General information

Anxiety disorders affect approximately 19 million adults in the United States. This makes anxiety disorders about as common as substance use disorders and more common than mood disorders (e.g., depression, bipolar disorder). Anxiety disorders are also among the most common types of psychiatric problems seen in children and adolescents. Anxiety disorders account for approximately 31% of the total mental health care costs. In addition, they are also associated with impaired occupational, social, and marital functioning - as well as with a decrease in overall life satisfaction.

There are several different types of anxiety disorders, but they all share a common theme of excessive fear and dread. Although everyone experiences anxiety from time to time, anxiety disorders distinguish themselves from normal anxiety in that the anxiety that is experienced is too frequent or out of proportion with the actual threat present. In addition, anxiety disorders are often chronic conditions; the anxiety does not simply surround a stressful life situation and resolve once that situation is over (as with normal anxiety). Although anxiety may wax and wane, if left untreated, most anxiety disorders tend to grow progressively worse over time.

Each anxiety disorder has its own distinct features. The primary anxiety disorders are:

	Panic Disorder (with or without agoraphobia)
	Obsessive Compulsive Disorder
	Social Phobia
	Generalized Anxiety Disorder
	Specific Phobias
	Post Traumatic Stress Disorder

In addition to Obsessive- Compulsive Disorder, there are also several disorders that share many common features with OCD. These disorders are commonly referred to as OCD - spectrum disorders. They are:

	Trichotillomania
	Skin picking
	Body Dysmorphic Disorder

In addition, current research also indicates that Irritable Bowel Syndrome (IBS) may be linked to panic disorder and respond to similar treatments that are used for panic.

It is not uncommon to have more than one anxiety disorder. In addition, those with anxiety problems may also suffer from depression - sometimes, these feelings of sadness are produced by the way their lives are limited or affected by their anxiety symptoms.

Symptoms of depression include: feelings of sadness, hopelessness, loss of interest in things that were previously enjoyed, changes in appetite or sleep, low energy, difficulty concentrating, and thoughts about life not being worth living. If more than one psychological problem is present, a mental health professional is often needed to determine which diagnosis should be treated first or if the disorders can be treated at the same time

When you are fearful or worried, this can cause you to experience many different bodily sensations associated with anxiety. For more information on this bodily response, see Anxiety/fear and your Body section. Some common physiological symptoms of anxiety are:

In children, anxiety may also be expressed by crying, tantrums, being frozen in place, or shying away from situations. When people experience several of these physical sensations accompanied by a sudden rush of intense fear, this usually means that they are having a panic attack. Most panic attacks peak quickly (within 10 minutes) but can take longer to subside. Panic attacks are also commonly accompanied by the thoughts/fears that one is: “going crazy”,“losing control”, or “having a heart attack”.

Panic attacks can occur in any of the anxiety disorders - panic disorder, obsessive compulsive disorder, social anxiety disorder, generalized anxiety disorder, specific phobia, and post- traumatic stress disorder. Usually, in these disorders, panic attacks occur when the person approaches the thing that they fear (e.g., public speaking in social phobia, a dirty bathroom for those with OCD contamination fears, etc.) However, in panic disorder, people fear the panic attacks themselves and often experience these attacks as coming on without warning or “out of the blue”.

All humans experience anxiety and fear. This is a biologically determined response that is very important to our survival. We probably wouldn't live too long if we did not have any fear -- for example, if we weren't fearful when we see a growling dog or a car speeding toward us. So, the bottom line is that some fear and anxiety is good. However, for people with anxiety disorders, anxiety and fear are experienced too frequently or out of proportion to the realistic danger that is actually present.

Anxiety and fear are actually two very different things. Anxiety is typically what people experience before the “dangerous“ situation is encountered. In other words, anxiety is the way that our body begins to prepare for facing the threat. This type of future orientation of fears is especially clear in Generalized Anxiety Disorder; in this disorder, worries frequently take the form of future oriented “what if ” questions (e.g., “What if you get sick?”, “What if I don't get a good job?,” “What if no one likes me at school?”). This type of anxiety response tends to be more verbal (e.g., people talk a lot about their worries) rather than physiological (e.g., shaking hands, sweating).

However, as people begin to approach (e.g., either in time or location) the situation/object that is feared, they begin to experience a greater physiological anxiety response. Many people speak of “anticipatory anxiety“ or anxiety that occurs in anticipation of approaching the feared situation or object. Anticipatory anxiety can be experienced in any of the anxiety disorders - for example, a person with the contamination type of OCD may experience anticipatory anxiety because they know that the next day they will have to go to some place they perceive as “dirty;“ a person with social anxiety disorder may experience anticipatory anxiety about a class presentation that needs to be given the following week; or a person with panic disorder may experience anticipatory anxiety because they know that tomorrow they will be visiting the same place where they had their first panic attack.

Fear (and panic) are activated when the threat situation is actually encountered (not just anticipated). People in a state of fear experience a very intense and immediate physiological response and their ability to think or talk about the situation is usually very limited. This kind of automatic fear response is designed to be very protective - as it is designed to automatically activate a series of bodily responses that will help you in times of danger. This automatic response is often termed the “fight/flight“ response - because if true danger were present, it allows you to protect yourself and survive by mobilizing your body to either fight the danger or to flee from the dangerous situation. However, in anxiety disorders, panic attacks or fear responses are often activated when there is no real danger present. Panic attacks can occur in any of the anxiety disorders when the feared situation is encountered.

Specifically, when the feared situation is encountered, a branch of your autonomic nervous system, the sympathetic nervous system, activates the fight/flight response. As a result, your body releases two chemicals called adrenalin and noradrenalin into your system. These two chemicals produce many changes in your body such as increased heart rate, respiration, and sweating. All the changes that occur are designed to help you in a truly dangerous situation. However, if there is no danger that is really present (and you do not need to fight or flee), people often experience unpleasant bodily side effects of this protective system. None of these side effects are dangerous but they can be very distressing.

No. Certainly no one would chose to have an anxiety disorder and, likewise, no one would wish these symptoms on someone that they love. It is currently unknown what exactly causes these disorders, but they are likely due to a combination of multiple factors. Two types of anxiety disorders, panic disorder and blood/injury/injection phobia, have been found to be slightly more genetically based than some of the other anxiety disorders. In other words, these two disorders are more likely to “run in families“ than some of the other disorders.

For the other types of anxiety disorders, what seems to be “inherited” is more of a generalized vulnerability. In other words, you are vulnerable to developing an anxiety disorder, but not inclined to develop a specific anxiety disorder. So, in other words, what may be inherited is a biological tendency to have an over-reactive sympathetic nervous system (fight/flight system). This biological tendency combined with early developmental experiences (e.g., what we are taught about the world and how threatening it is influences future perceptions and experiences) and later stressful life experiences, may then determine what type of anxiety disorder develops (or if one develops at all).

Many people are frequently surprised to learn that there are a combination of factors that lead to anxiety disorders because they have heard that these fears “may be due to a chemical imbalance in my brain”. In general, anxiety disorders are determined by various different factors. Current research indicates that there seems to be some genetic contribution in terms of who is more vulnerable to developing an anxiety disorder. However, this is a general genetic vulnerability to developing an anxiety disorder, but not to developing a specific type of anxiety disorder. There appears to be a slightly higher genetic vulnerability for those who develop panic disorder and for those who have blood/injection/injury phobia.

Thus, genetics are involved, but one's genetic vulnerability is only one factor that influences who develops anxiety disorders. Early developmental experiences and important life events have also been found to be very important in the development of anxiety disorders. In addition, recent research indicates that people's behaviors affect the chemicals (or neurotransmitters) in their brains. Therefore, if people already have extensive fears and avoid feared situations, it is no wonder that there may be some differences in the “chemicals” in their brain. It is the chicken and the egg phenomenon, it is unknown which comes first - the distress and related behaviors or the chemical changes. In addition, research shows that it is not just mediations that have the ability to alter brain chemicals, but if people change their behaviors, they can actually also create changes in those same brain chemicals -- even without any medications!

My child has an anxiety disorder

If your child has an anxiety disorder, the most important piece of advice is: Don't blame yourself and don't blame your child. Certainly no one would ever want these symptoms or wish them on someone they love. Anxiety disorders can be especially frustrating if they are accompanied by a lot of avoidance or other “safety“ behaviors (e.g., having a parent or other safely object with them in feared situations, compulsions, etc.). Please try to be patient with your child and remember...if it were so easy to “just stop“ these frustrating behaviors, it would have already happened. Tell your child that you love them despite any anxiety problems. Let them know that even though they may have some worries that don't make sense or some “bad habits,“ they are not a bad person.

It is also often beneficial to educate your child a bit about the problem so that they no longer feel so alone or “crazy“. This discussion should be tailored to your child's age, developmental level, and their concerns or insight about the problem itself. For example, some children with OCD may think that others are just “gross“ for not also washing their hands 10 times before leaving the bathroom; sometimes, children with trichotillomania do not seem to care about the effects of hair pulling on their appearance. In addition, sometimes children may engage in some anxiety related behaviors with only minimal awareness (because these behaviors have become so automatic), so they may not honestly know what behaviors you are referring to (or not be aware of their frequency).

Absolutely. Frequently, those with anxiety disorders alter their lifestyles and those of loved ones due to the “rules“ that their anxiety disorder makes them adhere to. These lifestyle alterations can run the gamut from mild to very severe. For example, a child with a specific phobia of dogs may insist that the family does not go to any parties at people's houses if they own a dog (i.e., relatively minimal life interference), but a child with severe checking OCD may insist that his family return home twice every time they leave the house to check that the front door is really locked (i.e., severe life interference). Thus, even though family members may not share or even understand the fears that are present, they conform to the “rules“ made by the anxiety disorder so that their loved one is not distressed. It is not uncommon for children to become very upset, cry, or have a tantrum if these “rules“ are disregarded.

One of the most common ways that anxiety disorders are identified in children is due to a change in their previous functioning. It is not uncommon for children with anxiety disorders to begin avoiding certain activities or contact with particular objects/people due to their fears. These indicators are often confusing to parents because they frequently involve things that their child formerly enjoyed (such as going to the beach or a playground). Some children will state their fears, but it is probably more common for children to instead make up excuses like “I'm tired“ or “I don't like doing that anymore“ rather than reveal that they are frightened to do certain things or go to specific places. For certain anxiety disorders, such as OCD, the number of avoided things often grows over time and symptoms worsen. Thus, time formerly spent having fun with family and friends is now spent engaging in anxiety related behaviors (e.g., dwelling on the worry, compulsions) or in avoiding things that are feared.

Typically the same treatments are used for children as are used with adults -- with some slight differences. For example, the disorders are explained in ways that they can better understand and a reward system is usually implemented for all their hard work in attempting therapy assignments. Reward systems tend to be especially helpful in keeping younger children on-track, given that the results of therapy are usually not seen for several weeks and children have a tendency to easily give up if they see no immediate benefit. Older children and adolescents may see standard reward systems as being “treated like a baby,“ so they frequently prefer that treatment be conducted in the same way as it is administered with adults or that monetary incentives are instead given.

The most essential element to successful treatment is that the child is self-motivated to change these anxiety related behaviors - and they are not solely in treatment because of parental pressure.

The role of family members usually varies depending on the age of the child. For younger children, more parental involvement is usually necessary (in part because children sometimes have a harder time reporting accurately on their symptoms, therapy assignments, and progress). Adolescents usually prefer to keep their sessions more private and only periodic check-ins with parents are usually implemented.

It is usually very beneficial for the family to have some role in treatment so that they can be further educated about the anxiety disorder and understand the sometimes frustrating symptoms that accompany them. The degree of family involvement usually depends on the child/adolescent and on the family itself. For some families, taking a step back and letting your child take the reins (with the help of their psychologist) in overcoming their symptoms is most helpful.

For some families, it may be beneficial for the parents to know about the treatment plan that has been designed by the psychologist. This is frequently helpful because then they will know where to look for successes and where to not yet expect improvements (until later). If family members are engaged in “helping“ their child with any anxiety related behaviors (e.g., compulsions), they can also learn how to gradually separate themselves from these fear-related behaviors. The biggest role that the family can play is by helping their child to implement the weekly goals that have been set between their child and the psychologist. Because each family is very different and has its own specific needs, you will have to work together with your psychologist to decide how you can best help your family member with their anxiety disorder.

Obsessive-Compulsive Disorder (OCD) affects 3.3 million adults in the United States. OCD also affects 1 - 2 children in every hundred. The age of onset of OCD symptoms is variable with symptoms typically first appearing anytime between preschool to early adulthood. Many people with OCD report that their symptoms wax and wane - for no apparent reason, there are periods of time when their symptoms are better and periods when they are worse. Symptoms typically worsen during stressful periods (e.g., getting laid off from work, getting married, starting school). In addition, it is also fairly common for the type of OCD to change over time - for someone to be bothered by different types of obsessional thoughts in their adolescence than in adulthood. Without treatment, OCD tends to be a chronic condition that generally gets worse over time.

People with OCD experience either obsessions or compulsions - with most people having both obsessions and compulsions. OCD thoughts and behaviors usually cause a significant amount of distress, take up a lot of time, or interfere with a person's work, school, social life, or family relationships.

Obsessions are recurrent, persistent thoughts, images, or impulses that are distressing and intrusive. People with OCD typically try to ignore, suppress, or in some way neutralize the thoughts. Usually people realize that their fears are not realistic or logical but this can vary. Sometimes OCD sufferers know that what they are fearful of can't really come true, but they are still worried. Other times, OCD sufferers are very certain that this illogical fear will really happen. Some examples of common obsessional thoughts are listed below.

Compulsions are repetitive physical behaviors or mental acts that a person feels driven to perform - typically, these compulsions are usually done in an attempt to neutralize or reduce the distress created by the disturbing obsessive thought. Some common compulsions are listed below.

Research indicates that it is not the content of the thoughts themselves that distinguishes people with OCD from those without OCD - rather, it is the frequency of these thoughts and the extreme amount of distress they cause that distinguishes OCD. Most people have thoughts like these from time to time but they just think that the thought was strange and easily let it go, but people with OCD are very distressed by the thoughts and have much more difficulty getting rid of thoughts. Some people with OCD describe it as feeling like having a faulty fire alarm in a building - the alarm keeps going off and making them think that danger is there, even though there really is no fire.

Obsessive thoughts/images/impulses:

** frequently people with contamination obsessions are fearful that they might get ill or die if they come in contact with a contaminant or that they will accidentally spread the contaminant and others will get sick as a result

Compulsive behaviors:

These compulsions can be present on their own, but they commonly occur in response to having a distressing obsessive thought. Although many compulsive behaviors are commonly linked to certain types of obsessive thoughts, any type of compulsion can be related to any type of obsession.

Even though there are very effective treatments available for OCD, it frequently goes unrecognized for years. In part, this is sometimes due to people being ashamed of their OCD symptoms and hiding them or making excuses for their “unusual“ behaviors. In children, OCD symptoms may sometimes be mistaken as “behavior problems“ at school or home; this is usually because children (like adults) become very upset when their obsessions are triggered or their compulsions are interrupted - thus, these situations may provoke temper tantrums. For example, a child with contamination fears may become very angry when her brother, who has just been at the “dirty“ park, tries to sit in her (“clean“) chair at home.

Unfortunately, OCD symptoms are sometimes also not correctly diagnosed or treated by professionals. Research indicates that on average, people see 3-4 doctors and spend over 9 years in various treatments before receiving the correct diagnosis or treatment for their symptoms.

The two treatments that have been found to be effective for OCD are medications, Cognitive-Behavioral Therapy (CBT), or a combination of both. The typical medications used for OCD are the serotonin reuptake inhibitors (or SRIs) - there are many different medications in this class (e.g., Prozac, Paxil, Luvox, Zoloft, etc.). Sometimes it is necessary to try several different medications to find the right one that will work for you. However, medications alone rarely eliminate all OCD symptoms and usually many compulsions and avoidances remain. Frequently, symptoms return when the medication is discontinued. For these reasons, medication management for OCD is rarely used alone and it is usually combined with CBT.

Although there are many different types of therapy that exist (e.g., psychoanalytic, psychodynamic, interpersonal, supportive, etc.), only one type of therapy has been found to be effective for OCD - Cognitive-Behavior Therapy or CBT. CBT generally results in a 50-80% reduction in OCD symptoms, and because patients are learning new life skills, these techniques generally do not suffer from the same relapse rates encountered with medications.

CBT for OCD involves educating the individual with OCD as well as important family members about the causes of OCD and the strategies that are helpful as well as harmful in overcoming the disorder. The most effective techniques involve Exposure and Response Prevention (ERP). This involves thinking of all the situations that provoke the obsessions (or worries/fears). The next step is to rank order how difficult it would be to do each of these things (i.e., “exposure“ to the feared situation) without engaging in the typical compulsions or behaviors that are normally used to alleviate the anxiety (i.e., “response prevention“). Usually, the most mild or moderate items are worked on first and the person with OCD will begin to realize that they do have control over their OCD and their anxiety does diminish. When these situations become easier, then the next item on the list is tackled until all situations are confronted.

Many people find it helpful to think about ERP as being similar jumping into a cold swimming pool. Often it is too scary to just jump right into the pool and many people might want to run away. This would be like confronting your worst fears all at once, and this is usually too difficult for most people. However, most people can first try putting their feet in the cold water, then they wait until that feels ok, then they might put their legs in up to their knees and then wait until that feels ok, and so on. Before they know it, they have the same result as just jumping in - it takes a little longer, but is far less scary and eventually they are swimming around in the pool and feel like the water temperature is just fine. This is usually how OCD fears are confronted too - a little at a time, then a little more, etc. In this kind of therapy, the psychologist and patient work together as collaborators to figure out where the right place to start is and what the next steps should be. Patients are also expected to work on these same practice assignments outside of sessions so that they will improve a lot faster and their improvements will generalize outside of the therapist's office to home, work, or school.

It is relatively common for individuals to feel like they can “get by“ with continuing to engage in their compulsive behaviors until their lives are limited to such an extent that the problem can no longer be ignored or tolerated. Until they reach this point, things can be very frustrating for family members, who are likely to be confused and irritated by the symptoms. Although frustrating, this can help you to better understand how terrifying the OCD fears are -- that the OCD sufferer is willing to go to such extremes to adapt their life to avoid contact with the feared situations.

In this type of situation, it is best for family members to become as educated as possible about OCD. This can be a big help to the OCD sufferer because you can help to educate them about their symptoms and help them understand that there are very effective treatments out there that can help. If your family member with OCD is still in denial about their problems despite your efforts to educate them, it is often useful for the family to consult with a psychologist who specializes in OCD for further help with this issue.

Panic disorder affects approximately 2.4 million adults in the United States. It usually develops during late adolescence or early adulthood. Panic attacks can occur in any place and at any time. Some people even suffer from nocturnal panic attacks - in other words, they are jolted out of sleep in the middle of a panic attack. Most attacks peak (or reach their worst point) in about 10 minutes, but residual symptoms can last for much longer.

Occasionally, some people experience only a few isolated panic attacks during their lives that never manifest themselves as panic disorder; in other words, they do not have repeated panics or live in fear of having another panic attack. In fact, 14% of people report experiencing an unexpected panic attack within the past year. However, once someone has developed fear of having another panic attack or begins changing their lives or their routines in any way (out of fear of panic), panic disorder usually becomes a more chronic problem.

Left untreated, panic disorder tends to become worse over time. More and more situations and activities are avoided over time (agoraphobia increases) and it is not uncommon for many important life decisions to be dictated by the fear of panic (e.g., whether or not to take a trip where you would need to get on a plane, whether or not to accept a promotion where speaking in front of others is necessary). Sometimes, people become so controlled by their fear of panic that they become completely housebound.

This is still somewhat unclear. However, the current research seems to indicate that people who are vulnerable to developing panic disorder tend to have an over-reactive autonomic nervous system -- the system that controls the fight/flight response that is part of panic (for more information, see Anxiety/Fear and your Body section on this website). It is believed that for many of the anxiety disorders, people are not genetically predisposed to developing a specific anxiety disorder - however, panic has a slightly stronger heritability. Onset of panic attacks usually surrounds stressful life events - this includes both bad stresses (e.g., having a heavy workload at school, getting laid off from work) and good stresses (e.g., getting married).

So, frequently, an over-responsive flight/flight system is unexpectedly set into motion under a time of high stress. This first panic attack tends to be very terrifying for most people and they might then begin to fear the panic attacks themselves. This is what differentiates panic disorder from the other anxiety disorders (where you might also have a panic attack). People with panic disorder begin to fear their own bodily sensations (“fear of fear“) because these are used as cues that another terrifying panic attack may be starting again. Thus, panic is viewed as a phobia of one's own bodily sensations. This differs from other phobias where the feared object can be more easily avoided. For example, if someone has a phobic fear of dogs, then they can run away when they see a dog and feel okay. If someone has a phobia of their own physical sensations, when they begin to notice a sensation that has been linked with panic (e.g., increased heart rate), they become afraid. Naturally, our flight/flight response is then designed to actually increase physical arousal - which is the very thing that people with panic fear. These internal sensations are also less predictable and controllable than other phobic stimuli - making them even more terrifying.

Although people with panic are very sensitive of these internal cues, these are often not consciously processed. For example, just as a person might discover that somehow they drove from one place to another without really thinking about it, this is what also happens when people are processing their bodily sensations. However, because people are aware of their bodily sensations but not explicitly thinking about them, this often accounts for why panic attacks frequently seem to “come out of the blue“. Agoraphobia develops as more and more situations that appear to trigger or affect panic are avoided (e.g., malls, driving, beaches).

Panic attacks are defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) as: A discrete period of intense fear or discomfort, that usually comes on suddenly and unexpectedly. They usually peak within 10 minutes. Several of the following physical symptoms and fears are often experienced:

	racing heart
	sweating
	trembling or shaking
	sensations of shortness of breath or smothering
	choking feelings
	chest pain or discomfort
	nausea or abdominal distress
	feeling dizzy or lightheaded
	feelings of unreality
	feelings of being detached from oneself
	numbness or tingling
	chills or hot flashes
	fear of losing control
	fear of going crazy
	fear of dying

Many people genuinely believe that these attacks mean that they are losing their mind, they are dying, or having a heart attack. It is not uncommon for people to have had visits to their primary care doctor or to the emergency room due to these symptoms.

For individuals with panic disorder, they have recurrent, unexpected panic attacks (as defined above) and frequently:

For people with panic disorder, their initial panic attacks are “out of the blue". However, many people find that, over time, certain situations or activities are more likely to trigger a panic attack. Thus, many people eventually begin restricting their behaviors because they fear that they may have a panic attack if they go to certain places or engage in particular activities. The avoidance is usually even more pronounced if these situations are not only a place that may trigger a panic attack, but also are places/situations where escape may not be easy, help may not be readily available, or if panic in that situation may be particularly embarrassing.

Over time, people with panic often begin to fear certain situations - thinking that these situations might be likely to trigger a panic attack or they don't know how they would cope if a panic attack occurred in that type of situation. When a person begins to avoid situations or endure situations with an extreme level of discomfort, this is called agoraphobia. Common agoraphobic situations are:

In addition, activities that trigger physical sensations may also be avoided such as:

If an individual needs to enter a feared situation, usually they do something that helps to make them feel safer there - for example, insist that someone they trust accompanies them or bringing things with them that help them feel safe (e.g., anxiety medications, cell phone, water bottle, etc.).

It is important to note that panic attacks may occur in any of the anxiety disorders. You may need professional help to determine if you have panic disorder or panic attacks in the context of another anxiety disorder.

The good news is that panic disorder is very treatable. The two treatments that have been proven by research to be effective for panic disorder and agoraphobia are medication and therapy - specifically, Cognitive-Behavioral Therapy (CBT). The types of medications that have been studied for the treatment of panic disorder are: the selective serotonin reuptake inhibitors (SSRIs; Prozac, Paxil, etc.), tricyclic antidepressants, monoamine oxidase inhibitors (MAOIs), and benzodiazepines. Although medications are often quite effective, it is not uncommon for panic attacks to resume once the medication is no longer taken. CBT is often implemented to minimize relapse if the patient decides to go off of medication. Medication and CBT can be combined, but it is often helpful if patients keep their medication regimen stable while engaging in CBT - especially if benzodiazepines are being taken.

The first step in Cognitive-Behavior Therapy (CBT) is education about panic and anxiety; this information is presented, in large part, to correct the misinterpretations of certain bodily sensations as scary or dangerous. Although many of the symptoms may not feel very good, they are actually linked to the fight/flight system that is designed to protect you during times of actual threat. This step is commonly referred to as “cognitive restructuring“ - where individuals learn how to more realistically appraise what is happening in panic and how not to interpret the sensations that they are feeling as being dangerous (e.g., “this feeling means I'm having a heart attack“). In addition, patients are also taught how to catch the common thinking errors that are very common in panic - overestimating the probability of the feared outcome (e.g., “if this feeling happens again, I will crash the car“) and catastrophizing (e.g., “if I fainted during the business meeting, I would never be able to show my face there again“).

In addition, patients are also taught how to breathe correctly; this step is often referred to as “breathing retraining“. This step is taught because the symptoms of hyperventilation often play a role in many panic attacks.

Patients are also guided through interoceptive exposures. This is a fancy term for evaluating what kinds of bodily sensations are feared (or are triggering the panic attacks), and then confronting these sensations in a structured way to learn that they are not really as dangerous as initially perceived. Typically, the types of sensations that are feared are placed on a hierarchy from the least to the most frightening. Then, the sensations are confronted, usually beginning with the least fear provoking sensations.

Finally, for those with agoraphobia, “in vivo“ exposures are also implemented. This involves entering the situations that have been currently avoided (or otherwise endured only when absolutely necessary with extreme distress) due to fear of panic. Like interoceptive exposures, the types of situations are placed on a hierarchy and the least anxiety provoking items are confronted first. Usually, even within one specific situation, there are things that can make that situation easier and harder (e.g., having a companion available, close to home, etc.). These factors that affect the difficulty of the situation are also taken into account when designing exposure assignments. Generally, treatment for panic takes longer if there are many agoraphobic situations. It is important to note that although initial exposures are usually conducted with the psychologist, patients are asked to practice what has been worked on in session at home as well.

It is estimated that specific phobias affect approximately 6.3 million adults in the United States. As previously stated, the different types of phobias tend to have very different peak ages of onset. For example, for those with blood/injury/injection phobias, the onset of the disorder tends to be from age 7 - 9. However, for those with situational phobias, onset usually occurs either in childhood or in early adulthood (mid-20's). Animal and natural environment phobias usually have a childhood onset.

All types of phobias tend to be very chronic conditions. Although specific phobias are very treatable conditions, people with phobias frequently simply avoid the feared object/situation and do not seek treatment unless the phobic fear begins to significantly interfere with their life or daily functioning.

The cause of specific phobias is currently unknown, but it is likely due to a combination of factors. As with the other types of anxiety disorders, specific phobias are likely due to “inheriting“ a nonspecific biological vulnerability to developing an anxiety disorder (but not a specific one) combined with individual life experiences. However, there tends to be a stronger genetic link for those with blood/injury/injection phobia.

Research indicates that phobias tend to fall into 4 different types: blood/injury/injection phobias, animal phobias, natural environment phobias (e.g., heights, water), and situational phobias (e.g., flying, driving, bridges). These classes of phobias have many different characteristics from each other - different peak ages of onset, differences in the likelihood of having other co-occurring psychological problems (e.g., depression), and differences in the likelihood that the phobia “runs in the family“.

In terms of the types of life experiences that may make one vulnerable to developing a phobia, researchers propose that there are several different means by which a person can become “conditioned“ (or learn) to fear a particular object or situation. The different modes of fear acquisition are: direct or traumatic conditioning (i.e., where an individual has personally had a terrifying encounter with the phobic object/situation), vicarious observation (i.e., observing someone else having a terrifying encounter with the phobic object/situation), and informational transmission (i.e., hearing about someone else expressing their fears of or their experience with the phobic object/situation). The impact of these types of aversive learning experiences is often mitigated by any previous good/neutral experiences with these objects/situations - thus, accounting for why people can have the same type of traumatic event but some people may develop a phobia and others do not.

Researchers have also speculated that certain phobias are acquired very quickly because we are biologically prepared to fear these objects or situations. In other words, throughout evolution, it was wise to fear these things (e.g., spiders, snakes, heights), so they became more biologically encoded as fearful objects/situations - thus, we are more vulnerable to developing a phobia to these types of things than to other things (e.g., flowers, rolling hills).

There are several main phobia types:

Specific phobias have the following characteristics:

1. There is a persistent fear of a specific object or situation that is excessive or unreasonable. This fear is usually triggered by the presence of (or the anticipation of encountering)the feared object/situation.

2. Being in the presence of the feared object/situation almost always produces an immediate and extreme anxiety response. This anxiety response may become so severe that the person has a panic attack (see section on panic disorder for more information on panic attacks). **

3. The person usually recognizes that the fear (or the degree of the fear) is excessive or unreasonable.

4. The phobic situation or being in the presence of the phobic object is avoided or endured with intense anxiety and distress.

5. The avoidance, anxious anticipation, or distress with the feared object/situation significantly interferes with the individual's functioning - school, work, or relationships with family or friends.

Sometimes it may be difficult to differentiate specific phobias from other anxiety disorders - in particular, panic disorder (with or without agoraphobia) or social anxiety disorder. In these cases, an evaluation by an expert is often necessary to determine the diagnosis. In addition, for children, there are certain types of fears that are very age appropriate. For a child to have a phobia of a specific object/situation, it is necessary that they are much more afraid of these objects/situations than other children their age.

** Those with blood/injury/injection phobias are more likely to faint than those with other phobias or other anxiety disorders. Although feeling faint is a common symptom of anxiety in general, it is rare that people actually do faint. However, for those with blood/injury/injection phobia, actual fainting is much more common.

The treatment of choice for specific phobias is Cognitive-Behavioral Therapy (CBT). Although some people use medications when entering a phobic situation (e.g., take Xanax when they need to go on a plane), this is only effective in temporarily managing the distress in that situation but does not eliminate fear of that situation or the anticipatory anxiety that often occurs (e.g., anxiety due to anticipation of the situation happening). There has been little research into the effectiveness of pharmacotherapy for phobias or the added benefit of taking medications in addition to engaging in CBT. The need for this kind of research is small because CBT is highly effective.

Depending on the type of specific phobia that exists, there are slight variations in the treatment method that is applied. However, a general outline for CBT for specific phobia is presented below. In CBT, treatment usually begins with education about why the phobia may have developed as well as an explanation of CBT and why it is effective in treating phobic fears. In addition, education about the specific phobic stimulus may be necessary (e.g., not all snakes are poisonous) as well as skills information about that stimulus (e.g., how to correctly handle a snake).

The next step in CBT is usually to identify what types of things make that object/situation easier or harder to confront. For example, for those who fear a specific type of situation like heights, the situation may be more fearful if they are high on a hill vs. high up in a building. For those who fear spiders, the size, the color, and how hairy it is may make a difference in terms of how feared the spider would be. In addition, any other safety behaviors that may make the situation/object less frightening are also taken into account. For example, common “safety behaviors“ are taking a friend with you, water bottles, anxiety medications, etc. This will help you and the psychologist you are working with to create your “fear hierarchy“ - in other words, enable you to rank order from easiest to hardest how difficult certain situations would be. Eventually, individuals begin confronting the feared objects/situations on their fear hierarchy - beginning with the least frightening object/situation.

Cognitive restructuring is also another technique that is very beneficial in treating specific phobias. In this technique, the dangerousness of the object/situation as well as the perceived dangerousness of one's response in this situation (e.g., I'll have a heart attack, I'll embarrass myself) is further explored. Frequently, individuals with specific phobias have certain types of cognitive errors such as overestimating the risk of any real danger that exists (e.g., if I try to pet a dog, I'm 99.9% sure that it will bite me) and catastrophizing the situation (e.g., if I hyperventilate, I will faint in the elevator, use up all the oxygen, and die there).

Treatment for phobias is generally short-term and effective.

Does this sound like you?

Generalized anxiety disorder from patients' perspectives

“My mom always called me a 'worry wart'. Even though she and my dad never really pushed me in school, I'd always worry about doing well and getting all A's. The night before each test, I always had problems falling asleep and when I did it was restless sleep. I worried - about what would be on the exam, if I had studied enough, what if the teacher threw a curve. It maybe would've been ok if my worries were confined to this one area or if they stopped when the exams were all over, but it seemed almost like my mind would search for the next thing to worry about. My friend hadn't called in a while, was she upset with me? What should I be when I grew up and how come I wasn't sure what I wanted to be yet? Did they say it was going to rain on Saturday - oh no, this would ruin our trip to the beach. All my life, my worries seem to have been endless -- if I'm not worried about one thing, my mind just moves on to the next thing to worry about…“.

“I spend a lot of time talking to my husband about all of my worries. Sometimes he tells me that he is tired of talking about everything in my life and analyzing it in a million different directions. But I feel like I can't help myself. My heart starts to pound, my hands get clammy, and I sometimes pace around the apartment. Primarily, I worry about the future. I worry that the job that I have is not the right one for me. I worry that maybe I should work more hours so that we can buy a house sooner. I worry that maybe I'm getting too old to have a child…My worries will also be triggered by things I see or hear about. Like, if I'm watching a TV show where someone dies, I think about what I would do if my husband suddenly died, how would I get along without him? Maybe we should draw up a will? I think about life without him and worry…“

GAD affects approximately 4 million adults in the United States. This disorder is about twice as common in women as in men. GAD tends to come on gradually so it is difficult to determine the onset of the disorder. It usually appears between childhood and middle age, and it is not uncommon for many people to report that they have “always been this way“ or that they have been this way for “as long as I can remember“. GAD tends to be a chronic disorder. Symptoms often wax and wane in concert with periods of increased life stress. Most people with GAD are generally able to function relatively well in life and typically don't avoid many situations; however, they do report that their chronic worrying does significantly impact their enjoyment of their life. However, it is possible for GAD to be very severe and to begin impacting even the most ordinary daily activities.

GAD frequently co-occurs with other anxiety disorders and other psychological difficulties (such as depression and substance abuse).

The answer to this question is currently uncertain. Like many of the other anxiety disorders, it is believed that GAD results, in part, from a genetic vulnerability to develop an anxiety disorder (however, there have been no genes identified that lead specifically to GAD). It is believed that this genetic vulnerability interacts with a person's innate temperament (their natural tendency from birth to be more extraverted, introverted, etc.) and developmental experiences to determine who will develop GAD.

Everybody worries. But, what distinguishes people with GAD from normal worrying is that people with GAD tend to worry about things that are unlikely to happen (see below) and they tend to underestimate their ability to cope if difficult situations do occur. Most people's worries tend to increase when life stressors arise (e.g., car accident, fired from a job, divorce, death of a loved one). However, people with GAD worry even when no real stressor is present; frequently individuals with GAD report that they feel like they are always playing a “what if“ game in their mind…always worried “what if“ one thing or another happens.

More specifically, the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) specifies the following criteria for GAD.

1. Excessive anxiety, worries, or anticipatory anxiety about several different areas or activities (see below). These types of worries must be predominant (occurring more days than not) for at least 6 months.

2. In addition, individuals with GAD have difficulty controlling the worry and have several physical symptoms associated with anxiety (see general information section of anxiety disorders for common symptoms of anxiety).

3. The worries and/or physical symptoms also cause distress or impairment in social, occupational, or other areas of functioning.

* Often, evaluation by a professional is needed to help determine whether performance worries are due to GAD or social anxiety disorder (social phobia). Frequently, those with GAD worry primarily about “being the best“ that they can be and the quality of their performance is important to them even if other people wouldn't even know about their successes or failures. However, in social phobia, anxieties are primarily driven by worries about evaluation from others and worries about what others will think about their performance (rather than an intrinsic need to “be the best“ for themselves).

Both medications, Cognitive-Behavioral Therapy (CBT), and a combination of the two have been found to be effective for GAD. The most common medications used for GAD are benzodiazepines (these usually provide only short-term relief, but are quick acting) and selective serotonin reuptake inhibitors (SSRIs; these provide longer-term relief but usually take about 3 weeks before they begin to be effective). It is not uncommon for people who take medications to report that it helps to “take the edge off“ of their anxiety, but that they are still left with many worries. These people frequently seek therapy as an adjunct to their medication regimen.

CBT for GAD typically involves the following steps. First, patients are further educated about the function of anxiety, and they are also asked to monitor and record their worries when they occur. This helps to determine what types of worries are present and if they tend to occur more frequently at certain times of the day.

People with GAD are also taught muscle relaxation techniques (e.g., progressive muscle relaxation). This strategy helps to reduce the general muscular tension that often accompanies GAD; in addition, this specific muscle relaxation strategy also helps to actively redirect one's mind from their worries onto more relaxing thoughts.

CBT also teaches cognitive restructuring techniques - or ways to analyze the worries to determine what exactly is feared, if that is a realistic worry or not, and how one would cope in the event that the worst scenario actually happens. In particular, patients are taught how to recognize probability overestimations (e.g., thinking that a bad outcome is much more likely than it really is) and catastrophizing errors (e.g., thinking that there would be no way that they could cope if the worst happened). These types of cognitive “errors“ are very common in GAD. In addition, it is also valuable for patients to explore their beliefs about worry itself - as it is common for some people to believe that worrying prevents bad things from occurring and worrying about one thing may help them from worrying about something else.

In addition to learning how to better relax and look at the reality of their thoughts, “worry exposure“ techniques are also frequently very helpful. In this strategy, certain worry thoughts or scenarios are rehearsed repeatedly in a very structured and specific way. Confronting these fears gives individuals with GAD an opportunity to practice the other skills that they have learned in therapy (e.g., muscle relaxation, cognitive restructuring). Additionally, this technique has an interesting effect - after having these worries repeatedly (in this structured way), when these thoughts later spontaneously arise on their own, they are often accompanied with a far lower level of anxiety.

If there are any situations that are avoided due to worry, patients are also taught how to confront these situations in a gradual, structured way. Additional techniques, such as time management and goal setting are also implemented to help tackle any realistic worries that may be present.

Obsessive-Compulsive Disorder (OCD) affects 3.3 million adults in the United States. OCD also affects 1 - 2 children in every hundred. The age of onset of OCD symptoms is variable with symptoms typically first appearing anytime between preschool to early adulthood. Many people with OCD report that their symptoms wax and wane - for no apparent reason, there are periods of time when their symptoms are better and periods when they are worse. Symptoms typically worsen during stressful periods (e.g., getting laid off from work, getting married, starting school). In addition, it is also fairly common for the type of OCD to change over time - for someone to be bothered by different types of obsessional thoughts in their adolescence than in adulthood. Without treatment, OCD tends to be a chronic condition that generally gets worse over time.

People with OCD experience either obsessions or compulsions - with most people having both obsessions and compulsions. OCD thoughts and behaviors usually cause a significant amount of distress, take up a lot of time, or interfere with a person's work, school, social life, or family relationships.

Obsessions are recurrent, persistent thoughts, images, or impulses that are distressing and intrusive. People with OCD typically try to ignore, suppress, or in some way neutralize the thoughts. Usually people realize that their fears are not realistic or logical but this can vary. Sometimes OCD sufferers know that what they are fearful of can't really come true, but they are still worried. Other times, OCD sufferers are very certain that this illogical fear will really happen. Some examples of common obsessional thoughts are listed below.

Compulsions are repetitive physical behaviors or mental acts that a person feels driven to perform - typically, these compulsions are usually done in an attempt to neutralize or reduce the distress created by the disturbing obsessive thought. Some common compulsions are listed below.

Research indicates that it is not the content of the thoughts themselves that distinguishes people with OCD from those without OCD - rather, it is the frequency of these thoughts and the extreme amount of distress they cause that distinguishes OCD. Most people have thoughts like these from time to time but they just think that the thought was strange and easily let it go, but people with OCD are very distressed by the thoughts and have much more difficulty getting rid of thoughts. Some people with OCD describe it as feeling like having a faulty fire alarm in a building - the alarm keeps going off and making them think that danger is there, even though there really is no fire.

Obsessive thoughts/images/impulses:

** frequently people with contamination obsessions are fearful that they might get ill or die if they come in contact with a contaminant or that they will accidentally spread the contaminant and others will get sick as a result

Compulsive behaviors:

These compulsions can be present on their own, but they commonly occur in response to having a distressing obsessive thought. Although many compulsive behaviors are commonly linked to certain types of obsessive thoughts, any type of compulsion can be related to any type of obsession.

Even though there are very effective treatments available for OCD, it frequently goes unrecognized for years. In part, this is sometimes due to people being ashamed of their OCD symptoms and hiding them or making excuses for their “unusual“ behaviors. In children, OCD symptoms may sometimes be mistaken as “behavior problems“ at school or home; this is usually because children (like adults) become very upset when their obsessions are triggered or their compulsions are interrupted - thus, these situations may provoke temper tantrums. For example, a child with contamination fears may become very angry when her brother, who has just been at the “dirty“ park, tries to sit in her (“clean“) chair at home.

Unfortunately, OCD symptoms are sometimes also not correctly diagnosed or treated by professionals. Research indicates that on average, people see 3-4 doctors and spend over 9 years in various treatments before receiving the correct diagnosis or treatment for their symptoms.

The two treatments that have been found to be effective for OCD are medications, Cognitive-Behavioral Therapy (CBT), or a combination of both. The typical medications used for OCD are the serotonin reuptake inhibitors (or SRIs) - there are many different medications in this class (e.g., Prozac, Paxil, Luvox, Zoloft, etc.). Sometimes it is necessary to try several different medications to find the right one that will work for you. However, medications alone rarely eliminate all OCD symptoms and usually many compulsions and avoidances remain. Frequently, symptoms return when the medication is discontinued. For these reasons, medication management for OCD is rarely used alone and it is usually combined with CBT.

Although there are many different types of therapy that exist (e.g., psychoanalytic, psychodynamic, interpersonal, supportive, etc.), only one type of therapy has been found to be effective for OCD - Cognitive-Behavior Therapy or CBT. CBT generally results in a 50-80% reduction in OCD symptoms, and because patients are learning new life skills, these techniques generally do not suffer from the same relapse rates encountered with medications.

CBT for OCD involves educating the individual with OCD as well as important family members about the causes of OCD and the strategies that are helpful as well as harmful in overcoming the disorder. The most effective techniques involve Exposure and Response Prevention (ERP). This involves thinking of all the situations that provoke the obsessions (or worries/fears). The next step is to rank order how difficult it would be to do each of these things (i.e., “exposure“ to the feared situation) without engaging in the typical compulsions or behaviors that are normally used to alleviate the anxiety (i.e., “response prevention“). Usually, the most mild or moderate items are worked on first and the person with OCD will begin to realize that they do have control over their OCD and their anxiety does diminish. When these situations become easier, then the next item on the list is tackled until all situations are confronted.

Many people find it helpful to think about ERP as being similar jumping into a cold swimming pool. Often it is too scary to just jump right into the pool and many people might want to run away. This would be like confronting your worst fears all at once, and this is usually too difficult for most people. However, most people can first try putting their feet in the cold water, then they wait until that feels ok, then they might put their legs in up to their knees and then wait until that feels ok, and so on. Before they know it, they have the same result as just jumping in - it takes a little longer, but is far less scary and eventually they are swimming around in the pool and feel like the water temperature is just fine. This is usually how OCD fears are confronted too - a little at a time, then a little more, etc. In this kind of therapy, the psychologist and patient work together as collaborators to figure out where the right place to start is and what the next steps should be. Patients are also expected to work on these same practice assignments outside of sessions so that they will improve a lot faster and their improvements will generalize outside of the therapist's office to home, work, or school.

It is relatively common for individuals to feel like they can “get by“ with continuing to engage in their compulsive behaviors until their lives are limited to such an extent that the problem can no longer be ignored or tolerated. Until they reach this point, things can be very frustrating for family members, who are likely to be confused and irritated by the symptoms. Although frustrating, this can help you to better understand how terrifying the OCD fears are -- that the OCD sufferer is willing to go to such extremes to adapt their life to avoid contact with the feared situations.

In this type of situation, it is best for family members to become as educated as possible about OCD. This can be a big help to the OCD sufferer because you can help to educate them about their symptoms and help them understand that there are very effective treatments out there that can help. If your family member with OCD is still in denial about their problems despite your efforts to educate them, it is often useful for the family to consult with a psychologist who specializes in OCD for further help with this issue.

It is unknown what causes IBS and currently there is no cure. IBS appears to be due to a combination of different factors - such as having more reactive and sensitive intestines, diet, and general stress level. In addition, current research seems to indicate that one's perceptions and reactions to the bodily sensations themselves may also cause more intense and frequent IBS symptoms.

Although people with IBS have real episodes of gastro-intestinal distress, recent research seems to indicate that the more these unpleasant bodily sensations are feared, the more they are actually likely to occur. Like many physical conditions, how we react to our bodily distress or sensations can have a big effect on subsequent symptoms. Sensations or situations that have previously been associated with IBS attacks may also become feared and avoided. Sometimes, people may fear the IBS sensations so much that they may have a panic attack or their functioning may become so limited due to fear of developing IBS symptoms in particular situations that they may develop agoraphobia.

IBS is a medical disorder characterized by intestinal problems. It is more likely to develop in those under age 35 and it appears to run in families. IBS also appears to be more common in those who suffer from panic disorder.

Some symptoms of IBS include: abdominal pain, gas, cramps, constipation, and diarrhea. Although some individual's IBS symptoms are characterized by constipation or diarrhea, it is not uncommon for people to alternate between having bouts of constipation and diarrhea. Symptoms tend to wax and wane, and, although some people tend to have some symptoms that are more characteristic of their attacks, a different constellation of symptoms can be present in each attack.

For some, IBS symptoms are nothing more than a minor irritation, but for others it can severely limit their functioning. Most people are able to get adequate control over their symptoms through a combination of medications, diet, and methods to reduce stress.

Although there are many things about IBS that are still unknown, it is clear that individuals who find means to reduce their stress usually experience a reduction in their IBS symptoms. It is not clear why this effect happens, but it may be because stress affects the movement of the intestines or stress influences the way people perceive the pain or sensations in their intestines.

This response is not unique - as many medical and physical problems are known to be exacerbated by stress. Current research appears to indicate that IBS is a medical problem that can be exacerbated by one's reactions to the IBS symptoms themselves. Anxiety responses and our “fight/flight“ fear system is known to produce intense physical sensations. Therefore, if you have anxiety or fear about certain IBS symptoms, this likely has the frustrating effect of exacerbating the very IBS symptoms you fear. Typically, not only the sensations but also the situations/places associated with IBS attacks have the ability to elicit even more IBS sensations.

IBS should first be diagnosed by a medical doctor; tests are usually given to exclude other medical problems before the diagnosis of IBS is given. Medical doctors then typically prescribe some changes in diet or medications to help alleviate the physical symptoms. As previously described, general methods to reduce life stress are also very helpful in alleviating symptoms. Cognitive-Behavioral Therapy (CBT) is a type of treatment that has been scientifically validated as being very beneficial for relieving general stress. In CBT, individuals examine the way they perceive and cope with stressful events as well as learn general relaxation techniques.

In addition, although general CBT techniques are likely to help with lowering overall stress level (and, thus, improve IBS symptoms), amendments to traditional CBT are currently being investigated as being especially effective in treating IBS. This type of treatment will be described below. It is thought to be of particular benefit to those who are very anxious about their IBS symptoms and who limit or change their daily routine in any way to accommodate the IBS.

The new treatment being developed for IBS (Craske & DeCola) is very similar to a CBT treatment that has already been found to be very effective for panic disorder. IBS has many similarities to panic disorder, and, indeed, the two disorders often co-occur.

The focus of CBT for IBS involves learning how to change one's reactions to internal physical sensations. By reducing one's anxiety or fear response to these symptoms, the sensations are more likely to subside and to appear less frequently. Treatment usually begins with first monitoring the sensations themselves so it is clearer what sensations are strongest in IBS attacks, where they tend to occur, what thoughts are present during attacks, behaviors in response to the sensations (e.g., running to the bathroom), etc.

While gaining more information about the IBS attacks, “attentional training“ is also taught. In attentional training, an individual learns to have better control over the tendency to hyper-focus on disturbing physical sensations, and learns how to be able to redirect attention to other things (rather than having exclusive focus on bodily sensations). This technique can often help people to moderate the intensity of the sensations that they experience.

In addition, thoughts that people have during IBS attacks tend to further exacerbate the fear response - thereby, increasing the IBS symptoms. For example, fearful thoughts such as “if I don't go to the bathroom immediately, I'll have an accident“ will escalate one's physiological fear response and increase the IBS sensations themselves. In particular, there is a tendency to over-estimate the risk of the worst case scenario happening (“If I have symptoms in a strange place, I'm sure I won't be able to find a bathroom in time and will poop my pants“) and catastrophize the consequences (“Everyone at the meeting will know if I pass gas, I'll never be able to show my face there again“). Therefore, IBS sufferers are taught how to analyze their thoughts and how to realistically examine them.

Finally, techniques are taught where IBS sufferers learn that although the sensations are uncomfortable they can be tolerated and managed. This is typically taught through a series of “interoceptive exposures“ - which is a fancy term for intentionally having the feared sensations and learning how to cope with them better, tolerate them more, and disprove the fearful thoughts associated with these sensations (e.g., “if I have this sensation, I need to go to the bathroom immediately or else“). These types of exposures are conducted in a very gradual way - beginning with the types of sensations least feared and working toward the most feared sensations.

After the interoceptive exposures have been mastered, individuals are then taught how to gradually reintroduce themselves to the situations that have been avoided due to fear of having IBS symptoms or not being able to cope with the symptoms if they developed in a particular place or context (e.g., the beach, going to crowded places, standing in lines, etc.). In addition, an assessment is made of “safety signals“ or things that a person usually needs to have with them or things that they feel they need to do to help them feel safer in these feared situations (e.g., scanning each new place immediately for bathrooms, going to places only with very trusted friends, carrying water bottles with them, etc.). Gradually, the IBS sufferer is taught how to eliminate these “safety signals“ and still function and cope with their sensations in these situations.

Approximately 5 million people in the United States have Body Dysmorphic Disorder (BDD) or dysmorphophobia. It is possible that this number may actually be too low because there are many people who have this disorder who go undetected. BDD is equally as common in women as in men.

It is very common for those with BDD to be very ashamed about their worries and to not reveal them to even their closest friends or family members. Many BDD suffers feel like all the reasons for things going wrong in their lives is due to their appearance and the idea that they “look too ugly“ for things to go right for them in their career or relationships. People with BDD frequently seek dermatological and cosmetic procedures, hoping that this will improve their concern with their appearance.

The onset of BDD is frequently in adolescence, and without intervention BDD symptoms tend to be chronic and persistent. BDD frequently interferes with an individual's ability to work and have relationships. People who suffer from BDD also commonly experience depression and social anxiety.

The answer to this question is unknown. Currently, it is believed that BDD is caused by a biological vulnerability that is triggered during stressful life circumstances (e.g., adolescence). It is also believed that social and early developmental factors may also play a role in determining who is most vulnerable to developing BDD.

Although everyone has aspects of their body or their appearance that they wish were different, for people with BDD these thoughts cause them extreme distress and they have trouble dismissing these thoughts. People with BDD perceive their appearance (or an aspect of their appearance) as being very flawed and perhaps even ugly or repellant to others. The focus of distress can be any aspect of one's appearance, but the five most common areas that are focused on are: skin, hair, nose, eyes, and legs/knees. Sometimes people with BDD only have one aspect of their appearance that distresses them, but it is very common to be concerned with several different features.

Sometimes, there may be a minor flaw that exists (e.g., a scar, mark from having had the chicken pox, minor acne, etc.), but the distress over this minor imperfection greatly exceeds what most other individuals would experience if they had this same flaw. Frequently others see nothing wrong with the way the person with BDD looks, and this can be even more frustrating to the BDD sufferer because no one can understand why they are so distressed. Frequently, people with BDD may be passed off as just being vain or superficial.

The Diagnostic and Statistical Manual of Mental Disorders (DSM-V) requires the following criteria for a diagnosis of BDD:

1. Preoccupation with a perceived defect in appearance (or excessive concern about an actual minor flaw in appearance)

2. The individual has performed repetitive behaviors (e.g., mirror checking, reassurance seeking) or mental acts (e.g., comparing appearance to others) in response to appearance concerns.

3. This preoccupation with appearance causes significant distress or impairment in functioning

Thus, people with BDD are preoccupied by a perceived defect in their appearance and they frequently spend a lot of time each day thinking about or trying to alter their appearance flaws. In addition, BDD sufferers frequently alter their behaviors in many ways as a result of their worries. These behaviors often occupy a significant amount of time and greatly interfere with daily functioning. For example, they may:

	spend a lot of time analyzing their perceived flaw (e.g., looking in the mirror, analyzing it for any change, comparing they way they look to others)
	avoid things that will remind them of their flaw (e.g., avoiding mirrors)
	spend a lot of time trying to improve the appearance of the perceived flaw (e.g., plastic surgery, buying numerous face creams, constantly exercising or working out, spending a lot of time grooming, skin picking)
	try to camouflage the perceived flaw (e.g., wear a lot of make up, wear hats, tan their skin)
	avoid situations where others might more easily see their flaw (e.g., avoid particular types of lighting, avoid going out of the house)

Those with BDD frequently feel anxious about their appearance and may feel very depressed. Sometimes the depression stemming from the anguish about one's appearance causes some people to consider or to actually attempt suicide.

BDD can be well controlled with certain types of medications and with therapy. The kind of medications that appear to be most effective are the serotonin reuptake inhibitors (or SRIs). The type of therapy that has proven to be most effective for BDD is Cognitive-Behavior Therapy (or CBT). Other types of therapy (e.g., psychoanalytic, psychodynamic, etc.) have not been shown to be effective for those who suffer from BDD.

CBT for BDD usually involves using the following techniques. In initial sessions, patients are educated about BDD and are taught how to monitor their thoughts and BDD related behaviors. Next, patients are shown how their thoughts, behaviors, and feelings all relate to each other, and are taught a technique commonly referred to as “cognitive restructuring“. In this technique, patients are taught how to analyze their thoughts and how to better determine when their thoughts may have errors or may be unrealistic. Although everyone tends to have thinking “errors“ at some time, certain types of errors tend to predominate in BDD. For example, BDD patients frequently engage in “mind reading“ (e.g., “I bet that person isn't talking to me because they think I look too ugly.“).

In CBT, patients are also asked to work on assignments to directly confront their fears. Basically, patients make a list of the different situations that they currently avoid or that they might have extreme difficulty doing if they didn't engage in their BDD rituals (e.g., comparing self to others, putting a lot of make-up on, seeking reassurance from others, etc.). Next, these situations are ordered in terms of their difficulty level. Then, beginning with the least anxiety provoking items, patients are then taught how to begin confronting these situations that they fear. This is frequently referred to as “exposure“ to the feared situation. Usually, patients first work on these assignments with their therapist, but then they are later asked to work on them at home to make sure that their successes in the psychologist's office generalize to their functioning at home (as well as work, school, and social life).

It is unknown what causes skin picking. However, like other psychological difficulties, it is likely due to a combination of many factors, including biological as well as life experience and stressors.

To date, there has been very little research into “neurotic excoriation“ or skin picking. Skin picking is currently not classified as a separate disorder in its own right but is rather classified in the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) as an Impulse Control Disorder, Not Otherwise Specified. Trichotillomania (i.e., hair pulling) is also currently classified as an impulse control disorder, and skin picking appears to have many features in common with this disorder as well as with Obsessive-Compulsive Disorder.

Most people pick their skin when they are alone. Some people appear to be more aware of their picking whereas others seem to do it completely automatically. People can pick the skin anywhere on their bodies but the most common areas tend to be the face, upper back, and chest. Frequently, people primarily pick blemishes, pimples, bumps, blackheads, or any sores. Some people report that in the moment it feels good to pick and they have a sense of relief when they are picking, but, afterward, most people are very distressed at the damage they have done to their skin. People will usually try to hide the damage that they have done to their skin from others.

Frequently, it is often necessary to have a professional evaluation to determine if skin picking is the result of an impulse control problem or is simply a symptom of another problem like Body Dysmorphic Disorder or Obsessive-Compulsive Disorder.

As previously indicated, the treatment for skin picking will depend on if it is the result of an impulse control problem, Body Dysmorphic Disorder, or Obsessive-Compulsive Disorder. Obviously, if the causes of the skin picking are due to BDD or OCD, treatment is implemented for those disorders (please see sections on this website for these disorders). However, if the skin picking is an impulse control problem, the treatment of choice is usually very similar to what is implemented for those with trichotillomania (i.e., hair pulling - also an impulse control disorder).

Both medications as well as Cognitive-Behavioral Therapy (CBT) seem to be effective for skin picking. Generally, selective serotonin reuptake inhibitors (SSRIs) are tried first, but then other drug classes (such as tricyclics or dopamine blockers) or combinations of medications might be tried to find the ideal medication. People respond very differently to each medication, so it is unfortunately a trial-and-error process to find the right medication or medications.

For most people with skin picking, a combination of medications and CBT are often necessary to help them fight the urges to pick. However, if a person prefers one treatment to another, it is usually permissible to try out the one treatment alone, but, if that is ineffective, to then augment the current treatment (whether that is medications or CBT) by adding the other treatment.

CBT for skin picking involves several steps - with the most integral one being the steps of “habit reversal“. In habit reversal, the first step is typically awareness training. This is a fancy term for the individual being taught how to monitor their behaviors. This is frequently very helpful in determining which situations a person is most likely to pick, what environmental or emotional triggers may initiate picking, and what types of situations produce the strongest urge to pick. Frequently, people find that they pick in some situations that they were not really aware of or they are surprised to find that their picking is limited to just a few types of situations. Sometimes, this basic intervention is successful in helping people substantially reduce their skin picking.

In addition, people with skin picking are also taught how to monitor the steps in their “behavioral chain“ - in other words, learning what the first behavior is that leads to skin picking. For example, someone might notice that the thing that first triggers their picking is a feeling of frustration, which then leads to leaning their head on their hand, then feeling their face, and eventually leads to picking a blemish that is found.

Once they are aware of when the picking occurs, individuals are then taught a competing response. In other words, they are taught how to engage in another behavior that prevents them from picking their skin. They are taught to engage in this response until the urge to do the picking decreases. For example, if the urge to pick arises when they are in bed at night reading a book, they are taught the competing response of gripping the edges of the book hard until the urge passes. Different competing behavioral responses can be designated for different situations.

In addition, many people with impulses to pick find learning relaxation techniques to be very helpful. Techniques such as breathing retraining and progressive muscle relaxation often help to control the distressing emotions and general stress level that led to the picking in the first place. When real stressors exist, it is often helpful to engage in problem solving techniques to explore additional ways of better coping with these life stressors. In addition, using techniques to analyze daily thoughts and stresses are often a very helpful adjunct to habit reversal - these techniques help people better deal with the stresses of life so that they are less likely to resort to skin picking to help relieve any stresses that occur in the future.

In addition, it is often helpful for people to write a list of all the ways in which skin picking has caused them any inconvenience or embarrassment and to keep this list with them. Many people also find that rewards help to keep them motivated with treatment. First, rewards are given for successfully reducing and then eliminating skin picking.

There has been little research into how many people suffer from trichotillomania. However, it appears that about 2-3% of adults in the United States may suffer from this problem. It seems that more women than men may suffer from this problem, but this is also inconclusive since women are more likely than men to seek treatment. In addition, for men it is often easier to hide the problem (e.g., shave if they pull facial hair, blame patchy hair on going bald, etc.).

The two most common age ranges for people to develop trichotillomania are between 11 - 15 and 6 - 10 years old. Although many people report not knowing why the onset occurred, others are able to link the onset of their trichotillomania with a stressful time in their life. Because many people are embarrassed to reveal to others that they pull their hair and because pulling is often done in private, if you notice hair loss in your child, the first step should be to take them to a medical doctor to rule out the existence of a dermatological problem.

It is unknown what causes trichotillomania. However, like other psychological difficulties, it is likely due to a combination of many factors, including biological as well as life experience and stressors.

It is not uncommon for people with trichotillomania to report having family members who also pull their hair. However, while it is possible that genetics play some role in determining who develops trichotillomania, research studies not have found hair pulling to “run in families“.

Most people pull their hair when they are alone. Some are “automatic“ pullers - they pull when their attention is focused elsewhere (usually on another activity). Others are “focused“ pullers where their attention is totally focused on the pulling itself. It is not uncommon for some people to be a mix of the two - with some automatic and some focused pulling.

Common areas where hairs are pulled from include: scalp, eyelashes, eyebrows, pubic area, arms, and legs. Sometimes, people select hairs based on certain characteristics such as their color, texture, location, or thickness. Many people report that it “feels good“ to pull their hair out - sometimes giving them relief from life stresses or helping them to deal with other emotions (such as being angry, anxious, tense, or bored). Many people also report that the sensations of pulling out their hair or their “achievement“ at pulling out certain types of hairs gives them a sense of satisfaction. In addition to having certain rituals for what types of hairs are pulled and how they are pulled, it is also common to have a ritual for what to do with the hair once it has been pulled out (e.g., bite on hair bulb, save it, etc.). In addition, people frequently try to hide the damage they have done to themselves using various different methods (e.g., wigs, “spray on“ hair, eye glasses, false eyelashes, shaving head).

Although many people report trying methods to stop pulling their hair, trichotillomania tends to be a chronic problem that does not remit without treatment. Some people tend to pull hairs in the same area throughout the course of the problem, while others “add“ new places to pull hairs from. However, it seems that once an area has been a “favorite“ place to pull from, people rarely completely discontinue pulling from that area.

Currently, Trichotillomania is categorized in the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), as an impulse control disorder. However, trichotillomania has many features in common with Obsessive-Compulsive Disorder, so many consider it to be an Obsessive-Compulsive Spectrum Disorder.

According to the DSM-V, the criteria for trichotillomania are the following:

1. Recurrent hair pulling, resulting in noticeable hair loss.

2. Having a sense of tension before pulling out the hair (or when the urge to pull is resisted).

3. Having a sense of satisfaction, pleasure, or relief after pulling the hair out.

4. The hair pulling causes significant distress or impairment in the person's life.

As there is more and more research on trichotillomania, it seems that there are some problems with the criteria requiring tension before pulling and relief or gratification afterward -- many people who pull their hair do not experience these emotions. Therefore, some people believe that the criteria itself should be changed to just include the first criterion -- recurrent pulling out of one's hair.

** Professional evaluation may be necessary to differentiate Trichotillomania from Obsessive-Compulsive Disorder (OCD) or Body Dysmorphic Disorder (BDD). Typically, those with OCD or BDD do not experience gratification from the hair pulling itself, and the pulling is usually accompanied by continual obsessive thoughts. In OCD and BDD, pulling is usually a response to try to calm the anxiety created by these disturbing thoughts.

Both medications as well as therapy have been found to be effective for trichotillomania. Generally, selective serotonin reuptake inhibitors (SSRIs) are tried first, but then other drug classes (such as tricyclics or dopamine blockers) or combinations of medications might be tried to find the ideal medication. People respond very differently to each medication, so it is unfortunately a trial-and-error process to find the right medication or medications.

Only one type of therapy has been scientifically found to be effective for Trichotillomania -- Cognitive-Behavioral Therapy (CBT). For most people with hair pulling, a combination of medications and CBT are often necessary to help them fight the urges to pull.

CBT for hair pulling involves several steps - with the most integral one being the steps of “habit reversal“. In habit reversal, the first step is typically awareness training. This is a fancy term for the individual being taught how to monitor their behaviors. This is frequently very helpful in determining which situations a person is most likely to pull, what environmental or emotional triggers may initiate pulling, and what types of situations produce the strongest urge to pull. Frequently, people find that they pull in some situations that they were not really aware of or they are surprised to find that their pulling is limited to just a few types of situations. On occasion, people might even be asked to save and bring in their pulled hairs as another form of monitoring. Sometimes, this basic intervention is successful in helping people substantially reduce their hair pulling.

In addition, people with trichotillomania are also taught how to monitor the steps in their “behavioral chain“ - in other words, learning what the first behavior is that leads to hair pulling. For example, someone might notice that the thing that first triggers their pulling is a feeling of frustration, which then leads to leaning their head on their hand, then twirling their hair, and eventually leads to pulling out a strand of hair.

Once they are aware of when the pulling occurs, people with trichotillomania are then taught a competing response. In other words, they are taught how to engage in another behavior that prevents them from pulling their hair. They are taught to engage in this response until the urge to do the pulling decreases. For example, if the urge to pull arises in the car, people are taught the competing response of gripping the steering wheel hard until the urge passes. Different competing behavioral responses can be designated for different situations.

In addition, many people with impulses to pull find learning relaxation techniques to be very helpful. Techniques such as breathing retraining and progressive muscle relaxation often help to control the distressing emotions and general stress level that led to the pulling in the first place. When real stressors exist, it is often helpful to engage in problem solving techniques to explore additional ways of better coping with these life stressors. In addition, using techniques to analyze daily thoughts and stresses are often a very helpful adjunct to habit reversal - these techniques help people better deal with the stresses of life so that they are less likely to resort to pulling to help relieve any stresses that occur in the future.

In addition, it is often helpful for people to write a list of all the ways in which hair pulling has caused them any inconvenience or embarrassment and to keep this list with them. Many people also find that rewards help to keep them motivated with treatment. First, rewards are given for successfully reducing and then eliminating hair pulling. It is often easier to provide rewards to children who pull their hair, since parents have more control over incentives like magazines, gum, video games, etc. For adults, it is slightly more difficult to control rewards; however, many adults also find it helpful to agree to treat themselves to a specific item or activity for their work in reducing or eliminating pulling.

Absolutely. Frequently, those with anxiety disorders alter their lifestyles and those of loved ones due to the “rules“ that their anxiety disorder makes them adhere to. These lifestyle alterations can run the gamut from mild to very severe. For example, a child with a specific phobia of dogs may insist that the family does not go to any parties at people's houses if they own a dog (i.e., relatively minimal life interference), but a child with severe checking OCD may insist that his family return home twice every time they leave the house to check that the front door is really locked (i.e., severe life interference). Thus, even though family members may not share or even understand the fears that are present, they conform to the “rules“ made by the anxiety disorder so that their loved one is not distressed. It is not uncommon for children to become very upset, cry, or have a tantrum if these “rules“ are disregarded.

One of the most common ways that anxiety disorders are identified in children is due to a change in their previous functioning. It is not uncommon for children with anxiety disorders to begin avoiding certain activities or contact with particular objects/people due to their fears. These indicators are often confusing to parents because they frequently involve things that their child formerly enjoyed (such as going to the beach or a playground). Some children will state their fears, but it is probably more common for children to instead make up excuses like “I'm tired“ or “I don't like doing that anymore“ rather than reveal that they are frightened to do certain things or go to specific places. For certain anxiety disorders, such as OCD, the number of avoided things often grows over time and symptoms worsen. Thus, time formerly spent having fun with family and friends is now spent engaging in anxiety related behaviors (e.g., dwelling on the worry, compulsions) or in avoiding things that are feared.

Typically the same treatments are used for children as are used with adults -- with some slight differences. For example, the disorders are explained in ways that they can better understand and a reward system is usually implemented for all their hard work in attempting therapy assignments. Reward systems tend to be especially helpful in keeping younger children on-track, given that the results of therapy are usually not seen for several weeks and children have a tendency to easily give up if they see no immediate benefit. Older children and adolescents may see standard reward systems as being “treated like a baby,“ so they frequently prefer that treatment be conducted in the same way as it is administered with adults or that monetary incentives are instead given.

The most essential element to successful treatment is that the child is self-motivated to change these anxiety related behaviors - and they are not solely in treatment because of parental pressure.

The role of family members usually varies depending on the age of the child. For younger children, more parental involvement is usually necessary (in part because children sometimes have a harder time reporting accurately on their symptoms, therapy assignments, and progress). Adolescents usually prefer to keep their sessions more private and only periodic check-ins with parents are usually implemented.

It is usually very beneficial for the family to have some role in treatment so that they can be further educated about the anxiety disorder and understand the sometimes frustrating symptoms that accompany them. The degree of family involvement usually depends on the child/adolescent and on the family itself. For some families, taking a step back and letting your child take the reins (with the help of their psychologist) in overcoming their symptoms is most helpful.

For some families, it may be beneficial for the parents to know about the treatment plan that has been designed by the psychologist. This is frequently helpful because then they will know where to look for successes and where to not yet expect improvements (until later). If family members are engaged in “helping“ their child with any anxiety related behaviors (e.g., compulsions), they can also learn how to gradually separate themselves from these fear-related behaviors. The biggest role that the family can play is by helping their child to implement the weekly goals that have been set between their child and the psychologist. Because each family is very different and has its own specific needs, you will have to work together with your psychologist to decide how you can best help your family member with their anxiety disorder.

If you are interested in learning more about anxiety disorders and their treatment, and you live in the Los Angeles area, contact Dr. Nelson at (310) 963-4891 or email at DrDeniseNelson@yahoo.com.

Children with Anxiety Disorders

My Child has an Anxiety Disorder

If your child has an anxiety disorder, the most important piece of advice is: Don't blame yourself and don't blame your child. Certainly no one would ever want these symptoms or wish them on someone they love. Anxiety disorders can be especially frustrating if they are accompanied by a lot of avoidance or other “safety“ behaviors (e.g., having a parent or other safely object with them in feared situations, compulsions, etc.). Please try to be patient with your child and remember...if it were so easy to “just stop“ these frustrating behaviors, it would have already happened. Tell your child that you love them despite any anxiety problems. Let them know that even though they may have some worries that don't make sense or some “bad habits,“ they are not a bad person.

It is also often beneficial to educate your child a bit about the problem so that they no longer feel so alone or “crazy“. This discussion should be tailored to your child's age, developmental level, and their concerns or insight about the problem itself. For example, some children with OCD may think that others are just “gross“ for not also washing their hands 10 times before leaving the bathroom; sometimes, children with trichotillomania do not seem to care about the effects of hair pulling on their appearance. In addition, sometimes children may engage in some anxiety related behaviors with only minimal awareness (because these behaviors have become so automatic), so they may not honestly know what behaviors you are referring to (or not be aware of their frequency).

Absolutely. Frequently, those with anxiety disorders alter their lifestyles and those of loved ones due to the “rules“ that their anxiety disorder makes them adhere to. These lifestyle alterations can run the gamut from mild to very severe. For example, a child with a specific phobia of dogs may insist that the family does not go to any parties at people's houses if they own a dog (i.e., relatively minimal life interference), but a child with severe checking OCD may insist that his family return home twice every time they leave the house to check that the front door is really locked (i.e., severe life interference). Thus, even though family members may not share or even understand the fears that are present, they conform to the “rules“ made by the anxiety disorder so that their loved one is not distressed. It is not uncommon for children to become very upset, cry, or have a tantrum if these “rules“ are disregarded.

One of the most common ways that anxiety disorders are identified in children is due to a change in their previous functioning. It is not uncommon for children with anxiety disorders to begin avoiding certain activities or contact with particular objects/people due to their fears. These indicators are often confusing to parents because they frequently involve things that their child formerly enjoyed (such as going to the beach or a playground). Some children will state their fears, but it is probably more common for children to instead make up excuses like “I'm tired“ or “I don't like doing that anymore“ rather than reveal that they are frightened to do certain things or go to specific places. For certain anxiety disorders, such as OCD, the number of avoided things often grows over time and symptoms worsen. Thus, time formerly spent having fun with family and friends is now spent engaging in anxiety related behaviors (e.g., dwelling on the worry, compulsions) or in avoiding things that are feared.

Typically the same treatments are used for children as are used with adults -- with some slight differences. For example, the disorders are explained in ways that they can better understand and a reward system is usually implemented for all their hard work in attempting therapy assignments. Reward systems tend to be especially helpful in keeping younger children on-track, given that the results of therapy are usually not seen for several weeks and children have a tendency to easily give up if they see no immediate benefit. Older children and adolescents may see standard reward systems as being “treated like a baby,“ so they frequently prefer that treatment be conducted in the same way as it is administered with adults or that monetary incentives are instead given.

The most essential element to successful treatment is that the child is self-motivated to change these anxiety related behaviors - and they are not solely in treatment because of parental pressure.

The role of family members usually varies depending on the age of the child. For younger children, more parental involvement is usually necessary (in part because children sometimes have a harder time reporting accurately on their symptoms, therapy assignments, and progress). Adolescents usually prefer to keep their sessions more private and only periodic check-ins with parents are usually implemented.

It is usually very beneficial for the family to have some role in treatment so that they can be further educated about the anxiety disorder and understand the sometimes frustrating symptoms that accompany them. The degree of family involvement usually depends on the child/adolescent and on the family itself. For some families, taking a step back and letting your child take the reins (with the help of their psychologist) in overcoming their symptoms is most helpful.

For some families, it may be beneficial for the parents to know about the treatment plan that has been designed by the psychologist. This is frequently helpful because then they will know where to look for successes and where to not yet expect improvements (until later). If family members are engaged in “helping“ their child with any anxiety related behaviors (e.g., compulsions), they can also learn how to gradually separate themselves from these fear-related behaviors. The biggest role that the family can play is by helping their child to implement the weekly goals that have been set between their child and the psychologist. Because each family is very different and has its own specific needs, you will have to work together with your psychologist to decide how you can best help your family member with their anxiety disorder.

If you are interested in learning more about anxiety disorders and their treatment, and you live in the Los Angeles area, contact Dr. Nelson at (310) 963-4891 or email at DrDeniseNelson@yahoo.com.