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Anxiety Disorders Course meets the qualifications for 7 hours of continuing education credit for MFTs and/or LCSWs as required by the California Board of Behavioral Sciences―

Course Objectives:

Upon completion of this course, the LCSW or MFT or Healthcare professional will be able to:

1. Identify the physical signs of Anxiety Disorders

2. Describe the psychological effects

3. Identify the causes of Anxiety Disorders

4. Learn the Diagnostic Process of Anxiety Disorders

5. Describe the available treatment modalities for Anxiety Disorders

6. Identify and describe medications and their uses in treating Anxiety Disorders

7. Understand Risk Factors to Assess Prior to Treatment

8. Understand Symptoms and How Symptoms are Reinforced

Anxiety Disorders

Introduction Obsessive-Compulsive Disorder Post-Traumatic Disorder Social ( Disorder) Specific Generalized What Causes Anxiety Disorders Diagnosis of Anxiety Disorders Anxiety Disorders in Children Treatment of Anxiety Disorders Medications use in Anxiety Disorders Psychotherapies for Anxiety Disorders Risk Factors to Assess Prior to Treatment Facts About Anxiety Disorders Symptoms and How Symptoms are Reinforced References

Introduction

Anxiety disorders are the most common of all the disorders. Considered in the category of anxiety disorders are: Generalized Anxiety Disorder, Panic Disorder, , Social Phobia, Obsessive Compulsive Disorder, , Post-Traumatic Stress Disorder, and . Anxiety disorders as a whole cost the United States between 42- 46 billion dollars a year in direct and indirect healthcare costs, which is a third of the yearly total mental health bill of 148 billion dollars. In the United States, social phobia is the most common anxiety disorder with approximately 5.3 million people per year suffering from it. Approximately 5.2 million people per year suffer from post-traumatic stress disorder. Estimates for panic disorder range between 3 to 6 million people per year, an anxiety disorder that twice as many women suffer from as men. Specific phobias affect more than 1 out of every 10 people with the prevalence for women being slightly higher than for men. Obsessive Compulsive disorder affects about every 2 to 3 people out of 100, with women and men being affected equally.

Many people still carry the misperception that anxiety disorders are a character flaw, a problem that happens because you are weak. They say, "Pull yourself up by your own bootstraps!" and "You just have a case of the nerves." Wishing the symptoms away does not work -- but there are treatments that can help.

Anxiety disorders and panic attacks are not signs of a character flaw. Most importantly, feeling anxious is not a person's fault. It is a serious , which affects a person's ability to function in every day activities. It affects one's work, one's family, and one's social life.

Today, much more is known about the causes and treatment of this mental health problem. We know that there are biological and psychological components to every anxiety disorder and that the best form of treatment is a combination of cognitive-behavioral psychotherapy interventions. Depending upon the severity of the anxiety, medication is used in combination with psychotherapy. Contrary to the popular misconceptions about anxiety disorders today, it is not a purely biochemical or medical disorder.

There are as many potential causes of anxiety disorders as there are people who suffer from them. Family history and genetics play a part in the greater likelihood of someone getting an anxiety disorder in their lifetime. Increased stress and inadequate coping mechanisms to deal with that stress may also contribute to anxiety. Anxiety symptoms can result from such a variety of factors including having had a traumatic experience, having to face major decisions in a one's life, or having developed a more fearful perspective on life. Anxiety caused by medications or substance or alcohol abuse is not typically recognized as an anxiety disorder.

Effective treatments for anxiety disorders are available, and research is yielding new, improved therapies that can help most people with anxiety disorders lead productive, fulfilling lives.

Panic Disorder

Case Examples: "It started 10 years ago, when I had just graduated from college and started a new job. I was sitting in a business seminar in a hotel and this thing came out of the blue. I felt like I was dying."

"For me, a is almost a violent experience. I feel disconnected from reality. I feel like I'm losing control in a very extreme way. My heart pounds really hard, I feel like I can't get my breath, and there's an overwhelming feeling that things are crashing in on me."

"In between attacks there is this dread and anxiety that it's going to happen again. I'm afraid to go back to places where I've had an attack. Unless I get help, there soon won't be anyplace where I can go and feel safe from panic."

People with panic disorder have feelings of terror that strike suddenly and repeatedly with no warning. They can't predict when an attack will occur, and many develop intense anxiety between episodes, worrying when and where the next one will strike.

If someone is having a panic attack, most likely his or her heart will pound and you he or she may feel sweaty, weak, faint, or dizzy. Hands may tingle or feel numb, and the person might feel flushed or chilled. The person may have nausea, chest pain or smothering sensations, a sense of unreality, or fear of impending doom or loss of control. The person may genuinely believe he or she having a heart attack or losing his or her mind, or on the verge of death. Panic attacks can occur at any time, even during sleep. An attack generally peaks within 10 minutes, but some symptoms may last much longer.

Panic disorder affects about 2.4 million adult Americans1 and is twice as common in women as in men. It most often begins during late adolescence or early adulthood. Risk of developing panic disorder appears to be inherited. Not everyone who experiences panic attacks will develop panic disorder—for example, many people have one attack but never have another. For those who do have panic disorder, though, it's important to seek treatment. Untreated, the disorder can become very disabling.

Many people with panic disorder visit the hospital emergency room repeatedly or see a number of doctors before they obtain a correct diagnosis. Some people with panic disorder may go for years without learning that they have a real, treatable illness.

Panic disorder is often accompanied by other serious conditions such as , drug abuse, or alcoholism and may lead to a pattern of avoidance of places or situations where panic attacks have occurred. For example, if a panic attack strikes while a person is riding in an elevator, the person may develop a fear of elevators. If he or she starts avoiding them, that could affect his or her choice of a job or apartment and greatly restrict other parts of his or her life.

Some people's lives become so restricted that they avoid normal, everyday activities such as grocery shopping or driving. In some cases they become housebound. Or, they may be able to confront a feared situation only if accompanied by a spouse or other trusted person.

Basically, these people avoid any situation in which they would feel helpless if a panic attack were to occur. When people's lives become so restricted, as happens in about one-third of people with panic disorder,2 the condition is called agoraphobia. Early treatment of panic disorder can often prevent agoraphobia.

Panic disorder is one of the most treatable of the anxiety disorders, responding in most cases to medications or carefully targeted psychotherapy. You may genuinely believe you're having a heart attack, losing your mind, or are on the verge of death. Attacks can occur at any time, even during sleep.

Obsessive-Compulsive Disorder

Case Examples:

"I couldn't do anything without rituals. They invaded every aspect of my life. Counting really bogged me down. I would wash my hair three times as opposed to once because three was a good luck number and one wasn't. It took me longer to read because I'd count the lines in a paragraph. When I set my alarm at night, I had to set it to a number that wouldn't add up to a "bad" number."

"Getting dressed in the morning was tough because I had a routine, and if I didn't follow the routine, I'd get anxious and would have to get dressed again. I always worried that if I didn't do something, my parents were going to die. I'd have these terrible thoughts of harming my parents. That was completely irrational, but the thoughts triggered more anxiety and more senseless behavior. Because of the time I spent on rituals, I was unable to do a lot of things that were important to me.

"I knew the rituals didn't make sense, and I was deeply ashamed of them, but I couldn't seem to overcome them until I had therapy."

Obsessive-compulsive disorder, or OCD, involves anxious thoughts or rituals a person feels he or she can't control. If a person has OCD, he or she may be plagued by persistent, unwelcome thoughts or images, or by the urgent need to engage in certain rituals. He or she may be obsessed with germs or dirt, and wash his or her hands over and over. She or he may be filled with doubt and feel the need to check things repeatedly, or may have frequent thoughts of violence, and fear that she or he will harm people close to she or he. The person may spend long periods touching things or counting; and become pre-occupied by order or symmetry; she or he may have persistent thoughts of performing sexual acts that are repugnant; or she or he may be troubled by thoughts that are against his or her religious beliefs.

The disturbing thoughts or images are called obsessions, and the rituals that are performed to try to prevent or get rid of them are called compulsions. There is no pleasure in carrying out the rituals you are drawn to, only temporary relief from the anxiety that grows when you don't perform them.

A lot of healthy people can identify with some of the symptoms of OCD, such as checking the stove several times before leaving the house. But for people with OCD, such activities consume at least an hour a day, are very distressing, and interfere with daily life. Most adults with this condition recognize that what they're doing is senseless, but they can't stop it. Some people, though, particularly children with OCD, may not realize that their behavior is out of the ordinary.

OCD afflicts about 3.3 million adult Americans.1 It strikes men and women in approximately equal numbers and usually first appears in childhood, adolescence, or early adulthood. One-third of adults with OCD report having experienced their first symptoms as children. The course of the disease is variable—symptoms may come and go, they may ease over time, or they can grow progressively worse. Research evidence suggests that OCD might run in families.

Depression or other anxiety disorders may accompany OCD and some people with OCD also have eating disorders. In addition, people with OCD may avoid situations in which they might have to confront their obsessions, or they may try unsuccessfully to use alcohol or drugs to calm themselves. If OCD grows severe enough, it can keep someone from holding down a job or from carrying out normal responsibilities at home.

OCD generally responds well to treatment with medications or carefully targeted psychotherapy. The disturbing thoughts or images are called obsessions, and the rituals performed to try to prevent or get rid of them are called compulsions. There is no pleasure in carrying out the rituals you are drawn to, only temporary relief from the anxiety that grows when you don't perform them.

Post-Traumatic Stress Disorder

Case Example:

"I was raped when I was 25 years old. For a long time, I spoke about the rape as though it was something that happened to someone else. I was very aware that it had happened to me, but there was just no feeling. Then I started having flashbacks. They kind of came over me like a splash of water. I would be terrified. Suddenly I was reliving the rape. Every instant was startling. I wasn't aware of anything around me, I was in a bubble, just kind of floating. And it was scary. Having a flashback can wring you out. The rape happened the week before Thanksgiving, and I can't believe the anxiety and fear I feel every year around the anniversary date. It's as though I've seen a werewolf. I can't relax, can't sleep, don't want to be with anyone. I wonder whether I'll ever be free of this terrible problem."

Post-traumatic stress disorder (PTSD) is a debilitating condition that can develop following a terrifying event. Often, people with PTSD have persistent frightening thoughts and memories of their ordeal and feel emotionally numb, especially with people they were once close to. PTSD was first brought to public attention by war veterans, but it can result from any number of traumatic incidents. These include violent attacks such as mugging, rape, or torture; being kidnapped or held captive; child abuse; serious accidents such as car or train wrecks; and natural disasters such as floods or earthquakes. The event that triggers PTSD may be something that threatened the person's life or the life of someone close to him or her. Or it could be something witnessed, such as massive death and destruction after a building is bombed or a plane crashes.

Whatever the source of the problem, some people with PTSD repeatedly relive the trauma in the form of and disturbing recollections during the day. They may also experience other sleep problems, feel detached or numb, or be easily startled. They may lose interest in things they used to enjoy and have trouble feeling affectionate. They may feel irritable, more aggressive than before, or even violent. Things that remind them of the trauma may be very distressing, which could lead them to avoid certain places or situations that bring back those memories. Anniversaries of the traumatic event are often very difficult.

PTSD affects about 5.2 million adult Americans. About 30 percent of the men and women who have spent time in war zones experience PTSD. One million war veterans developed PTSD after serving in Vietnam. PTSD has also been detected among veterans of the Persian Gulf War, with some estimates running as high as 8 percent.

It can occur at any age, including childhood, and there is some evidence that susceptibility to PTSD may run in families. The disorder is often accompanied by depression, , or one or more other anxiety disorders. In severe cases, the person may have trouble working or socializing. In general, the symptoms seem to be worse if the event that triggered them was deliberately initiated by a person—such as a rape or kidnapping.

Ordinary events can serve as reminders of the trauma and trigger flashbacks or intrusive images. A person having a flashback, which can come in the form of images, sounds, smells, or feelings, may lose touch with reality and believe that the traumatic event is happening all over again. Not every traumatized person gets full-blown PTSD, or experiences PTSD at all. PTSD is diagnosed only if the symptoms last more than a month. In those who do develop PTSD, symptoms usually begin within 3 months of the trauma, and the course of the illness varies. Some people recover within 6 months, others have symptoms that last much longer. In some cases, the condition may be chronic. Occasionally, the illness doesn't show up until years after the traumatic event.

People with PTSD can be helped by medications and carefully targeted psychotherapy. Ordinary events can serve as reminders of the trauma and trigger flashbacks or intrusive images. Anniversaries of the traumatic event are often very difficult.

Social Phobia ()

Case Examples:

"In any social situation, I felt fear. I would be anxious before I even left the house, and it would escalate as I got closer to a college class, a party, or whatever. I would feel sick at my stomach—it almost felt like I had the flu. My heart would pound, my palms would get sweaty, and I would get this feeling of being removed from myself and from everybody else."

"When I would walk into a room full of people, I'd turn red and it would feel like everybody's eyes were on me. I was embarrassed to stand off in a corner by myself, but I couldn't think of anything to say to anybody. It was humiliating. I felt so clumsy, I couldn't wait to get out."

"I couldn't go on dates, and for a while I couldn't even go to class. My sophomore year of college I had to come home for a semester. I felt like such a failure." Social phobia, also called social anxiety disorder, involves overwhelming anxiety and excessive self-consciousness in everyday social situations. People with social phobia have a persistent, intense, and chronic fear of being watched and judged by others and being embarrassed or humiliated by their own actions. Their fear may be so severe that it interferes with work or school, and other ordinary activities. While many people with social phobia recognize that their fear of being around people may be excessive or unreasonable, they are unable to overcome it. They often worry for days or weeks in advance of a dreaded situation.

Social phobia can be limited to only one type of situation—such as a fear of speaking in formal or informal situations, or eating, drinking, or writing in front of others—or, in its most severe form, may be so broad that a person experiences symptoms almost anytime they are around other people. Social phobia can be very debilitating—it may even keep people from going to work or school on some days. Many people with this illness have a hard time making and keeping friends.

Physical symptoms often accompany the intense anxiety of social phobia and include blushing, profuse sweating, trembling, nausea, and difficulty talking. If you suffer from social phobia, you may be painfully embarrassed by these symptoms and feel as though all eyes are focused on you. You may be afraid of being with people other than your family.

People with social phobia are aware that their feelings are irrational. Even if they manage to confront what they fear, they usually feel very anxious beforehand and are intensely uncomfortable throughout. Afterward, the unpleasant feelings may linger, as they worry about how they may have been judged or what others may have thought or observed about them.

Social phobia affects about 5.3 million adult Americans. Women and men are equally likely to develop social phobia.0 The disorder usually begins in childhood or early adolescence, and there is some evidence that genetic factors are involved. Social phobia often co-occurs with other anxiety disorders or depression. Substance abuse or dependence may develop in individuals who attempt to "self-medicate" their social phobia by drinking or using drugs. Social phobia can be treated successfully with carefully targeted psychotherapy or medications.

Social phobia can severely disrupt normal life, interfering with school, work, or social relationships. The dread of a feared event can begin weeks in advance and be quite debilitating.

Specific Phobias

Case Examples:

"I'm scared to death of flying, and I never do it anymore. I used to start dreading a plane trip a month before I was due to leave. It was an awful feeling when that airplane door closed and I felt trapped. My heart would pound and I would sweat bullets. When the airplane would start to ascend, it just reinforced the feeling that I couldn't get out. When I think about flying, I picture myself losing control, freaking out, climbing the walls, but of course I never did that. I'm not afraid of crashing or hitting turbulence. It's just that feeling of being trapped. Whenever I've thought about changing jobs, I've had to think, 'Would I be under pressure to fly?' These days I only go places where I can drive or take a train. My friends always point out that I couldn't get off a train traveling at high speeds either, so why don't trains bother me? I just tell them it isn't a rational fear."

A specific phobia is an intense fear of something that poses little or no actual danger. Some of the more common specific phobias are centered around closed-in places, heights, escalators, tunnels, highway driving, water, flying, dogs, and injuries involving blood. Such phobias aren't just extreme fear; they are irrational fear of a particular thing. You may be able to ski the world's tallest mountains with ease but be unable to go above the 5th floor of an office building. While adults with phobias realize that these fears are irrational, they often find that facing, or even thinking about facing, the feared object or situation brings on a panic attack or severe anxiety.

Specific phobias affect an estimated 6.3 million adult Americans and are twice as common in women as in men.0 The causes of specific phobias are not well understood, though there is some evidence that these phobias may run in families. Specific phobias usually first appear during childhood or adolescence and tend to persist into adulthood.

If the object of the fear is easy to avoid, people with specific phobias may not feel the need to seek treatment. Sometimes, though, they may make important career or personal decisions to avoid a phobic situation, and if this avoidance is carried to extreme lengths, it can be disabling. Specific phobias are highly treatable with carefully targeted psychotherapy.

Phobias aren't just extreme fears; they are irrational fears. You may be able to ski the world's tallest mountains with ease but feel panic going above the 5th floor of an office building.

Generalized Anxiety Disorder

Case Examples:

"I always thought I was just a worrier. I'd feel keyed up and unable to relax. At times it would come and go, and at times it would be constant. It could go on for days. I'd worry about what I was going to fix for a dinner party, or what would be a great present for somebody. I just couldn't let something go."

"I'd have terrible sleeping problems. There were times I'd wake up wired in the middle of the night. I had trouble concentrating, even reading the newspaper or a novel. Sometimes I'd feel a little lightheaded. My heart would race or pound. And that would make me worry more. I was always imagining things were worse than they really were: when I got a stomachache, I'd think it was an ulcer."

"When my problems were at their worst, I'd miss work and feel just terrible about it. Then I worried that I'd lose my job. My life was miserable until I got treatment."

Generalized anxiety disorder (GAD) is much more than the normal anxiety people experience day to day. It's chronic and fills one's day with exaggerated worry and tension, even though there is little or nothing to provoke it. Having this disorder means always anticipating disaster, often worrying excessively about health, money, family, or work. Sometimes, though, the source of the worry is hard to pinpoint. Simply the thought of getting through the day provokes anxiety.

People with GAD can't seem to shake their concerns, even though they usually realize that their anxiety is more intense than the situation warrants. Their worries are accompanied by physical symptoms, especially fatigue, headaches, muscle tension, muscle aches, difficulty swallowing, trembling, twitching, irritability, sweating, and hot flashes. People with GAD may feel lightheaded or out of breath. They also may feel nauseated or have to go to the bathroom frequently.

Individuals with GAD seem unable to relax, and they may startle more easily than other people. They tend to have difficulty concentrating, too. Often, they have trouble falling or staying asleep. Unlike people with several other anxiety disorders, people with GAD don't characteristically avoid certain situations as a result of their disorder. When impairment associated with GAD is mild, people with the disorder may be able to function in social settings or on the job. If severe, however, GAD can be very debilitating, making it difficult to carry out even the most ordinary daily activities.

GAD affects about 4 million adult Americans and about twice as many women as men. The disorder comes on gradually and can begin across the life cycle, though the risk is highest between childhood and middle age. It is diagnosed when someone spends at least 6 months worrying excessively about a number of everyday problems. There is evidence that genes play a modest role in GAD. GAD is commonly treated with medications. GAD rarely occurs alone, however; it is usually accompanied by another anxiety disorder, depression, or substance abuse. These other conditions must be treated along with GAD.

What Causes Anxiety Disorders

Several parts of the brain are key actors in a highly dynamic interplay that gives rise to fear and anxiety. Using brain imaging technologies and neurochemical techniques, scientists are finding that a network of interacting structures is responsible for these emotions. Much research centers on the amygdala, an almond-shaped structure deep within the brain. The amygdala is believed to serve as a communications hub between the parts of the brain that process incoming sensory signals and the parts that interpret them. It can signal that a threat is present, and trigger a fear response or anxiety. It appears that emotional memories stored in the central part of the amygdala may play a role in disorders involving very distinct fears, like phobias, while different parts may be involved in other forms of anxiety.

Other research focuses on the hippocampus, another brain structure that is responsible for processing threatening or traumatic stimuli. The hippocampus plays a key role in the brain by helping to encode information into memories. Studies have shown that the hippocampus appears to be smaller in people who have undergone severe stress because of child abuse or military combat.5,6 This reduced size could help explain why individuals with PTSD have flashbacks, deficits in explicit memory, and fragmented memory for details of the traumatic event.

The Brain's Response to a Threat The Limbic System. The limbic system is a region deep in the brain that is most important in responding and storing information on a real or perceived threat. The following regions in this system are particularly important in the fear response: ·

Hypothalamus: The hypothalamus is a small structure that regulates body temperature, appetite, sexual behavior, and reproductive hormones. The hypothalamus plays a role in controlling our behavior such as eating, sexual behavior and sleeping, and regulates body temperature, emotions, secretion of hormones and movement. ·

The Pituitary Gland: The pituitary gland develops from an extension of the hypothalamus downwards. It is involved in controlling thyroid functions, the adrenal glands, growth and sexual maturation. The back part of the pituitary gland regulates urine production. ·

Thalamus: The thalamus serves as a relay station for almost all information that comes and goes to the cortex (the outer portion of the brain). It plays a role in pain sensation, attention and alertness.

Hippocampus: The hippocampus stores memory, including emotional memories. Amygdala. This small-almond like structure lies deep in the brain and connects with the hippocampus and other parts of the brain. It is associated with regulation and control of major emotional activities, including anxiety, depression, aggression, and affection.

Researchers have specifically identified the hypothalamic-pituitary-adrenal (HPA) axis, as an important region in the fear response.

Release of Steroid Hormones. The HPA systems trigger the production and release of steroid hormones ( glucocorticoids), including the primary stress hormone cortisol. Cortisol is very important in marshaling systems throughout the body (including the heart, lungs, circulation, metabolism, immune systems, and skin) to deal quickly with the threat. Among the physical consequences are the following:

. The heart rate and blood pressure increase instantaneously.

·Breathing becomes rapid and the lungs take in more oxygen. Blood flow may actually increase 300% to 400%, priming the muscles, lungs, and brain for added demands. Release of Neurotransmitters. The HPA system also releases certain neurotransmitters (chemical messengers). Those of particular importance in the fear response are dopamine, norepinephrine, and epinephrine (also called adrenaline), glutamate, (gamma)-aminobutyric acid (GABA), and serotonin.

· Neurotransmitters activate the amygdala, which apparently triggers the brain's response to emotions to a stressful event.

· Neurotransmitters then signal the hippocampus to store the emotionally loaded experience in long-term memory. In primitive times, this combination of responses would have been essential for survival, when long-lasting memories of dangerous stimuli would be critical for avoiding such threats in the future.

· During a stressful event, neurotransmitters also suppress activity in areas at the front of the brain concerned with short-term memory, concentration, inhibition, and rational thought. This sequence of mental events allows a person to react quickly to the threat, either to fight or to flee from it. (It also hinders the ability to handle complex social or intellectual tasks and behaviors.)

Also, research indicates that other brain parts called the and are involved in obsessive-compulsive disorder.7

By learning more about brain circuitry involved in fear and anxiety, scientists may be able to devise new and more specific treatments for anxiety disorders. For example, it someday may be possible to increase the influence of the thinking parts of the brain on the amygdala, thus placing the fear and anxiety response under conscious control. In addition, with new findings about neurogenesis (birth of new brain cells) throughout life,8 perhaps a method will be found to stimulate growth of new neurons in the hippocampus in people with PTSD.

Studies of twins and families suggest that genes play a role in the origin of anxiety disorders. But heredity alone can't explain what goes awry. Experience also plays a part. In PTSD, for example, trauma triggers the anxiety disorder; but genetic factors may explain why only certain individuals exposed to similar traumatic events develop full-blown PTSD. Researchers are attempting to learn how genetics and experience interact in each of the anxiety disorders—information they hope will yield clues to prevention and treatment.

Scientists are also conducting clinical trials to find the most effective ways of treating anxiety disorders. For example, one trial is examining how well medication and behavioral therapies work together and separately in the treatment of OCD. Another trial is assessing the safety and efficacy of medication treatments for anxiety disorders in children and adolescents with co-occurring attention deficit hyperactivity disorder (ADHD). Diagnosis of Anxiety Disorders

An anxiety disorder, however, is an excessive or inappropriate aroused state characterized by feelings of apprehension, uncertainty, or fear. The word is derived from the Latin, angere, which means to choke or strangle. The anxiety response is often not attributable to a real threat; nevertheless it can still paralyze the individual into inaction or withdrawal. An anxiety disorder also persists, while a healthy response to a threat resolves once the threat is removed.

Anxiety disorders have been classified according to the severity and duration of their symptoms and specific behavioral characteristics. Categories include:

· Generalized anxiety disorder (GAD), which is long-lasting and low-grade. · Panic disorder, which has more dramatic symptoms. · Phobias. · Obsessive-compulsive disorder (OCD). · Post-traumatic stress disorder (PTSD). · Separation anxiety disorder (nearly always only in children).

GAD and panic disorder are the most common. Anxiety disorders are usually caused by a combination of psychological, physical, and genetic factors, and treatment is, in general, very effective.

Generalized anxiety disorder (GAD) is the most common anxiety disorder, and affects about 5% of Americans over the course of their lifetimes. It is characterized by the following:

· A more-or-less constant state of worry and anxiety, which is out of proportion to the level of actual stress or threat in their lives.

· This state occurs on most days for more than six months despite the lack of an obvious or specific stressor. (It worsens with stress, however.)

· It is very difficult to control worry. For a clear diagnosis of GAD, the specific worries should be differentiated from those that would define other anxiety disorders, such as fear of panic attacks or appearing in public, nor are they obsessive as in obsessive-compulsive disorder. (It should be noted, however, that over half of those with GAD also have another anxiety disorder or depression.)

· Patients may experience anxiety physically (such as with gastrointestinal complaints) in addition to, or even in place of, mental worries. (This latter case may be more common in people from non-Western cultures such as those with Asian backgrounds.)

· People with GAD tend to be unsure of themselves and overly perfectionist and conforming. Given these conditions, a diagnosis of GAD is then confirmed if three or more of the following symptoms are present (only one for children) on most days for six months:

· Being on edge or very restless. · Feeling tired. · Having difficulty concentrating. · Being irritable. · Having muscle tension. · Experiencing sleep disturbances. Symptoms should cause significant distress and impair normal functioning and not be due to a medical condition or to another mood disorder or . People with GAD may be likely to experience bouts of depression between episodes of anxiety.

Panic Disorder Diagnosis

Panic disorder is characterized by periodic attacks of anxiety or terror ( panic attacks ). They usually last 15 to 30 minutes, although residual effects can persist much longer. The frequency and severity of acute states of anxiety determine the diagnosis. (It should be noted that panic attacks can occur in nearly every anxiety disorder, not just panic disorder. In other anxiety disorders, however, there is always a cue or specific trigger for the attack.) A diagnosis of panic disorder is made under the following conditions:

· A person experiences at least two recurrent, unexpected panic attacks. · For at least a month following the attacks, the person fears that another will occur.

Symptoms of a Panic Attack. During a panic attack a person feels intense fear or discomfort with at least four or more of the following symptoms:

· Rapid heart . · Sweating. · Shakiness. · Shortness of breath. · A choking feeling. · Dizziness. · Nausea. · Feelings of unreality. · Numbness. · Either hot flashes or chills. · Chest pain. · A fear of dying. · A fear of going insane.

Panic attacks that include only one or two symptoms, such as dizziness and heart pounding, are known as limited-symptom attacks . These may be either residual symptoms after a major panic attack or precursors to full-blown attacks. (It should be noted that panic attacks can also accompany other anxiety disorders, such as phobias and post-traumatic stress disorder. In such cases, however, additional characteristics differentiate these disorders from panic disorder.)

Frequency of Panic Attacks. Frequency of attacks can vary widely. Some people have frequent attacks (for example, every week) that occur for months; others may have clusters of daily attacks followed by weeks or months of remission.

Triggers of Panic Attacks. Panic attacks may occur spontaneously or in response to a particular situation. Recalling or re-experiencing even harmless circumstances surrounding an original attack may trigger subsequent panic attacks.

Phobic Disorders Diagnosis

Phobias, manifested by overwhelming and irrational fears, are common. In most cases, people can avoid or at least endure phobic situations, but in some cases, as with agoraphobia, the anxiety associated with the feared object or situation can be incapacitating. Agoraphobia. Agoraphobia has been somewhat misleadingly described as fear of open spaces, the term having been derived from the Greek word agora, meaning outdoor marketplace. In its severest form, agoraphobia is characterized by a paralyzing terror of being in places or situations from which the patient feels there is neither escape nor accessible help in case of an attack. (One patient described the terror of going outside as opening a door onto a landscape filled with snakes.) Consequently, people with agoraphobia confine themselves to places in which they feel safe, usually at home. The patient with agoraphobia often makes complicated plans in order to avoid confronting feared situations and places.

Social Phobia. Social phobia, also known as social anxiety disorder, is the fear of being publicly scrutinized and humiliated and is manifested by extreme shyness and discomfort in social settings. This phobia often leads people to avoid social situations and is not due to a physical or mental problem (such as , acne, or personality disorders). The incidence of social phobia is approximately 13% and has been termed "the neglected anxiety disorder" because it is often missed as a diagnosis.

The associated symptoms vary in intensity, ranging from mild and tolerable anxiety to a full-blown panic attack; symptoms include sweating, shortness of breath, pounding heart, dry mouth, and tremor.

The disorder may be further categorized as generalized or specific social phobia: · Generalized social phobia is the fear of being humiliated in front of other people during most social situations.

· Specific social phobia usually involves a phobic response to a specific event. Performance anxiety ("") is the most common specific social phobia and occurs when a person must perform in public.

· with social anxiety develop symptoms in settings that include their peers, not just adults, and they may include tantrums, blushing, or not being able to speak to unfamiliar people. These children should be able to have normal social relationships with familiar people, however.

Specific Phobias Diagnosis

Specific phobias (formerly simple phobias) is an irrational fear of specific objects or situations. Specific phobias are among the most common medical disorders. Most cases are mild, however, and not significant enough to require treatment.

The most common phobias are fear of animals (usually spiders, snakes, or mice), flying ( pterygophobia), heights ( acrophobia), water, injections, public transportation, confined spaces ( ), dentists ( odontiatophobia), storms, tunnels, and bridges.

When confronting the object or situation, the phobic person experiences panicky feelings, sweating, avoidance behavior, difficulty breathing, and a rapid heartbeat. Most phobic adults are aware of the irrationality of their fear, and many endure intense anxiety rather than disclose their disorder.

Obsessive-Compulsive Disorder Diagnosis

Obsessive-compulsive disorder (OCD) has been described as hiccups of the mind. OCD is time-consuming, distressing, and can disrupt normal functioning. Much research suggests that a critical feature in this disorder is an overinflated sense of responsibility, in which the patient's thoughts center around possible dangers and an urgent need to do something about it.

Obsessions are recurrent or persistent mental images, thoughts, or ideas. The obsessive thoughts or images can range from mundane worries about whether one has locked a door to bizarre and frightening fantasies of behaving violently toward a loved one.

Compulsive behaviors are repetitive, rigid, and self-prescribed routines that are intended to prevent the manifestation of an associated obsession. Such compulsive acts might include repetitive checking for locked doors or unlit stove burners or calls to loved ones at frequent intervals to be sure they are safe. Some people are compelled to wash their hands every few minutes or to spend inordinate amounts of time cleaning their surroundings in order to subdue the fear of contagion.

Over half of OCD-sufferers have obsessive thoughts without the ritualistic . Although individuals recognize that the obsessive thoughts and ritualized behavior patterns are senseless and excessive, they cannot stop them in spite of strenuous efforts to ignore or suppress the thoughts or actions. OCD often accompanies depression or other anxiety disorders. There is some evidence that the symptoms improve over time and that nearly half will eventually recover completely or have only minor symptoms.

Symptoms in children may be mistaken for behavioral problems (taking too long to do homework because of perfectionism, refusing to perform a chore because of fear of germs). Children do not usually recognize that their obsessions or compulsions are excessive.

Associated Obsessive Disorders. Certain other disorders that may be part of, or strongly associated with, the OCD spectrum include the following:

· (BDD). In BDD, people are obsessed with the belief that they are ugly, or part of their body is abnormally shaped.

· . People with trichotillomania continually pull their hair, leaving bald patches.

· Tourettes syndrome. Symptoms of Tourettes syndrome include jerky movements, , and uncontrollably uttering obscene words.

Obsessive-Compulsive Personality. OCD should not be confused with obsessive-compulsive personality, which defines certain character traits (eg, being a perfectionist, excessively consciousness, morally rigid, or preoccupied with rules and order). These traits do not necessarily occur in people with obsessive-compulsive disorder, which is a psychiatric condition.

Post-Traumatic Stress Disorder Diagnosis

Post-traumatic stress disorder (PTSD) is an extreme and usually chronic emotional reaction to a traumatic event that severely impairs ones life; it is classified as an anxiety disorder because of the similarity of symptoms. Triggering Events. PTSD is triggered by violent or traumatic events that are usually outside the norm of human experience. The symptoms are the same whether the triggering event is a violent action or natural disaster. Such events include, but are not limited to, experiencing or even witnessing sexual assaults, accidents, combat, natural disasters (such as earthquakes), or unexpected deaths of loved ones. PTSD may also occur in people who have serious illness and receive aggressive treatments or who have close family members or friends with such conditions.

Acute Stress Disorder: Warning Symptoms. Experts have identified a syndrome called acute stress disorder, which occurs within two days to four weeks after the traumatic event. This syndrome may help predict who is at highest risk for PTSD. To be diagnosed with acute stress disorder, victims should meet these criteria:

· They are exposed to traumatic events in which they witness or have been confronted by an actual or potential threat of death, serious injury, or physical harm (such as rape) to themselves or others.

· Their response is one of fear, helplessness, or horror. In addition, during or after these experiences, they must have three or more of the following: an emotional numbness, being in a daze, a sense of losing contact with external reality, a feeling of loss of self or identity, or inability to remember important aspects of the event. (Such symptoms indicate a psychological state known as dissociation.)

· They persistently re-experience the trauma in at least one of the following ways: in recurrent images, thoughts, flashbacks, dreams, or feelings of distress at situations that remind them of the traumatic event.

· They avoid reminders of the event, such as thoughts, people, or any other factors that trigger recollection. · They have symptoms of anxiety or heightened awareness of danger (sleeplessness, irritability, being easily startled, or becoming overly vigilant to unknown dangers).

· Their emotional state significantly impairs normal function and relationships, and they fail to seek necessary help.

· The condition occurs within four weeks of the event and lasts for at least two days and up to four weeks. · The condition is not due to alcohol, medications, or drugs and is not an intensification of a pre-existing psychological disorder.

The criteria for acute stress disorder are accurate at identifying up to 94% of victims at risk for PTSD, and between 50% and 80% actually develop the more chronic and serious disorder. In other words, it is very sensitive for identification of those at highest danger for PTSD but less successful in determining specifically who will or will not recover emotionally.

Symptoms of Full-Blown PTSD. They are usually similar to those of acute stress disorder with certain differences:

· Symptoms of PTSD can occur months or even years after the traumatic event. · They last beyond a month and are much more severe. · They are chronic (three months or more). · Other symptoms of PTSD may include: · Emotional withdrawal. · Phobic avoidance of reminders of the trauma that become severe enough to impair personal and work relationships. · Hopelessness. · Self-destructive behavior. · Personality changes. · Mood swings. · Difficulty with sleep. · Other anxiety disorder. · Guilt over surviving the event.

In children, engaging in play in which traumatic events are repetitively enacted.

Long-Term Outlook. The long-term impact of a traumatic event is uncertain. In one study of people who survived a mass killing-spree in Texas, less than half of those who suffered PTSD (28% of all survivors) had recovered after a year. In another study, PTSD became chronic in 46% of the subjects. In fact, PTSD may cause actual physical changes in the brain and can last a lifetime in some cases.

Anxiety Disorders in Children

Separation Anxiety Disorder

Separation anxiety disorder almost always occurs in children. It is suspected in children who are excessively anxious about separation from important family members or from home. For a diagnosis of separation anxiety disorder, the child should also exhibit at least three of the following symptoms for at least four week:

· Extreme distress from either anticipating or actually being away from home or separated from a parent or other loved one.

· Extreme worry about losing or about possible harm befalling a loved one.

· Intense worry about getting lost, being kidnapped, or otherwise separated from loved ones.

· Frequent refusal to go to school or to sleep away from home.

· Experiencing physical symptoms, such as headache, stomach ache, or even vomiting, when faced with separation from loved ones.

Separation anxiety often disappears as the child grows older, but if not addressed, it may lead to further anxiety disorders, such as panic disorder, agoraphobia, or combinations of anxiety disorders.

DSM IV Anxiety Disorders Classification

Agoraphobia

* The patient has anxiety about being in a place or situation from which either or both -Escape was difficult or embarrassing or -If a panic attack occurred, help might not be available

* The patient: -Avoids these situations or places (restricting travel) or -Endures them, but with material distress (a panic attack might occur) or -Requires a companion when in the situation

* Other mental disorders don't explain the symptoms better. *

Coding Notes

By itself, agoraphobia is not a codable DSM-IV diagnosis. Criteria for it (and, below, panic attack) are presented to help clarify the picture of this common clinical condition.

* These include Social Phobias (the patient avoids eating for fear of embarrassment); Specific Phobias (avoids certain limited situations, such as telephone booths); Obsessive-Compulsive Disorder (avoids dirt for fear of contamination); Posttraumatic Stress Disorder (for example, the patient avoids movies about Vietnam). Children who avoid leaving home should be evaluated for Separation Anxiety Disorder.

Agoraphobia Without History of Panic Disorder

* The patient has agoraphobia (page 206) related to the fear of experiencing panic-like symptoms.

* The patient has never fulfilled criteria for Panic Disorder (page 215).

* The symptoms are not directly caused by a general medical condition or by substance use, including medications and drugs of abuse.

* If the patient does have a general medical condition, the fears clearly exceed those that usually accompany it.

Coding Note

The "panic-like symptoms" mentioned above can include any of the panic attack symptoms plus any other symptoms that could embarrass or incapacitate the patient. For example, the patient might refuse to leave home for fear of losing bladder control.

Panic Attack

* The patient suddenly develops a severe fear or discomfort that peaks within 10 minutes.

* During this discrete episode, 4 or more of the following symptoms occur: -Chest pain or other chest discomfort -Chills or hot flashes -Choking sensation -Derealization (feeling unreal) or depersonalization (feeling detached from self) -Dizzy, lightheaded, faint or unsteady -Fear of dying -Fears of loss of control or becoming insane -Heart pounds, races or skips beats -Nausea or other abdominal discomfort -Numbness or tingling -Sweating -Shortness of breath or smothering sensation -Trembling

No-Coding Note

By itself, panic attack is not a codable DSM-IV diagnosis. Criteria for it (and, above, agoraphobia) are presented to help clarify the picture of this common clinical condition.

Panic Disorder With Agoraphobia

* The patient has recurrent panic attacks that are not expected.

* For a month or more after at least 1 of these attacks, the patient has had 1 or more of: -Ongoing concern that there will be more attacks -Worry as to the significance of the attack or its consequences (for health, control, sanity) -Material change in behavior, such as doing something to avoid or combat the attacks -The patient also has agoraphobia

* The panic attacks are not directly caused by a general medical condition or by substance use, including medications and drugs of abuse.

* The panic attacks are not better explained by another Anxiety or .*

Coding Note

*DSM-IV specifically notes that panic attacks can occur in the following Anxiety Disorders, which should be ruled out before diagnosing agoraphobia: Social Phobias; Specific Phobias; Obsessive-Compulsive Disorder; Posttraumatic Stress Disorder. Children who have panic attacks on leaving home should be evaluated for Separation Anxiety Disorder.

Panic Disorder Without Agoraphobia

* The patient has recurrent panic attacks that are not expected.

* For a month or more after at least 1 of these attacks, the patient has had 1 or more of: -Ongoing concern that there will be more attacks -Worry as to the significance of the attack or its consequences (for health, control, sanity) -Material change in behavior, such as doing something to avoid or combat the attacks

* The patient does not have agoraphobia

* The panic attacks are not directly caused by a general medical condition or by substance use, including medications and drugs of abuse.

* The panic attacks are not better explained by another Anxiety or Mental Disorder.*

Coding Note

*DSM-IV specifically notes that panic attacks can occur in the following Anxiety Disorder, which should be ruled out before diagnosing agoraphobia: Social Phobias; Specific Phobias; Obsessive-Compulsive Disorder; Posttraumatic Stress Disorder. Children who have panic attacks on leaving home should be evaluated for Separation Anxiety Disorder.

Specific Phobia

* The patient experiences a strong, persistent fear that is excessive or unreasonable. It is set off (cued) by a specific object or situation that is either present or anticipated.

* The phobic stimulus almost always immediately provokes an anxiety response, which may be either a panic attack or symptoms of anxiety that do not meet criteria for a panic attack.

* The fear is unreasonable or out of proportion, and the patient realizes this.*

* The patient either avoids the phobic stimulus or endures it with severe anxiety or distress.

* Patients under the age of 18 must have the symptoms for 6 months or longer.

* Either there is marked distress about this fear or it markedly interferes with the patient's usual routines or social, job or personal functioning.

* The symptoms are not better explained by a different mental disorder, including Anxiety Disorders,** Dysmorphic Disorder, Pervasive or Schizoid .

Specify type:*** Situational Type (airplane travel, being closed in) Natural Environment Type (thunderstorms, heights, for example) Blood, Injection, Injury Type Animal Type (spiders, snakes) Other Type (situations that might lead to illness, choking, vomiting) Coding Notes

*Children with Specific Phobia may express the anxiety response by clinging, crying, freezing or tantrums. They may not have insight that their fear is unreasonable or out of proportion. "Other Type" in children can include avoiding loud noises or people in costumes.

**DSM-IV specifically notes some of the other Anxiety Disorders that should be ruled out before diagnosing Specific Phobia: Social Phobias (the patient avoids public eating or other activities for fear of embarrassment); Obsessive-Compulsive Disorder (fears dirt or contamination); Posttraumatic Stress Disorder (for example, the patient avoids movies about Vietnam); agoraphobia (with or without Panic Disorder). Children who avoid leaving home should be evaluated for Separation Anxiety Disorder.

***The types of Specific Phobia are arranged in descending order of frequency (as found in adults). If more than one type is present, code them all.

Social Phobia

* The patient strongly, repeatedly fears at least one social or performance situation that involves facing strangers or being watched by others. The patient specifically fears showing anxiety symptoms or behaving in some other way that will be embarrassing or humiliating. * The phobic stimulus almost always causes anxiety, which may be a cued or situationally predisposed panic attack.

* The patient realizes that this fear is unreasonable or out of proportion.

* The patient either avoids the situation or endures it with severe distress or anxiety.*

* Either there is marked distress about having the phobia or it markedly interferes with the patient's usual routines or social, job or personal functioning.

* Patients under the age of 18 must have the symptoms for 6 months or longer.

* The symptoms are not better explained by a different mental disorder, including Anxiety Disorders, Dysmorphic Disorder, Pervasive Developmental Disorder or Schizoid Personality Disorder.

* The symptoms are not directly caused by a general medical condition or by substance use, including medications and drugs of abuse.

* If the patient has another mental disorder or a general medical condition, the phobia is not related to it.

Specify whether Generalized. The patient fears most social situations. Coding Notes

*Children cannot receive this diagnosis unless they have demonstrated the capacity for social relationships. They anxiety must occur not just with adults, but with peers. They may express the anxiety response by clinging, crying, freezing or withdrawing. They may not recognize that the fear is unreasonable, or out of proportion.

If the Social Phobia is Generalized, evaluate the patient for an Axis II diagnosis of Avoidant Personality Disorder.

Obsessive-Compulsive Disorder

* The patient has obsessions or compulsions, or both. Obsessions. The patient must have all of: 1 Recurring, persisting thoughts, impulses or images inappropriately intrude into awareness and cause marked distress or anxiety. 2 These ideas are not just excessive worries about ordinary problems. 3 The patient tries to ignore or suppress these ideas or to neutralize them by thoughts or behavior. 4 There is insight that these ideas are a product of the patient's own mind.

Compulsions. The patient must have all of: 1 The patient feels the need to repeat physical behaviors (checking the stove to be sure it is off, handwashing) or mental behaviors (counting things, silently repeating words). 2 These behaviors occur as a response to an obsession or in accordance with strictly applied rules. 3 The aim of these behaviors is to reduce or eliminate distress or to prevent something that is dreaded. 4 These behaviors are either not realistically related to the events they are supposed to counteract or they are clearly excessive for that purpose.

* During some part of the illness the patient recognizes that the obsessions or compulsions are unreasonable or excessive.*

* The obsessions and/or compulsions are associated with at least 1 of: -Cause severe distress -Take up time (more than an hour per day) -Interfere with the patient's usual routine or social, work or personal functioning

* If the patient has another Axis I disorder, the content of obsessions or compulsions is not restricted to it.

* The symptoms are not directly caused by a general medical condition or by substance use, including medications and drugs of abuse.

Specify if With Poor Insight. During most of this episode the patient does not realize that these thoughts and behaviors are unreasonable or excessive. Coding Notes

*Children to not have to have insight.

DSM-IV specifies preoccupations typical of other Axis I disorders that must be ruled out: appearance (Body Dysmorphic Disorder); food (Eating Disorders); being seriously ill (); guilt (Mood Disorders); sexual fantasies or urges (); drugs (Substance Use Disorders); hair pulling (Trichotillomania).

Posttraumatic Stress Disorder

* The patient has experienced or witnessed or was confronted with an unusually traumatic event that has both of these elements: The event involved actual or threatened death or serious physical injury to the patient or to others, and The patient felt intense fear, horror or helplessness*

* The patient repeatedly relives the event in at least 1 of these ways: -Intrusive, distressing recollections (thoughts, images)* -Repeated, distressing dreams* -Through flashbacks, hallucinations or illusions, acts or feels as if the event were recurring (includes experiences that occur when intoxicated or awakening)* -Marked mental distress in reaction to internal or external cues that symbolize or resemble the event. -Physiological reactivity (such as rapid heart beat, elevated blood pressure) in response to these cues

* The patient repeatedly avoids the trauma-related stimuli and has numbing of general responsiveness (absent before the traumatic event) as shown by 3 or more of: -Tries to avoid thoughts, feelings or conversations concerned with the event -Tries to avoid activities, people or places that recall the event -Cannot recall an important feature of the event -Marked loss of interest or participation in activities important to the patient -Feels detached or isolated from other people -Restriction in ability to love or feel other strong emotions -Feels life will be brief or unfulfilled (lack of marriage, job, children)

* At least 2 of the following symptoms of hyperarousal were not present before the traumatic event: - (initial or interval) -Irritability -Poor concentration -Hypervigilance -Increased startle response

* The above symptoms have lasted longer than one month.

* These symptoms cause clinically important distress or impair work, social or personal functioning.

Specify whether:

Acute. Symptoms have lasted less than 3 months

Chronic. Symptoms have lasted 3 months or longer

Specify if:

With Delayed Onset. The symptoms did not appear until at least 6 months after the event. Coding note

*In children, response to the traumatic event may be agitation or disorganized behavior. Young children may relive the event through repetitive play, trauma-specific reenactment or nightmares without recognizable content.

Acute Stress Disorder

* The patient has experienced or witnessed or was confronted with an unusually traumatic event that has both of these elements: 1 The event involved actual or threatened death or serious physical injury to the patient or to others, and 2 The patient felt intense fear, horror or helplessness.

* Either during the event or just afterward, the patient experiences 3 or more of these symptoms of dissociation: -Feels numbed or detached or is unresponsive emotionally -Seems less aware of surroundings, as in a daze -Derealization -Depersonalization - for important aspects of the event

* The patient repeatedly reexperiences the event in one or more of these ways: -Recollections (dreams, flashbacks, illusions, images, thoughts) -The sense of reliving the event -Mental distress as a reaction to reminders of the event * The patient strongly avoids activities, conversations, feelings, people, places or thoughts reminiscent of the trauma.

* There are marked symptoms of anxiety or hyperarousal, such as hypervigilance, insomnia, irritability, poor concentration, restlessness or increased startle response.

* At least 1 of the following applies: -The patient feels marked distress from the symptoms -They interfere with usual social, job or personal functioning. -They block the patient from doing something important such as getting legal or medical help or telling family or other supporters about the experience

* The symptoms begin within 4 weeks of the trauma and last from 2 days to 4 weeks.

* The symptoms are not directly caused by a general medical condition or by substance use, including medications and drugs of abuse.

* They are not merely a worsening of another Axis I or Axis II disorder.

* is ruled out.

Generalized Anxiety Disorder

* For more than half the days in at least 6 months, the patient experiences excessive anxiety and worry about several events or activities.

* The patient has trouble controlling these feelings.

* Associated with this anxiety and worry, the patient has 3 or more of the following symptoms, some of which are present for over half the days in the past 6 months:* -Feels restless, edgy, keyed up -Tires easily -Trouble concentrating -Irritability -Increased muscle tension -Trouble sleeping (initial insomnia or restless, unrefreshing sleep)

* · Aspects of another Axis I disorder do not provide the focus of the anxiety and worry.**

* The symptoms cause clinically important distress or impair work, social or personal functioning.

* The disorder is not directly caused by a general medical condition or by substance use, including medications and drugs of abuse.

* It does not occur only during a Mood Disorder, Psychotic Disorder, Posttraumatic Stress Disorder or Pervasive Developmental Disorder.

Coding Notes

*Children need fulfill only 1 of these 6 symptoms. **Aspects of another Axis I disorder include worry about: weight gain (); contamination (Obsessive-Compulsive Disorder); having a panic attack (Panic Disorder); separation from home or relatives (Separation Anxiety Disorder); public embarrassment (Social Phobia); having physical symptoms (Somatoform Disorders).

Anxiety Disorder Due to A General Medical Condition

* The patient has prominent anxiety, compulsions, obsessions or panic attacks.

* History, physical exam or laboratory findings suggest a general medical condition that seems likely to have directly caused these symptoms.

* No other mental disorder better accounts for these symptoms.*

* The symptoms cause important clinical distress or impair work, social or personal functioning.

* The symptoms don't occur solely during a .

Depending on the dominant symptomatology, specify whether:

With Generalized Anxiety

With Panic Attacks

With Obsessive-Compulsive symptoms Coding Notes

*DSM-IV specifically mentions an With Anxiety, precipitated by the stress of a serious medical illness.

In the Axis I diagnosis, include the name of the actual general medical condition (not the term "general medical condition").

On Axis III code the specific general medical condition.

Substance-Induced Anxiety Disorder

* The patient has prominent anxiety, compulsions, obsessions or panic attacks

* History, physical exam or laboratory data substantiate that either -These symptoms have developed within a month of or Withdrawal, or -Medication use has caused the symptoms

* No other anxiety disorder better accounts for these symptoms.*

* The symptoms cause clinically important distress or impair work, social or personal functioning.

* The symptoms don't occur solely during a delirium. Codes for Substance-Induced Anxiety Disorders

291.8 Alcohol

292.89 Amphetamine [or Amphetamine-Like Substance], Caffeine, Cannabis, Cocaine, Hallucinogen, Inhalant, Phencyclidine [or Phencyclidine-Like Substance], Sedative, Hypnotic, or , Other [or Unknown] Substance

Depending on the dominant symptomatology, specify whether: With Generalized Anxiety With Obsessive-Compulsive symptoms With Panic Attacks With Phobic Symptoms

Depending on time of onset, specify (see page 57): With Onset During Intoxication With Onset During Withdrawal Coding Notes

*No other anxiety disorder must account for the symptoms better than does substance use. A variety of historical information could suggest that this is the case: a. Anxiety disorder symptoms precede the onset of substance abuse. b. There have been previous episodes of an anxiety disorder. c. The symptoms are much worse than you would expect for the amount and duration of the substance abuse. d. Anxiety disorder symptoms continue long (at least a month) after substance abuse or withdrawal stops.

The diagnosis of a Substance-Induced Anxiety Disorder should be made only when the anxiety symptoms considerably exceed what you would expect from an ordinary case of Intoxication or Withdrawal from that specific substance.

Anxiety Disorder caused by most medications taken in therapeutic doses would be coded as, for example:

Axis I 292.89 Thyroxin-Induced Anxiety Disorder, With Generalized Anxiety, With Onset During Intoxication

Axis III E932.7 Thyroid replacement (Thyroxin)

300.00 Anxiety Disorder NOS

Treatment of Anxiety Disorders

Effective treatments for each of the anxiety disorders have been developed through research. In general, two types of treatment are available for an anxiety disorder—medication and specific types of psychotherapy (sometimes called "talk therapy"). Both approaches can be effective for most disorders. The choice of one or the other, or both, depends on the patient's and the doctor's preference, and also on the particular anxiety disorder. For example, only psychotherapy has been found effective for specific phobias.

Before treatment can begin, the doctor must conduct a careful diagnostic evaluation to determine whether your symptoms are due to an anxiety disorder, which anxiety disorder(s) you may have, and what coexisting conditions may be present. Anxiety disorders are not all treated the same, and it is important to determine the specific problem before embarking on a course of treatment. Sometimes alcoholism or some other coexisting condition will have such an impact that it is necessary to treat it at the same time or before treating the anxiety disorder.

If a person has been treated previously for an anxiety disorder, assess what treatment they tried. If it was a medication, what was the dosage, was it gradually increased, and how long did you take it? If he or she had psychotherapy, what kind was it, and how often were the sessions? It often happens that people believe they have "failed" at treatment, or that the treatment has failed them, when in fact it was never given an adequate trial.

During treatment for an anxiety disorder, the doctor and therapist should working together as a team. Together, they can attempt to find the best approach. If one treatment doesn't work, the odds are good that another one will. And new treatments are continually being developed through research. So don't give up hope.

Medications Used in Anxiety Disorders

Psychiatrists or other physicians can prescribe medications for anxiety disorders. These doctors often work closely with psychologists, social workers, or counselors who provide psychotherapy. Although medications won't cure an anxiety disorder, they can keep the symptoms under control and enable you to lead a normal, fulfilling life.

The major classes of medications used for various anxiety disorders are described below:

Antidepressants

A number of medications that were originally approved for treatment of depression have been found to be effective for anxiety disorders. If your doctor prescribes an , you will need to take it for several weeks before symptoms start to fade. So it is important not to get discouraged and stop taking these medications before they've had a chance to work.

Some of the newest are called selective serotonin reuptake inhibitors, or SSRIs. These medications act in the brain on a chemical messenger called serotonin. SSRIs tend to have fewer side effects than older antidepressants. People do sometimes report feeling slightly nauseated or jittery when they first start taking SSRIs, but that usually disappears with time. Some people also experience when taking some of these medications. An adjustment in dosage or a switch to another SSRI will usually correct bothersome problems. It is important to discuss side effects with your doctor so that he or she will know when there is a need for a change in medication.

Fluoxetine, , , , and are among the SSRIs commonly prescribed for panic disorder, OCD, PTSD, and social phobia. SSRIs are often used to treat people who have panic disorder in combination with OCD, social phobia, or depression. , a drug closely related to the SSRIs, is useful for treating GAD. Other newer antidepressants are under study in anxiety disorders, although one, bupropion, does not appear effective for these conditions. These medications are started at a low dose and gradually increased until they reach a therapeutic level.

Similarly, antidepressant medications called tricyclics are started at low doses and gradually increased. Tricyclics have been around longer than SSRIs and have been more widely studied for treating anxiety disorders. For anxiety disorders other than OCD, they are as effective as the SSRIs, but many physicians and patients prefer the newer drugs because the tricyclics sometimes cause dizziness, drowsiness, dry mouth, and weight gain. When these problems persist or are bothersome, a change in dosage or a switch in medications may be needed.

Tricyclics are useful in treating people with co-occurring anxiety disorders and depression. , the only antidepressant in its class prescribed for OCD, and imipramine, prescribed for panic disorder and GAD, are examples of tricyclics.

Monoamine oxidase inhibitors, or MAOIs, are the oldest class of antidepressant medications. The most commonly prescribed MAOI is , which is helpful for people with panic disorder and social phobia. and isoprocarboxazid are also used to treat anxiety disorders. People who take MAOIs are put on a restrictive diet because these medications can interact with some foods and beverages, including cheese and red wine, which contain a chemical called tyramine. MAOIs also interact with some other medications, including SSRIs. Interactions between MAOIs and other substances can cause dangerous elevations in blood pressure or other potentially life-threatening reactions.

Anti-Anxiety Medications

High-potency benzodiazepines relieve symptoms quickly and have few side effects, although drowsiness can be a problem. Because people can develop a tolerance to them—and would have to continue increasing the dosage to get the same effect—benzodiazepines are generally prescribed for short periods of time. One exception is panic disorder, for which they may be used for 6 months to a year. People who have had problems with drug or alcohol abuse are not usually good candidates for these medications because they may become dependent on them.

Some people experience withdrawal symptoms when they stop taking benzodiazepines, although reducing the dosage gradually can diminish those symptoms. In certain instances, the symptoms of anxiety can rebound after these medications are stopped. Potential problems with benzodiazepines have led some physicians to shy away from using them, or to use them in inadequate doses, even when they are of potential benefit to the patient.

Benzodiazepines include clonazepam, which is used for social phobia and GAD; alprazolam, which is helpful for panic disorder and GAD; and lorazepam, which is also useful for panic disorder.

Buspirone, a member of a class of drugs called azipirones, is a newer anti-anxiety medication that is used to treat GAD. Possible side effects include dizziness, headaches, and nausea. Unlike the benzodiazepines, buspirone must be taken consistently for at least two weeks to achieve an anti-anxiety effect.

Other Medications

Beta-blockers, such as propanolol, are often used to treat heart conditions but have also been found to be helpful in certain anxiety disorders, particularly in social phobia. When a feared situation, such as giving an oral presentation, can be predicted in advance, your doctor may prescribe a beta-blocker that can be taken to keep your heart from pounding, your hands from shaking, and other physical symptoms from developing.

Psychotherapies for Anxiety Disorders

Cognitive-Behavioral and Behavioral Therapy

Research has shown that a form of psychotherapy that is effective for several anxiety disorders, particularly panic disorder and social phobia, is cognitive-behavioral therapy (CBT). It has two components. The cognitive component helps people change thinking patterns that keep them from overcoming their fears. For example, a person with panic disorder might be helped to see that his or her panic attacks are not really heart attacks as previously feared; the tendency to put the worst possible interpretation on physical symptoms can be overcome. Similarly, a person with social phobia might be helped to overcome the belief that others are continually watching and harshly judging him or her.

The behavioral component of CBT seeks to change people's reactions to anxiety-provoking situations. A key element of this component is exposure, in which people confront the things they fear. An example would be a treatment approach called exposure and response prevention for people with OCD. If the person has a fear of dirt and germs, the therapist may encourage them to dirty their hands, then go a certain period of time without washing.

The therapist helps the patient to cope with the resultant anxiety. Eventually, after this exercise has been repeated a number of times, anxiety will diminish. In another sort of exposure exercise, a person with social phobia may be encouraged to spend time in feared social situations without giving in to the temptation to flee. In some cases the individual with social phobia will be asked to deliberately make what appear to be slight social blunders and observe other people's reactions; if they are not as harsh as expected, the person's social anxiety may begin to fade.

For a person with PTSD, exposure might consist of recalling the traumatic event in detail, as if in slow motion, and in effect re-experiencing it in a safe situation. If this is done carefully, with support from the therapist, it may be possible to defuse the anxiety associated with the memories. Another behavioral technique is to teach the patient deep breathing as an aid to relaxation and anxiety management.

Behavioral therapy alone, without a strong cognitive component, has long been used effectively to treat specific phobias. Here also, therapy involves exposure. The person is gradually exposed to the object or situation that is feared. At first, the exposure may be only through pictures or audiotapes. Later, if possible, the person actually confronts the feared object or situation. Often the therapist will accompany him or her to provide support and guidance. When undergoing CBT or behavioral therapy, exposure will be carried out only when the person is ready; it will be done gradually and only with his or her permission. The therapist and client will determine how much can handle and at what pace to proceed.

A major aim of CBT and behavioral therapy is to reduce anxiety by eliminating beliefs or behaviors that help to maintain the anxiety disorder. For example, avoidance of a feared object or situation prevents a person from learning that it is harmless. Similarly, performance of compulsive rituals in OCD gives some relief from anxiety and prevents the person from testing rational thoughts about danger, contamination, etc.

To be effective, CBT or behavioral therapy must be directed at the person's specific anxieties. An approach that is effective for a person with a specific phobia about dogs is not going to help a person with OCD who has intrusive thoughts of harming loved ones. Even for a single disorder, such as OCD, it is necessary to tailor the therapy to the person's particular concerns. CBT and behavioral therapy have no adverse side effects other than the temporary discomfort of increased anxiety, but the therapist must be well trained in the techniques of the treatment in order for it to work as desired. During treatment, the therapist probably will assign "homework"—specific problems that the patient will need to work on between sessions.

CBT or behavioral therapy generally lasts about 12 weeks. It may be conducted in a group, provided the people in the group have sufficiently similar problems. Group therapy is particularly effective for people with social phobia. There is some evidence that, after treatment is terminated, the beneficial effects of CBT last longer than those of medications for people with panic disorder; the same may be true for OCD, PTSD, and social phobia.

Medication may be combined with psychotherapy, and for many people this is the best approach to treatment. As stated earlier, it is important to give any treatment a fair trial. And if one approach doesn't work, the odds are that another one will.

If a person recovered from an anxiety disorder, and at a later date it recurs, don't consider it "treatment failure." Recurrences can be treated effectively, just like an initial episode. In fact, the skills you learned in dealing with the initial episode can be helpful in coping with a setback.

Coexisting Conditions

It is common for an anxiety disorder to be accompanied by another anxiety disorder or another illness. Often people who have panic disorder or social phobia, for example, also experience the intense sadness and hopelessness associated with depression. Other conditions that a person can have along with an anxiety disorder include an or alcohol or drug abuse. Any of these problems will need to be treated as well, ideally at the same time as the anxiety disorder.

Strategies To Make Treatment More Effective

Many people with anxiety disorders benefit from joining a self-help group and sharing their problems and achievements with others. Talking with trusted friends or a trusted member of the clergy can also be very helpful, although not a substitute for mental health care. Participating in an Internet chat room may also be of value in sharing concerns and decreasing a sense of isolation, but any advice received should be viewed with caution.

The family is of great importance in the recovery of a person with an anxiety disorder. Ideally, the family should be supportive without helping to perpetuate the person's symptoms. If the family tends to trivialize the disorder or demand improvement without treatment, the affected person will suffer. You may wish to show this booklet to your family and enlist their help as educated allies in your fight against your anxiety disorder.

Stress management techniques and meditation may help calm the person and enhance the effects of therapy, although there is as yet no scientific evidence to support the value of these "wellness" approaches to recovery from anxiety disorders. There is preliminary evidence that aerobic exercise may be of value, and it is known that caffeine, illicit drugs, and even some over-the-counter cold medications can aggravate the symptoms of an anxiety disorder.

Risk Factors to Assess Prior to Treatment

The primary care clinician must first decide whether the patient has other serious, frequently encountered, morbid risk factors which may require immediate intervention: depression, addiction, suicidal behavior, genetic and family factors, preoccupation with physical disease, anger, shame, and life events (including trauma).

Depression and Anxiety Disorders

When anxiety and depression occur together, greater functional impairment results. Prognosis is poor unless the syndrome is recognized, therapy initiated and compliance maintained.11,9,12 In this regard, it is important to talk with a close family member of the patient, as they are often the first to notice a change of mood or function. Treatment will help to allay concerns about the medically unexplained somatic symptoms and thus avoid unnecessary and expensive workups that can further add stress to the patient and their family.

Alcohol and Substance Abuse

About 15% of patients with an anxiety disorder also suffer from a substance abuse disorder. 13 More common is the substance-abusing patient who also has an anxiety disorder. The patient's attitude toward taking medication helps to differentiate the two. Patients who are addicted tend to want higher doses of prescribed medication ("It's not relaxing me enough, Doc"), 8,13,14 while anxious patients, in contrast, worry about taking medications ("It's very hard for me to do everything I need to do if I'm drowsy"). The purely anxious patient needs to be reminded that first-line anti-anxiety drugs, tri-cyclics (TCAs) and SSRIs, are nonaddicting.

The clinician should take a careful lifetime history of the patient's substance use. In particular, try to determine whether the patient abused alcohol or drugs prior to the onset of anxiety. Contrary to popular medical mythology, few individuals drink to "treat" their anxiety, 13 but successful management of anxiety may have an impact on alcohol consumption. If the patient suffers from anxiety and substance abuse disorder, they will need to be referred to appropriate mental health professionals and community resources (e.g., Alcoholics Anonymous, Narcotics Anonymous). Serious addiction should be treated first, before anxiety, because it is progressive and potentially fatal.

Suicide and Anxiety Disorders

There is a high incidence of suicide attempts among anxious patients, particularly those with panic disorder, which is often underestimated by medical professionals. This is not surprising, as the anxiety these patients experience is unbearable! Suicide attempts related to anxiety disorders appear to be more frequent in women than in men, particularly in women who are single, divorced, or widowed.15,16 Once again, the primary care professional will need to consult with a mental health clinician and consider safe environment alternatives (e.g., hospitalization) for the patient.

Life Events and Trauma

A significant minority of individuals who experience loss develop pathological reactions resembling anxiety or depression. The primary care physician must be able to intervene during the time of bereavement or catastrophic loss by listening empathetically and attentively. Patients will not discuss their feelings unless given permission to talk, and even a few minutes of face-to-face interaction can help the individual feel less alone and more cared for by the doctor. The elderly are particularly prone to anxiety and depression after the death of a spouse with whom they have spent most of their lives.

Murrey et al. found that 48.5% of women with an anxiety disorder in their sample had a history of childhood sexual abuse.17 Although sexual abuse has most frequently been linked with posttraumatic stress disorder, these investigators were surprised to find high rates of panic disorder, obsessive-compulsive disorder, and depression in this group. Moreover, samples of battered women,18 Vietnam war veterans19 and victims of political persecution20 also had an increased incidence of anxiety. Anxiety may be prolonged and potentiated where there is a dearth of caretaking in the environment.

For example, the patient may live alone or have few social interactions and even fewer close ties. In such cases, these patients should be encouraged to reach out for support; try to put yourself in their shoes. Since fear is the overriding emotion coloring the patient's experience, any way the clinician can help the patient feel safe enough to acknowledge that fear is an important first step. The physician needs to reach out, and not turn away from, the anxious individual, who benefits enormously from another human being who seriously listens to his or her concerns, neither laughing them off as ridiculous nor seeming to feel they are terribly unusual.

Educate the Patient About the Range of Available Treatments

At present, there are three highly effective and specific treatment modalities for anxiety disorders: (1) medication;21,22,23 (2) cognitive-behavioral therapy;24,25,26,27 and (3) psychodynamic treatment.28,29,30 The family or primary care physician in the position of initially suggesting such treatment should understand and be able to explain the approach of each type of treatment in a general way. However, it is best to refrain from "prescribing" a specific treatment since patients and anxiety disorders respond to different treatments differently, making it impossible to know, at initial intake, which interventions will most benefit a specific patient.

As clinicians, we are in a privileged position to help patients gain a better understanding and relief of the anxiety they may be experiencing. We can attain considerable satisfaction from making the diagnosis of anxiety and helping patients, who may be riddled with shame about anxiety and might otherwise suffer in silence without effective treatment.

Additional Reading: Facts About Anxiety Disorders

Most people experience feelings of anxiety before an important event such as a big exam, business presentation, or first date. Anxiety disorders, however, are illnesses that fill people's lives with overwhelming anxiety and fear that are chronic, unremitting, and can grow progressively worse. Tormented by panic attacks, obsessive thoughts, flashbacks of traumatic events, nightmares, or countless frightening physical symptoms, some people with anxiety disorders even become housebound.

How Common Are Anxiety Disorders?

Anxiety disorders, as a group, are the most common mental illness in America. More than 19 million American adults are affected by these debilitating illnesses each year. Children and adolescents can also develop anxiety disorders.

What Are the Different Kinds of Anxiety Disorders?

· Panic Disorder—Repeated episodes of intense fear that strike often and without warning. Physical symptoms include chest pain, heart palpitations, shortness of breath, dizziness, abdominal distress, feelings of unreality, and fear of dying.

· Obsessive-Compulsive Disorder—Repeated, unwanted thoughts or compulsive behaviors that seem impossible to stop or control.

· Post-Traumatic Stress Disorder—Persistent symptoms that occur after experiencing or witnessing a traumatic event such as rape or other criminal assault, war, child abuse, natural or human-caused disasters, or crashes. Nightmares, flashbacks, numbing of emotions, depression, and feeling angry, irritable or distracted and being easily startled are common. Family members of victims can also develop this disorder.

· Phobias—Two major types of phobias are social phobia and specific phobia. People with social phobia have an overwhelming and disabling fear of scrutiny, embarrassment, or humiliation in social situations, which leads to avoidance of many potentially pleasurable and meaningful activities. People with specific phobia experience extreme, disabling, and irrational fear of something that poses little or no actual danger; the fear leads to avoidance of objects or situations and can cause people to limit their lives unnecessarily.

· Generalized Anxiety Disorder—Constant, exaggerated worrisome thoughts and tension about everyday routine life events and activities, lasting at least six months. Almost always anticipating the worst even though there is little reason to expect it; accompanied by physical symptoms, such as fatigue, trembling, muscle tension, headache, or nausea. What Are Effective Treatments for Anxiety Disorders? Treatments have been largely developed through research institutions. They help many people with anxiety disorders and often combine medication and specific types of psychotherapy.

A number of medications that were originally approved for treating depression have been found to be effective for anxiety disorders as well. Some of the newest of these antidepressants are called selective serotonin reuptake inhibitors (SSRIs). Other antianxiety medications include groups of drugs called benzodiazepines and beta-blockers. If one medication is not effective, others can be tried. New medications are currently under development to treat anxiety symptoms.

Two clinically-proven effective forms of psychotherapy used to treat anxiety disorders are behavioral therapy and cognitive-behavioral therapy. Behavioral therapy focuses on changing specific actions and uses several techniques to stop unwanted behaviors. In addition to the behavioral therapy techniques, cognitive-behavioral therapy teaches patients to understand and change their thinking patterns so they can react differently to the situations that cause them anxiety.

Do Anxiety Disorders Co-Exist with Other Physical or Mental Disorders?

It is common for an anxiety disorder to accompany depression, eating disorders, substance abuse, or another anxiety disorder. Anxiety disorders can also co-exist with illnesses such as cancer or heart disease. In such instances, the accompanying disorders will also need to be treated. Before beginning any treatment, however, it is important to have a thorough medical examination to rule out other possible causes of symptoms.

Children and Anxiety Disorders

Children who experience fear and anxiety will tell you how they feel, but only when they are not afraid of being embarrassed, humiliated or punished. Parents face special challenges because children with anxiety tend to be nervous, avoidant, annoying or exhausting. If you become frustrated and make these children feel bad, they stop being honest and start telling you that they are tired, sick, "fine" or just don't care.

Without real help, anxious and nervous children will try to avoid feeling bad. Many start to avoid situations where there is only a small chance they will end up feeling bad. Eventually they end up making choices based on feared situations and not realities. If this continues, many of these kids will try to make new friends who will help them feel better. But in most cases they just end up learning to avoid and escape the challenges of life through isolation, skipping school, joining "fringe" groups, thrill seeking, rejecting socially responsible behavior or using alcohol and other drugs.

In time, children begin to express anger instead of their fear. Anger feels better than fear and it is easier for children to blame others if they can’t escape feeling bad. On the other hand, blaming their self instead of others leads to depression. Children reinforce and give power to their fears when they act to avoid or escape unrealistic fears. In this way the anxiety grows. The child's confidence will suffer and they will fail to thrive at home and in school.

How Common is Anxiety?

Approximately 1 out of 10 children suffer from an anxiety disorder. Most children experience anxiety purely on the basis of psychological, social and environmental influences. Twin studies of identical twins have shown that anxiety can occur with one twin but not the other. Anxiety disorders are not necessarily inherited although some people appear to inherit a risk or vulnerability for an anxiety disorder from their family. Brain imaging studies have produced minimal data to suggest there is a single defect or problem in the brain that causes or contributes to anxiety.

What are the Symptoms and How Symptoms are Reinforced Most people don't realize that anxiety and fear are the same emotional condition. The feeling of anxiety is generally characterized as diffuse, unpleasant, a sense of apprehension or worry, and has physical symptoms that may include headache, muscle tension, perspiration, restlessness, tension in the chest and mild stomach discomfort. Anxiety can produce confusion, memory problems, as well as distortions of reality and the meaning of events. Anxious kids do poorly in school and eventually learn to dislike and avoid anything connected to school. Many become depressed. The relationship with their family tends to get worse.

Once a fear or anxiety reaction has been created, the reaction tendency can be maintained number of ways. The most common are:

· Self-talk or "automatic" thoughts

. What a person believes can cause an emotional reaction. Errors in thinking or catastrophic conclusions contribute a great deal to anxiety reactions (e.g. I can't handle new situations alone. All dogs want to bite me.)

· Escape and avoidance behavior

. Taking actions to escape or avoid a fearful situation reinforces and give power to a fear (e.g. A child steps on a dogs tail and is bitten by the certain type of dog. The child is then afraid of dogs and avoids them. The fear grows as the child begins to avoid all dogs.)

· Inappropriate responses to a fearful child

. The response of parents and significant others can create secondary trauma. Feelings of shame, guilt and inadequacy increase the risk of self-defeating thought as well as escape and avoidance behavior (e.g. A parent ridicules a child for feeling afraid instead of rewarding the child’s effort and courage.) Medications

Parents should be concerned if their child requires medication for anxiety. The idea of a child using medications before a child’s brain is fully developed is a concern to many professionals. Benzodiazapenes are the largest class of these drugs and are referred to as sedative-hypnotics. These drugs are effective in reducing or eliminating symptoms, but they can be highly addictive. Very few physicians will prescribe these drugs to children because of the addiction risks. There are a number of non-addictive medications but children are generally unwilling to tolerate the side effects. Medication is usually the second choice after a comprehensive and competent trial of psychotherapy.

Psychotherapy Techniques

The challenge for parents is to find a competent mental health professional and to create a structured life experience for their child that supports treatment and recovery over an extended period of time. A structured and therapeutic life experience is more powerful than individual counseling and psychotherapy. A well run group therapy can be equally effective. Programs and activities that build confidence are generally superior to "talk therapy" and intellectual approaches. The time required to treat these disorders can range for months to years. Most should be resolved within 3 months. There are essentially four treatment approaches that underlie all therapy: · Prolonged Exposure

The child is encouraged to confront feared situations and objects gradually over time using similar, real or imagined versions in conjunction with other supportive aids such as skill enhancement, positive self-talk, relaxation, hypnosis or biofeedback.

· Modeling

Children observe another person interacting effectively with the feared situation or object. Adaptive responding is demonstrated with guided instruction, encouragement, a perception of improvement and constructive feedback.

· Contingency Management

External events that follow the patient's fear/anxiety reactions are manipulated using rewards for successful interaction and bolder steps. Rewards are withheld for refusing to interact. Children are made to feel better while facing their fears.

· Self-Management

Subjective and physiological reactions are altered or changed by teaching the child adaptive ways to appraise an upcoming situation, adaptive ways of thinking and deep muscle relaxation techniques.

Psychotherapy requires significant commitment of time while treatment of anxiety with medication requires less effort. Psychotherapy is almost always the first treatment of choice except in cases where anxiety is so severe that immediate relief is necessary to restore functioning and to prevent immediate and severe consequences.

Psychotherapy, or the psychotherapist, can generally be considered ineffective if a trial of 3 months has not produced a measurable and noticeable improvement. A decision to change therapists or to start a medication may be necessary at this point. Several trials of psychotherapy or medications may be necessary to successfully treat anxiety disorders.

Anxiety Disorders One-Year Prevalence (Adults)

Percent Population Estimate*(Millions)

Any Anxiety Disorder 13.3 19.1

Panic Disorder 1.7 2.4

Obsessive-Compulsive Disorder 2.3 3.3

Post-Traumatic Stress Disorder 3.6 5.2

Any Phobia 8.0 11.5

Generalized Anxiety Disorder 2.8 4.0 * Based on 7/1/98 U.S. Census resident population estimate of 143.3 million, age 18-54

References 1. Narrow WE, Rae DS, Regier DA. NIMH epidemiology note: prevalence of anxiety disorders. One-year prevalence best estimates calculated from ECA and NCS data. Population estimates based on U.S. Census estimated residential population age 18 to 54 on July 1, 1998. Unpublished.

2. Robins LN, Regier DA, eds. Psychiatric disorders in America: the Epidemiologic Catchment Area Study. New York: The Free Press, 1991.

3. The NIMH Genetics Workgroup. Genetics and mental disorders. NIH Publication No. 98-4268. Rockville, MD: National Institute of Mental Health, 1998.

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6. Wonderlich SA, Mitchell JE. Eating disorders and comorbidity: empirical, conceptual, and clinical implications. Psychopharmacology Bulletin, 1997; 33(3): 381-90.

7. Davidson JR. Trauma: the impact of post-traumatic stress disorder. Journal of Psychopharmacology, 2000; 14(2 Suppl 1): S5-S12.

8. Margolin G, Gordis EB. The effects of family and community violence on children. Annual Review of Psychology, 2000; 51: 445-79.

9. Yehuda R. Biological factors associated with susceptibility to posttraumatic stress disorder. Canadian Journal of Psychiatry, 1999; 44(1): 34-9.

10. Bourdon KH, Boyd JH, Rae DS, et al. Gender differences in phobias: results of the ECA community survey. Journal of Anxiety Disorders, 1988; 2: 227-41.

11. Kendler KS, Walters EE, Truett KR, et al. A twin-family study of self-report symptoms of panic-phobia and somatization. Behavior Genetics, 1995; 25(6): 499-515.

12. Boyd JH, Rae DS, Thompson JW, et al. Phobia: prevalence and risk factors. Social Psychiatry and Psychiatric Epidemiology, 1990; 25(6): 314-23.

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14. LeDoux J. Fear and the brain: where have we been, and where are we going? Biological Psychiatry, 1998; 44(12): 1229-38.

15. Bremner JD, Randall P, Scott TM, et al. MRI-based measurement of hippocampal volume in combat-related posttraumatic stress disorder. American Journal of Psychiatry, 1995; 152: 973-81. 16. Stein MB, Hanna C, Koverola C, et al. Structural brain changes in PTSD: does trauma alter neuroanatomy? In: Yehuda R, McFarlane AC, eds. Psychobiology of posttraumatic stress disorder. Annals of the New York Academy of Sciences, 821. New York: The New York Academy of Sciences, 1997.

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19. Hyman SE, Rudorfer MV. Anxiety disorders. In: Dale DC, Federman DD, eds. Scientific American® Medicine. Volume 3. New York: Healtheon/WebMD Corp., 2000, Sect. 13, Subsect. VIII.

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