occurring conditions. Furthermore, treatment must be delivered by properly trained and supervised staff that follows evidence-based protocols, the Health Insurance Portability and Accountability Act (HIPPA) rules, informed consent for all treatment plans, principles of ethical practice, collaboration, and sound decision-making techniques.

Overview of treatments and therapies With the increased focus on modern technology, many innovative therapy formats are available beyond the more traditional ones. The ADAA (2016b) identifies these new therapy formats, which include mobile apps that provide unlimited accessibility and portability for effective therapy resources, and include apps for coping skills and

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mindfulness. Texting with licensed professionals on a 24/7 basis and telemental health services can be provided through contact with professional therapists via the internet, email, phone, video, and online chat.

The following section is from the National Institute of Mental Health (NIMH, 2016b).

Psychotherapy Psychotherapy, or “talk therapy,” can help people with anxiety disorders. To be effective, psychotherapy must be directed at the person’s specific anxieties and tailored to his or her needs. A typical “side effect” of psychotherapy is temporary discomfort involved with thinking about, and confronting, feared situations.

Cognitive behavioral therapy (CBT) CBT is a type of psychotherapy that can help people with anxiety disorders. It teaches a person different ways of thinking, behaving, and reacting to anxiety-producing and fearful situations. CBT can also help people learn and practice social skills, which is vital for treating social anxiety disorders.

Two specific stand-alone components of CBT used to treat social anxiety disorders are cognitive therapy and exposure therapy. Cognitive therapy focuses on identifying, challenging, and then neutralizing unhelpful thoughts that underlie anxiety disorders.

Exposure therapy focuses on confronting the fears that underlie an anxiety disorder in order to help people engage in activities that they have avoided. Exposure therapy is used along with relaxation exercises and/or imagery. One study, called a “meta-analysis” (because it pulls together all of the previous studies and calculates the statistical magnitude of the combined effects), found that cognitive therapy was superior to exposure therapy for treating social anxiety disorder.

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CBT may be conducted individually or with a group of people who have similar problems. Group therapy is particularly effective for social anxiety disorder. “Homework” is often assigned for participants to complete between sessions. “Thought challenging” in CBT, also known as cognitive restructuring, is a process in which the client challenges the negative thinking patterns that contribute to anxiety, and then replaces them with more positive, realistic thoughts (Smith, Segal, and Segal, 2017). Cognitive restructuring involves three steps:

1. Identifying negative thoughts. With anxiety disorders, situations are perceived as more dangerous than they really are. To individuals with germ phobias, for example, shaking others’ hands can seem life threatening. Although they may easily see that this is an irrational fear, identifying their own irrational, scary thoughts can be very difficult. One strategy is to ask what they were thinking when they started feeling anxious. The therapist will help with this step.

2. Challenging negative thoughts. In the second step, the therapist will teach clients how to evaluate anxiety-provoking thoughts. This involves questioning the evidence for frightening thoughts, analyzing unhelpful beliefs, and testing out the reality of negative predictions. Strategies for challenging negative thoughts include conducting experiments, weighing the pros and cons of worrying, or avoiding the thing they fear, and then determining the realistic chances that what they are anxious about will actually happen.

3. Replacing negative thoughts with realistic thoughts. Once they have identified the irrational predictions and negative distortions in their anxious thoughts, they can replace them with new thoughts that are more accurate and positive. The therapist may help clients develop realistic, calming statements, or “self-talk,” to use when facing or anticipating a situation that normally sends anxiety levels soaring.

The negative thought patterns are often developed and ingrained over many years; they are not easy to change. On average, it takes 12 to 16 weeks to achieve results from CBT. The client will need to practice the techniques at home and in community settings with support. 48

CBT may also include: • Learning to recognize situations that cause anxiety and what these situations feel like in the body. • Learning coping skills and relaxation techniques to counteract anxiety and panic. • Confronting fears— either imagined or in real life.

Systematic desensitization (Gilston, 2017) Systematic desensitization is a behavioral technique whereby a person is gradually exposed to an anxiety-producing object, event, or place while simultaneously being engaged in some type of relaxation technique in order to reduce the symptoms of anxiety.

For example, a very common phobia is the fear of flying. Some people become very anxious when travel involves a plane; others may become extremely fearful at the thought of flying and refuse to go anywhere near a plane. Systematic desensitization has two steps that could be applied to a fear of flying in order to help reduce the anxiety involved.

Relaxation training First, a clinician or behavioral therapist will train a client with the fear of flying in relevant relaxation techniques. This is very similar to meditation: there are scripts with exact wordings that can be followed. The therapist could begin by asking the client to close his/her eyes, sit in a comfortable position, and relax all his/her muscles while paying close attention to breathing, slowly and naturally. The therapist will read through the script and encourage the client to relax each muscle in his/her body, from the head to the toes. The goal is to get the client into a completely relaxed physical state.

Hierarchy of fears The next step in the systematic desensitization process involves constructing what is called the “hierarchy of fears.” This is a list of the things that the person identifies as

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fearful which are related to flying—from from the least to the most anxiety-provoking. The list could look something like this:

1. Looking at a toy plane (least). 2. Hearing or watching a plane flying in the sky. 3. Going to an airport. 4. Walking onto a plane. 5. Taking off and flying

Once a client has learned these relaxation techniques, the therapist helps him/her to integrate the two. The client will start by using relaxation to achieve a calm state and then imagine the first level of the toy plane. Once s/he can remain relaxed at that level, the client would then move up the hierarchy with the goal of reaching the last stage of flying while remaining relaxed and in control.

Flooding therapy (Claus, 2017) As psychologists began to better understand phobias (and the role that classical conditioning plays in their development), new thoughts and ideas about how to treat phobias followed shortly thereafter. One such treatment technique that has been used with success is called flooding. “Flooding” is the process of teaching patients self- relaxation techniques first and then exposing them abruptly, and directly, to the fear- evoking stimulus itself. Classical conditioning has taught the person to associate fear with the stimulus; however, the same principles can be used to extinguish the fear response and replace it with a feeling of relaxation, thus eliminating the phobia.

In contrast to other slower-paced forms of behavioral therapy used to treat phobias (such as systematic desensitization), as its name implies, flooding is rapid, abrupt exposure and yields relatively quick results. Flooding is commonly used by behavioral therapists across the world.

Dialectical behavioral therapy (DBT) (APA, 2016)

Dialectical behavior therapy (DBT) treatment is a cognitive-behavioral approach that emphasizes the psychosocial aspects of treatment. The theory behind the approach is that 50

some people are prone to react in a more intense and in an out-of-the-ordinary manner toward certain emotional situations. These situations are primarily found in romantic, family, and friend relationships. DBT theory suggests that some people’s arousal levels in such situations can increase far more quickly than the average person’s, attain a higher level of emotional stimulation, and take a significant amount of time to return to baseline arousal levels.

Components of DBT: . Support-oriented: This helps a person identify his/her strengths and build on them so that the person can feel better about him/herself and life. . Cognitive-based: DBT helps identify thoughts, beliefs, and assumptions that make life harder: “I have to be perfect at everything.” “If I get angry, I’m a terrible person.” DBT helps people learn different ways of thinking that will make life more bearable: “I don’t need to be perfect at things for people to care about me,” and, “Everyone gets angry, it’s a normal emotion.” . Collaborative: DBT requires constant attention to relationships between clients and staff. In DBT, individuals are encouraged to work out problems in their relationships with their therapist and the therapists to do the same with them. DBT asks people to complete homework assignments, from role-playing new ways of interacting with others, to practicing skills— such as self-soothing when upset. These skills, a crucial part of DBT, are taught in weekly lectures, reviewed in weekly homework groups, and referred to in nearly every group. The individual’s therapist helps the person learn, apply, and master the DBT skills.

Self-help or support groups (NIMH, 2016b) Stress management techniques and meditation can help people with anxiety disorders calm themselves and may enhance the effects of therapy. While there is evidence that aerobic exercise has a calming effect, the quality of the studies is not strong enough to support its use as treatment.

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The family can be important in the recovery of a person with an anxiety disorder. Ideally, the family should be supportive, yet not help perpetuate their loved one’s symptoms. Additionally, yoga, meditation, breathing, relaxation, including muscle relaxation, techniques can accompany medication and psychotherapy techniques in managing anxiety.

Medication (NIMH, 2016b) Medication does not cure anxiety disorders but often relieves symptoms. Medication can only be prescribed by a medical doctor (such as a psychiatrist or a primary care provider); however, a few states allow psychologists to prescribe psychiatric medications. Medications are sometimes used as the initial treatment of an anxiety disorder or are used only if there is insufficient response to a course of psychotherapy. In research studies, it is common for patients treated with a combination of psychotherapy and medication to have better outcomes than those treated with only one or the other.

The most common classes of medications used to combat anxiety disorders are antidepressants, anti-anxiety drugs, and beta-blockers. Note that some medications are effective only if they are taken regularly and that symptoms may recur if the medication is stopped.

Certain medications – such as caffeine, certain illicit drugs, and even some over-the- counter (OTC) cold medications – can aggravate the symptoms of anxiety disorders and should be avoided. The client’s physician should be consulted before any OTC or supplemental medications are taken.

Antidepressants (NIMH, 2016b) Antidepressants are used to treat depression; they also are helpful for treating anxiety disorders. They take several weeks to start working and may cause side effects such as headache, nausea, or difficulty sleeping. The side effects are usually not a problem for most people, especially if the dose starts off low and is increased slowly over time.

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Please note: Although antidepressants are safe and effective for many people, they may be risky for children, teens, and young adults. A “black box” warning (the most serious type of warning that a prescription can carry) has been added to antidepressant labels. The labels now warn that antidepressants may cause some people to have suicidal thoughts or make suicide attempts. For this reason, anyone taking an antidepressant should be monitored closely, especially when they first start taking the medication.

Anti-anxiety medications (NIMH, 2016b) Anti-anxiety medications help reduce the symptoms of anxiety, panic attacks, or extreme fear and worry. The most common anti-anxiety medications are called benzodiazepines. Benzodiazepines are the first-line treatments for generalized anxiety disorder. With panic disorders or social phobias (social anxiety disorder), benzodiazepines are usually second- line treatments, behind antidepressants.

Benzodiazepines used to treat anxiety disorders include: • Clonazepam. • Alprazolam. • Lorazepam.

Short half-life (or short-acting) benzodiazepines (such as Lorazepam) and beta-blockers are used to treat the short-term symptoms of anxiety. Beta-blockers help manage the physical symptoms of anxiety—such as trembling, rapid heartbeat, and sweating— that people with phobias (an overwhelming and unreasonable fear of an object or situation, such as public speaking) experience in difficult situations. Taking these medications for a short period of time can help the person keep his/her physical symptoms under control and can be used “as needed” to reduce acute anxiety.

Buspirone (which is unrelated to the benzodiazepines) is sometimes used for the long- term treatment of chronic anxiety. In contrast to the benzodiazepines, buspirone must be taken every day for a few weeks to reach its full effect. It is not useful on an “as-needed” basis.

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Anti-anxiety medications, such as benzodiazepines, are effective in relieving anxiety. They also take effect more quickly than the antidepressant medications (or buspirone) that are often prescribed for anxiety. However, people can build up a tolerance to benzodiazepines if they are taken over a long period of time and may need higher and higher doses to achieve the same effect. Some people may even become dependent on them. To avoid these problems, doctors usually prescribe benzodiazepines for short periods—a practice that is especially helpful for older adults, people who have substance abuse problems, and people who easily become dependent on medication. If people suddenly stop taking benzodiazepines, they may experience withdrawal symptoms or their anxiety may return; therefore, benzodiazepines should be tapered off slowly.

Beta-blockers Beta-blockers, such as propranolol and atenolol, are also helpful in the treatment of the physical symptoms of anxiety, especially social anxiety. Physicians prescribe them to control rapid heartbeat, shaking, trembling, and blushing in anxious situations. Choosing the right medication, medication dose, and treatment plan should be based on a person’s needs and medical situation, and should be administered under an expert’s care. Only an expert medical clinician can help clients decide whether or not the medication’s ability to help is worth the risk of its side effect(s); the doctor may try several medicines before finding the right one.

The doctor should discuss the following issues with patients: • How well the medications are working, or might work, to improve symptoms. • Benefits and side effects of each medication. • Risk for serious side effects based on medical history. • The likelihood of the medications requiring lifestyle changes. • Costs of each medication. • Other alternative therapies, medications, vitamins, and supplements the client is taking and how these may affect symptoms and treatment.

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• How the medication should be stopped. Some drugs cannot be stopped abruptly; rather, they must be tapered off slowly under a doctor’s supervision.

Potential side effects of anti-anxiety medications (NIMH, 2016b)

Like other medications, anti-anxiety medications may cause side effects. Some of these side effects and risks are serious. The most common side effects for benzodiazepines are drowsiness and dizziness. Patients should consult their physician if these side effects occur: • Nausea; • Blurred vision; • Headache; • Confusion; • Tiredness; • Nightmares; • Drowsiness; • Dizziness; • Unsteadiness; • Problems with coordination; • Difficulty thinking or remembering; • Increased saliva; • Muscle or joint pain; • Frequent urination; • Blurred vision; and/or • Changes in sex drive or ability.

A doctor should immediately be consulted if the following side effects occur: • Rash; • Hives; • Swelling of the eyes, face, lips, tongue, or throat; • Difficulty breathing or swallowing;

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• Hoarseness; • Seizures; • Yellowing of the skin or eyes; • Depression; • Difficulty speaking; • Yellowing of the skin or eyes; • Thoughts of suicide or harm to self or others; and/or • Difficulty breathing.

Common side effects of beta-blockers include: • Fatigue; • Cold hands; • Dizziness or light-headedness; and/or • Weakness.

Beta-blockers generally are not recommended for people with asthma or diabetes: they may worsen symptoms related to both.

Possible side effects from buspirone include: • Dizziness; • Headaches; • Nausea; • Nervousness; • Lightheadedness; • Excitement; and/or • Trouble sleeping.

Anti-anxiety medications may cause other side effects that are not included in the lists above. To report any serious adverse effects associated with the use of these medicines,

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please contact the FDA MedWatch program using the contact information at the bottom of this page.

Treating social anxiety disorder

According to the Social Anxiety Support (2015) website, CBT is a widely-used treatment for social phobia. It consists of the following elements: • Psychoeducation, which aims to increase a person’s understanding of social phobia: where it came from, how to treat it. • Cognitive restructuring, which helps people overcome their irrational thoughts and replace them with positive thoughts. • In vivo exposure: a therapist guides the patient through exposure to anxiety- provoking situations. • Interoceptive exposure, where a patient is helped to cope with the body sensations that arise in socially-anxious situations that are also capable of producing anxiety in and of themselves (pounding heart, dizziness, etc.). • Social skills training: practicing various social situations to gain mastery of the skills necessary to feel comfortable in these situations.

Social anxiety disorder is typically treated with an SSRI or SNRI. Benzodiazepines are sometimes used when the SSIR or SNRI does not work. In the case of panic disorder or social phobia (social anxiety disorder), benzodiazepines are usually second-line treatments behind SSRIs or other antidepressants.

(See the previous medication section.)

Treating separation anxiety disorder

Cognitive behavioral therapy, systematic desensitization, and exposure therapies are the most effective with separation anxiety disorder. (See the treatment section for additional details on these therapies.)

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Medications are also used to treat separation anxiety disorder. Both antidepressants (e.g., Clomipramine or Imipramine) and anxiolytic medications (anxiety-reducing medications, such as Buspar) have been used with success (Jacofsky et al., 2013).

Various side effects can occur with the use of medications. This may include dry mouth, dizziness, seizures, aggressive behaviors, drowsiness, etc. Many antidepressants have a "black box" warning for use with children: studies have shown that in a small number of children, these medications can increase suicidal thoughts and behaviors. A mental health professional should closely monitor children taking these drugs, and closely monitor possible suicidal thoughts and behaviors

Treating panic disorder

Distraction techniques can help clients move from an inward focus (that exacerbates intense negative emotions) to an outward focus toward safe activities which evoke pleasant emotions. The client also learns that s/he can take charge and self-regulate his/her behaviors by focusing his/her attention on safe and enjoyable activities to address situations that stimulate panic feelings. Distraction techniques are often used in conjunction with CBT as a part of a repertoire of coping mechanisms which clients can employ. With systematic practice, clients can learn to identify and anticipate situations that stimulate negative feelings of panic, and may use distraction techniques to short circuit and avert these feelings from taking hold. This allows clients to feel empowered and in control of their own situations by using positive activities, rather than turning to alcohol and drugs to avoid the frequently-occurring panic.

The following is a list of distraction techniques that may help clients cope with overwhelming emotions (Star, 2017): • Use entertainment. Read something of interest or flip through an enjoyable magazine. If reading does not work, watch television or a movie to focus on something else. Listening to music may help the client feel calmer and headsets may help them focus on the music and limit other stimuli. • Count breaths, inhale and exhale, counting one then inhale and exhale on

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count two, etc. Continue counting each cycle of breath at least to ten or until calm. • Try physical exercise. There are many beneficial forms of exercise that can be done alone or with a group. When negative emotions take hold, try participating in some form of exercise like taking a walk outdoors, exercising at the gym, or participating in some type of vigorous exercise with cardiovascular benefits. If that is not possible try stretching or yoga poses to increase circulation. Jumping jacks or other easy and quick exercises can be done if time is limited. Many exercises can be done in a chair for older clients or those with physical or medical limitations. • Engage in a relaxation technique. Relaxation techniques— such as visualization, progressive muscle relaxation (PMR), yoga breathing, or mindfulness meditation— can help to re-center the focus on positive thoughts to find a sense of calm. These activities can help divert and refocus the mind to promote pleasant feelings. It is difficult to feel anxious and upset when in a relaxed state of mind. • Participate in a creative pursuit. Negative emotions are lessened when focusing on a creative, an enjoyable, or an artistic project. Some activities may include making art or craft projects, singing, dancing, or playing a simple instrument. • Write it out. Writing exercises can be another powerful tool of distraction and clarity. Through journal writing, the emotional self is able to refocus and adjust to manage emotions through the writing process. • Talk to a loved one. Consider calling a friend or a loved one to distract from negative feelings. Be careful not to spend time talking about negative emotions and feelings. Rather, ask the person about his/her life.

Other hobbies or activities that evoke pleasant emotions and require focus can be used as a distraction— such as gardening, sewing, hiking or bike riding with friends, cooking, home improvement, or any activity the person enjoys. Individuals may have a support system of friends they can call to participate in activities with them; however, they should learn to apply these techniques, when appropriate, any time they feel panic coming on. 59

For instance, a client at work may learn to use visualization, meditation, or breathing techniques in the office if a stimulus that triggers panic is encountered.

An example of CBT for panic disorder To understand how thought challenging works in cognitive behavioral therapy, consider the following example: Maria will not take the subway because she is afraid she will pass out and then everyone will think she is crazy. Her therapist has asked her to write down her negative thoughts, identify the errors (or cognitive distortions) in her thinking, and come up with a more rational interpretation. The results are below (Smith, Segal, and Segal, 2017):

Challenging negative thoughts

Negative thought #1: What if I pass out on the subway?

Cognitive distortion: Predicting the worst. More realistic thought: I’ve never passed out before, so it’s unlikely that I will on the subway.

Negative thought #2: If I pass out, it will be terrible!

Cognitive distortion: Blowing things out of proportion. More realistic thought: If I faint, I’ll come to in a few moments. That’s not so terrible.

Negative thought #3: People will think I’m crazy.

Cognitive distortion: Jumping to conclusions. More realistic thought: People are more likely to be concerned if I’m okay.

Replacing negative thoughts with more realistic ones is easier said than done. Often, negative thoughts are part of a lifelong pattern. It takes practice to break these habits; cognitive behavioral therapy includes practicing both at home and in community settings.

Treating specific phobias 60

Exposure therapy (Perelman, 2017): In this treatment, patients are gradually—yet repeatedly— exposed to their feared situations until the situation no longer triggers the fear response. This can be done via “imaginal exposure,” such as imagining confronting the feared situation in one’s mind, or via “in vivo exposure,” which involves confronting the feared situation in real life. Treatment plans often combine these two techniques. Exposure is most effective when it is done frequently and lasts for long enough for the fear to decrease. In certain situations, in fact, exposure-based treatment has been shown to work in as little as one extended session.

With the increasing availability of virtual reality technology, promising results have been shown through the use of computer-generated interactive virtual realities (VR). These include visual displays of moving objects, other sensory inputs, and body-tracking devices to conduct exposure therapy. Specific phobias are particularly responsive to exposure-based therapies and are therefore considered the treatment of choice for this disorder (Emmelkamp, Ehring, and Hamm, 2014).

Cognitive therapy: In cognitive therapy, patients learn to identify their anxious thoughts and replace them with more realistic thoughts. For example, someone with a fear of driving is shown evidence that driving is usually not dangerous. However, cognitive therapy alone is usually not an appropriate choice for people with specific phobias: most individuals with phobias recognize that their fears are irrational.

Relaxation: Relaxation techniques (such as breathing and muscle relaxation training) and exercise can help individuals cope effectively with the stresses and any physical reactions related to their specific phobias.

Medication: For recurrent phobias that cause temporary, yet intense, anxiety (such as the fear of flying), short-acting benzodiazepines (Ativan, Xanax) may be prescribed on an occasional, as-needed basis to reduce anticipatory anxiety. Unless a phobia is accompanied by other conditions like depression or panic disorder, long-term or daily medicines are not recommended. Serotonergic antidepressants (Paxil) may have value for some patients.

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Additionally, common blood pressure drugs called beta-blockers have been used to treat anxiety related to specific phobias (NIMH, 2016b).

(See the previous section on medication.)

Systematic desensitization Rather than facing the biggest fear right away, which can be traumatizing, exposure therapy usually starts with a situation that is only mildly threatening and then works up from there. This step-by-step approach is called systematic desensitization. Systematic desensitization allows clients to gradually challenge fears, build confidence, and master skills for controlling panic (Smith, Segal, and Segal, 2017): • Facing a fear of flying

o Step 1: Look at photos of planes. o Step 2: Watch a video of a plane in flight. o Step 3: Watch real planes take off. o Step 4: Book a plane ticket. o Step 5: Pack for the flight. o Step 6: Drive to the airport. o Step 7: Check in for the flight. o Step 8: Wait for boarding. o Step 9: Get on the plane. o Step 10: Take the flight.

Systematic desensitization involves three parts: 1. Learning relaxation skills. First, the therapist will teach relaxation techniques, such as progressive muscle relaxation or deep breathing. Clients practice these techniques in therapy and on their own at home. Once they start confronting fears, they will use relaxation techniques to reduce physical anxiety responses, such as trembling and hyperventilating, and encourage relaxation.

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2. Creating a step-by-step list. Next, clients will create a list of 10 to 20 frightening situations that progress toward a final goal. For example, if the final goal is to overcome a fear of flying, the client might begin by looking at photos of planes and end with taking an actual flight. Each step should be as specific as possible, and should include a clear, measurable objective. 3. Working through the steps. Under the guidance of the therapist, clients begin to work through the list. The goal is to stay in each uncomfortable situation until the fears subside. That way, clients learn that the feelings will not hurt them and that they do go away. Every time the anxiety gets too intense, clients will switch to the learned relaxation technique. Once they have relaxed again, they can turn their attention back to the situation.

The client will work through these steps until s/he is able to complete each one without feeling overly distressed.

Treating PTSD in adults The following section is taken from the publication on treatment for PTSD from the U.S. Office of Veteran Affairs (2017b).

Trauma-focused psychotherapies Trauma-focused psychotherapies are the most highly-recommended type of treatment for PTSD. "Trauma-focused" means that the treatment focuses on the memory of the traumatic event or its meaning. These treatments use different techniques to help the client process your traumatic experience. Some involve visualizing, talking, or thinking about the traumatic memory. Others focus on changing unhelpful beliefs about the trauma. They usually last about 8-16 sessions. The trauma-focused psychotherapies with the strongest evidence are:

• Prolonged exposure (PE) PE teaches the individual how to gain control by facing negative feelings. It

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involves talking about trauma with a provider and doing some of the things that have been avoided since the trauma.

• Cognitive processing therapy (CPT) CPT instructs the client how to reframe negative thoughts about the trauma. It involves talking with the health provider about negative thoughts and doing short writing assignments.

• Eye-Movement Desensitization and Reprocessing (EMDR) EMDR helps clients process and make sense of trauma. It involves calling the trauma to mind while paying attention to a back-and-forth movement or sound (like a finger waving side to side, a light, or a tone).

There are other types of trauma-focused psychotherapy that are also recommended for people with PTSD. These include:

• Brief eclectic psychotherapy (BEP) A therapy in which clients practice relaxation skills, recall details of the traumatic memory, reframe negative thoughts about the trauma, write a letter about the traumatic event, and hold a farewell ritual to leave trauma in the past.

• Narrative Exposure Therapy (NET) NET was developed for people who have experienced trauma from ongoing war, conflict, and organized violence. Clients talk through stressful life events in order (from birth to the present day) and put them together into a story.

• Written narrative exposure Written narrative exposure involves writing about the trauma during sessions. The health care provider gives instructions on the writing assignment, allows clients to complete the writing alone, and then returns at the end of the session to briefly discuss any reactions to the writing assignment.

• Specific cognitive behavioral therapies (CBTs) for PTSD This includes a limited number of psychotherapies shown to work for PTSD where the provider helps clients learn how to change unhelpful behaviors or thoughts. (See the previous section on CBT)

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Suggested treatments: Treatments with some research support Some psychotherapy does not focus on the traumatic event; rather, it helps the client process his/her reactions to the trauma and manage symptoms related to PTSD. The research behind these treatments is not as strong as the research supporting trauma- focused psychotherapies (listed above). However, these psychotherapies may be a good option if a client is not interested in trauma-focused psychotherapy, or if it is not available:

• Stress inoculation training (SIT) A cognitive-behavioral therapy that teaches skills and techniques to manage stress and reduce anxiety.

• Present-centered therapy (PCT) Focuses on current life problems that are related to PTSD.

• Interpersonal psychotherapy (IPT) Focuses on the impact of trauma on interpersonal relationships.

Medication: Antidepressants (SSRIs and SNRIs) Medications that have been shown to be helpful in treating PTSD symptoms are some of the same medications also used for symptoms of depression and anxiety. These are antidepressant medications called SSRIs (selective serotonin reuptake inhibitors) and SNRIs (serotonin-norepinephrine reuptake inhibitors). SSRIs and SNRIs affect the level of naturally occurring chemicals in the brain called serotonin and/or norepinephrine. These chemicals play a role in brain cell communication and affect how feelings are experienced.

There are four antidepressant medications that are recommended for PTSD: • Sertraline (Zoloft); • Paroxetine (Paxil); • Fluoxetine (Prozac); and/or • Venlafaxine (Effexor).

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Note: Medications have two names: a brand name (for example, Zoloft) and a generic name (sertraline).

There are other types of antidepressant medications; however, the four medications listed above are the ones that are the most effective for PTSD. (See the previous medication section.)

There are also other medications that may be helpful, although the evidence behind them is not as strong as for SSRIs and SNRIs (listed above). These include:

• Nefazodone (Serzone) A serotonin reuptake inhibitor (SRI) that works by changing the levels and activity of naturally occurring chemical signals in the brain.

• Imipramine (Tofranil) A tricyclic antidepressant (TCA) which acts by altering naturally occurring chemicals which help brain cells communicate and can lift mood.

• Phenelzine (Nardil) A monoamine oxidase inhibitor (MAOI) which inactivates a naturally-occurring enzyme which breaks down the neurotransmitters serotonin, norepinephrine, and dopamine.

Dialectical behavior therapy DBT may be seen as having two main components to address PTSD (APA, 2016): 1. Individual weekly psychotherapy sessions that emphasize problem-solving behavior for the past week’s issues and troubles that arose in the person’s life. Self-injurious and suicidal behaviors take first priority, followed by behaviors that may interfere with the therapy process. Quality of life issues and steps to work toward improving life in general may also be discussed. Individual sessions in DBT also focus on decreasing and dealing with post-traumatic stress responses (from previous trauma in the person’s life) and helping enhance the client’s own self-respect and self-image.

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2. Weekly group therapy sessions are generally 2 1/2 hours per session and are led by a trained DBT therapist. Individuals learn skills from one of four different modules: interpersonal effectiveness, distress tolerance/reality acceptance skills, emotion regulation, and mindfulness skills.

Treating PTSD in children The initial goals of treatment for children with PTSD are as follows (Lubit, 2016): • Provide a safe environment; • Reassurance, emotional support, nurturance; and • Attend to urgent medical needs.

Psychological therapy for PTSD in children involves the following: • Helping the child gain a sense of safety; and • Addressing the multiple emotional and behavioral problems that can arise.

Nonpharmacological forms of therapy include the following: • Cognitive-behavioral therapy (CBT), especially trauma-focused CBT (TF-CBT); • Dialectical behavior therapy (DBT); • Relaxation techniques (e.g., biofeedback, yoga, deep relaxation, self-hypnosis, or meditation; efficacy unproven); and • Play therapy.

In children who have persistent symptoms despite CBT, or who need additional help with symptom control, the following pharmacologic treatments may be considered: • Selective serotonin reuptake inhibitors (SSRIs) - SSRIs are the medications of choice for managing anxiety, depression, avoidance behavior, and intrusive recollections; however, they are not specifically approved by the FDA for the treatment of PTSD in the pediatric population; • Beta blockers (e.g., propranolol); • Alpha-adrenergic agonists (e.g., guanfacine and clonidine); • Mood stabilizers (e.g., carbamazepine and valproic acid); or 67

• Atypical antipsychotics (infrequently used).

Treating obsessive-compulsive disorders

The two main treatments for OCD are psychotherapy and medication. Treatment is often most effective with a combination of these (Mayo, 2017).

Psychotherapy Cognitive behavioral therapy (CBT) is effective for many people with OCD. Exposure and response prevention (ERP), a type of CBT therapy, gradually exposes the client to a feared object or obsession, such as dirt, and has them learn healthy ways to cope with anxiety. In ERP treatment, clients with OCD are placed in situations where they are gradually exposed to their obsessions and are asked not to perform the compulsions that have historically eased their anxiety and distress. This is done at their pace; therapists should never force the client to do anything that they do not want to do (ADAA, 2016b). ERP takes effort and practice: it can be uncomfortable and anxiety-producing at first, but it can help clients enjoy a better quality of life once they have learned to manage their obsessions and compulsions.

(See previous section on CBT.)

Therapy may take place in individual, family, or group sessions.

Certain psychiatric medications can help control the obsessions and compulsions of OCD. Antidepressants are most commonly tried first.

Antidepressants approved by the Food and Drug Administration (FDA) to treat OCD include (Mayo, 2017): • Clomipramine (Anafranil) for adults and children 10 years and older; • Fluoxetine (Prozac) for adults and children seven years and older; • Fluvoxamine for adults and children eight years and older; • Paroxetine (Paxil, Pexeva) for adults only; or 68

• Sertraline (Zoloft) for adults and children six years and older.

A doctor may prescribe other antidepressants and psychiatric medications. (See the previous medication section.)

Imaginal exposure (ADAA, 2016b) For those who may be resistant to jumping into real world situations, imaginal exposure (IE) (sometimes referred to as visualization) can be a helpful way to alleviate enough anxiety to move willingly to ERP. With visualization, the therapist helps create a scenario that elicits the anxiety that someone might experience in a routine situation. For someone who fears walking down a hallway in a way that diverts from the “perfect” pattern, the therapist may have the client picture him/herself walking in that divergent manner for several minutes each day and then record the corresponding level of anxiety. As he/she habituates to the discomfort with decreased anxiety over time, the client is gradually desensitized to the feared situation. This makes the individual more willing to move the process to real life and engage in the next step, ERP.

Habit reversal training (ADAA, 2016b) Habit reversal training includes awareness training— an introduction of a competing response, social support, positive reinforcement, and often a relaxation technique. Awareness training may include practicing the habit or the tic in front of a mirror, focusing on the sensations of the body and the specific muscles, before and while engaging in the behavior, and then identifying and recording when the habit or tic occurs. These techniques increase awareness about how (and when) these urges develop. The awareness makes it more likely that the individual will be able to intervene and make a change.

That is where the competing response comes in: the individual and the therapist then work together to find something similar to the movement or tic that is not noticeable to others. Someone with a vocal tic who learns an awareness of the developing urge may practice tensing the muscles around their cheeks and mouth to ride out the urge and prevent the tic. Or someone with a compulsion to touch things symmetrically may be

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directed to tense the opposite arm, holding it tightly against their body, preventing them from completing the ritual.

This method of treatment takes time, diligent practice and patience, as well as integrating relaxation skills prior to beginning. Also, extremely critical to success is the support and reinforcement from family and friends.

Treating selective mutism: Behavioral strategies

According to ASHA (2017), the behavioral perspective views selective mutism as a learned behavior that the individual has developed as a coping mechanism for anxiety. The purpose of treatment is to decrease anxiety and increase verbal communication in a variety of settings, incorporating practice and reinforcement for speaking in subtle, nonthreatening ways. Reinforcements may be (Kotrba, 2015): • Verbal (e.g., praise); • Tangible (e.g., toys, special outings, belongings); and/or • Privileges (e.g., staying up later, having additional time to play a video game, choosing a movie or board game to enjoy with a parent/caregiver).

Behavioral strategies may be incorporated into interventions for children with selective mutism across disciplines. These strategies include: • Exposure-based practice. This involves the child saying words in gradually (but increasingly difficult) anxiety-provoking situations. Exposure-based practice aims to (a) replace anxious feelings/behaviors with more relaxed feelings and (b) increase the child's feelings of independence by gradually improving his/her ability to speak in different situations (Kearney, 2010). • Systematic desensitization. This involves the use of relaxation techniques, along with gradual exposure to successively more anxiety-provoking situations (Kearney, 2010). • Stimulus fading. This involves gradually increasing exposure to a fear-evoking stimulus (e.g., the number of people present or the presence of an unfamiliar 70

person in the room while the child is speaking). This process usually includes rewarding the child when he/she is speaking in the presence of someone to whom he/she does not typically speak. • Contingency management, positive reinforcement, and shaping. This includes (a) providing positive reinforcement contingent upon verbalization and (b) reinforcing attempts and approximations to communicate (i.e., shaping) until such attempts are shaped into verbalizations. The goal is to make verbalizing more rewarding than not responding. Shaping is commonly used in combination with contingency management and positive reinforcement.

Treatment of anxiety disorder due to another medical condition In the case of anxiety due to another medical condition, treatment of the anxiety may have to be postponed until the underlying medical condition is successfully treated. This depends on if the medical condition is potentially life-threatening. Often, treatment of both conditions can occur simultaneously. The determination about whether or not simultaneous treatment should happen may depend on the treatment conditions for the medical disorder (NIMH, 2016b).

Treatment of substance or medication-induced anxiety disorder The physician will need to determine the drugs or substance that relate to the anxiety and assess the level of drug use to determine if a substance use disorder, dependence, or an addiction is present. If necessary, the physician may need to assist the client in withdrawal management including a team of interdisciplinary professionals and therapists. If the drugs that are contributing to the anxiety are prescribed to treat an illness or a medical condition, alternative drugs can be prescribed.

Medicines The physician may prescribe anti-depressant or anti-anxiety medications during the transformation phase to control the symptoms of anxiety, including panic attacks.

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Cognitive behavioral therapy (CBT) is often used effectively in these cases, especially if substance use disorders are diagnosed.

Support groups for the client and family Support groups are often effective for this type of anxiety and are also effective for those clients working through substance use disorders. Support groups improve the chances of avoiding relapse: clients meet people facing the same challenges and hear their stories. Clients may feel motivated when they know they are not alone in the process of treatment. Individuals can support each other and share ideas to help improve their ability to gain control over the disorder.

Family members and caregivers can also benefit from this network for education and support purposes.

Conclusion The various forms of anxiety disorders are distinctly different from each other. Each disorder has particular interventions that are most effective. These interventions may include medication, therapy, or a combination of both. The most effective treatment involves the delivery of services by a comprehensive, interdisciplinary team of professionals including social service agencies, therapists, medical, and school personnel trained to work with clients and their families.

Many forms of anxiety disorders respond well to treatment; however, people are often reluctant to seek therapy because of embarrassment or the belief that treatment cannot help them. More public education is needed to remove the stigma of mental disorders. It is also important to encourage those who are suffering from these disorders to become aware of existing treatments to improve their quality of life.

It is important for the practitioner to stay current with the changes in diagnostic criteria and evidence-based treatment modalities to best assist his/her clients. This includes new

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therapies and pharmacology research to treat specific subcategories of anxiety disorders for adults and children.

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Anxiety Disorders: Assessment and Treatment Test Questions

1. According to the Anxiety and Depression Association of America (2013), anxiety disorders are the ______mental illness in the U.S., and affect about 18.1 percent of the U.S. adult population. a. Most common. b. Least common. c. Most treatable. d. Least treatable.

2. A symptom of generalized anxiety disorder includes excessive anxiety and worry (apprehensive expectation) that occurs more days than not for at least ______, about a number of events or activities (such as work or school performance).

a. Two weeks. b. One month. c. Two months. d. Six months.

77 3. In the new DSM-5, panic disorder and are listed as two separate and distinct mental health disorders. a. Agoraphobia. b. Arachnophobia. c. Social phobia. d. Communal phobia.

4. The previous edition of the DSM distinguished the types of panic attacks as belonging to one of three categories: situationally bound/cued, situationally predisposed, or unexpected/uncued. The DSM-5 has removed some of this jargon and simplified panic attacks as fitting into two simplified types: a. Situational or unexpected. b. Expected or unexpected. c. Severe or non-severe. d. Chronic or fleeting.

5. Diagnostic criteria for PTSD include a history of exposure to a traumatic event that meets specific stipulations and symptoms from each of four symptom clusters: intrusion, avoidance, negative alterations in cognitions and mood, and alterations in . a. Emotional response. b. Arousal and reactivity. c. Interpersonal relations. d. Cognitive behavior.

6. A person who has a experiences significant and persistent fear when in the presence of, or anticipating the presence of, the object of fear— which may be an object, a place, or a situation. a. Specific phobia disorder. b. General anxiety disorder. c. Specialized anxiety disorder. d. General phobia disorder.

7. An example of an obsession is: a. Repeatedly checking locks, alarms, appliances. b. Saving trash or unnecessary items. c. Intense distress when objects are disordered or asymmetric. d. Praying, counting, repeating words silently.

78 8. The Y-BOCS-II Severity Scale includes changes for assessing OCD including expansion of the rating scale to range from 0 to 5 and provides ______. a. Easier and faster administration. b. More credibility as a measure of obsessions among children. c. Greater severity distinction and treatment sensitivity for individuals with high OCD severity. d. A measure that is less anxiety provoking for client.

9. When the fear and anxiety symptoms are the direct effect of a medical condition, this would be referred to as .

a. A somatic medical anxiety disorder. b. An anxiety disorder due to another medical condition. c. A pseudo-anxiety disorder. d. A psychosomatic anxiety disorder.

10. CBT involves three steps including: a. Challenging negative thoughts. b. Removing all negative thoughts. c. Aversive therapy. d. Biofeedback.

11. Patients treated with to have better outcomes than those treated with only one or the other. a. Inpatient treatment and group therapy. b. One to one and group therapy. c. Medication and psychotherapy. d. Hypnosis and medication.

12. Another promising treatment for specific phobias is through the use of .

a. Hypnotherapy (HT). b. Outcome-based reality (OR). c. Static stimuli (SS). d. Virtual reality (VR).

79 13. allows clients to gradually challenge fears, build confidence, and master skills for controlling panic.

a. Reverse reinforcement. b. Aversive therapy. c. Systematic desensitization. d. Reality therapy.

14. psychotherapies are the most highly recommended type of treatment for PTSD. a. Trauma-focused. b. Electroconvulsive. c. Cognitive-behavioral. d. Hypnosis and regression therapy.

15. Stimulus fading involves gradually . a. Reducing stimuli. b. Increasing exposure to a fear-evoking stimulus. c. Reducing exposure. d. Increasing intensity of stimuli for shorter periods of time.

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