Anxiety Disorders

Anxiety Disorders
December 2001 W
H A T

X I

Fear and stress reactions are essential for human survival. They enable people to pursue important goals and to respond appropriately to danger. In a healthy individual, the stress response (fight, fright, or flight) is provoked by a genuine threat or challenge and is used as a spur for appropriate action. [See Box The Brain's Response to a Threat.] 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 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 t h e following symptoms are present (only one for children) on most days for six months: Being on edge or very restless.

Anxiety Disorders

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 beat. 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 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

Anxiety Disorders

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 ("stage fright") is the most common specific social phobia and occurs when a person must perform in public. Children 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. 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 (claustrophobia ), 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 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 t h a t a critical feature in this disorder is an overinflated sense of responsibility, in which t h e 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 compulsive behavior. 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

Anxiety Disorders

necessarily occur in people with obsessive-compulsive disorder , which is a psychiatric condition. Post-Traumatic Stress Disorder 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 t h a t remind them of the traumatic event. They avoid reminders of the event, such as thoughts, people, or any other factors t h a t 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).

Anxiety Disorders 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. 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 t h e 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.

Anxiety Disorders

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 t h e hippocampus and other parts of the brain. It is associated with regulation and control of major emotional activities, including anxiety, depression, aggression, and affection. Within the limbic system, researchers have specifically identified the h y p o t h a l a m i c 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 a m y g d a l a , 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.)

Anxiety Disorders Some scans have detected abnormalities in the amygdala in people with anxiety disorders. This a part of the brain regulates fear, memory, and emotion and coordinates them with heart rate, blood pressure, and other physical responses to stressful events. OCD is the anxiety disorder most strongly associated with specific brain dysfunctions. For example, abnormalities in a specific pathway of nerves have been linked to OCD, attention deficit disorder, and Tourettes syndrome. The symptoms of the three disorders are similar and they often coexist. A number of imaging studies have reported less volume in the hippocampus in people with post-traumatic stress disorder. This important region is related to emotion and memory storage. Neurotransmitters. Studies suggest that an imbalance of certain substances called neurotransmitters (chemical messengers in the brain) may contribute to anxiety disorders. Examples of study findings on some neurotransmitters are the following: Abnormalities in the neurotransmitters gamma-aminobutyric acid (GABA) and serotonin may have a particular role in susceptibility to generalized anxiety disorder. GABA helps prevent nerve cells from over-firing and serotonin is a brain chemical important in feelings of well-being. Serotonin is also a major player in OCD. People with post-traumatic stress disorder have abnormalities in stress hormones (cortisol) and neurotransmitters (epinephrine and norepinephrine), which could account for their inability to reduce anxiety and their tendency to startle easily after a trauma. Abnormalities in Breathing Functions. Some interesting research suggests that rather than fear triggering a physical response, the opposite may occur. A few studies suggest that some people with anxiety disorders have an abnormality t h a t causes them to be very sensitive to the effects of carbon dioxide (CO2). Since CO2 is released from the lungs when people exhale, the condition may be aggravated in crowded spaces, such as airplanes or elevators. In such cases, exposure to excessive CO2 causes these individuals to hyperventilate , in which their breathing becomes rapid and heart rate quickens. Such a response also occurs during danger. Over time, then, a series of such responses creates a pattern of impaired breathing and a sense of panic that evolves into a full-fledged anxiety disorder. Genetic Factors Up to 50% of people with panic disorder and 40% of generalized anxiety (GAD) patients have close relatives with the disorder., (About half of GAD patients also have family members with panic disorder, and about 30% have relatives with simple phobias.) One study reported the risk for inheriting the major phobia types ranges from 25% to 37%. OCD is also strongly related to a family history of the disorder. Researchers are looking for specific genetic factors that might contribute to an inherited risk. Of particular interest are possibly defective genes that regulate specific neurotransmitters, including serotonin and dopamine. Family Dynamics The influence of the family on anxiety is complicated by both genetic and psychological factors. Panic Disorder and Family Influence. Certain psychodynamic theories suggest, and a few studies support the idea, that some people may develop panic disorder if they cannot resolve the early childhood conflict of dependence vs. independence. In one study, for example, young adults who had experienced childhood anxiety were more likely to live with their parents until their early to mid-twenties. Many people with panic disorder perceive their parents as being extremely controlling and overly protective while showing little actual affection

Anxiety Disorders

Traumatic Events Traumatic events can trigger anxiety disorders but nearly always only in individuals who are susceptible to them because of psychological, genetic, or biochemical factors. The clearest example is post-traumatic stress disorder. Specific traumatic events in childhood, particularly those that threaten family integrity, such as spousal or child abuse, can also lead to other anxiety and emotional disorders. Some individuals may even have a biological propensity for specific phobias, for instance of spiders or snakes, that have been triggered and perpetuated after a single first exposure. Medical Conditions Although no causal relationships have been established certain medical conditions have been associated with panic disorder. They include migraines, obstructive sleep apnea, mitral valve prolapse, irritable bowel syndrome, chronic fatigue syndrome, and premenstrual syndrome. A number of studies have reported a strong link between childhood rheumatic fever, which is caused by a streptococcal infection, and the development of tic-related disorders, including OCD and Tourettes syndrome. G E T S A N W H O Risk Factors for Anxiety in General
X I E T Y

As many as 25% of all American adults experience intense anxiety at sometime in their lives. The prevalence of true anxiety disorders is much lower, although they are still t h e most common psychiatric conditions in the United States and affect more than 20 million Americans. Gender. With the exception of obsessive-compulsive disorder (OCD) and possibly social anxiety, women have twice the risk for most anxiety disorders as men. A number of factors may increase the reported risk in women, including hormonal factors, cultural pressures to meet everyone else's needs except their own, and fewer self-restrictions on reporting anxiety to physicians. Family History. Anxiety disorders run in families. Although family dynamics and psychological influences are often at work, genetic factors may also play a role in some cases. Socioeconomic Factors. A study of Mexican adults living in California reported that nativeborn Mexican-Americans were three times more likely to have anxiety disorders (and even more likely to be depressed) as those who had recently immigrated to the US. And t h e longer the immigrants lived in the US, the greater was their risk for psychiatric problems. Traditional Mexican cultural effects and social ties, then, appear to protect recently arrived immigrants from mental illness, even when they are poor. Eventually, however, t h e consequences of Americanization may lead to depression and anxiety, probably resulting from feelings of alienation and inferiority, not only in many Mexican Americans, but also in other impoverished minority groups. General Risk Factors for Anxiety in Children and Adolescents. Studies suggest that between 3% to 5% of children and adolescents have some anxiety disorder. Indeed, this may be an underestimation, particularly since symptoms in children may differ from those in adults. In general, phobias, OCD and separation anxiety show up early in childhood, while social phobia and panic disorder are often diagnosed during the teen years. Two 2000 studies reported a significant increase in anxiety levels in children and college students in the past two decades compared to children in the 1950s. In both studies, anxiety was associated with lack of social connections and a sense of a more threatening environment. One study linked teenage smoking with anxiety disorders in adulthood. The common link

Anxiety Disorders

believe that it is underdiagnosed and more common than any other anxiety disorder. It is certainly the most common anxiety disorder among the elderly. Risk Factors for Panic Disorder Age and Panic Disorder. Studies indicate that the prevalence of panic disorder among adults is between 1.6% and 2% and is much higher in adolescence, 3.5% to 9%. In one study, 18% of adult patients with panic disorder reported the onset of the disorder before 10 years of age. In general, however, panic disorders tend to begin in late adolescence and peak at around 25 years of age. Gender and Panic Disorder. Women have about twice the risk for panic disorder than men do. The effects of pregnancy on panic disorder appear to be mixed; it seems to improve t h e condition in some women and worsen it in others. Risk Factors for Obsessive-Compulsive Disorder (OCD) Obsessive-compulsive disorder occurs equally in men and women and affects about 2% to 3% of people over a lifespan. About 80% of people who develop OCD shows signs of t h e disorder in childhood, although the disorder usually develops fully in adulthood. Risk Factors for Social Phobias Age and Phobias. The onset of social anxiety disorder usually occurs in adolescence, although most people with this disorder are not diagnosed and do not receive treatment until or unless they develop an accompanying anxiety disorder. Gender and Phobias. Like other anxiety disorders, the rates of social phobia are higher in women. Unlike their response to other emotional disorders, however, men are more likely than women to seek treatment for this disorder, probably because social phobias can interfere strongly with many jobs in white-collar professions. Risk Factors for Post-Traumatic Stress Disorder Studies estimated a lifetime risk for PTSD of about 0.8% in men and 1.2% in women. Specific groups, such as combat troops, have a much higher incidence. Among adolescents, studies have found the prevalence of PTSD to be as high as 8.1%. Simply experiencing a traumatic event, however, does not predict post-traumatic stress disorder. Studies estimated that between 6% to 30% or more of trauma survivors develop PTSD, with children being among those at the high end of the range. Researchers are trying to determine factors that might increase vulnerability to catastrophic events and put people at risk for develop PTSD. Some studies report the following may be risk factors: A psychiatric illness. One study reported that having a pre-existing emotional disorder, particularly depression, before the traumatic event most often predicted PTSD in women. Drug or alcohol abuse. A family history of anxiety. A history of abuse, particularly that which threatens family integrity, such as spousal or child abuse. Studies of individuals who had suffered physical or sexual abuse or neglect as children suggest that up to one-third develop PTSD. An early separation from parents. Having sleep-disordered breathing. In one study 91% of crime victims with PTSD h a d either sleep apnea or a lesser condition that partially blocked the airways during sleep. Sleep apnea occurs when tissues in the upper throat (or airway) collapse at intervals during sleep, thereby blocking the passage of air. Airway resistance may intensify symptoms of PTSD, including sleeplessness and nightmares. (Sleep apnea has also been associated with a risk for panic disorder.) H O W S E R I O U D I S O R D E R S ?
S

X I

Anxiety Disorders Most patients with GAD will experience at least one episode of significant depression and many develop recurrent episodes to the point that GAD becomes the intermittent state. In patients with both disorders, GAD usually precedes the onset of depression. Social anxiety during adolescence or young adulthood has been associated with a higher risk for depression, and the presence of both increases the danger for severe depression. People with PTSD are four to seven times as likely to be depressed as are people without PTSD. According to one interesting 2000 study of teen-agers, anxiety disorders were associated with later bipolar disorders (manic-depression) in adulthood, while, conversely, manic behavior in adolescence appeared to increase the risk for adult anxiety disorders. Increased Risk for Suicide Studies suggest that 18% of people with panic disorder attempt suicide and up to 30% harbor suicidal thoughts. One study reported suicide attempts in about 12% of people with social phobias or OCD. It is not altogether clear whether people with both depression and anxiety have a higher risk for suicide than those with one disorder. According to some studies, the development of anxiety in people with depression increases their risk of suicide by a factor of two to six. Some, however, have found no higher risk. Alcoholism and Other Forms of Substance Abuse Severely depressed or anxious people are at high risk for alcoholism, smoking, and other forms of addiction. Anxiety disorders are highly prevalent among people with alcoholism. It should be noted, moreover, that long-term alcohol use can itself cause biologic changes that may actually produce anxiety and depression. Risk for Substance Abuse in Specific Anxiety Disorders. The following are some observations on specific anxiety disorders and substance abuse. Some people with GAD and panic disorders may use alcohol or drugs to self-medicate. Social phobia appears to pose a particular risk for alcohol abuse. People with this disorder are likely to drink in order to boost confidence. Alcohol itself has no direct beneficial effect on anxiety, but studies suggest that the b e l i e f in its effect appears to relieve anxious feelings. (Alcohol or substance abuse is not associated with specific phobiassuch as fear of flying or of spiders.) Heavy smoking and substance abuse are common in people with PTSD. In adolescents, t h e disorder not only increases the risk for drug and alcohol use but also for eating disorders. Effects on Work, School, and Relationships Studies consistently report negative effects of anxiety disorders on work and relationships. Some examples from studies are the following: In one 2001 study, more than 10% of patients with GAD missed at least six days of work within the previous month. In a survey of OCD sufferers, 40% reported that they had to stop working because of t h e disorder; only 40% worked full-time, and only half were married. In another study, people with social phobia, even if they were not depressed, were more likely than others to drop out of school or to report lower functioning. Effects on Physical Health People with panic disorder perceive their own physical and emotional well-being as poor. They use alternative therapies and seek medical help more often than do those in t h e general population. Any causal connection between anxiety and medical disorders is unclear. Effects on the Heart. Anxiety has been associated with a number of heart problems. A 2001

Anxiety Disorders

Effects on Headache. One study reported that 32% of people with chronic tension headaches met criteria for anxiety. It isn't clear whether the psychological disorder preceded or followed the onset of headaches. Similarly, another study reported that young girls with anxiety disorders were three times more likely to have chronic headaches than those without the disorder. (Headaches in both studies were also strongly associated with depression.) Effects on Sleep Disorders in Children. One study of children linked anxiety with a higher risk for sleep disorders, such as frequent nightmares, restless legs, and bruxism (grinding and gnashing of the teeth during sleep). Physical Effects of Post-Traumatic Stress Disorder. Some studies on people, including military veterans, who have endured major traumatic events have found a higher risk for health problems. One study of Vietnam veterans reported that PTSD was associated with greater physical limitations, poorer physical health, and a lower quality of life than in those in the normal population, regardless of other accompanying emotional or medical disorders. In another study of these veterans, PTSD sufferers had double the risk for abnormal heart rhythms and four times the risk of a heart attack compared to men without PTSD. Injuries from Obsessive-Compulsive Disorder. People with obsessive-compulsive disorders can experience skin problems from excessive washing, injuries from repetitive physical acts, and hair loss from repeated hair pulling (behavior known as trichotillomania). Effect of PTSD on the Brain Studies are reporting that PTSD is associated with shrinkage in the hippocampus , the part of the brain important for memory and learning. Studies of animals indicate that such damage may result from long-term exposure to cortisol, the major stress hormone. Groups who had suffered severe trauma also scored 40% lower in tests of verbal memory than the general population. There was no difference in IQ or in scores of other types of memory. One study suggests that exposure to chronic stress, common in PTSD patients, may compromise t h e function of the brains receptors for benzodiazepines (a class of medications used to treat anxiety). W I L L C O W H A T D I A G N O S I S O F D I S O R D E R ? Physical Examination and History
N F I A N R M N A X I

A physical examination and medical and personal history is essential. Because anxiety accompanies so many medical conditions, some serious, it is extremely important for t h e physician to uncover any medical problems or medications that might underlie or be masked by an anxiety attack. The patient should describe any occurrence of anxiety disorders or depression in the family and mention any other contributing factors, such as excessive caffeine use, recent life changes, or stressful events. It is very important to be honest with the physician about all conditions, including excessive drinking, substance abuse, or other psychological or mood states that might contribute to, or result from, the anxiety disorder. Diagnosing children is very difficult, since often anxiety results in disruptive behaviors t h a t overlap with attention-deficit hyperactivity or oppositional disorder. Parents and children may report different symptoms. Ruling Out Conditions That Accompany or Resemble Anxiety Disorders People with anxiety disorders are more likely to see a family physician first rather than a mental health specialist, since so often their symptoms are physical. They can include muscle tension, trembling, twitching, aching, soreness, cold and clammy hands, dry mouth, sweating, nausea or diarrhea, and urinary frequency. Anxiety attacks can mimic or

Anxiety Disorders Women who are having an actual heart attack or acute heart problem are much more likely to be misdiagnosed as having an anxiety attack than men with similar symptoms. Mitral valve prolapse, a common and usually mild heart problem, may have symptoms that are nearly identical to those of panic disorder. The two conditions, in fact, frequently occur together. Two-thirds of people with a heart-rhythm disturbance called paroxysmal supraventricular tachycardia have the same symptoms as those with panic attacks. Asthma. Asthma attacks and panic attacks have similar symptoms and can also coexist. Hyperthyroidism. Hyperthyroidism can cause many of the same symptoms of generalized anxiety disorder and must be ruled out. Epilepsy. The symptoms of partial seizures and panic attacks often overlap, although partial seizures are usually very short (one to two minutes). Other Medical Conditions. In addition, anxiety-like symptoms are seen in many other medical problems, including hypoglycemia, recurrent pulmonary emboli, and adrenal-gland tumors. Women can also experience intense anxiety attacks with hot flashes during menopause. Medication Side Effects. Many drugs, including some for high blood pressure, diabetes, and thyroid disorders, can produce symptoms of anxiety. Withdrawal from certain drugs, often those used to treat sleep disorders or anxiety, can also precipitate anxiety reactions. Substance Abuse. People with anxiety disorders often drink alcohol or abuse drugs in order to conceal or ameliorate symptoms, but substance abuse and dependency can also cause anxiety. In addition, withdrawal from alcohol can produce physiologic symptoms similar to panic attacks. Clinicians often have difficulty determining whether alcoholism or anxiety is t h e primary disorder. Overuse of caffeine or abuse of amphetamines can cause symptoms resembling a panic attack. Screening Tests Although most family physicians can identify panic disorder, very few (10% in one study) recognize social phobias. Clinicians can use various tests to determine the causes, type, severity, and frequency of anxiety. Such tests include the Beck Anxiety Inventory, t h e Hamilton Anxiety Rating Scale, and the Anxiety Disorders Interview Schedule. Screening tests for children may include Child Behavior Checklist, which measures a child's ability to function, or for OCD the Leyton Obsessional Inventory-Child Version. W H A T A R E T H E G E N E R A L G U I D E L I N E S F O R T R E A T I A N X I E T Y D I S O R D E R S ?

Anxiety disorders require treatment; simply trying to talk oneself out of anxiety is as futile as trying to talk oneself out of a heart or stomach problem. Most anxiety disorders, especially the phobias, respond well to treatment. They may, however, require long-term treatment. For instance, one study reported that two thirds of GAD patients who were treated for only six weeks had a recurrence, and half of these patients required additional medications. Nevertheless, most adults in the US do not receive appropriate care for anxiety disorders. In one study, for example, about two-thirds of people with GAD never received any treatment. Treatment Options The standard current approach to most anxiety disorders in adults is a combination of cognitive-behavioral therapy (CBT) with medications, typically antidepressants, usually SSRIs or, less commonly, tricyclics. In one 2000 study of panic disorder patients, CBT or a tricyclic antidepressant, either alone or in combination, were more effective than a placebo

Anxiety Disorders

Treatments for Anxiety Disorders Anxiety Disorder Generalized Anxiety Disorder Drug Treatment Options Cognitive-Behavioral and other Non-Drug Therapies

Benzodiazepines; buspirone; Cognitive-behavioral, antidepressants, particularly extended interpersonal therapy, stress release venlafaxine (Effexor) and some management, biofeedback tricyclics. Possibly antipsychotics in severe case. SSRIs, benzodiazepines, tricyclics, MAO inhibitors, potentially, anticonvulsants. Investigation of immediate administration of combinations (e.g. an SSRI with a benzodiazepine). Benzodiazepines, beta-blockers, SSRIs Cognitive-behavioral therapy

Panic Attacks

Phobias

Cognitive-behavioral therapy (desensitization therapy), hypnosis Cognitive-behavioral therapy (Exposure and response prevention) Cognitive-behavioral therapy (Group therapy)

Obsessive Compulsive Disorder

SSRIs as first choice; antipsychotics used for tics; clomipramine (a tricyclic), Combinations of these drugs likely. MAO inhibitors for those who do not respond to other drugs. Antidepressants, particularly the SSRIs (sertraline and paroxetine approved at this time); clonidine.

Post-traumatic Stress Disorder

Note: For anxiety disorders in adults, the most effective treatments are usually combinations of drugs and behavioral techniques

W
F

M E D I C A T I O N S A N X I E T Y D I S O R General Guidelines
H A O R T

A
D E

R R

E S

U ?

Until recently, the anti-anxiety drugs known as benzodiazepines were the primary medications for anxiety. Increasingly, antidepressants, particularly the selective serotoninreuptake inhibitors (SSRIs), are being used as the initial treatment. They are proving to be effective, nonaddictive, and to have relatively minor side effects. Many standard antidepressants take two to four weeks, and sometimes up to 12 weeks, before they are fully effective. People who take them may also experience a temporary period of increased anxiety. Consequently, about a third of patients stop taking antidepressants for anxiety disorders before completing the initial phase of therapy. A combination of a benzodiazepine and an antidepressant is sometimes used to avoid the initial anxiety symptoms and to hasten control of panic symptoms. The benzodiazepine can then be withdrawn and the antidepressant, with its negligible chance for long-term abuse, is continued. No one should become disheartened if one drug treatment fail. Another may prove to be very effective, even it is a drug of a similar type. Drug combinations should be tried if a single drug and cognitive-behavior therapy has failed. Because many anxiety disorders are chronic, drug therapy sometimes is needed for prolonged periods, even years. Antidepressants Selective Serotonin Reuptake Inhibitors (SSRIs). Fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa), and fluvoxamine (Luvox) are antidepressant drugs known as selective serotonin reuptake inhibitors (SSRIs). They are proving to be very valuable for adults and even for many children with most anxiety disorders The following

Anxiety Disorders Phobias. SSRIs may also help people with phobias, including agoraphobia and social phobias. Relapse is common in social phobia patients even after prolonged treatment. Combining medications with cognitive-behavioral therapy can help prevent relapse. Post-Traumatic stress Disorder. Studies have also indicated that, and may even help some people with post-traumatic stress disorder (PTSD). At this time only sertraline (Zoloft) and paroxetine (Paxil) are specifically FDA-approved for PTSD, although studies suggest that other SSRIs including fluvoxamine (Luvox) and citalopram (Celexa) may be helpful. Their benefits may be limited. Victims of child abuse, for example, tend to respond poorly to SSRIs. A study on sertraline reported that although it was particularly effective in women it did not offer many benefits for veterans. Anxiety Disorders in Children. SSRIs appear to be effective for children who have both OCD and major depression. In one 2001 study, fluvoxamine (Luvox) reduced symptoms of social phobia, separation anxiety disorder, or generalized anxiety disorder in children and teens. Still, controversy remains about when and if young people should be given drugs for these disorders. SSRIs can cause agitation, nausea, and sexual dysfunction (including delay in or loss of orgasm and low sexual drive). (Taking a supervised drug "holiday" on the weekend may improve sexual function during that time, although it may also cause dizziness, exhaustion, and depression.) Over time, many SSRI-treated patients gain weight, although the degree of weight gain may vary depending on the agent. For example paroxetine appears to pose a greater risk for weight gain than citalopram. Elderly people taking these drugs should take the lowest effective dose possible, and those with heart problems should be monitored closely. Designer Antidepressants. A number of newer antidepressants that target other neurotransmitters alone or in addition to serotonin are proving to be very promising for anxiety. They include nefazodone (Serzone), venlafaxine (Effexor), and mirtazapine (Remeron). Venlafaxine (Effexor) is now approved for generalized anxiety disorder. In studies of patients with GAD, venlafaxine significantly reduced anxiety and improved overall wellbeing compared with placebo. It may have some benefits for social anxiety. As with t h e SSRIs, and unlike other newer antidepressants, venlafaxine impairs sexual function. Of concern are reports of changes in blood pressure and heart conduction abnormalities, which may cause serious problems in elderly patients. Some patients report severe withdrawal symptoms, including dizziness and nausea. Nefazodone (Serzone) has shown some effectiveness in patients with GAD, social phobias, and panic disorder. The drug is more rapidly effective and has fewer distressing side effects, including sexual dysfunction, than SSRIs. Nefazodone is one of the only antidepressants that has a positive effect on sleep efficiency, which may particularly benefit patients with insomnia. The drug may cause an abrupt drop in blood pressure after standing up suddenly. Of concern are rare cases of liver failure in patients taking nefazodone. Mirtazapine (Remeron) may be an effective treatment for panic disorder, generalized anxiety disorder, obsessive-compulsive disorder, and even posttraumatic stress disorder. In addition to taking it orally, mirtazapine is now available as a tablet that dissolves on the tongue. It may be more rapidly effective than other SSRIs and has stronger early actions against anxiety in patients who also suffer depression. It may cause less sexual dysfunction than some other antidepressants. It interacts with histamine, a chemical involved in allergic responses; these actions can cause drowsiness, which may make it a useful drug for patients who suffer from insomnia. The drug also causes blurred vision. The drug has been associated with weight gain, although in one study it was not significant. I t

Anxiety Disorders Clomipramine (Anafranil) is also effective for panic disorders and has been approved for OCD. The drug causes significant reduction in OCD symptoms for patients, including some children, who can tolerate it. (The other tricyclics do not appear to benefit OCD patients.) Many patients stop using Anafranil, however, because of side effects; many of those who stay on the drug experience adverse effects. Side effects of TCAs include sleep disturbance, abrupt reduction in blood pressure upon standing, weight gain, sexual dysfunction, and mental disturbance. Elderly patients and those with a history of seizures, cardiac problems, closed-angle glaucoma, and urinary retention or obstruction should be closely supervised when taking tricyclics. Monamine Oxidase Inhibitors. Monoamine oxidase inhibitors (MAOIs), typically phenelzine (Nardil) or tranylcypromine (Parnate), are antidepressants used for panic disorder or OCD that does not respond to other treatments. MAOIs commonly cause weight gain, drowsiness, dizziness, sexual dysfunction, and insomnia. They can also cause birth defects and should not be taken by pregnant women. Hypertension, a potentially serious side effect, can be brought on by eating certain foods that have a high tyramine content, including cheese, red wine, vermouth, dried meats and fish, canned figs, and fava beans. MAOIs can have serious interactions with certain drugs, including some common over-the-counter cough medications and decongestants. Warning Note Fatal reactions have occurred when SSRIs and MAOIs were taken at the same time. There should be at least a two- to five-week break if a patient is changing from one type of antidepressant to the other. (There should be a five-week break after taking Prozac, because of its long duration of action, and before taking an MAOI.) Benzodiazepines Benzodiazepines are the most broadly effective medications for most anxiety disorders and have been the standard treatment for years. They have significant side effects, however, including a risk for dependency and abuse, and so have been supplanted in many cases by SSRIs and newer antidepressants. They include the following: Alprazolam (Xanax) and clonazepam (Klonopin) are effective for panic disorder, agoraphobia, and generalized anxiety disorder. Benzodiazepines in combination with selective serotonin reuptake inhibitors may be particularly helpful in the treatment of a panic attack, although there is no standard as yet for the safest and most effective method for administering this combination. Other benzodiazepines, including diazepam (Valium), lorazepam (Ativan), halazepam (Paxipam), and chlordiazepoxide (Librium), are used mainly for generalized anxiety. Side Effects. Common side effects of benzodiazepines are daytime drowsiness and a hungover feeling. In rare cases, they actually cause agitation. Some respiratory problems may be exacerbated by their use. The drugs appear to stimulate eating and can cause weight gain. Benzodiazepines can interact with certain drugs, including cimetidine (Tagamet), antihistamines, and oral contraceptives. Benzodiazepines are potentially dangerous when used in combination with alcohol. Overdoses are serious, although very rarely fatal. The elderly are more susceptible to side effects and should usually start at half the dose prescribed for younger people. The agents increase the risk of falling, and some studies have reported a higher risk for hip fracture in older people who take the drugs, although this may occur only with certain benzodiazepines (eg, lorazepam) or with the use of more than one. In any case, more research is needed. Also of concern are studies showing high risk of automobile accidents in people who take benzodiazepines. Benzodiazepines taken during pregnancy are associated with birth defects and should not be used by pregnant women or

Anxiety Disorders

medication. Some patients experience withdrawal symptoms, including stomach distress, sweating, and insomnia, that can last from one to three weeks. Azapirones Buspirone (BuSpar) is a unique anti-anxiety agent known as an azapirone. Clinical trials have suggested that it is as effective as a benzodiazepine for treating generalized anxiety disorder. Some experts also think it may be useful for adolescents and children. It usually takes several days to weeks for the drug to be fully effective, and it is not useful against panic attacks. It should be noted that the drug does not produce any immediate euphoria or change in sensation, so some people believe, erroneously, that the drug doesn't work. Such qualities result in a very low potential for abuse. In fact, unlike the benzodiazepines, buspirone is not addictive, even with long-term use, so it may be particularly useful for patient whose anxiety disorder coexists with alcoholism or drug abuse. Buspirone also seems to have less pronounced side effects than benzodiazepines and no withdrawal effects, even when the drug is discontinued quickly. Common side effects include dizziness, drowsiness, and nausea. BuSpar should not be used with monoamine oxidase inhibitors (MAOIs). Beta-Blockers Beta-blockers, including propranolol (Inderal) and atenolol (Tenormin), block the nerves t h a t stimulate the heart to beat faster. They affect only the physiologic symptoms of anxiety and are most helpful for phobias, particularly performance anxiety. Beta-blockers are less effective for other forms of anxiety. Clonidine Clonidine, a drug that relaxes blood vessels, has been used to treat children with posttraumatic stress disorder. Some experts believe it should be tried for anxiety disorders i f other therapies fail. The drug can have severe side effects. Atypical Antipsychotics In certain severe cases agents called atypical antipsychotics may be useful. They include risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel), ziprasidone (Zeldox), and others. In one study, risperidone was useful in combination with an SSRI for OCD patients who did not respond to an SSRI alone. They also may useful for severe GAD. Common side effects include sleepiness and dizziness. Most cause weight gain. In high doses they may cause extrapyramidal symptoms, which involve the nerves and muscles controlling movement and coordination. The risk for these side effects, however, are far less than with old antipsychotic agents. Investigative Drugs Biperiden. Biperiden (Akineton), a drug used to treat Parkinson disease, has been used in some studies to reduce the response to carbon dioxide, which may trigger panic attacks in some people. (More research is needed.) Pagoclone. Pagoclone is known as a gamma amino butyric acid (GABA) receptor modulator. I t is showing promise in trials for significantly reducing panic attacks with few side effects. Prazosin. Prazosin, a drug that reduces blood pressure and is sometimes used in benign prostate hyperplasia. In one very small preliminary study, the drug alleviated nightmares in four men with PTSD. Immunotherapies for Obsessive Compulsive Disorder. Some research suggests that some cases of OCD originated with a strep throat infection during childhood. Investigators, then, are investigating therapies that affect the immune system. They include immunoglobulin treatments (injections of certain antibody groups), penicillin, corticosteroids (prednisone), and plasmapheresis (blood exchange).

Anxiety Disorders

O
T

E R N O N - D R U G A P P R O A C H A N X I E T Y D I S O R D E R ? Cognitive-Behavioral Therapy T O H

The goal of cognitive-behavioral therapy (CBT) is to regain control of reactions to stress and stimuli, thus reducing the feeling of helplessness that often accompanies anxiety disorders. CBT works on the principle that the thoughts that produce and maintain anxiety can be recognized and altered using various techniques, thereby changing the behavioral response and eliminating the anxiety reaction. A number of CBT approaches have been designed to treat both the general symptoms of anxiety and specific disorders. In one 2000 study of panic disorder patients, either CBT or a tricyclic antidepressant alone or in combination was effective for short-term and maintenance therapy. After discontinuing treatment, however, CBT alone offered the best chance for a persistent response. Other studies have also reported similar benefits in specific groups. For example, a CBT program has been developed for children with obsessive-compulsive disorder, and this approach may be as effective as medications for some children. Cognitive-behavioral therapy may also help people with post-traumatic stress disorder. CBT used in group therapy for children with PTSD may be especially helpful. Treatments are equally effective in men and women. Anxiety disorders are chronic, however, and recurrence is common. Some studies indicate, in fact, that between 30% and 82% of people with panic disorder and phobias have a recurrence of attacks at an average of nine months even after successful short-term therapy. Medications, then, are also generally recommended for most patients. Basic Cognitive Therapy Techniques. Treatment usually takes about 12 to 20 weeks. The essential goal of cognitive therapy is to understand the realities of an anxiety-provoking situation and to respond to reality with new actions based on reasonable expectations. First, the patient must learn how to recognize anxious reactions and thoughts as they occur. One way of accomplishing this is by keeping a daily diary that reports the occurrences of anxiety attacks and any thoughts and events associated with them. An OCD patient, for instance, may record repetitive thoughts. These entrenched and automatic reactions and thoughts must be challenged and understood. Again, using the OCD example, one approach is to record and play back the words of t h e repetitive thoughts, over exposing the patient to the thoughts and reducing their effect. Patients are usually given behavioral homework assignments to help them change their behavior. For example, a person with generalized social phobia may be asked to buy an item and then return it the next day. As the patient performs this action, he or she observes any unrealistic fears and thoughts triggered by such an event. As the patient continues with self-observation, he or she begins to perceive the false assumptions that underlie the anxiety. For example, OCD patients may learn to recognize that their heightened sense of responsibility for preventing harm in non-threatening situations is not necessary or even useful. At that point, the patient can begin substituting new ways of coping with the feared objects and situations. Systematic Desensitization. Systematic desensitization is a specific technique that breaks the link between the anxiety-provoking stimulus and the anxiety response; this treatment requires the patient to gradually confront the object of fear. There are three main elements to the process: Relaxation training.

Anxiety Disorders

Exposure treatments are usually either known as flooding or graduated exposure: Flooding exposes the person to the anxiety-producing stimulus for as long as one to two hours. Graduated exposure gives the patient a greater degree of control over the length and frequency of exposures. In both cases the patient experiences the anxiety over and over until the stimulating event eventually loses its effect. Combining exposure with standard cognitive therapy may be particularly beneficial. This approach has helped certain patients in most anxiety disorder categories. Modeling Treatment. Phobias can often be treated successfully with modeling treatment: The therapy typically uses an actor who approaches an anxiety-producing object or engages in a fear-provoking activity that is similar to the patient's specific problem. Either a live or video-taped situation may be used, although the live model is considered to be more effective. The patient observes this event and tries to learn how to behave in a comparable manner. Eventually, so-called "virtual reality" may prove to be a very useful modeling tool. This technology employs computer-generated images and special headgear to realistically simulate a natural environment and allow interaction with it. In one case, a psychologist used virtual reality to cure a woman of arachnophobia (fear of spiders). More research is needed. Other Forms of Psychotherapy Other forms of psychotherapy, commonly called "talk" therapies, deal more with childhood roots of anxiety and usually, although not always, require longer treatments. They include interpersonal therapy, supportive psychotherapy, attention intervention, and psychoanalysis. All work is done during the sessions. Some experts believe that such therapies might be more useful for generalized anxiety, which may require more sustained work to process and recover from early traumas and fears. In one 2001 study, although they were not very effective for treating panic disorder, they were superior to other approaches, including medications, in helping patients stay in treatment. Alternative Procedures Biofeedback. Biofeedback uses special sensors that allow patients to recognize anxiety states by changes in specific physical functions, such as changes in pulse rate, skin temperatures, and muscle tone. Eventually they learn to modify these changes, which in turn helps relieve anxiety. One investigative approach uses a device that provides feedback to allow patients with panic disorder to reduce breathing rates. Breathing Retraining. Breathing retraining techniques may help reduce the physical effects of anxiety. For example, hyperventilation is one of the primary physical manifestations of panic disorders. This involves rapid, tense breathing, resulting in chest pain, dizziness, tingling of the mouth and fingers, muscle cramps, and even fainting. By practicing measured, controlled breathing at the onset of a panic attack, patients may be able to prevent full attacks. Relaxation Techniques. Relaxation methods, such as learning how to gradually relax all t h e muscles, may also be helpful. Acupuncture. One small study reported that acupuncture relieved anxiety before surgery; whether this study has any relevance to anxiety disorders is unknown. Surgery A surgical technique called cingulotomy involves interrupting the cingulate gyrus, a bundle of nerve fibers in the front of the brain. It is sometimes used as a last resort for patients with

Anxiety Disorders

Or on the Internet (http://www.nimh.nih.gov/) The organization is part of the National Institutes of Health. Anxiety Disorders Association of America (ADAA), 11900 Parklawn Drive, Suite 100, Rockville, MD 20852 Call (301-231-9350) Or on the Internet (http://www.adaa.org) This is the major anxiety association; it provides information and lists of professionals and self-help groups. National Anxiety Foundation, 3135 Custer Drive, Lexington, KY 40517-4001 Call (606-272-7166) Or on the Internet (http://lexington-on-line.com/nafmasthead.html) The Obsessive Compulsive Foundation, Inc., 337 Notch Hill Road, North Branford, CT 06471 Call (203-315-2190) Or on the Internet (http://www.ocfoundation.org/) Provides information and support to people and families with OCD, as well as referrals, two newsletters, videos, and support groups. A.I.M. (Agoraphobic in Motion), 1719 Crooks Rd., Royal Oak, MI 48067-1305 Call (248-547-0400) Hotline refers people to volunteers and gives information. Phobics Anonymous, PO Box 1180, Palm Springs, CA 92263 Call (760) 322-COPE or (760) 327-2184 or (619) 322-2673 Send self-addressed stamped envelope for support groups and information. National Alliance for the Mentally Ill (NAMI), Colonial Place Three, 2107 Wilson Blvd., Suite 300, Arlington, VA 22201 Call (703) 524-7600 or NAMI HelpLine: (800) 950-NAMI [6264] Or on the Internet (http://www.nami.org/) NAMI is a national grass roots organization providing ways for self-help and support organizations to individuals and families of people with psychological disorders. National Mental Health Association, 1021 Prince St., Alexandria, VA 22314-2971 Call (800) 969-6642 or (703) 684-7722 Or on the Internet (http://www.nmha.org) This organization will give the names and numbers of regional chapters and provides information on 200 mental health topics. Emotions Anonymous, PO Box 4245, St. Paul, MN 55104 C ll ( )

Anxiety Disorders

International Society for Traumatic Stress Studies, 60 Revere Drive, Suite 500 Northbrook, IL 60062. Call (847) 480-9028 Or on the Internet (http://www.istss.org) National Center for Victims of Crime, 2000 M Street, Suite 480, Washington, D.C. 20036 Call (202-467-8700) Or on the Internet (http://www.ncvc.org/) National Center for Post-Traumatic Stress Disorder, 215 North Main St., White River Junction, VT 05009 Call (802) 296-5132 Or on the Internet (http://www.ncptsd.org/) Rape, Abuse, and Incest National Washington, DC 20003 Network (RAINN), 635 Pennsylvania Ave., S.E.,

call (800) 656-HOPE (1-800-656-4673) (24-hour confidential hot line) Or on the Internet (http://www.rainn.org) American Institute for Cognitive Therapy, 136 East 57th Street, Suite 1101, New York City, New York 10022 Call (212) 308-2440 Or on the Internet (http://www.cognitivetherapynyc.com/) Association for the Advancement of Behavior Therapy, 305 Seventh Avenue, 16th Floor, New York, NY 10001-60008 Call (212) 647-1890 or (800) 685-AABT Or on the Internet (http://www.aabt.org/) The American Psychiatric Association, 1400 K Street N.W., Washington, DC 20005 Call(202) 682-6000 or (888) 357-7924 Or on the Internet (http://www.psych.org) The American Psychological Association, 1010 Vermont Avenue, NW - Suite 1100 Washington, DC 20005-4907 Call(800) 964-2000 or (202) 783-2077 Or on the Internet (http://www.psychologicalscience.org/) (http://www.dotcomsense.com) for consumers. and

The National Association of Social Workers, 750 First Street NE, Suite 700, Washington, DC 20002-4241 Call(202) 408-8600 or (800) 638-8799 Or on the Internet (http://www socialworkers org)

Anxiety Disorders

On the Internet: Mental Help Net (http://mentalhelp.net/) Information on cognitive therapy (http://www.cognitivetherapy.com/) Internet Mental Health (http://www.mentalhealth.com/) is a free encyclopedia of mental health information. A site with very good information on anxiety run by R. Reid Wilson, Ph.D., a psychologist in anxiety disorders and author of books on anxiety (http://www.anxieties.com/) Interesting site assists in finding the right therapist (http://www.1-800-therapist.com/) OC & Spectrum Disorders Association (http://www.ocdhelp.org) Surgeon General's Report on Mental Health (http://www.surgeongeneral.gov/library/mentalhealth/index.html) Find A Therapist (http://www.4therapy.com/locator/) Assess Your Own Anxiety (http://www.4therapy.com/consumer/assessment/taketest.php?&uniqueid=19&) R
E C E N T

L I

A B O U T W E L L - C O N N E C T E D Well-Connected reports are written and updated by experienced medical writers and reviewed and edited by the in-house editors and a board of physicians, including faculty at Harvard Medical School and Massachusetts General Hospital. The reports are distinguished from other information sources available to patients and health care consumers by their quality, detail of information, and currency. These reports are not intended as a substitute for medical professional help or advice but are to be used only as an aid in understanding current medical knowledge. A physician should always be consulted for any health problem or medical condition. The reports may not be copied without the express permission of the publisher. Board of Editors Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital Stephen A. Cannistra, MD, Oncology, Associate Professor of Medicine, Harvard Medical School; Director, Gynecologic Medical Oncology, Beth Israel Deaconess Medical Center Masha J. Etkin, MD, PhD, Gynecology, Harvard Medical School; Physician, Massachusetts General Hospital John E. Godine, MD, PhD, Metabolism, Harvard Medical School; Associate Physician, Massachusetts General Hospital Daniel Heller, MD, Pediatrics, Harvard Medical School; Associate Pediatrician, Massachusetts General Hospital; Active Staff, Children's Hospital Paul C. Shellito, MD, Surgery, Harvard Medical School; Associate Visiting Surgeon, Massachusetts General Hospital Theodore A. Stern, MD, Psychiatry, Harvard Medical School; Psychiatrist and Chief, Psychiatric Consultation Service, Massachusetts General Hospital