Category Archives: Anxiety Disorder

Social Anxiety Disorder (Social Phobia) Symptoms, Diagnosis and Treatment

Social Anxiety Disorder Symptoms:

Social Anxiety Disorder, previously referred to as social phobia is one of the more common anxiety disorders. It is usually experienced when you must perform in front of others or feel like you are being scrutinized by other people. The overall feeling is one of fear of possible embarrassment or humiliation. While many people find some way to endure the high level of anxiety they experience, others may avoid these feared experiences altogether. Usually you fear that you are going to be judged by others as being nervous, weak or stupid when you say or do something. In most cases people believe that their anxiety is excessive, and their fear is way out of proportion to the situation. Children however, do not recognize that their fear is excessive.

Studies have found that the most common social anxiety disorder or phobia is the fear of public speaking. It is believed to affect 3 out of 4 people or 75% of the population. It also accounts for approximately 19% and is easily the largest majority of those suffering from some form of phobia. This anxiety speech disorder is known to commonly affect speakers, people whose jobs require them to make public presentations, and even students speaking before the class. This form of social anxiety disorder is just as prevalent among men as among women. Overall, the most common social anxiety disorders include the following:

• fear of signing documents and writing in public
• fear of crowds
• fear of using restrooms in public
• fear of eating, spilling food or choking in public
• fear of being watched by others at work
• fear of taking examinations

Social Anxiety Disorder Diagnosis:

Social Anxiety Disorder is often distinguished by whether it is generalized or specific. The DSM-V has a performance only specifier which is given if you only experience this severe level of anxiety performing such as when public speaking. In these cases you may not feel otherwise impaired in your occupational, social or academic situations where public speaking is a requirement. You may not be afraid or avoid other social experiences. Also, if you experience panic attacks in conjunction with Social Anxiety Disorder, the specifier with panic attacks should be added to the diagnosis. If you experience anxiety in a more generalized sense in any social group situation where you fear being watched or evaluated, you may be experiencing a more generalized form of Social Anxiety Disorder. In most cases, the actual Social Anxiety Disorder diagnosis will not be given unless it interferes with your work, social activities or important personal relationships in very significant ways, usually causing a high level of personal distress. Like agoraphobia, Social Anxiety Disorder may be accompanied by panic that is related to the feelings of being embarrassed or humiliated, when trapped in a circumstance that provokes a high level of anxiety and distress. In these situations, the anxiety would rise only in circumstances related to the specific type of social situation feared.

Social Anxiety Disorder treatment:

There are several treatments that have been used to cope with Social Anxiety Disorder. One of the common sense recommendations by lay persons and some clinicians is to “take a deep breath”. Deep breathing from the abdomen and relaxation techniques can be practiced on a regular basis to relieve the physical symptoms of anxiety.

Social Anxiety Disorder Psychological Treatments:

Cognitive Behavior Therapy:

Cognitive Behavior Therapy has been effectively used for Social Anxiety Disorder. With this type of therapy, fearful thoughts are identified, challenged and often replaced by more realistic and adaptive thoughts. For example, a thought such as “I am going to be so nervous that I make a fool of myself” may be replaced by a thought such as “I will be nervous at first, but most people will not be bothered by that”.

Exposure Techniques for Social Anxiety Disorder:

One of the more effective long-term treatments for Social Anxiety Disorder is the use of exposure. Exposure can be imaginal or real-life exposure to the actual circumstances that are feared. The exposure is usually gradual or incremental in facing circumstances you are phobic or fearful of. If you experience an extremely high level of social anxiety about public speaking, you may give a very short talk to one or several friends, and then gradually increase it to a longer period of time with more observers. You would incrementally build up both the length of time and individuals observing to reduce the level of anxiety over a period of time.

While treatment for Social Anxiety Disorder is often done on a one-on-one basis, many mental health clinicians recommend group therapy as the ideal treatment format. This seems to more directly reflect the stimuli that would provoke the actual phobic reaction or Social Anxiety Disorder.

Social Skills and Assertiveness Training:

Sometimes learning basic social skills and learning to assert oneself can be very helpful in overcoming social phobias and Social Anxiety Disorder. Learning to smile, make eye contact, and maintaining conversations can be very helpful to developing a sense of mastery and coping with social situations, reducing the underlying level of anxiety. Also, learning to assert oneself can also be very helpful in learning how to tell others what you want or don’t want, without feeling like you must just go along with others demands.

Medications for Social Anxiety Disorder:

Medications are often given for Social Anxiety Disorder. The most common medications are the antidepressants, SSRI medications such as Paxil, Zoloft, Luvox and Serzone, and anxiety medications such as the benzodiazepines, which include Xanax or Klonopin. These medications are usually used as an adjunct to the cognitive behavior and exposure-based therapies mentioned above. Occasionally, MAO inhibitors such as Nardil and Parnate have been recommended to treat social phobias or social anxiety disorders.

Summary of Social Anxiety Disorder:

Many people suffer from Social Anxiety Disorder sometimes referred to as social phobia. The actual diagnosed disorder was changed in the new DSM-V which is used to diagnose mental health disorders by clinicians. You don’t have to suffer from Social Anxiety Disorder forever as both medications and psychological treatments are now available to relieve suffering.

Some information adapted by Paul Susic Ph.D. Licensed Psychologist from The Anxiety and Phobia Workbook by Edmund J. Bourne Ph.D.

Agoraphobia Symptoms and Treatments: Must know Information

Agoraphobia Symptoms and Treatment Overview:

The symptoms of agoraphobia may be the most prevalent of all of the anxiety disorders with as many as 5% of the general population or one in 20 people experiencing varying degrees of agoraphobic symptoms. In the United States, the only mental health disorder that experiences a higher level of prevalence may be alcoholism. Therefore, an understanding of agoraphobia symptoms, diagnosis and treatment is imperative to a well rounded understanding of panic and mental health disorders.

Agoraphobia symptoms:

From a practical perspective, agoraphobia is experienced as a fear of having panic attacks although the term actually refers to a fear of open spaces. An individual experiencing agoraphobia usually has an intense fear of having a panic attack and being in a circumstance in which escape is impossible. An individual may avoid such things as driving on highways for fear of having a panic attack, and being unable to escape the circumstances. Most people experiencing agoraphobia symptoms fear not only the panic attack , but being observed by others while having panic symptoms. Some of the more common circumstances avoided by agoraphobics are:

• Being trapped home alone.
• Being in areas where they feel enclosed such as while getting an MRI, tunnels etc.
• Being on public transportation and unable to leave if necessary such as on a bus or train.
• Being in places such as grocery stores or restaurants and other crowded places.

Agoraphobics frequently feel comforted when a “safe person” is present, which seems to help alleviate the agoraphobia symptoms. One of the more common features of this panic related disorder is a fear of being away from home and/or away from this “safe person”. A “safe person” may be a spouse, parent or anyone whom you have a significant relationship with who provides some comfort in these anxiety provoking situations. You may have an intense fear of driving or walking alone or experiencing any other circumstance without this “safe person”.

Most people who are agoraphobic have a relatively high level of anxiety most of the time. Much of this anxiety seems to be anticipatory, fearing future circumstances and situations which may provoke a panic attack, such as a fear of being left alone at home in the future. The severe restrictions on your life related to future panic attacks may also result in depression. Some people experience depression when they are in adverse circumstances that they have no control over which seem unescapable.

Agoraphobia Symptoms and Panic Disorder:

Agoraphobia develops as a result of having panic attacks or panic disorder. At the very beginning you may have panic attacks that occur for no reason, eventually resulting in a panic disorder. Later you begin to recognize that these panic attacks are occurring in specific situations and you begin to avoid those circumstances for fear of having continued panic attacks. These panic symptoms may be mild at the beginning resulting in uncomfortable feelings but not necessarily avoiding these specific circumstances. When experienced at a more moderate level the panic symptoms begin to result in avoidance of these panic inducing circumstances such as avoiding public transportation or shopping on your own. In these moderate anxiety circumstances, you may avoid some panic inducing situations but still continue on without serious restrictions on other aspects of your life. The restriction is usually only partial. When experiencing severe agoraphobic symptoms, you may experience restrictions which seem to affect every aspect of your life, resulting in being unable to leave home unaccompanied.

It is not really known why some people develop agoraphobia from their panic attacks and why others do not, or why agoraphobia is more severe for some rather than others. Some clinicians and researchers believe that the development of agoraphobia may have some environmental and hereditary components. It has been observed to run in families and twin studies have found that identical twins have a higher risk for both to develop agoraphobia. When looking at environmental factors, there may be some childhood experiences that predispose a child to agoraphobia. Some of these experiences may include growing up with parents who (1) are overprotective and/or (2) are overly anxious and communicate that the world is a “dangerous place” and/or (3) overly critical and perfectionistic.

People experience agoraphobia symptoms from all walks of life and all socioeconomic levels, At the present time, approximately 80% of agoraphobics are women. It is unclear what environmental issues factor into the gender difference, although it has been noticed recently that the level of agoraphobic women relative to men with the disorder seems to be leveling off somewhat. That would probably indicate more of a environmental than a genetic influence.

Agoraphobia Symptoms and Treatment:

There are various treatments available to help alleviate the symptoms of agoraphobia. Since agoraphobia is basically a disorder developed in relation to panic disorder and panic attacks, the same treatments are utilized for both including psychosocial treatments and the management of panic attack symptoms utilizing anxiety medications and antidepressant medications. An overall analysis of the medication management of panic disorder and panic attacks as well as an overview of the psychosocial treatments of panic disorder follow on separate pages.

Some of the main psychosocial treatments include relaxation training, panic control therapy and interoceptive desensitization. Once again, the same treatments that are utilized for panic disorder and panic attacks are also used for patients with agoraphobia. Also, additional assistance or treatment for agoraphobia symptoms may also include assertiveness training since agoraphobics frequently have difficulty standing up for themselves. Finally, as mentioned previously, some of the main treatments for agoraphobia include medication, graded exposure, cognitive therapy and group therapy.

Agoraphobia Treatments with Medication:

Some of the main treatments for agoraphobia as well as panic attacks and panic disorder include treatment with medication such as selective serotonin reuptake inhibitors (SSRI’s) such as, Zoloft and Paxil and tranquilizers such as Xanax, Ativan or Klonopin. The SSRI’s are more likely to be used in very severe cases where a person is homebound and otherwise very restricted in their activities of daily living. Low doses of tranquilizers such as Xanax may also be used to assist people who are going through the early stages of exposure treatment as well as being used by many doctors as a mainline treatment for anxiety and panic.

Graded exposure treatment for Agoraphobia:

When the treatment or intervention is referred to as “exposure” therapy it usually means that the person is exposed to the stimuli that seems to provoke the anxiety or panic reaction. Situations or circumstances that have been feared and/or avoided are exposed to the individual in incremental steps to gradually increase the amount of time and exposure without having a full-blown panic attack. A good example of graded exposure may be if a person has a severe fear of driving long distances or on the highway. They may initially drive short distances or at slower speeds and build up to greater distances or greater speeds. Sometimes a support person is used to accompany the agoraphobic. Finally, they may then eventually be able to drive alone. If a person is fearful of staying home alone, they may be at home by themselves for short periods of time building up to longer times alone.

Cognitive Treatment to Alleviate Agoraphobia Symptoms:

The goal of cognitive therapy is to help the individual recognize and eliminate exaggerated, fearful thinking which result in phobias and panic attacks in a more realistic way. You will then learn to identify, challenge and ultimately replace counterproductive thoughts with ones that are more helpful and realistic to the stimuli or environment.

Group therapy:

Agoraphobia symptoms can be effectively treated in a group setting with other individuals experiencing similar symptoms and disorders. Group therapy provides an opportunity for an individual to share their experiences with others and recognize that they are not alone and that there are many others who experience agoraphobic related panic attacks.

Agoraphobia Symptoms and Treatment: Some Final Words

Agoraphobia symptoms are successfully treated through the use of several psychosocial interventions and medications to alleviate the symptoms. Additional information is also available on this website related to panic disorder, psychosocial interventions and medication management. Do not allow yourself to continue to suffer agoraphobia symptoms when treatment is so readily available.

Some information adapted by Paul Susic Ph.D. Licensed Psychologist from The Anxiety and Phobia Workbook by Edmund J. Bourne Ph.D.

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Panic Disorder Treatment: The Best Long-term Solution

Panic Disorder Treatment: An Overview

The treatment of panic disorder is usually approached very differently from the way it probably should be in that the first line of treatment is almost always to “throw a medication at it”. When given the fact that the medications usually used for panic disorder treatment have serious side effects, a more reasonable approach would probably be to consider possible psychological interventions prior to using medications that have serious side effects. These medications may be necessary in place of psychological interventions or in addition to, but they should not always be the first line of defense in the treatment of panic disorder. In fact, efficacy studies related to the treatment of panic disorder with cognitive behavioral therapy, have found that it performs as well as pharmacological interventions in the short-term and may possibly be more durable in the long-term.

Panic Disorder Treatment: The Psychological Approach

The core feature in the treatment of panic disorder from a psychological treatment perspective, is that panic disorder is frequently caused by and maintained by heightened fears associated with anxiety symptoms. The main psychological treatment modality in current practice by psychologists and other mental health practitioners is cognitive behavioral therapy (CBT) which seeks to reduce those fears. The belief which has also been confirmed by research is that it is this “fear of fear” that is the main culprit and the focus of intervention. This fear can be reduced, resulting in the clinical improvement of panic disorder. Cognitive behavioral therapists utilize various cognitive techniques including psychoeducation about panic along with cognitive restructuring, as well as behavioral methods such as interoceptive exposure to assist in the reduction of the symptoms of panic disorder.

Psychoeducation for Panic Disorder:

Psychotherapists using the cognitive behavioral method, usually first begin by providing patients with information about panic disorder. Information and education about panic and how it is maintained is seen as the most basic aspect of this program, allowing the patient and therapist to collaborate on future treatment and intervention. It has been found that there is an enormous amount of misinformation about panic symptoms as well as how they will affect the individual patient. Many patients present to emergency rooms mistaking intercoastal muscle tension in the chest as an indication that they are having a heart attack. Cardiac arrest is much more than pain in the chest. It most often involves a crushing pain in the chest usually accompanied by pain shooting downward through the arm. Also, many patients mistake hyperventilation-related dizzy feelings for fainting, without realizing that ultimately dizziness may be the result of blood pressure and the heart rate suddenly dropping. In actuality, an elevated heart rate during panic will actually protect against fainting in spite of dizziness.

There are certain physiological reactions that protect us from various threats including what has been referred to as the “fight or flight” reaction to stress or danger. The “fight or flight” syndrome is actually believed to help protect us against danger but is not in itself threatening or dangerous. It is a heightened level of physiological arousal that allows us to respond to threatening or dangerous circumstances, but does not specifically pose a threat to our well-being.

Some patients also fear that the physiological symptoms of panic disorder will lead them to more serious mental health concerns. These additional mental health worries also exacerbate the underlying mistaken beliefs that bodily sensations and a fearful response to dizziness and heart palpitations for example, will lead to a full-blown panic attack or result in some other type of mental illness.

Panic Disorder Treatment and Basic Beliefs:

Cognitive behavioral therapy focuses on catastrophic beliefs and misconceptions about our bodily sensations and the prevention of testing these misconceptions and refuting these beliefs. In order to assist with alleviating these catastrophizing beliefs, the therapist may ask the patient what has kept them from experiencing the actual catastrophe that they had envisioned. In most circumstances, patients will indicate that they have taken various safety measures to short-circuit the catastrophe from actually occurring. For example, a patient may state that they are afraid that the panic disorder related dizziness will result in them becoming weak and falling down. The therapist may then ask what has kept them from falling down in the past? The patient will usually state that they were able to sit down prior to falling down. They were able to rely upon these safety measures to keep the catastrophe from actually occurring. So, in effect, specific catastrophic thinking can be addressed along with safety measures that maintain the related fears that seem to drive the panic process.

Panic Disorder Treatment: Using Cognitive Restructuring

Another important aspect of panic disorder treatment using the cognitive behavioral approach involves using the cognitive restructuring of catastrophic beliefs. An important part of cognitive restructuring of these beliefs is that behavioral experiments are also used along with psychoeducation to alleviate the panic symptoms. The behavioral experiments are used to provide direct, experimental evidence that catastrophic consequences are not the inevitable result of catastrophic thoughts and the experience of heightened physiological sensations. A behavioral experiment may involve something as simple as when an individual believes that they will faint when dizzy and immediately sits down to avoid falling down. The behavioral experiment might involve having the patient hyperventilate while sitting down and experiencing the related sensations of dizziness and lightheadedness. The patient’s catastrophic thinking might involve the thought that they will faint if they stand up. The therapist may then encourage the alternative prediction that only a slight sense of unsteadiness will actually occur. Having the patient experience the physical sensations without having them engage in the customary safety behavior is one of the most powerful ways to help an individual change the catastrophic thinking that maintains the panic disorder. The goal of the therapist is to have the patient experience behavioral experiments that allow them to refute the beliefs associated with the usual bodily symptoms. Cognitive restructuring is actually a combination of psychoeducation and the creation of behavioral experiments that allow the individual to refute the catastrophic beliefs.

Panic Disorder Treatment: Exposure

Panic disorder is experienced pretty much in the same way that individuals experience phobias. After an individual experiences a high level of anxiety in relation to a certain stimuli they may then attempt to avoid similar experiences. Prolonged exposure to stimuli that is feared causing an extinction of the fear is an important feature of the behavioral treatments associated with anxiety and panic disorders. In individuals with panic disorder, the principle of exposure requires people to expose themselves to the stimuli that they fear and feel the related bodily sensations until they no longer hold the same capacity to provoke fear and discomfort.

Deep Breathing and Additional Treatments for panic disorder:

Some additional panic disorder treatments include applied muscle relaxation and breathing retraining, which is oriented toward counteracting hyperventilation. However, some therapists now wonder if these techniques are such a good idea. These methods were originally designed to help reduce the intensity of the bodily sensations which by implication were bad, which is contrary to the psychoeducational component in which these sensations are essentially taught to be considered harmless. However, teaching the concept that anxiety management techniques are a means of helping an individual to feel some sense of control over their bodies may indeed have some value.

Panic Disorder Treatment and Agoraphobia:

An intense fear of certain circumstances and objects can cause patients to avoid those experiences. This residual agoraphobia can continue even after panic has been successfully treated using cognitive behavioral techniques. Psychologists and mental health clinicians will frequently develop in vivo (real-life) exposure situations where individuals will purposefully enter into feared experiences and circumstances without avoiding the stimuli until the intense discomfort is reduced or goes away.

Some final words on panic disorder treatment:

There have been many studies over time that have identified the efficacy of psychological approaches to the management of panic disorder. Cognitive behavioral therapy delivered on an individual basis or in a group setting has been found to significantly reduce symptoms of panic. Some studies have found as many as 74 4% of cognitive behavioral therapy treated patients are panic free posttreatment. Similar outcomes have also occurred in community mental health settings. Also, cognitive behavioral therapy has significantly outperformed other interventions including the use of some medications such as imipramine, applied relaxation and emotion focused therapy. Finally, panic disorder treatment using psychological methods including cognitive behavioral therapy with or without medication have frequently been found to be the best long-term solution to the treatment of panic disorder.

Some information adapted by Paul Susic Ph.D. Licensed Psychologist from Practitioner’s Guide to Evidenced-Based Psychotherapy by Jane E. Fisher and William T. O’Donohue

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Having a Panic Disorder? Symptoms, Diagnosis and Treatment

Panic Disorder Overview:

Panic disorders are usually identified by extreme feelings of apprehension or intense fear that may appear suddenly or “out of the blue”. They may or may not have an apparent cause. In most cases, intense panic usually lasts no more than a few minutes but in rarer circumstances it can continue for up to about two hours. If you’re having a panic attack and ultimately have developed a panic disorder you should notice some of the following symptoms:

A fear of dying
Fears of going crazy or losing control
Shortness of breath or a feeling of being smothered
Heart palpitations, pounding heart or accelerated heart rate
Chest discomfort or pain
Dizziness, faintness or unsteadiness
Hot and cold flashes
Shaking and trembling
Numbness or tingling in feet and/or hands
Feeling of choking
Abdominal distress or nausea
Feeling of unreality is if you’re not all there

In a full-blown panic attack, at least four of the symptoms will be present. In a limited-symptom attack you may experience possibly two or three of the symptoms.

Panic Attack or Panic Disorder:

If you experience (1) two or more panic attacks and had of at least (2) one of these attacks followed by a month of concern about continuing panic attacks or their consequences, you may be experiencing a panic disorder. In most cases, panic disorder by itself does not usually involve the development of a phobia. The panic itself is usually spontaneous rather than when you’re approaching, thinking about or entering a phobic situation. In many cases, its spontaneity and unexpected nature makes it difficult to recognize any apparent cause. Also, panic attacks are not the result of physiological precipitating factors such as a drug use or withdrawal or a medical condition.

You can possibly have several panic attacks within a month or two and never have another one for years, or may never have a recurrent attack. Or you could have several attacks, followed by a period of time with no attacks, only to have the panic return several months later. Panic attacks can have many different symptom patterns. You could have several within a week or many within the same month. In all of these cases, there is a tendency to develop anticipatory anxiety which is a deep feeling of apprehension and fear about having further attacks. It is usually after several attacks that individuals seek treatment.

Diagnosing Panic Disorder:

People having panic attacks frequently go to the emergency room or otherwise seek a medical or physiological answer to why they are feeling heart palpitations and excessive anxiety. They are often very frightened by the symptoms which often lead to an EKG or other cardiac tests which in most cases turn out to be normal. Occasionally, they may find a mitral valve prolapse (a benign arrhythmia of the heart) which may coexist with the panic attack. However, doctors have become much better at distinguishing between purely physical complaints, anxiety attacks and panic disorders.

A diagnosis of a panic disorder is only made after ruling out all possible medical considerations including hyperthyroidism, reactions to excess caffeine, hypoglycemia or withdrawal from alcohol, tranquilizers or sedatives. The root cause of panic disorder is most often some combination of heredity, personal stress and chemical changes within the body and brain.

The specific criteria for panic disorder can be found on another page of this website but in summary it requires recurrent and unexpected panic attacks of the previously mentioned symptoms. At least one of the attacks must be followed by a month or more of persistent concern, maladaptive change in behavior, and the disturbance cannot be attributable to the physiological effects of a substance or any other medical condition. Also, the disturbance cannot be better explained by any other mental disorder.

Development of panic disorder:

People most often first develop panic disorder in their late teens and early twenties. In some cases, the panic disorder can become complicated by developing into agoraphobia. It is estimated that between 1% and 2% of the population have a pure form of panic disorder while approximately 5% experience panic disorder with agoraphobia.

Panic Disorder Treatment:

Effective treatment for panic disorder usually requires both physiological and/or psychological intervention. Physiological treatments usually involve medications specifically for anxiety referred to as anxiolytics or anti-anxiety drugs, and/or antidepressants to reduce the symptoms of panic attacks. Psychological interventions frequently include lifestyle and personality changes, psychotherapy, and relaxation training.

Some of medications used to treat panic disorder include the benzodiazepine medication such as Xanax, Ativan, Valium or Klonopin. Also, antidepressants may be used such as Paxil, Serzone, Zoloft, or Celexa. These medications are most effectively used in conjunction with psychological interventions however.

A common sense understanding of the psychological dynamics associated with an individual’s experience of anxiety and panic disorders is imperative. Frequently, there are precipitating events or experiences that seem to maintain or exacerbate underlying symptoms of anxiety. Only by recognizing, problem solving and focusing on these precipitating and exacerbating experiences, may you truly have a reduction in your anxiety symptoms. There are various lifestyle and personality changes that can be used to focus on and reduce the symptoms of panic disorder including stress management, eliminating stimulants and sugar from your diet, regular exercise, slowing down your life and creating some “downtime” and even focusing on personality characteristics such as expecting too much of yourself, having excessive need to please others or even an excessive need for control of your life or others.

Relaxation training can be helpful also. Practicing breathing from your abdomen and some type of progressive muscle relaxation on a daily basis has been found to be helpful by many people. This may be helpful in reducing the physical symptoms of panic as well as helping to bring an element of control into your life, and possibly reducing the feeling of anticipatory anxiety that you may have before having a panic attack. Physical exercise is also recommended to assist in reducing underlying symptoms of anxiety.

Psychological interventions also include a form of panic control therapy which focuses on eliminating catastrophic thoughts such as “I’m going to have a heart attack”. Cognitive behavioral therapy is frequently used effectively in assisting people to understand the connections between their thinking and moods as well as physiological reactions. Many times, these catastrophic thoughts are believed to trigger panic attacks.

Another psychological intervention is referred to as interoceptive desensitization. This type of desensitization involves voluntarily habituating to the bodily symptoms of panic such as sweaty hands, shortness of breath, dizziness and rapid heartbeat. Often the symptoms are created deliberately in a therapist’s office through such activities as spinning in a chair to create dizziness, or rapid heartbeat by running up and down stairs. Repeatedly being exposed to unpleasant bodily symptoms promotes desensitization which means adjusting to and learning to cope better with the actual symptoms associated with panic attacks and panic disorder.

Summary of Panic Disorder:

Panic attacks and panic disorder can become very uncomfortable and even disabling. If not treated they can become even worse resulting in such comorbid conditions as panic disorder with agoraphobia. Thankfully, psychological and physiological treatments are available to effectively assist with panic disorder.

Some information adapted by Paul Susic Ph.D. Licensed Psychologist from The Anxiety and Phobia Workbook Third Edition by Edmund J. Bourne Ph.D.

The Causes of Anxiety Disorders: You Just Never Know

Cause of Anxiety Disorders: Introduction

Anxiety disorders can present themselves in many ways and have many different causes. They can be mild or severe, general or specific to certain circumstances and they can have one or many different causative factors. They may be somewhat understandable or may be absolutely irrational.

When considering the causes of anxiety disorders there are a couple of things to keep in mind. The first is that although you may understand the cause of an anxiety disorder it may not be absolutely necessary in order to learn to cope with or diminish it. Many of the techniques used to deal with anxiety disorders such as relaxation, exercise, changing self-talk and mistaken beliefs and so forth do not really depend on understanding the underlying cause of the anxiety disorder. The second important factor is that frequently there is not one certain cause, there could be several or even many operating on several different levels. These different levels could include hereditary factors, biology, family background, experiences and even beliefs.

“Single Cause” Theories of Anxiety Disorders:

There are some experts in the field of mental health who see anxiety disorders as developing from a single cause. Often, this perspective is not very helpful in working with anxiety disorders as they may come from various biological and psychological considerations. This oversimplification may result in two different mistaken lines of reasoning referred to as the biological fallacy and the psychological fallacy. The biological fallacy refers to the usually mistaken belief that the anxiety disorder is caused specifically by an underlying biological or physiological imbalance in the brain or body or a specific dysfunction in a certain part of the brain. Frequently, we will hear advertisements and even individuals refer to their depression or anxiety disorder as a chemical imbalance. This is usually an oversimplification that fails to recognize the dynamic interplay between our brains and the environment that surrounds us.

The Biological Fallacy:

It obviously is helpful to know the physiological components involved in anxiety disorders, but it is not helpful to ignore the potential complexity of the disorder. You may ask yourself, “What caused the physiological disturbance?” It is a known fact that chronic stress and psychological conflict may cause the locus ceruleus to malfunction in panic disorder, for example. Also, it has been identified that chronically suppressed anger may change the serotonin (neurotransmitter or brain messenger) levels in the brain contributing to obsessive-compulsive disorder. Both of these causative factors may be more related to the environment and the way an individual is raised rather than any specific inherited physiological or biological factors. To say that these are just chemical imbalances is very much an oversimplification and really not very helpful in the treatment of anxiety disorders.

The Psychological Fallacy:

The psychological fallacy of the cause of anxiety disorder can be equally as mistaken as the biological fallacy. To say that a specific anxiety disorder such as generalized anxiety disorder or social phobia are as a result of being neglected or abused as a child, or related to any other negative childhood experiences may be very misplaced and even destructive to individuals and families. In order to consider that the environment has contributed to the manifestation of an anxiety disorder doesn’t mean that it’s necessary to exclude biological factors such as inherited characteristics and other physiological considerations.

Cause of Anxiety Disorders – Summary of the Psychological Fallacy and Biological Fallacy:

in summary, the idea that the cause of anxiety disorders is either strictly psychological or strictly biological neglects the whole interactive aspect of “nature versus nurture”. We interact with the environment and as a result the brain and body chemistry change. The physiological aspects can include vulnerability to anxiety disorders but to say which came first may be impossible to know. Consequently, a comprehensive approach to treatment from anxiety disorders may include a multidimensional approach as opposed to treating specific factors in isolation. An effective treatment approach may include a consideration of biological, behavioral, mental, interpersonal, and even spiritual factors for lasting, meaningful treatment to take place.

Cause of anxiety disorders – Additional considerations:

In addition to the physiological and psychological aspects, some additional considerations include the time period over which anxiety disorders develop and are maintained. There are some factors which are considered to be predisposing factors, which may be inherited or experienced early in childhood making you more vulnerable to anxiety disorders. Others may be maintaining causes or triggering causes which are factors that continue the anxiety disorders going forward into your life.

In the Anxiety and Phobia Workbook Third Edition, Edward J. Bourne, Ph.D. has provided a list of the causes of anxiety disorders:

Causes of Anxiety Disorders:

I. Long-Term, Predisposing Causes

A. Heredity

B. Childhood Circumstances
1. Your parents communicate an overly cautious view of the world.
2. Your parents are overly critical and set excessively high standards.
3. Emotional insecurity and dependence.
4. Your parents suppress your self- assertiveness.

C. Cumulative Stress Over Time

II. Biological Causes

A. Physiology of Panic

B. Panic Attacks and the Noradrenergic Hypothesis

C. Generalized Anxiety and the GABA/Benzodiazepine Hypothesis

D. Obsessive-Compulsive Disorder and the Serotonin Hypothesis

E. Medical Conditions That Can Cause Panic Attacks or Anxiety

III. Short-Term Triggering Causes

A. Stressors That Precipitate Panic Attacks
1. Significant Personal Loss
2. Significant Life Change
3. Stimulants and Recreational Drugs

B. Conditioning and the Origin of Phobias

C. Trauma, Simple Phobias, and Post-Traumatic Stress Disorder

IV. Maintaining Causes

A. Avoidance of Phobic Situations

B. Anxious Self-Talk

C. Mistaken Beliefs

D. Withheld Feelings

E. Lack of Assertiveness

F. Lack of Self-Nurturing Skills

G. Muscle Tension

H. Stimulants and Other Dietary Factors

I. High-Stress Lifestyle

J. Lack of Meaning or Sense of Purpose

Cause of anxiety disorders: Conclusion

While the above list of the “Cause of Anxiety Disorders” is comprehensive it is not exhaustive of all the factors that may be considered when doing a diagnosis and trying to determine effective treatment of a specific anxiety disorder for a specific individual.

Some information adapted from the Anxiety and Phobia Workbook Third Edition, Edward J. Bourne, Ph.D. by Paul Susic Ph.D. Licensed Psychologist (Health and Geriatric Psychologist).

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Other Specified Anxiety Disorder Symptoms and Related DSM–5 Diagnosis

Other Specified Anxiety Disorder 300.09 (F41.8):

Information related to Other Specified Anxiety Disorder as well as the specific symptoms follow below. While some of these Other Specified Anxiety Disorder symptoms may be recognized by family, teachers, legal and medical professionals, and others, only properly trained mental health professionals (psychologists, psychiatrists, professional counselors etc.) can or should even attempt to make a mental health diagnosis.

A multitude of factors are considered in addition to the psychological symptoms in making a proper diagnosis, including medical and psychological testing considerations. This information is for information purposes only and should never replace the judgment and comprehensive assessment of a trained mental health clinician.

Other Specified Anxiety Disorder diagnostic criteria 300.09 (F41.8):

This category applies to presentations in which symptoms characteristic of an anxiety disorder that causes clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the anxiety disorders diagnostic class. The other specified anxiety disorder category is used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for any specific anxiety disorder. This is done by recording “other specified anxiety disorder” followed by the specific reason (e.g. “generalized anxiety not occurring more days than not”).

Examples of presentations that can be specified using the “other specified” designation include the following:

1. Limited-symptom attacks.
2. Generalized anxiety not occurring more days than not.
3. Khyal “wind attacks”:
4. Ataque de nerios (attack of nerves).

Diagnostic Information and Criterion for Anxiety Disorders adapted from the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition American Psychological Association by Paul Susic Ph.D. Licensed Psychologist

Unspecified Anxiety Disorder Symptoms and Related DSM–5 Diagnosis

Unspecified Anxiety Disorder 300.00 (F41.9)

Information related to Unspecified Anxiety Disorder as well as the specific symptoms follow below. While some of these Unspecified Anxiety Disorder symptoms may be recognized by family, teachers, legal and medical professionals, and others, only properly trained mental health professionals (psychologists, psychiatrists, professional counselors etc.) can or should even attempt to make a mental health diagnosis.

A multitude of factors are considered in addition to the psychological symptoms in making a proper diagnosis, including medical and psychological testing considerations. This information is for information purposes only and should never replace the judgment and comprehensive assessment of a trained mental health clinician.

Unspecified Anxiety Disorder diagnostic criteria 300.00 (F41.9):

This category applies to presentations in which symptoms characteristic of an anxiety disorder that causes clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the anxiety disorders diagnostic class. The unspecified anxiety disorder category is used in situations in which the clinician chooses not to specify the reason that the criteria are not met for specific anxiety disorder, and includes presentations in which there is insufficient information to make a more specific diagnosis (e.g. in emergency room settings).

Diagnostic Information and Criterion for Anxiety Disorders adapted from the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition American Psychological Association by Paul Susic Ph.D. Licensed Psychologist

300.02 (F41.1) Generalized Anxiety Disorder Symptoms and Related DSM–5 Diagnosis

300.02 Generalized Anxiety Disorder (F 41.1): An Overview

The diagnosis of generalized anxiety disorder has been part of the DSM diagnostic system since the DSM-3. It is believed to be one of the most commonly experienced anxiety disorders in the United States with approximately 2.9% of adults experiencing this condition. The key feature of generalized anxiety disorder is an excessive worry or anxiety about various events and circumstances significantly out of proportion to the actual threat involved.
One of the things that differentiates generalized anxiety disorder from other anxiety disorders is the fact that it seems to take place over a variety of circumstances and situations for more days than not over a minimum of six months. An individual experiencing this disorder finds it hard to control the anxiety and worry and includes at least three characteristic symptoms. The symptoms include sleep disturbance, restlessness or feeling on edge, difficulty concentrating or the mind going blank, easily fatigued, muscle tension, and irritability.

Special Concerns:

The key feature is a pathological sense of worry and anxiety and is easily distinguished from nonclinical levels of anxiety by the high level or intensity of the anxiety, as well as the level of impairment in an individual’s daily functioning. Somatic and physical symptoms often accompany generalized anxiety disorder and include diarrhea, nausea, sweating, dizziness, accelerated heart rate, and muscle tension. As with many anxiety disorders, women seem to be affected more often by generalized anxiety disorder than men and seem to receive this diagnosis more frequently.

In the United States, generalized anxiety disorder seems to be more often experienced by Caucasian and Native American populations and seems to be more often among younger individuals. Latinos, Asians, African-Americans and Caribbean black populations have lower levels of generalized anxiety disorder.

Generalized Anxiety Disorder Coding:

There is only one code for generalized anxiety disorder 300. 02 (F 41.1) in the DSM-5. There are no specifiers for this disorder although mental health clinicians can choose to use the with panic attacks specifier when necessary.
General information on generalized anxiety disorder as well as medication and treatment can be found on the following pages and specific criteria follow below.

Generalized Anxiety Disorder diagnostic criteria 300.02 (F41.1):

A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least six months, about a number of events or activities (such as work or school performance).
B. The individual finds it difficult to control the worry.
C. Anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms having been present for more days than not for the past six months):

Note: Only one item is required in children.

1. Restlessness or feeling keyed up or on edge.
2. Being easily fatigued.
3. Difficulty concentrating or mind going blank.
4. Irritability.
5. Muscle tension.
6. Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep).

D. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
E. The disturbance is not attributable to the physiological effects of a substance (e.g. a drug of abuse, a medication) or another medical condition (e.g. hyperthyroidism).
F. The disturbance is not better explained by another mental disorder (e.g. anxiety or worry about having panic attacks and panic disorder, negative evaluation social anxiety disorder [ social phobia], contamination or other obsessions and obsessive-compulsive disorder, separation from attachment figures in separation anxiety disorder, reminders of traumatic events in posttraumatic stress disorder, gaining weight in anorexia nervosa, physical complaints in somatic symptom disorder, perceived appearance flaws in body dysmorphic disorder, having a serious illness in illness anxiety disorder, or the content of delusional beliefs in schizophrenia or delusional disorder).

Diagnostic Information and Criterion for Anxiety Disorders adapted from the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition American Psychological Association by Paul Susic Ph.D. Licensed Psychologist

293.84 Anxiety Disorder Due to Another Medical Condition Symptoms and Related DSM–5 Diagnosis

Anxiety Disorder Due to Another Medical Condition

Information related to Anxiety Disorder Due to Another Medical Condition as well as the specific symptoms follow below. While some of these Anxiety Disorder Due to Another Medical Condition symptoms may be recognized by family, teachers, legal and medical professionals, and others, only properly trained mental health professionals (psychologists, psychiatrists, professional counselors etc.) can or should even attempt to make a mental health diagnosis. A multitude of factors are considered in addition to the psychological symptoms in making a proper diagnosis, including medical and psychological testing considerations. This information is for information purposes only and should never replace the judgment and comprehensive assessment of a trained mental health clinician.

Anxiety Disorder Due to Another Medical Condition diagnostic criteria 293.84 (F06.4):

A. Panic attacks or anxiety is predominant in the clinical picture.
B. There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct pathophysiological consequence of another medical condition.
C. The disturbance is not better explained by another mental disorder.
D. The disturbance does not occur exclusively during the course of delirium.
E. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Coding note: Include the name of the other medical condition within the name of the mental disorder (e.g., 293. 84[F06.4] anxiety disorder due to pheochromocytoma). The other medical condition should be coded and listed separately immediately before the anxiety disorder due to the medical condition (e.g. 227.0 [D35. 00] pheochromocytoma; 293. 84 [F06.4] anxiety disorder due to pheochromocytoma.

Diagnostic Information and Criterion for Anxiety Disorders adapted from the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition American Psychological Association by Paul Susic Ph.D. Licensed Psychologist

300.22 Agoraphobia Symptoms and Related DSM–5 Diagnosis

300. 22 Agoraphobia Diagnosis (F40.00):

Agoraphobia is a diagnosis recently codable according to the new DSM-5 (Diagnostic And Statistical Manual Fifth Edition) published by the American Psychiatric Association. The agoraphobia diagnosis is given when you experience a high level of fear from either real or imagined exposure to specific circumstances or situations. It is most frequently experienced by teens and middle-aged adults in the U.S. with a prevalence rate of 1.7%. It is rarely initially experienced among seniors and young children. If you receive a diagnosis of agoraphobia, you may have anywhere from a moderate to severe level of impairment in your activities of daily living. It has been noted that approximately 33% of people diagnosed with this anxiety disorder feel restricted to their homes.

Agoraphobia Diagnosis: Key Features

Some of the primary aspects of agoraphobia are that you feel fear in situations in which you believe you cannot escape or in which you believe that bad things can happen to you beyond your control. The fear can vary according to your experience with the actual situation or even may occur in anticipation of the circumstance. This response must occur every time you have experience with the situation. An agoraphobia diagnosis cannot be given if you only experience the fear and potential avoidance occasionally. Agoraphobia usually results in avoidance of that situation and may affect both your thinking and behaviors.

An agoraphobia diagnosis can be given whether you meet the criteria or not for a . If the criteria is met for both disorders, you may be given a diagnosis for both. This is a very intense, disabling diagnosis frequently resulting in an individual becoming homebound. An initial agoraphobia diagnosis is rare among children and seniors with a mean age of onset of 17 years old. It usually shows its first signs in the teen and middle-aged years. There are some gender-related differences in that females are about twice as likely to have agoraphobia as males. In most cases if you have a agoraphobia diagnosis you most often experience comorbid mental health disorders such as anxiety and depression. In most cases if you meet the criteria of both agoraphobia and another diagnosis, both diagnoses are given.

Agoraphobia is typically treated within the context of panic disorder. Additional information related to agoraphobia symptoms and treatments may be found on additional pages of this website.

Coding for a Agoraphobia Diagnosis:

Coding for Agoraphobia diagnosis is 300.22 (F40.00). Also, a specifier with panic attacks is often given in conjunction with a diagnosis of agoraphobia.
More specific agoraphobia diagnostic criteria follow below.

Agoraphobia diagnostic criteria 300.22 (F40.00):

A. Marked fear or anxiety about two (or more) of the following five situations:

1. Using public transportation such as automobiles, buses, trains, ships or planes.
2. Being in open spaces such as parking lots, marketplaces or bridges.
3. Being in enclosed places such as shops, theaters, or cinemas.
4. Standing in line or being in a crowd.
5. Being outside of the home alone.

B. The individual fears or avoids these situations because of the thoughts that escape might be difficult or help might not be available in the event of developing panic-like symptoms or other incapacitating or embarrassing symptoms such as fear of falling in the elderly or fear of incontinence.

C. The Agoura phobic situations almost always provoke fear or anxiety.

D. The agoraphobic situations are actively avoided, require the presence of a companion, or are endured with intense fear or anxiety.

E. The fear or anxiety is out of proportion to the actual danger posed by the agoraphobic situations and to the sociocultural context.

F. The fear, anxiety, or avoidance is persistent, typically lasting for six months or more.

G. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

H. If another medical condition such as inflammatory bowel disease or Parkinson’s disease is present, the fear, anxiety, or avoidance is clearly excessive

I. The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder, for example, the symptoms are not confined to specific phobia, situational type; do not involve only social situations as in social anxiety disorder; and are not related exclusively to obsessions as in obsessive-compulsive disorder, perceived effects of flaws in physical appearance as in body dysmorphic disorder, reminders of traumatic events as in posttraumatic stress disorder, or fear of separation as in separation anxiety disorder.

Note: Agoraphobia is diagnosed irrespective of the presence of panic disorder. If an individual’s presentation meets criteria for panic disorder and Agoraphobia, both diagnosis should be assigned.

Diagnostic Information and Criterion adapted from the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition American Psychological Association by Paul Susic Ph.D. Licensed Psychologist