a case study on anxiety

Module 4: Anxiety Disorders

Case studies: examining anxiety, learning objectives.

• Identify anxiety disorders in case studies

Case Study: Jameela

Jameela was a successful lawyer in her 40s who visited a psychiatrist, explaining that for almost a year she had been feeling anxious. She specifically mentioned having a hard time sleeping and concentrating and increased feelings of irritability, fatigue, and even physical symptoms like nausea and diarrhea. She was always worried about forgetting about one of her clients or getting diagnosed with cancer, and in recent months, her anxiety forced her to cut back hours at work. She has no other remarkable medical history or trauma.

For a patient like Jameela, a combination of CBT and medications is often suggested. At first, Jameela was prescribed the benzodiazepine diazepam, but she did not like the side effect of feeling dull. Next, she was prescribed the serotonin-norepinephrine reuptake inhibitor venlafaxine, but first in mild dosages as to monitor side effects. After two weeks, dosages increased from 75 mg/day to 225 mg/day for six months. Jameela’s symptoms resolved after three months, but she continued to take medication for three more months, then slowly reduced the medication amount. She showed no significant anxiety symptoms after one year. [1]

Case Study: Jane

Jane was a three-year-old girl, the youngest of three children of married parents. When Jane was born, she had a congenital heart defect that required multiple surgeries, and she continues to undergo regular follow-up procedures and tests. During her early life, Jane’s parents, especially her mother, was very worried that she would die and spent every minute with Jane. Jane’s mother was her primary caregiver as her father worked full time to support the family and the family needed flexibility to address medical issues for Jane. Jane survived the surgeries and lived a functional life where she was delayed, but met all her motor, communication, and cognitive developmental milestones.

Jane was very attached to her mother. Jane was able to attend daycare and sports classes, like gymnastics without her mother present, but Jane showed great distress if apart from her mother at home. If her mother left her sight (e.g., to use the bathroom), Jane would sob, cry, and try desperately to open the door. If her mother went out and left her with a family member, Jane would fuss, cry, and try to come along, and would continually ask to video-call her, so her mother would have to cut her outings short. Jane also was afraid of doctors’ visits, riding in the car seat, and of walking independently up and down a staircase at home. She would approach new children only with assistance from her mother, and she was too afraid to take part in her gymnastics performances.

Jane also had some mood symptoms possibly related to her medical issues. She would intermittently have days when she was much more clingy, had uncharacteristically low energy, would want to be held, and would say “ow, ow” if put down to stand. She also had difficulty staying asleep and would periodically wake up with respiratory difficulties. [2]

• Bandelow, B., Michaelis, S., & Wedekind, D. (2017). Treatment of anxiety disorders. Dialogues in clinical neuroscience, 19(2), 93–107. ↵
• Hirshfeld-Becker DR, Henin A, Rapoport SJ, et alVery early family-based intervention for anxiety: two case studies with toddlersGeneral Psychiatry 2019;32:e100156. doi: 10.1136/gpsych-2019-100156 ↵
• Modification, adaptation, and original content. Authored by : Margaret Krone for Lumen Learning. Provided by : Lumen Learning. License : CC BY: Attribution
• Treatment of anxiety disorders. Authored by : Borwin Bandelow, Sophie Michaelis, Dirk Wedekind. Provided by : Dialogues in Clinical Neuroscience. Located at : http://Treatment%20of%20anxiety%20disorders . License : CC BY: Attribution

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• Spring 2024 | VOL. 22, NO. 2 Autism Across the Lifespan CURRENT ISSUE pp.147-262
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Cognitive-Behavioral Treatments for Anxiety and Stress-Related Disorders

• Joshua E. Curtiss , Ph.D. ,
• Daniella S. Levine , B.A. ,
• Ilana Ander , B.A. ,
• Amanda W. Baker , Ph.D.

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Cognitive-behavioral therapy (CBT) is a first-line, empirically supported intervention for anxiety disorders. CBT refers to a family of techniques that are designed to target maladaptive thoughts and behaviors that maintain anxiety over time. Several individual CBT protocols have been developed for individual presentations of anxiety. The article describes common and unique components of CBT interventions for the treatment of patients with anxiety and related disorders (i.e., panic disorder, social anxiety disorder, generalized anxiety disorder, obsessive-compulsive disorder, posttraumatic stress disorder, prolonged grief). Recent strategies for enhancing the efficacy of CBT protocols are highlighted as well.

Anxiety disorders are among the most prevalent of mental disorders and are associated with high societal burden ( 1 ). One of the most well-researched and efficacious treatments for anxiety disorders is cognitive-behavioral therapy (CBT). At its core, CBT refers to a family of interventions and techniques that promote more adaptive thinking and behaviors in an effort to ameliorate distressing emotional experiences ( 2 ). CBT differs from other therapeutic orientations in that it is highly structured and often manualized. CBT sessions often occur weekly for a limited period (e.g., 12–16 weeks), and a small number of booster sessions are sometimes offered subsequently to reinforce independent use of skills. A cognitive-behavioral conceptualization of anxiety disorders includes identification of dysfunctional thinking patterns, distressing feelings or physiological experiences, and unproductive behaviors. When each of these three components interact and mutually reinforce one another, distressing and impairing levels of anxiety can be maintained over time. Although there are several CBT interventions for different types of anxiety, some common techniques and treatment goals form the basis of the CBT philosophy.

Cognitive Interventions

One of the primary CBT strategies is cognitive intervention. In brief, CBT holds that one’s emotional experience is dictated by one’s interpretation of the events and circumstances surrounding that experience ( 2 , 3 ). Anxiety disorders are associated with negatively biased cognitive distortions (e.g., “I think it’s 100% likely I will lose my job, and no one will ever hire me again”). The objective of cognitive interventions is to facilitate more adaptive thinking through cognitive restructuring and behavioral experiments. Cognitive restructuring promotes more adaptive and realistic interpretations of events by identifying the presence of thinking traps. These cognitive traps are patterns of biased thinking that contribute to overly negative appraisals. For example, “black-and-white thinking” describes the interpretation of circumstances as either all good or all bad, without recognition of interpretations between these two extremes, and “overgeneralization” describes the making of sweeping judgments on the basis of limited experiences). Through identification of thinking traps, cognitive restructuring can be used to promote more balanced thinking, encouraging patients to consider alternative interpretations of circumstances that are more helpful and less biased by anxiety (e.g., “Maybe thinking the chance of losing my job is 100% is overestimating the likelihood that it will actually happen. And, it’s not a forgone conclusion that even if I lose my job, I will never find another one for the rest of my life.”). Similarly, behavioral experiments can be used to facilitate cognitive change. Behavioral experiments involve encouraging patients to empirically test maladaptive beliefs to determine whether there is evidence supporting extreme thinking. For example, if a patient believes that he/she/they is romantically undesirable and that asking someone on a date will cause the other person to react with disgust and disdain, then the patient would be encouraged to test this belief by asking someone on a date. Some combination of cognitive restructuring and behavioral experiments are often implemented in CBT across all anxiety disorders.

Behavioral Interventions

There are several behavioral strategies in CBT for anxiety disorders, yet the central behavioral strategy is exposure therapy. Exposure techniques rely on learning theory to explain how prolonged fear is maintained over time. Specifically, heightened anxiety and fear prompt individuals to avoid experiences, events, and thoughts that they believe will lead to catastrophic outcomes. Continued avoidance of feared stimuli and events contributes to the maintenance of prolonged anxiety. Consistent with the premises underlying extinction learning, exposure exercises are designed to encourage a patient to confront a feared situation without engaging in avoidance or subtle safety behaviors (i.e., doing something to make an anxiety-inducing situation less distressing). After repeated exposures to a feared situation (e.g., heights) without engaging in avoidance or safety behaviors (e.g., closing one’s eyes to avoid looking down), the patient will learn that such a situation is less likely to be associated with disastrous outcomes, and new experiences of safety will be reinforced. Similar to the behavioral experiments described in the cognitive intervention section above, which test whether a faulty thought is true or false, exposure exercises offer the opportunity for patients to test their negative beliefs about the likelihood of a bad outcome by exposing themselves to whatever situations they have been avoiding. Thus, cognitive approaches and exposure exercises are complementary techniques that can benefit individuals with anxiety disorders. In the following sections, different aspects of CBT will be explored and emphasized insofar as they relate to specific presentations of anxiety.

CBT for Specific Disorders

Panic disorder.

Panic disorder, as defined by the DSM-5 , is characterized by recurrent, unexpected panic attacks accompanied by worry and behavioral changes in relation to future attacks. Panic attacks are marked by acute, intense discomfort, with symptoms including heart palpitations, sweating, and shortness of breath. Individuals with panic disorder exhibit cognitive and behavioral symptoms, such as catastrophic misinterpretations of their symptoms as dangerous (e.g., “my heart pounding means I will have a heart attack”) and avoidance of situations or sensations that induce panic ( 4 ). Cognitive-behavioral treatments thus target these symptoms. For example, cognitive restructuring is used to help patients reinterpret their maladaptive thoughts surrounding panic (e.g., “if I get dizzy, I will go crazy”) to be more flexible (e.g., “if I get dizzy, it may just mean that I spun around too fast”). Behavioral treatments for panic include exposure to the situations (i.e., in-vivo exposure, which might include driving in traffic or riding the subway) and bodily sensations (i.e., interoceptive exposure, which would include physical exercises to bring on physical symptoms) that trigger panic in order to reduce the fear and anticipatory anxiety that maintain the symptoms. The aim of these exposures is to illustrate that the situations and sensations are benign and not indicative of danger.

Generalized Anxiety Disorder

Generalized anxiety disorder (GAD) is characterized by excessive and uncontrollable worry about several life domains (e.g., finances, health, career, the future in general). Treatment for GAD involves a wholesale approach to target excessive worry with a combination of cognitive and behavioral strategies ( 5 ). Although cognitive restructuring exercises are indeed emphasized throughout the treatment to target dysfunctional thoughts, usually further cognitive treatments are included to address worry behavior in addition to thought content. Individuals with GAD rarely achieve complete remission after restructuring only one of their negative thoughts. The CBT conceptualization of worry describes worry as a mental behavior or process, characterized by repetitive negative thinking about catastrophic future outcomes. To target worrying as a process, cognitive techniques, such as mindfulness, are emphasized. Rather than targeting the content of worry (e.g., “I think I will definitely lose my job if I do not prepare for this meeting”), mindfulness exercises target the worry behavior by promoting the opposite of repetitive negative thinking (i.e., nonjudgmental and nonreactive present moment awareness), thereby facilitating greater psychological distance from negative thoughts. Exposure therapy is often implemented as imaginal exposures for GAD, because individuals with GAD rarely have an external object that is feared. Such imaginal exposures will encourage patients with GAD to write a detailed narrative of their worst-case scenario or catastrophic outcome and then imagine themselves undergoing such an experience without avoiding their emotions. Cognitive restructuring and imaginal exposure exercises can benefit patients with GAD by targeting their tendency to give catastrophic interpretations to their worries, whereas mindfulness can be helpful in targeting worry as a mental behavior itself ( 5 ).

Social Anxiety Disorder

Social anxiety disorder involves a fear of negative evaluation in social situations and is accompanied by anxiety and avoidance of interpersonal interactions and performance in front of others. The primary treatment approach for social anxiety disorder consists of exposure exercises to feared social situations ( 6 ). Cognitive restructuring is used in conjunction with exposure exercises to reinforce the new learning and shift in perspective occurring through exposure therapy. Typically, exposure exercises for social anxiety disorder come in two stages ( 6 ). The first stage of exposures often targets patients’ overestimation that something bad will happen during a social interaction. For instance, patients with this disorder may fear that they will make many verbal faux pas (e.g., saying “uh” more than 30 times) during a conversation. An exposure exercise may consist of recording the patient having a 2-minute conversation and listening to the recording afterward to see whether the feared outcome actually occurred. The second stage of exposure exercises (i.e., social cost exposures) consists of having patients directly making their worst-case social anxiety scenario come true to determine how bad and intolerable it actually is. Such a social cost exposure might involve encouraging a patient to embarrass her- or himself on purpose by singing “Twinkle, Twinkle Little Star” in a crowded public street. After fully confronting a social situation that the patient predicted would be very embarrassing, the patient can then determine whether such a situation is as devastating and intolerable as predicted. After repeated social cost exposures, patients with social anxiety disorder experience less anxiety in embarrassing social situations and are more willing to adopt less catastrophic beliefs about the meaning of making mistakes in social situations.

Obsessive-Compulsive Disorder

Obsessive-compulsive disorder (OCD) is characterized by obsessions (i.e., unwanted thoughts or images that are intrusive in nature) and compulsions (i.e., actions or mental behaviors that are performed in a rule-like manner to neutralize the obsession). A CBT conceptualization of OCD considers compulsions as a form of emotional avoidance. Although both cognitive interventions and exposure exercises are helpful for individuals with OCD, the latter are often emphasized. The gold-standard CBT treatment for OCD is exposure and ritual prevention therapy ( 7 ). The primary idea underlying exposure and ritual prevention is to expose individuals with OCD to the feared circumstance associated with the obsession and prevent them from performing the compulsive ritual that gives them comfort through avoidance. For example, patients who experience frequent obsessions about whether their doors are locked or their appliances are off (e.g., “If my door is unlocked, then my house might be robbed or something bad might happen.”) will often feel compelled to perform a compulsion (e.g., ritualistic checking) to avoid the likelihood of having their obsession come true. Exposure and ritual prevention would be used to expose such patients to a feared situation, such as leaving their door unlocked on purpose, and resisting the compulsion to check the door or to lock it. During these exposures, the patients would be asked to embrace the uncertainty surrounding the possibility of the feared outcome coming true (i.e., someone entering the house). Repeated sessions of exposure and ritual prevention will facilitate corrective learning about the likelihood that feared outcomes will occur.

Posttraumatic Stress Disorder

As defined by the DSM-5 , posttraumatic stress disorder (PTSD) can arise after a traumatic event in which an individual directly experiences, witnesses, or learns about the actual or threatened death, serious injury, or sexual violence toward a loved one. After the traumatic stressor event, an individual with PTSD may experience intrusion symptoms (e.g., upsetting dreams or flashbacks of the event), avoidance of reminders of the event, changes in cognitions and affect (e.g., distorted beliefs about oneself, others, and the world), and changes in physiological arousal (e.g., jumpiness, irritability) ( 4 ). Gold-standard treatments for PTSD involve targeting the cognitive and behavioral symptoms that maintain the disorder ( 8 ). PTSD treatments target negative changes in cognition by restructuring the thoughts and beliefs surrounding the traumatic event. For example, evidence-based treatments alter persistent negative beliefs about the world (e.g., “I was assaulted; therefore, the world is dangerous”) to be more flexible (e.g., “even though I was assaulted, there are safe places for me to be”). In challenging these beliefs, the patient may be better able to foster flexible thinking, positive affect, trust, and control in their lives. PTSD treatments are also designed to help patients confront the upsetting memories and situations associated with the traumatic event. Through in-vivo exposures (i.e., approaching situations that are reminders of the trauma) and imaginal exposures (i.e., confronting upsetting memories of the trauma), the patient can begin to behaviorally approach, rather than avoid, reminders of the event to overcome their fears of the trauma and the associated symptoms.

Prolonged Grief Disorder

After losing a loved one, many individuals experience grief symptoms, such as thoughts (e.g., memories of the deceased, memories of the death), emotions (e.g., yearning, emotional pain), and behaviors (e.g., social withdrawal, avoidance of reminders). For most bereaved individuals, these symptoms decrease over time; however, some individuals experience a debilitating syndrome of persistent grief called prolonged grief disorder. This disorder is a direct consequence of the loss, thereby differentiating it from depression and PTSD. Evidence-based and efficacious treatment options for prolonged grief disorder draw from interpersonal therapy, CBT, and motivational interviewing, with additional psychoeducation components ( 9 ). These treatments aim to facilitate the natural bereavement process as individuals accept and integrate the loss. Strategies can be either loss-related or restoration-related. Specific loss-related strategies that draw from CBT include imaginal and situational revisiting (e.g., retelling the story of the loss, going to places that have been avoided since the loss) and a grief monitoring diary. Restoration-related strategies include short- and long-term planning, self-assessment and self-regulation, and rebuilding interpersonal connections.

Transdiagnostic Approaches to CBT for Anxiety Disorders

Throughout the past several decades, there has been a proliferation of CBT approaches that have been individualized to specific anxiety disorder presentations (e.g., panic disorder, specific phobias, social anxiety disorder). Each disorder-specific treatment manual is written to consider unique applications of CBT strategies for the presenting disorder. However, in recent years, there has been increased interest in considering transdiagnostic approaches to the treatment of anxiety and related disorders ( 10 ). The commonalities among individual anxiety disorders and the high levels of comorbidity have contributed to the rationale for a unified CBT approach that can target transdiagnostic mechanisms underlying all anxiety disorders. The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) has been the most studied transdiagnostic treatment for anxiety disorders, and recent evidence ( 10 ) corroborates the equivalent efficacy of the UP relative to disorder-specific treatment protocols for individual anxiety disorders.

The UP consists of five core modules that target transdiagnostic mechanisms of emotional disorders, particularly neuroticism and emotional avoidance, underlying all anxiety disorders. Specifically, the modules are mindfulness of emotions, cognitive flexibility, identifying and preventing patterns of emotion avoidance, increasing tolerance of emotion-related physical sensations, and interoceptive and situational emotion-focused exposures ( 10 ). Each module may be used flexibly for individual patients. The first two modules are more cognitive in nature, whereas the latter modules are more behavioral and emphasize the treatment of avoidance. The first module emphasizes mindfulness of emotions, which consists of allowing oneself to fully and nonjudgmentally experience emotions and allow them to come and go while remaining focused on the present. The second module fosters cognitive flexibility by identifying thinking traps that lead to overly negative thoughts and interpretations and by teaching restructuring strategies to generate alternative interpretations of circumstances that are less biased and more adaptive. The third module promotes the identification of emotion-driven behaviors (i.e., actions that a given emotion compels a person to do, such as avoidance behaviors in response to fear) and the adoption of alternative actions (i.e., behaviors that are different from or the opposite of the emotion-driven behavior). For example, if social anxiety prompts an individual to avoid eye contact as an emotion-driven behavior, then an alternative action would be to intentionally maintain eye contact with another speaker to counteract this subtle form of avoidance. The final two modules consist of exposure exercises to develop better tolerance of unwanted physical symptoms produced by anxiety (e.g., increased heart rate) and to reduce fear in anxiety-provoking situations.

Because the UP contains many of the core components of disorder-specific protocols and has demonstrated equivalent efficacy, such a treatment approach may reduce the need for excessive reliance on disorder-specific protocols ( 10 ). Furthermore, the UP can be extended to other emotional disorders, such as depression.

Complementary Approaches for CBT

Mindfulness.

Mindfulness-based interventions function both as transdiagnostic adjunctive treatments to CBT for patients with anxiety and stress disorders as well as stand-alone treatments. Mindfulness is the practice of nonjudgmental awareness of the present moment experience. The aim of these interventions is to reduce emotional dysregulation and reactivity to stressors. Common mindfulness-based interventions include manualized group skills training programs called mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy ( 11 ). MBSR involves eight, 2–2.5-hour sessions with an instructor, in conjunction with a daylong retreat, weekly homework assignments, and practice sessions. Modules are designed to train participants in mindful meditation, interpersonal communication, sustained attention, and recognition of automatic stress reactivity. Mindfulness-based cognitive therapy has a structure similar to MBSR but includes cognitive therapy techniques to train participants to recognize and disengage from negative automatic thought patterns ( 12 ). These interventions omit aspects of traditional CBT (e.g., cognitive restructuring). Mindfulness-based interventions have been explored as both brief and Internet-delivered interventions and have been integrated into other evidence-based practices (e.g., dialectical behavior therapy and acceptance and commitment therapy).

Pharmacotherapy

There has been much interest in determining whether combination strategies of CBT and pharmacotherapy yield greater efficacy than either one alone for individuals with anxiety disorders. A comprehensive meta-analysis ( 13 ) examining this combination strategy suggested that adding pharmacotherapy to CBT may produce short-term benefit, yet such improvements diminished during 6-month follow-up. This combination strategy was more efficacious for individuals with panic disorder or GAD than for individuals with other presentations of anxiety. Moreover, the meta-analysis ( 13 ) indicated that the effect size for CBT combined with benzodiazepines was significantly greater than that for CBT combined with serotonin reuptake inhibitors (SSRIs) or tricyclic antidepressants. Another important consideration for pharmacotherapy in the treatment of individuals with anxiety disorders is to ensure that anxiolytic medications, such as benzodiazepines, are administered carefully in the context of exposure therapy. Anxiolytic medications taken to temporarily reduce anxiety may undermine quality exposure therapy sessions by preventing patients from fully learning whether they can tolerate fear without resorting to avoidance behaviors. Thus, although pharmacotherapy appears to improve outcomes in combination with CBT for patients with anxiety disorders, further research is needed to determine the durability of these effects.

D-Cycloserine in Conjunction With Exposures

One approach for improving patient outcomes is to target the extinction learning process underlying exposure exercises. There has been recent interest in cognitive enhancers, such as d-cycloserine (DCS) or methylene blue, as pharmacological adjuncts to exposure therapy ( 14 , 15 ). In preclinical studies, DCS has demonstrated evidence as a cognitive enhancer, consolidating new learning during extinction training. Specifically, the efficacy associated with DCS depends on the efficacy of the exposure exercise. For instance, during a successful exposure exercise, in which anxiety levels decrease substantially, the administration of DCS may confer additional benefit by consolidating this learning. However, if an exposure exercise was unsuccessful and fear levels never decreased, then DCS might consolidate the fear memory, thereby exacerbating the severity of the anxiety disorder ( 14 ). Recently, however, there has been evidence ( 16 ) suggesting that the efficacy of cognitive enhancers, such as DCS, has been declining, possibly because of changes in dose and dose timing. More research needs to be undertaken to understand under what circumstances (e.g., length of exposure session, amount of fear reduction, timing of dose) DCS would offer the greatest therapeutic effect in conjunction with exposure therapy.

Novel Delivery Methods

Internet-delivered CBT (I-CBT) is an alternative modality for the delivery of CBT for patients with anxiety and related disorders. I-CBT is a scalable alternative to in-person treatment, with the Internet used as an accessible and cost-effective method of delivery for evidence-based treatment. In I-CBT, CBT modules are delivered via computer or an application on a mobile device, with the support of a therapist or through a self-guided system. I-CBT has been shown ( 17 – 19 ) to be superior to waitlist and placebo conditions in the treatment of adults with a range of anxiety and trauma disorders, including anxiety and PTSD. Results ( 18 ) have indicated that I-CBT is similarly effective at reducing panic disorder symptoms as face-to-face CBT. The results of another trial ( 20 ) have indicated that I-CBT is also effective at reducing symptoms of OCD and social anxiety disorder.

In addition to Internet and mobile application platforms for CBT, virtual reality technology offers novel avenues to access cognitive-behavioral interventions ( 21 ). One key advantage is that recent advances in the sensory vividness of virtual reality platforms have facilitated more meaningful exposure exercises. For example, virtual reality flight simulators can be leveraged to expose a patient with flight phobia to several flight conditions with enhanced sensory detail (e.g., sounds of liftoff or landing, vibrations, images of clouds through a window, images of in-cabin atmosphere). This technology could obviate the need to purchase several expensive flights to participate in exposure exercises, thereby permitting more frequent exposure opportunities.

Conclusions

CBT is an effective, gold-standard treatment for anxiety and stress-related disorders. CBT uses specific techniques to target unhelpful thoughts, feelings, and behaviors shown to generate and maintain anxiety. CBT can be used as a stand-alone treatment, may be combined with standard medications for the treatment of patients with anxiety disorders (e.g., selective serotonin reuptake inhibitors), or used with novel interventions (e.g., mindfulness). Furthermore, this treatment is flexible in terms of who may benefit from it. Overall, whenever a patient is experiencing some form of emotional psychopathology (e.g., an anxiety or depression disorder) or distressing emotions that do not meet disorder threshold but cause distress or interference in daily activities, referral to a CBT provider is indicated to pursue a course of treatment to actively address such symptoms and problems.

The authors report no financial relationships with commercial interests.

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• Efficacy of cognitive behavioral therapy after the surgical treatment of women with endometriosis: A preliminary case-control study Medicine, Vol. 101, No. 51

• Anxiety and anxiety disorders
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• Very early family-based intervention for anxiety: two case studies with toddlers
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• http://orcid.org/0000-0001-5603-6959 Dina R Hirshfeld-Becker 1 , 2 ,
• Aude Henin 1 , 2 ,
• Stephanie J Rapoport 1 ,
• Timothy E Wilens 2 , 3 and
• Alice S Carter 4
• 1 Child CBT Program, Department of Psychiatry , Massachusetts General Hospital , Boston , Massachusetts , USA
• 2 Department of Psychiatry , Harvard Medical School , Boston , Massachusetts , USA
• 3 Division of Child and Adolescent Psychiatry, Department of Psychiatry , Massachusetts General Hospital , Boston , Massachusetts , USA
• 4 Department of Psychology , University of Massachusetts Boston , Boston , Massachusetts , USA
• Correspondence to Dr Dina R Hirshfeld-Becker; dhirshfeld{at}partners.org

Anxiety disorders represent the most common category of psychiatric disorder in children and adolescents and contribute to distress, impairment and dysfunction. Anxiety disorders or their temperamental precursors are often evident in early childhood, and anxiety can impair functioning, even during preschool age and in toddlerhood. A growing number of investigators have shown that anxiety in preschoolers can be treated efficaciously using cognitive–behavioural therapy (CBT) administered either by training the parents to apply CBT strategies with their children or through direct intervention with parents and children. To date, most investigators have drawn the line at offering direct CBT to children under the age of 4. However, since toddlers can also present with impairing symptoms, and since behaviour strategies can be applied in older preschoolers with poor language ability successfully, it ought to be possible to apply CBT for anxiety to younger children as well. We therefore present two cases of very young children with impairing anxiety (ages 26 and 35 months) and illustrate the combination of parent-only and parent–child CBT sessions that comprised their treatment. The treatment was well tolerated by parents and children and showed promise for reducing anxiety symptoms and improving coping skills.

• childhood anxiety disorders
• preschoolers
• cognitive behavioural therapy

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/gpsych-2019-100156

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Introduction

Anxiety disorders affect as many as 30% of children and adolescents and contribute to social and academic dysfunction. These disorders or their temperamental precursors 1 are often evident in early childhood, with 10% of children ages 2–5 already exhibiting anxiety disorders. 2 Anxiety symptoms in toddlerhood 3 and preschool age 4 show moderate persistence and map on to the corresponding Diagnostic and Statistic Manual anxiety disorders. 5 6 Well-meaning parents, particularly those with anxiety disorders themselves, may respond to a child’s distress around separating from parents or being around unfamiliar children by decreasing the child’s exposure to these situations, for example, by not having the child start preschool or by not leaving the child with a childcare provider to go to work or socialise. In the short term, such responses may impair concurrent family function, strain the parent–child relationship, and reduce the child’s opportunity for increased autonomy, learning and social development. 7 These avoidant strategies may initiate a trajectory where the child takes part in fewer and fewer activities, leading to social and academic dysfunction. 8

Members of our research team began championing the idea of early intervention with young anxious children over two decades ago, with the aim of teaching children and their parents cognitive–behavioural strategies to manage anxiety before their symptoms became too debilitating. 8 Although cognitive–behavioural therapy (CBT) has since emerged as the psychosocial treatment of choice for treating and preventing anxiety, 9 10 at that time, most protocols that had been empirically tested were aimed at children ages 7 through early adolescence, with only a few enrolling children as young as age 6. 11 We developed and tested a parent–child CBT intervention (called ‘Being Brave’) and reported efficacy in children as young as 4 years. 12 13 The treatment involved teaching parents about fostering adaptive coping and implementing graduated exposures to feared situations, and modelling how to teach children basic coping skills and conduct exposures with reinforcement. In parallel, a growing number of investigators confirmed that anxiety in preschoolers could be treated efficaciously using CBT administered either by training parents to apply CBT strategies with their children or through direct intervention with children. 14 15 Early family-based intervention using cognitive–behavioural strategies was shown to reduce rates of later anxiety and to attenuate the onset of depression in adolescence in girls. 16

The question remains as to whether early intervention can be extended even younger. With few exceptions, 17 18 most investigators do not offer direct CBT for anxiety to children under age 3 or 4, 15 and none to our knowledge have treated anxiety disorders with CBT in children under age 2.7. 15 However, we reasoned that since toddlers can also present with impairing symptoms, and since behaviour strategies can be feasibly applied even in preschoolers with poor language ability, 19 it ought to be possible to apply family-based CBT for anxiety to toddlers as well. We therefore present two cases of anxious children, ages 26 and 35 months, treated with parent and child CBT.

Recruitment

Parents of children ages 21–35 months were recruited for a pilot intervention study (a maximum of three cases) using advertisements to the community. To be included, children had to be rated by a parent as above a standard deviation on the Early Childhood Behavior Questionnaire Fear or Shyness Scale 20 and could not have global developmental delays, autism spectrum disorder or a primary psychiatric disorder other than anxiety.

Children were evaluated for behavioural inhibition using a 45 min observational protocol. 21 Parents completed a structured diagnostic interview about the child (Kiddie Schedule for Affective Disorders and Schizophrenia-Present and Lifetime) that has been used with parents of children as young as 2 years; 22 23 an adapted Coping Questionnaire, 24 in which parents assessed the child’s ability to cope with their six most feared situations; and questionnaires assessing child symptoms (Child Behavior Checklist 1-1/2-5 (CBCL), 25 subscales from the Infant Toddler Social Emotional Assessment (ITSEA) 26 ), family function (Family Life Impairment Scale 27 ) and parental stress (Depression Anxiety Stress Scale 28 ). These assessments were repeated following the intervention, with the exception of the behavioural observation for the child initially rated ‘not inhibited’. The clinician rated the global severity of the child’s anxiety on a 7-point severity scale (Clinician Global Impression of Anxiety 29 ) at baseline and rated global severity and improvement of anxiety postintervention. Participant engagement in session and adherence to between-session assignments were rated by the clinician at each visit, and parents completed a post-treatment questionnaire rating the intervention.

Children were treated by the first author, a licensed child psychologist, using the ‘Being Brave’ programme. 13 It includes six parent-only sessions, eight or more parent–child sessions and a final parent-only session on relapse prevention. An accompanying parent workbook reinforces the information presented. Parent-only sessions focus on factors maintaining anxiety; monitoring the child’s anxious responses and their antecedents and consequences; restructuring parents’ anxious thoughts; identifying helpful/unhelpful responses to child anxiety; modelling adaptive coping; playing with the child in a non-directive way; protecting the child from danger rather than anxiety; using praise to reinforce adaptive coping; and planning and implementing graduated exposure. Child–parent sessions teach the child basic coping skills; and focus on planning, rehearsing and performing exposure exercises, often introduced as games, with immediate reinforcement. All parent–child sessions were preserved from the original protocol, but two sessions teaching the child about the CBT model, relaxation and coping plans were omitted, as were two sessions in which the (older) child does a summary project and celebrates gains. Up to six child–parent sessions focusing on exposure practice were included.

In the cases that follow, identifying details are disguised to protect participants’ privacy. Parents of both children provided written consent for the publication of de-identified case reports.

Background information

‘J’ was a 35-month-old girl, the third of three children of married parents. She had congenital medical problems requiring multiple surgeries, and she continued to undergo regular follow-up procedures. J met the criteria for separation anxiety disorder with marked severity, mild social phobia and mild specific phobia. Although she was able to attend her familiar day care if handed directly to a teacher and attend a gymnastics class with a friend while her mother waited in the hall, J showed great distress if apart from her mother at home. If her mother left her sight (eg, to use the bathroom), J would sob, cry and try to open the door to get in. If her mother went out and left her with a family member, J would fuss, cry and try to come along, and would continually ask to video-call her, so her mother would cut her outings short. J also had fears of doctors’ visits, of riding in the car seat, and of walking independently up and down a staircase at home. She would approach new children only with assistance from her mother, and she was afraid to take part in gymnastics performances.

J also had some mood symptoms possibly related to her medical issues. She would intermittently have days when she was much more clingy, had uncharacteristically low energy, would want to be held, and would say ‘ow, ow’ if put down to stand. She also had difficulty staying asleep and would periodically wake up with respiratory difficulties.

‘K’ was a 26-month-old boy, the only child of married parents. He met the criteria for moderate separation anxiety disorder. Although able to go to a day care he had been attending since infancy, he showed distress at drop-off particularly at the start of each week, crying for 15 min. He feared being apart from his mother in the house: he could not tolerate his mother leaving the room even to change clothes and would cry if his mother left the playroom while K played with his father. He would get distressed if his father took him on outings without his mother. He could not be dropped off at a childcare centre at his parents’ gym, leading to their avoiding exercise. He slept in his own crib, rocked to sleep by a parent, but would wake in a panic (alert but distressed) two to three times per month, crying for over an hour until his parents took him into their bed. K also was very particular about where objects were placed in the playroom and would fuss if they were put in the wrong place. He got anxious about deviations in routine (eg, taking a different path on a walk) and had trouble throwing things away (eg, used Band-Aids).

Intervention Feasibility and Outcomes

To demonstrate feasibility, the application of the treatment protocol with both participants is summarised in table 1 . Both participants completed the treatment, in 11 and 10 sessions, respectively. For each, session engagement was rated ‘moderately’ or ‘completely engaged’ at all but one session, and homework adherence was rated as ‘moderate work’ to ‘did everything assigned’ at all but one session.

• View inline

Application of treatment protocol with both participants

The quantitative results of the treatment are presented in table 2 . Both children were rated by the clinician as having shown ‘much improvement’ (Clinician Global Impression of Anxiety-Improvement 1 or 2), and both showed changes in quantitative measures of anxiety and family function. In both families, parents rated their satisfaction with the treatment as ‘extremely satisfied’, and felt that they would ‘definitely’ recommend the intervention to a friend. They rated all strategies introduced in the intervention as ‘very-’ or ‘moderately helpful’ and rated the change in their ability to help their child handle anxiety as ‘moderately-’ to ‘very much improved’.

Quantitative changes in diagnoses, coping ability, symptoms and family function in both participants

These pilot cases demonstrate the feasibility and acceptability of parent–child CBT for toddlers with anxiety disorders. The two participating families completed the treatment protocol and were consistently engaged with in-session exercises and adherent to between-session skills practice. The cases demonstrate that basic coping skills and exposure practice can be conducted with toddlers.

Although efficacy cannot be determined from uncontrolled case studies, the cases did show promising preliminary results. Both children showed a decrease in number of anxiety disorders, both were rated by the clinician (and parents) as either ‘moderately-’ or ‘much improved’ in their overall anxiety, and both showed increases in their parent-rated ability to cope with their most feared situations. Participant 2 improved on all symptom measures as well. Most significantly, his ITSEA general anxiety, separation distress, inhibition to novelty, negative emotionality, compliance and social relatedness scores and his CBCL total score, internalising score and somatic complaints scale score normalised from clinical to non-clinical range. Participant 1 had a more complicated clinical presentation, and whereas her diagnoses and coping scores improved, her parent-rated symptom scores were more mixed, perhaps related to medical problems which impacted sleep. Beyond changes in the children’s behaviour, family life impairment was reduced for both families, and parental stress was decreased out of clinical range for participant 1. Notably, both children also showed gains in areas of competence, including prosocial peer relations and mastery motivation.

This work extends previous research demonstrating that very young children experience impairing levels of anxiety that are amenable to CBT. Previous studies have found that CBT is as efficacious with older preschool-age children with anxiety disorders as it is with school-aged youth, 14 15 with approximately two-thirds of treated youth demonstrating clinically significant improvement. There is increasing recognition that anxiety disorders start early in childhood, and that there are significant advantages to intervening proximally to their onset, before anxiety symptoms crystallise and impairment accumulates. For example, one study of 1375 consecutive referrals (mean age 10.7) to a paediatric psychopharmacology clinic found that the median age of onset of a child’s first anxiety disorder was 4 years. 30 Children seeking treatment for anxiety often present in middle childhood, for symptoms which began much earlier, exposing the child and family to undue stress for years. By teaching parents and very young children skills to manage anxiety, we hope to give families important tools to navigate the developmental transitions inherent in this age range, and to help children develop a sense of mastery during a critical developmental period. Of course, a larger controlled trial is needed to further evaluate this intervention and its efficacy over time.

Assessing and treating toddlers require a developmentally informed approach. Anxiety and other symptoms may present differently in younger children, and because of limited language and cognitive abstraction capabilities toddlers are not as able to describe their fears and worries. Because some forms of anxiety (eg, separation anxiety, stranger anxiety) are normative, determination of clinically significant levels of anxiety requires an understanding of typical development in toddlerhood and the ability to conduct a detailed assessment with parents and the child using measures normed for this age group (such as the ITSEA and CBCL 1-1/2-5). Similarly, implementing CBT with toddlers and preschoolers requires age-appropriate modifications of empirically supported techniques. The adaptations we used included increased parental involvement in planning exposures, decreased focus on child cognitive restructuring (beyond framing the practice as ‘being brave’ and redirecting the child’s attention to rewarding aspects of the situation), and adaptations to exposure exercises to maximise child participation and motivation (practising at times when the child was rested and not irritable, incorporation of games and reinforcers, and allowing the child maximal choice about when/how to carry out the exposure). The cases we presented demonstrate that existing interventions can be effectively adapted and implemented with children as young as 2 years of age. By sharing the information gleaned from our research, we hope to inform providers who may be less familiar with treating children in this age range and increase their confidence in intervening with very young children.

Acknowledgments

The authors acknowledge Jordan Holmen for assistance with data checking.

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Dina Hirshfeld-Becker earned her undergraduate degree from Harvard and her doctorate in clinical psychology from Boston University, and completed post-doctoral training at Massachusetts General Hospital. Dr Hirshfeld-Becker is currently co-founder and co-director of the Child Cognitive Behavioral Therapy (CBT) Program in the Department of Psychiatry at MGH and an associate professor of psychology in the Department of Psychiatry at Harvard Medical School. The Child CBT Program offers short-term empirically supported CBT with youths ages 3-24, research in novel treatment adaptations, and clinical training in CBT, including on-line training courses. She pioneered the development and empirical evaluation of one of the first manualized cognitive-behavioral intervention protocols for anxiety in 4- to 7-year-old children, the “Being Brave” program, and has been exploring its use with children with autism spectrum disorder and with younger toddlers and their parents. Dr Hirshfeld-Becker has published numerous articles, reviews, and chapters. Her main research interests include the etiology, development, and treatment of childhood psychiatric disorders, particularly anxiety disorders, and in the study of early risk factors for these disorders.

Contributors DRHB designed the study with input from ASC, AH and TEW. DRHB developed the intervention and treated the cases, and DRHB, SJR and AH collected, scored, analysed and tabulated the data. DRHB wrote the first draft of the manuscript, SJR drafted parts of the Results section, and AH made significant additions to the Discussion section. AH, ASC and TEW revised the manuscript critically for important intellectual content. DRHB incorporated all of their edits and finalised the document. All authors approved the final version and are accountable for ensuring accuracy and integrity of the work.

Funding This work was supported by a private philanthropic donation by Mrs. Eleanor Spencer.

Competing interests DRHB and AH receive or have received research funding from the National Institutes of Health (NIH). ASC reports receipt of royalties from MAPI Research Trust on the sale of the ITSEA, one of the instruments included in the manuscript. TEW receives or has received grant support from the NIH (NIDA), and is or has been a consultant for Alcobra, Neurovance/Otsuka, Ironshore and KemPharm. TEW has published a book, Straight Talk About Psychiatric Medications for Kids (Guilford Press); and co/edited books: ADHD in Adults and Children (Cambridge University Press), Massachusetts General Hospital Comprehensive Clinical Psychiatry (Elsevier), and Massachusetts General Hospital Psychopharmacology and Neurotherapeutics (Elsevier). TEW is co/owner of a copyrighted diagnostic questionnaire (Before School Functioning Questionnaire), and has a licensing agreement with Ironshore (BSFQ Questionnaire). TEW is Chief of the Division of Child and Adolescent Psychiatry, and (Co)Director of the Center for Addiction Medicine at Massachusetts General Hospital. He serves as a clinical consultant to the US National Football League (ERM Associates), US Minor/Major League Baseball, Phoenix House/Gavin Foundation and Bay Cove Human Services.

Patient consent for publication Parental/guardian consent obtained.

Ethics approval All procedures were approved by our hospital’s institutional review board (Partners Human Research Committee, 2018P000376), and parents provided informed consent for themselves and their child.

Provenance and peer review Not commissioned; externally peer reviewed.

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Ten years of researches on generalized anxiety disorder (GAD): a scientometric review

• Published: 11 April 2024

Cite this article

• Ying Zhou 1 , 2 ,
• Yulin Luo 2 ,
• Na Zhang 3 &
• Shen Liu   ORCID: orcid.org/0000-0002-6900-8831 2  

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Generalized anxiety disorders (GAD) is a chronic anxiety disorder characterized by autonomic excitability and hypervigilance. However, there was currently a lack of a quantitative synthesis of this time-varying science, as well as a measure of researchers’ networks and scientific productivity. Searching from the Web of Science Core Collection, PubMed, and Scopus on January 31st, 2024. The scientometric analysis was realized and the clinical research of GAD in recent ten years was explored. 9703 studies published from 2014 to 2023 were included, which aggregated into a well-structured network with credible clustering. It was worth studying the recent trend of productivity. Eleven clusters were identified by the co-citation reference network. The network structure was reasonable ( Q  = 0.5996) and the clustering reliability was high ( S  = 0.8378). The main trend of research is ‘’china’’, ‘’epidemic’’. These results can provide reference for the future development of funding agencies and research groups.

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Data availability.

The datasets generated and analyzed during the current study are not publicly available. The datasets are available from the corresponding author on reasonable request when the aim is to verify the published results.

Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.

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This study was supported by the Outstanding Youth Program of Philosophy and Social Sciences in Anhui Province (2022AH030089) and the Starting Fund for Scientific Research of High-Level Talents at Anhui Agricultural University (rc432206).

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CASE REPORT article

Case report: short-term psychotherapy for alexithymia in a patient with generalized anxiety disorder.

• 1 Department of Psychological Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
• 2 4 + 4 Medical Doctor Program, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China

Alexithymia is common among patients with generalized anxiety disorder (GAD) and may negatively affect the efficacy of treatment. This case report described a sole short-term psychotherapy focusing on alexithymia for a GAD patient. The intervention extends over 3 weekly 50-minute sessions and incorporates components of: (a) understanding the basic categories of emotions and the importance of processing them consciously and building one’s own vocabulary of emotions; (b) developing skills in identifying and labeling emotions and learning to register both positive and negative emotions in daily life; (c) observing and interpreting emotion-related body sensations and learning to get in touch with, be empathetic to, and take care of one’s own inner feelings in daily life. The Hamilton Rating Scale for Depression (HRSD), Hamilton Anxiety Rating Scale (HAMA), and Toronto Alexithymia Scale (TAS) were used to evaluate depression, anxiety, and alexithymia before and after the sessions. The results suggested that the treatment was not only effective in reducing alexithymia helping the patient to clarify, identify and describe her feelings, but also effective in reducing anxiety and depression.

1 Introduction

Alexithymia is a set of cognitive and emotional features observed in patients with psychosomatic disorders, characterized by difficulties in perceiving, identifying, describing, and interpreting emotions in oneself and others ( 1 , 2 ). This condition encompasses four main dimensions: (a) difficulty identifying and describing feelings; (b) difficulty distinguishing feelings from bodily sensations; (c) diminution of fantasy; and (d) concrete and minimally introspective ( 3 ). Individuals with alexithymia face difficulties in self-regulation and managing emotions due to diminished emotional awareness ( 4 ). Alexithymia have been implicated across a range of psychological disorders, with Leweke and colleagues finding a total prevalence rate of 21.36% in a mixed sample of psychiatric outpatients ( 5 ).

In the context of Generalized Anxiety Disorder (GAD), alexithymic traits are notably common, with prevalence rates varying between 12.5% and 58% among various subtypes of anxiety disorders ( 6 ). Patients with GAD and alexithymia often experience pronounced functional somatic symptoms and exhibit heightened somatosensory amplification and health-related anxieties (hypochondriasis), frequently presenting physical discomfort as their primary concern ( 7 , 8 ). This is attributed to their difficulty in transitioning emotions from a somatosensory to a representational level, therefore using physical symptoms as an expression of psychological distress ( 9 – 11 ). Furthermore, these patients tend to have limited responses to pharmacotherapy ( 12 , 13 ) and psychotherapy ( 14 , 15 ). For limited response to pharmacotherapy, is partly due to the overlap in brain regions implicated in alexithymia and those targeted by selective serotonin reuptake inhibitors (SSRIs) ( 16 – 18 ). As for psychotherapy, is because these patients tend to have challenges in verbally articulating emotional experiences, affecting treatment motivation and efficacy ( 14 , 15 , 19 ).

Given the high prevalence of alexithymia among GAD patients and its detrimental impact on treatment outcomes, it is imperative to devise targeted interventions. Berking and colleagues advocate for a treatment model emphasizing emotional skills training, comprising nine specific objectives designed to enhance emotional awareness and regulation ( 20 , 21 ). In alignment with this model, we have developed a concise, three-session psychological treatment plan for GAD patients with alexithymia, focusing on problem-solving and reducing dependency on long-term therapy. This case report details the application and effectiveness of this innovative approach, underscoring its potential in clinical practice.

2 Case information

2.1 patient information.

The patient was a 46-year-old heterosexual female, married with children, without any religious beliefs. She had no family history of mental illness, and no significant somatic medical conditions. The ethics committee of Peking Union Medical College Hospital has approved this study (Approval number: I-23PJ955), with assurance that data would be reported anonymously. A written informed consent has been obtained from the participant.

2.2 Chief complaint

The patient’s chief complaint was one year of somatic discomfort, and she was seeking treatment to alleviate her somatic symptoms.

2.3 History of present illness

The patient presented with symptoms of joint pain, dizziness, palpitations, and hot flashes one year ago, coinciding with the cessation of menstruation. Upon evaluation at the gynecology endocrinology outpatient clinic, a decreased estrogen level was detected, and the patient has been taking Fematone since then, which led to an improvement in joint pain but did not alleviate the other symptoms. A neurological consultation included a head magnetic resonance imaging (MRI) that revealed scattered punctuate ischemic lesions but no other abnormalities, and no specific treatment was needed. Over the past year, the symptoms have been variable, with a severe exacerbation one week ago. This exacerbation was characterized by a sensation of electrical sensations throughout the body, dizziness, head heaviness, palpitations, feelings of depression and anxiety, poor sleep quality with waking up around five in the morning, increased fatigue, and difficulty in concentrating on her daily office tasks. Laboratory blood tests, including complete hemogram, comprehensive metabolic panel, reproductive hormones and thyroid function, yielded results within the normal range. The patient also denied any substance use. There were no identifiable physical factors that could account for the patient’s symptoms.

2.4 Past medical history

The patient was diagnosed with multiple uterine fibroids with a maximum diameter of 1.2 cm during a medical examination two years ago. No specific treatment was administered. The patient denied a history of any other significant physical diseases. Additionally, there was no history of food or drug allergies.

2.5 Family members and personal growth history

The patient reported that the relationship between her parents in the original family was harmonious, and her parents were very focused on the patient’s upbringing. However, this focus was primarily on the patient’s academic performance. During childhood, the patient had aspirations to learn talents such as singing and dancing but felt that her academic achievements were only pursued due to her parents’ insistence. The patient’s parents believed that the sole focus should be on academics and did not fulfill the patient’s desires for other pursuits. The patient perceived herself as often feeling tense and unable to express herself freely.

In adulthood, the patient got married and had one child. Her overall relationship with her husband was also harmonious, but they had some disagreements regarding their child’s education. The patient believed that their child should be enrolled in extracurricular activities such as speech, recitation, and programming, while her husband did not share the same perspective on these matters.

3 Assessment

3.1 psychological assessment.

The patient was assessed using the Hamilton Anxiety Rating Scale (HAMA) ( 22 , 23 ), the 17-item version of Hamilton Rating Scale for Depression (HRSD) ( 23 , 24 ), and the 20-item version of Toronto Alexithymia Scale (TAS) ( 25 , 26 ) as assessment tools. The patient scored 22 points on the HAMA scale, with 15 points in the psychic anxiety subscale and 7 points in the somatic anxiety subscale, indicating moderate anxiety. On the HRSD scale the patient scored 16 points, suggesting the presence of mild depression. As for the TAS scale, the patient scored 81 points, with sub-scale scores as follows: 17 points for difficulty identifying and describing feelings, 24 points for difficulty distinguishing feelings from bodily sensations, 24 points for diminution of fantasy, and 16 points for concrete and minimally introspective. The patient’s total score on the TAS-20 was significantly higher than the norm for Chinese females (66.94 ± 8.34) ( 26 ), indicating a notable presence of alexithymia.

3.2 Mental status exam

Appearance and Behavior: The patient maintained minimal eye contact, but responded coherently. Her facial expression reflected distress.

Mood and Affect: The patient exhibited a preoccupation with multiple concerns, leading to heightened anxiety and frequent startle reactions. She had difficulty relaxing and appeared restless. The patient was prone to jittery and sadness when influenced by external environment.

Thought Content: The patient described various somatic discomforts and occasionally reported a sense of loss of control. She expressed concerns related to somatic discomfort, life stressors, and associated worries.

3.3 Diagnostic assessment

Based on the criteria outlined in the fifth edition of diagnostic and statistical manual of mental disorders (DSM-5) for GAD ( 27 ), the diagnosis for this patient was generalized anxiety disorder.

3.4 Case conceptualization

Through her life experience, the patient formed a high critical superego demanding that she has to study/work hard and be outstanding, or she will lag behind and be worthless. She never learned to take care of her own emotional needs and perceives her own emotional experiences as unworthy of attention. Alexithymia made it difficult for her to articulate emotions and instead expressing psychological distress through somatization. The patient’s case conceptualization was illustrated in Figure 1 .

Figure 1 Cognitive conceptualization diagram.

4 Therapeutic intervention

4.1 therapeutic goals and plan.

The patient declined pharmaceutical recommendations. Based on the case conceptualization, a short term psychotherapy focusing on alexithymia was recommended: (a) to learn and respect her emotional feelings and get in touch with her own feelings; (b) to understand and narrate her somatic symptoms from an emotional perspective; and (c) to be empathetic to herself and thus build a more soothing part of superego.

A three-session treatment plan aligned with the aforementioned goals was specified as follows: (a) to understand the basic categories of emotions and the importance of processing them consciously and build her own vocabulary of emotions; (b) to develop skills in identifying and labeling emotions and learn to register both positive and negative emotions in daily life; (c) to observe and interpret emotion-related body sensations and learn to get in touch with, be empathetic to, and take care of one’s own inner feelings in daily life. The acting therapist (first correspondant author) is an associate professor in psychiatry holding a Doctor of Medicine degree, with a psychotherapeutic training in psychodynamic therapy and cognitive behavioral therapy (CBT). The co-designer of the study (second correspondant author) is a professor in psychiatry holding a Doctor of Medicine degree, with a psychotherapeutic training in Gestalt therapy. The therapists specialize in general hospital psychiatry, with a long time experience in treating common psychosomatic problems with integrative psychotherapeutic approaches.

4.2 Therapeutic sessions

Following discussions with the patient, a total of three therapy sessions were planned, each lasting 50 minutes. Homework was set in collaboration with the patient between sessions to facilitate a better post-therapy work.

4.2.1 First therapy session

The initial session primarily focused on psychoeducation, encompassing two main areas: firstly, explaining to the patient the concept of emotions, their biological and psychological origins, their importance in our psychological function; secondly, the patient was then asked to name as many emotions as possible. The patient had great difficulty in abiding to the task of naming emotions. She very often switched to describe her physical symptoms and her concerns and ravels. The therapist attentively listened but did not give direct response to her worries, gently brought her back to the task, and facilitated the process by naming emotions in turn with the patient. Special attention was given to name not only negative emotions, but also positive emotions. At the end of the first session, homework was assigned to expand her vocabulary of emotions as far as possible through various ways such as reading short novels and discussing this topic with others.

4.2.2 Second therapy session

The second session began by reviewing the homework completed after the previous session. This patient presents a very long list of carefully grouped emotions(just as a good student was supposed to present). The therapist encouraged and thanked the patient for her homework. The second session’s main task was to identify her own emotional experiences and label her emotions. With the help of her homework, we discussed which emotions could she identify from the last week’s work and life. The patient was asked to describe specific scenarios where these emotions were experienced and rated the intensity of emotions on a scale of 0-10. The patient listed various emotions, including feelings of grievance, disappointment, and relaxation. Special attention was given to her positive emotions to help her exemplify and register them. In the second session, the patient was more open to the task, but had difficulty in recalling finite emotions at the beginning. The therapist helped facilitate the process by describing own recent experiences. The patient gave a feedback that she felt being understood and in resonance with the therapist’s feelings and also felt relaxed at the end of this session. The homework for the second session was keep a diary of observing and logging emotions in daily life, with particular attention to positive emotions.

4.2.3 Third therapy session

Building on the skills acquired in the first two sessions of naming and identifying emotions, the third session focused on guiding the patient to get in touch with bodily sensations and be empathetic to herself. The patient learned to observe, identify, and describe bodily sensations associated with emotions and to connect physical discomfort with emotional states. With the therapist’s guidance, the patient successfully described bodily sensations associated with the emotion of “nervousness,” including cold extremities, tight scalp, rapid breathing, muscle tension, and trembling voice and movements. The patient also connected her worries in the specific scenarios when these feelings occurred or worsened. She came to understand herself. The therapist demonstrated an attitude of being empathetic to these feelings and to her real life conditions and encouraged the patient try to sooth herself with her positive remembrances. The patient felt being accepted and decided to be more empathetic to herself in future. In the end, the therapist encouraged the patient to review the homework from previous sessions, summarize and apply the learned techniques in life and work.

4.2.4 End and follow up

The patient reported that she improved a lot after the three sessions and agreed to feedback at one month and two months after the last session. The patient did not receive any other psychotherapy during or after the short term psychotherapy.

5 Therapeutic effectiveness assessment

5.1 psychometric-based evaluation of therapeutic effectiveness.

At one month after ending of therapy the patient gave a feedback that she kept doing fine. At two months after ending of therapy a reassessment with psychometric scales was done. The patient’s total score on HAMA decreased to 9, with psychic anxiety at 5 and somatic anxiety at 4; the total score on HDRS-17 decreased to 4; the total score on TAS-20 decreased to 76, with scores in the following dimensions: 14 points for difficulty identifying and describing feelings, 19 points for difficulty distinguishing feelings from bodily sensations, 16 points for diminution of fantasy, and 27 points for concrete and minimally introspective. Additionally, the patient reported a significant reduction in somatic symptoms and a marked improvement in sleep quality.

In summary, the patient’s anxiety and depressive symptoms has been largely relieved, and the severity of alexithymia was also reduced, with the TAS score now within the normal range (66.94 ± 8.34) ( 26 ) for Chinese women. Based on the above, the patient was assessed to be in a state of anxiety remission after treatment.

5.2 Patient perspective

After treatment, the patient reported feeling emotionally much more stable, improved family relationships, and restored sleep and appetite, also enabling herself to engage in work. In terms of long-term goals, the patient has made positive changes cognitively, attitudinally, and behaviorally, acquiring the ability to recognize, describe and value her own emotions. The timeline of the case is shown in Figure 2 .

Figure 2 Timeline of case.

6 Discussion

Alexithymia is common among patients with GAD ( 6 ) and may negatively affect the efficacy of both pharmacological and psychological treatments ( 12 – 15 ). This case primarily explored a short term psychotherapy designed focusing on alexithymia in in the treatment of a GAD patient. The outcomes tentatively indicate that this short-term psychotherapy approach could be beneficial in simultaneously reducing symptoms of anxiety and alexithymia in GAD patients.

Although alexithymia is considered to be associated with a wide spectrum of psychiatric disorders, it is particularly significant for mental disorders characterized by emotional components ( 5 , 28 , 29 ), such as GAD. Individuals with alexithymia exhibited heightened overall severity of disorder, a phenomenon particularly attributed to the increased severity of somatic symptoms associated with GAD ( 30 ). This correlation has been attributed to alexithymia originating from an inhibitory mechanism, which is believed to impede emotional processing within the right hemisphere, thereby diminishing the ability to verbalize emotional content within the left hemisphere ( 31 , 32 ). Moreover, it has been established that GAD is specifically marked by deficiencies in emotional intelligence and in the experiences and regulation of emotions. This leads to an evasion of emotional stimuli processing, favoring the utilization of worry as a coping strategy in individuals with GAD ( 33 ). Consequently, alexithymic individuals with GAD may exhibit a diminished awareness of psychic anxiety, attributable to the hindrance of emotional processing and reduced capacity for verbalization of emotional content. Hence, the generalized anxiety in these subjects is predominantly manifested through pronounced somatic symptoms ( 30 , 34 ). Our study provided treatment for a typical GAD patient exhibiting significant alexithymic characteristics and concurrent somatic symptoms, consistent with the aforementioned description. Improvements in anxiety and alexithymia were observed, while the mechanisms underlying these improvements warrant further investigation.

Whether alexithymia is modifiable remains a topic of ongoing controversy ( 35 ). One perspective suggests that alexithymia acts as a stable structure over time and often is independent of changes in somatic and psychological symptoms ( 36 , 37 ). For example a large-scale, long-term Finnish study suggested that alexithymia exhibits high levels of both relative and absolute stability in adults, resembling a stable personality trait ( 38 ). Another view posits that alexithymia is substantially correlated with current anxiety and depression severity and can be changed through methods such as psychotherapy ( 39 , 40 ). Norman and colleagues synthesized four studies intervening in alexithymia with mindfulness-based approaches through a meta-analysis and found that mindfulness intervention was an effective method to ameliorate alexithymia ( 41 ). The mechanisms by which psychotherapy ameliorates alexithymia are not yet fully clear. This may be because changes in alexithymia represent a secondary response to alterations in primary symptoms such as depression or anxiety. Alexithymia can be considered a defense or coping strategy against distressing emotions ( 42 ). Depression and anxiety might exacerbate features of alexithymia; however, these changes are reversible, and baseline alexithymia traits may remain unchanged after the alleviation of these disorders ( 38 ).

During the treatment of this case, we likewise observed a phenomenon that the patient experienced relief in anxiety and depression following interventions targeting alexithymia. This aligns with the current viewpoint that alexithymia may act as a mediator in a range of psychopathological phenomena including anxiety and depression ( 43 – 46 ). One hypothesis suggests that alexithymia may be a mediator between atypical interoception and anxiety ( 45 ). There is substantial research illustrating the correlation between interoception, alexithymia, and anxiety ( 47 ). Patients with alexithymia often exhibit deficits in interoception, such as inability to accurately report their own arousal states ( 48 , 49 ) or to evaluate their feelings through subjective measures ( 50 ). Evidence from neuroimaging studies also indicated that individuals with alexithymia may exhibit atypical activity patterns in the interoceptive cortex ( 51 ). Palser and colleagues further discovered that alexithymia mediated the relationship between interoceptive sensibility and anxiety ( 45 ). They proposed that heightened sensibility to interoceptive signals, coupled with difficulty attributing these sensations to emotions, could lead to catastrophic interpretations of these sensations. Hence, alexithymia could become one of the intervention targets for anxiety symptoms in GAD patients. Nevertheless, given the predominance of cross-sectional studies in this area, the efficacy of alexithymia-targeted interventions for anxiety remains to be further validated through more rigorous research designs.

The findings presented in this study should be interpreted within the context of potential limitations. Firstly, as the study was a single-case report, the efficacy of this therapy should be approached with caution, necessitating further verification through future research based on Randomized Controlled Trial (RCT) designs. Secondly, the patient involved in the study was referred from somatic disease departments of a general hospital, which may not accurately represent the characteristics of GAD patients in psychiatric specialty hospitals. Subsequent RCT studies should employ a multicenter approach, recruiting both outpatient and inpatient GAD patients from psychiatric specialty and general hospitals to obtain a more representative sample. Lastly, since this study only reported the treatment process of a single GAD patient, it is challenging to establish the causal relationship between treatment, alleviation of alexithymia, and reduction of anxiety. Future RCT studies could consider employing a mediated cross-lagged design to further clarify the causal relationships among these variables.

In conclusion, we designed a three-session short-term psychotherapy integrating various elements of previous researches such as labeling emotions, correctly interpreting bodily sensations connected with emotions, being mindful of and empathetic to emotions. Besides, we also added the element of balanced attention to and registry of both negative and positive emotions in the therapy. The efficacy of this intervention deserves further test through RCT-based designs. The effectiveness of this intervention warrants further investigation through RCT-based studies.

Data availability statement

The original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding authors.

Ethics statement

The studies involving humans were approved by The ethics committee of Peking Union Medical College Hospital. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.

Author contributions

YW: Writing – original draft. JC: Conceptualization, Data curation, Funding acquisition, Methodology, Writing – review & editing. JW: Conceptualization, Funding acquisition, Project administration, Supervision, Writing – review & editing.

The author(s) declare financial support was received for the research, authorship, and/or publication of this article. This work was supported by the National High Level Hospital Clinical Research Funding (Grant Number: 2022-PUMCH-B-093) and the STI2030-Major Projects (Grant Number: 2021ZD0202001). Funders played no role in the content of this manuscript.

Acknowledgments

We would like to express our gratitude to the patient and her family, as well as to the entire medical staff who participated in the patient’s treatment. We sincerely thank Xiang-yu Gu from Peking Union Medical College Hospital for improving the writing quality of our manuscript.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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Keywords: generalized anxiety disorder, psychotherapy, alexithymia, anxiety, case report

Citation: Wang Y, Cao J and Wei J (2024) Case report: Short-term psychotherapy for alexithymia in a patient with generalized anxiety disorder. Front. Psychiatry 15:1342398. doi: 10.3389/fpsyt.2024.1342398

Received: 21 November 2023; Accepted: 25 March 2024; Published: 15 April 2024.

Reviewed by:

Copyright © 2024 Wang, Cao and Wei. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Jing Wei, [email protected] ; Jinya Cao, [email protected]

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

Case-based learning: anxiety disorders

There are many types of anxiety disorders with varying levels of severity. Pharmacists should know the treatment options that are available and how to support patients. 

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Anxiety is a common mental health condition that affects approximately 6.6% of the population in England each week, along with one in six adults experiencing or being identified as having a common mental health condition per week [1] , [2] . Data suggest that women are almost twice as likely to be diagnosed with anxiety compared with men; however, the reason for this is unclear [3] , [4] . Although a large number of people are affected by mental health conditions (e.g. anxiety or depression), only 39% of adults aged 16–74 years are accessing treatment for them [5] .

Mental health conditions typically worsen over time and can negatively impact on social activities, relationships, career performance, academic work and general quality of life [6] . As such, patients that present with conditions, such as generalised anxiety disorder (GAD), are frequently seen in the community, with pharmacists having the opportunity to significantly impact on the patient’s quality of life by providing information on the treatment options that are available [7] . While occasional anxiety is a normal aspect of day-to-day life, persistent symptoms can indicate the possible presence of an anxiety disorder, which can often be debilitating. Anxiety has also been known to precipitate physiological responses, such as tachycardia and hyperhidrosis [8] . ’Functional impairment’ is a term that is often used to describe the degree to which an illness can limit a person’s ability to carry out some of their normal daily tasks; anxiety can affect this to differing degrees [9] .

There are multiple factors that could predispose or potentially encourage the manifestation of anxiety, which are often attributable to a combination of genetic and environmental factors [10] . In addition, studies suggest that alcohol and illicit drug use, particularly the use of stimulants and hallucinogens, are associated with higher rates of incidence [11] , [12] . Instances of childhood abuse and sexual abuse are also identified as potential causative factors for anxiety and depression [13] . However, there is a broad range of patients affected by anxiety, for whom there is often an unknown cause.

Types of anxiety

Anxiety disorder is an inclusive term for several disorders, including:

• Panic disorder;
• Selective mutism;
• Separation anxiety;
• Social anxiety disorder [14] .

The most common types of anxiety disorder include:

• Social anxiety disorder — this is considered to be the most common form of anxiety; in up to 50% of cases, it is present in individuals by age 11 years [15] . Symptoms include a persistent fear of social performance, panic attacks and a large fear of humiliating oneself in public [15] ;
• Phobic disorder — this broadly refers to a fear of places, situations, objects and animals. For example, agoraphobia is often considered to be simply a fear of open spaces, but it is far more serious and can include a fear of being in a place that individuals will find difficult to escape from or receive aid if things go wrong [16] .

Avoidance behaviour is common to both social anxiety disorder and phobic disorder, with patients actively trying not to encounter the feared stimulus (e.g. avoiding going outside, such as in cases of agoraphobia) [17] , [18] , [19] . This behaviour can hugely impact on a patient’s ability to maintain functional capacity.

Symptoms and diagnosis

Symptoms may involve feelings of restlessness, palpitations, problems with concentrating, uncontrollable worry, sleep disturbances and general irritability [6] .

Diagnosis of anxiety would initially be made by a GP following a comprehensive review of the following:

• Symptomatic presentation of the patient;
• Frequency of symptoms;
• Degree of severity of distress;
• Functional impairment.

History of substance misuse, comorbidities and past medical history should be considered as part of a holistic approach to diagnosis [20] .

In addition, differential diagnoses must be considered before a formal diagnosis is made. Anaemia and hyperthyroidism are two conditions that must be ruled out and/or treated as they can both manifest symptoms of anxiety disorders [21] , [22] . Blood analysis and further tests may be necessary to ensure a correct diagnosis is made [22] , [23] . As stated by the National Institute for Health and Care Excellence (NICE), diagnostic tools, such as the Diagnostic and Statistical Manual of Mental Disorders , can be utilised for anxiety disorders [21] . The criteria include a minimum of six months of incessant and uncontrollable worries, disproportionate to actual risk, and three of the following symptoms:

• Being easily fatigued;
• Irritability;
• Muscle tension;
• Poor concentration;
• Restlessness/nervousness;
• Sleep disturbance [21] .

The ‘International Classification of Diseases, 10th revision’, a disease classification tool, offers a similar criteria [21] . There are also other resources available to healthcare professionals to work through with patients, such as the GAD-7 questionnaire for anxiety and the personal health questionnaire-9 (PHQ-9) for depression [21] . Questions typically ask how frequently certain symptoms have occurred in the preceding two weeks. Both GAD-7 and PHQ-9 allow assessors to distinguish between anxiety and depression, and provide an indication as to the severity of presentation, which can guide therapy. These are typically asked by a GP during an initial consultation with the patient and may include questions such as: ‘Over the past two weeks, how often have you been bothered by feeling nervous, anxious or on edge?’ [24]

The GAD-7 questionnaire can also be used as a tool to determine the severity of its presentation, with scores of 5 and above, 10 and above, and 15 and above (out of a possible 21) referring to mild, moderate and severe anxiety, respectively [25] . Higher scores are strongly associated with functional impairment, although individual characteristics of presentation will affect how the patient is treated.

Pharmacological treatment

For patients with mild anxiety, pharmacotherapy is not recommended. However, as per NICE guidelines, pharmacological treatment is recommended where significant functional impairment exists [26] . First-line drug treatment involves selective serotonin reuptake inhibitors (SSRIs; e.g. sertraline or fluoxetine) [26] .

SSRIs are widely used for GAD and are often well tolerated. In addition, they are considered to be safer in overdose than most other similarly indicated medicines, because they carry a lower risk of cardiac conduction abnormalities and seizures [27] , [28] , [29] . Selective serotonin–noradrenaline reuptake inhibitors (SNRIs; e.g. duloxetine and mirtazapine) are a suitable alternative; pregabalin is a tertiary option if the others are unsuitable or poorly tolerated [26] .

It is important to manage the patients’ expectations with pharmacological therapies. Providing a clear message that it could take between four and six weeks before the patient notices a benefit from their medicine is essential, as this will help ensure that they take their medication as directed. Patients should also be made aware of side effects and the withdrawal process (e.g. associated side effects) prior to commencing therapy [26] .

Common side effects of SSRIs include abnormal appetite, arrhythmias, impaired concentration, confusion, gastrointestinal discomfort and sleep disorders [27] . The incidence of side effects is reported to be highest within the first two weeks of starting treatment [30] . Although most common side effects tend to improve over time, sexual dysfunction can persist [31] . There is an increased risk with SSRIs in certain patient groups (e.g. young adults, children and patients with a previous history of suicidal behaviour) of suicidal ideation and self-harm; therefore, initiation of SSRIs must be reviewed weekly in those under aged under 30 years for the first four weeks of treatment. If the risk of recurrent suicidal behaviour is a concern, the healthcare professional may want to seek advice from the local crisis or home-based treatment team; SSRIs generally have a better safety profile than other drugs used for anxiety, but may require frequent monitoring in this case [32] , [26] .

SSRIs are one of several classes of medicines that pose a risk for long QT syndrome, which occurs as a result of a prolonged QT interval on the electrocardiogram measurements of the heart. This can lead to torsades de pointes (a specific type of abnormal heart rhythm) and possible sudden cardiac death [33] [34] , [35] .

It is important that SSRIs are withdrawn slowly to minimise the occurrence of SSRI discontinuation syndrome — an abrupt cessation of treatment that can cause a combination of psychological and physiological symptoms; the most common including nausea, dizziness, headache and lethargy [36] . Tapering drug doses slowly over several weeks will mitigate the effects of the withdrawal and minimise unnecessary re-initiation of the SSRI [37] .

Considerations for selective serotonin reuptake inhibitors and selective serotonin–noradrenaline reuptake inhibitors

Serotonin syndrome is a serious side effect that can occur with the use of SSRIs and SNRIs. It occurs as a result of overactivation of the 5-HT1A and 5-HT2A receptors, precipitated by serotonergic drug use [38] . Symptoms typically range from confusion and agitation to more serious symptoms, such as seizures, arrhythmias and loss of consciousness [31] . The risk of the syndrome is higher if patients are taking other medicines that can increase serotonin levels in the brain, such as tramadol and metoclopramide. Taking 5-HT1F agonists, which include sumatriptan, or a combination of medicines with the same effect, can also increase risk [39] .

If a decision is made to initiate an SSRI, despite the associated risk, patients should be provided with suitable information concerning the syndrome, which can be found on or printed from the NHS website [31] . If a patient experiences symptoms of serotonin sydrome, they should be advised to contact their GP surgery immediately. If this is unavailable, they should call NHS 111 for advice.

Alongside serotonin syndrome, SSRIs have been known to contribute to inappropriate antidiuretic hormone secretion, which is related to hyponatremia and has symptoms including headache, insomnia, nervousness and agitation [40] . 

Patients with anxiety disorders should be monitored as frequently as the severity of the disorder demands, which is essential to protect patients and improve their quality of life. Guidance from the British National Formulary states that patients being initiated on an SSRI should be reviewed every one to two weeks after initiation, with response being assessed at four weeks to determine whether continuation of the drug is suitable [27] . NICE guidelines expand on this by encouraging three-monthly reviews of drug therapy to assess clinical effectiveness [20] .

Non-pharmacological treatment

Patients should be advised to minimise alcohol intake and make time for activities they find relaxing. They should also be encouraged to exercise every day, aiming to do 150 minutes of moderate-intensity exercise (e.g. walking or cycling) per week as exercising has been shown to improve mental health [41] , [42] . A study has demonstrated that those who exercise had 43.2% fewer days of poor mental health, with team sports having the largest association with reduction in mental health burden [43] .

Psychological treatment

Cognitive behavioural therapy (CBT) is a common psychological treatment used for those with anxiety. This therapy aims to transform negative thinking into more structured thought patterns, which then assist the patient in making changes to their thought processes to encourage positive thinking. CBT is suitable for patients that present with ongoing anxiety and does not look at patient history [34] . This type of treatment may be useful for patients with mild anxiety, as an addition to medicine or for those who do not wish to take medicine. It can be conducted individually or as part of a group.

Guided self-help — a process by which a patient is able to work through a course with the support of a trained therapist — and counselling are other treatments available through the NHS that may benefit patients with mild anxiety or as an adjunct to prescription medicines [44] .

Specialist referral and suicide risk

Specialist referral should be considered if patients:

• Have not responded to initial therapy;
• Have comorbidities, such as alcohol or substance misuse;
• Are at significant suicide risk.

Healthcare professionals should always assess suicide risk by discussing the patients’ feelings about self-harm openly and considering other contributing factors, such as the use of prescribed or illicit drugs. Healthcare professionals must take opportunities to make interventions — for example, referring patients for urgent mental health assessment or in the case of serious concerns, calling emergency services [23] .

In the UK, area-specific community programmes and the charity  Anxiety UK  can provide patients with further advice on managing their anxiety. However, many primary care networks are now recruiting social prescribers, who will have the ability to direct patients to attend local groups that are more suited to individual needs. Community pharmacists are also likely to be aware of local support networks.

Case studies

Case study 1: a woman taking interacting medicines

Joanne*, a woman aged 65 years, approaches the pharmacy counter. She is concerned about heart palpitations she has been experiencing recently.

After inviting Joanne into the consultation room, you ask her if she is taking any medicines. She says that she is taking amitriptyline for the pain in her legs. She has also recently started taking a new medicine and states that she is on other medicines, but cannot recall the names. You ask for permission to view her summary care record and note that there is furosemide on her list of medicines. She was started on citalopram two weeks prior and was prescribed a seven-day course of clarithromycin three days ago.

You are concerned that Joanne is experiencing long QT syndrome, since the selective serotonin reuptake inhibitor (SSRI) citalopram is a risk factor for QT prolongation — as are the tricyclic antidepressant amitriptyline and the antibiotic clarithromycin [33] , [45] , [46] . In addition, furosemide can also precipitate hypokalaemia, which has been known to affect the QT interval [47] .

Advice and recommendations

You advise Joanne to stop taking the citalopram that has been prescribed to her until she can see a GP, which is a matter of urgency, as you believe it could be related to the medicines she is taking. You advise that she should try and get a same-day appointment if possible. The GP will likely request an electrocardiogram and stop the SSRI if results demonstrate long QT syndrome.

Case study 2: a man with concerns about his medicine

Gareth*, an investment banker aged 52 years, attends the pharmacy and asks to purchase sildenafil over the counter, owing to his erectile dysfunction. He is referred to you and you sit with him in the consultation room.

During the consultation, you begin to ask questions about his history and whether the erectile dysfunction is a new condition that he is experiencing. He states that he has been worried about it for the last couple of months. You then discuss his lifestyle and ask him questions about his medicines, in which he states he started taking a new medicine, fluoxetine, several months ago. He has been under significant stress at his workplace and was started on fluoxetine owing to his anxiety.

You consider the following:

• The erectile dysfunction that Gareth is experiencing could be related to the stress he is experiencing as part of his work;
• The possibility there could be an underlying reason for the problem related to his general health;
• That the prescribed fluoxetine may be causing his erectile dysfunction because this is a side effect of selective serotonin reuptake inhibitors [48] .

You explain your rationale with Gareth and indicate that you do not think it is appropriate to sell him sildenafil now. You suggest he goes back to his GP to discuss the symptoms that he has been having. The GP may decide to try an alternative medicine, but, given that he has been taking the fluoxetine for a few months, he should not discontinue it until advised to do so by his GP. You explain that if his GP advises him to stop the medicine, there will be a specific withdrawal process to minimise the side effects and that you would be able to advise him on this.

Case study 3: a man who is displaying symptoms of moderate anxiety

Anton*, a university graduate aged 21 years, attends the pharmacy and asks to speak to the pharmacist in private. He states he is worried about heart palpitations that he has been experiencing. He is visibly sweating and looks on edge.

You invite Anton into the consultation room and ask him about his symptoms. He states that he has started a new job and that the palpitations start when he is feeling anxious. His symptoms are occurring most days of the week and he says it makes him “feel on edge”. He adds that he does not want to socialise with his co-workers. It is starting to affect his sleep and he does not know what to do. He also states that he has occasional pain in his chest.

Treatment options

Anton is demonstrating symptoms of moderate anxiety, given his desire to avoid socialising, and has a degree of functional impairment. However, as he has potential cardiac symptoms, these issues could be related to another condition.

When questioned, he confirms he has no other problems with his health, but you feel the patient needs further investigation — for example, an electrocardiogram test to measure the electrical activity of his heart to rule out underlying cardiac problems. His presentation concerns you and you feel he needs to see a doctor today to assess the differential diagnosis, as you are worried about his chest pain and palpitations.

You encourage Anton by saying that it is great that he felt he could talk to a pharmacist about this, but explain that he would benefit from a consultation with a GP. You explain that his symptoms could be related to anxiety and that you think he may need something to help him manage. He agrees to let you contact his local practice. As you have a good relationship with the practice, you manage to secure an appointment for him to see a GP that day. If a GP appointment had been unavailable, you could have telephoned NHS 111 for Anton to seek access to support.

*All cases are fictional

Useful resources

• NHS: Do I have an anxiety disorder?

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• NEWS FEATURE
• 10 April 2024

The rise of eco-anxiety: scientists wake up to the mental-health toll of climate change

• Helen Pearson

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The Bahamas is vulnerable to storms and hurricanes. Extreme weather can exacerbate mental-health illnesses. Credit: Zak Bennett/AFP via Getty

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Every year for six years, Laureen Wamaitha hoped that her fields in Kenya would flourish. Every year, she’d see drought wither the crops and then floods wash them away. The cycle of optimism and loss left her constantly anxious, and she blamed climate change. “You get to a situation where you have panic attacks because you’re always worried about something,” she says.

Medical student Vashti-Eve Burrows, meanwhile, saw powerful hurricane Dorian rage through the Bahamas in 2019 and now she is fearful about the future of the country, an island archipelago that is vulnerable to sea-level rise and storms. “Will there even be a Bahamas in maybe 20 to 30 years?” she says.

Wamaitha and Burrows are part of a growing chorus of people speaking up about the impacts of climate change on mental health. Climate change is exacerbating mental disorders, which already affect almost one billion people and are among the world’s biggest causes of ill health. A global survey in 2021 found that more than half of people aged 16–25 felt sad, anxious or powerless, or had other negative emotions about climate change 1 . Altogether, hundreds of millions of people might be experiencing some type of negative psychological response to the climate crisis.

What happens when climate change and the mental-health crisis collide?

Scientists say the topic has been sorely neglected, but is leaping up the research agenda. “I’ve seen an explosion of research in the last five years for sure. That’s been very exciting,” says Alison Hwong, a psychiatrist and mental-health researcher at the University of California, San Francisco. The growing severity of heat, hurricanes and other impacts mean “it’s impossible to ignore”, she says.

Researchers want to unpick the many pathways by which climate change affects mental health, from trauma caused by hurricanes, floods, droughts and fires to ‘eco-anxiety ’— a chronic fear of environmental doom. Studies on methods that can help people prevent or manage these problems are also needed, although some work suggests that climate action and activism might help.

A seam of climate injustice is exposed by the research. Young people are likely to experience the greatest mental burden from climate change that older generations have caused. Groups of people that already experience poverty, illness or inequalities are most at risk of deteriorating mental health. “Climate change exacerbates already existing economic situations, where it’s the poorer people who are feeling even worse,” says Jennifer Uchendu, a researcher, climate activist and founder of SustyVibes, an environmental group based in Lagos, Nigeria.

Mental-health toll

The fact that climate change affects people’s mental health is not surprising: what’s new is the attention the issue is attracting — and the myriad ways that scientists are documenting its varied and sometimes shocking effects.

It is well known that extreme weather events and disasters can have an immediate traumatic impact — as well as “a long tail of mental-health conditions like post-traumatic stress disorder, anxiety, depression, substance abuse,” says Emma Lawrance, who studies mental health at Imperial College London. Also taking a mental-health toll in vulnerable countries are less sudden — but nonetheless devastating — disruptions caused by global warming’s impacts, such as forced migration, loss of livelihoods, food insecurity and community breakdown.

Research on how climate-change impacts, such as drought, affect mental health is growing. Credit: Simone Boccaccio/SOPA Images/LightRocket via Getty

There is evidence that directly experiencing higher temperatures can worsen mental health. A 2018 study of suicide data from the United States and Mexico over two or more decades showed that suicide rates rose by 0.7% in the United States and 2.1% in Mexico, with a 1 °C increase in average monthly temperature 2 . The researchers projected an extra 9,000–40,000 suicides by 2050 in the two countries if no action was taken against climate change. Other work has shown that higher temperatures are linked to poor sleep — which can in turn contribute to mental distress 3 .

Studies also suggest that people with existing mental illness are at greater risk of dying during extreme heat 4 , but “understanding why that is and what we can do to stop it is really unexplored”, Lawrance says. One potential explanation is that some psychiatric drugs can interfere with the body’s response to heat 5 .

Eco-anxiety goes global

Another striking field of research examines how the awareness of climate change and its impacts can lead to concern or distress, a phenomenon sometimes called eco-anxiety, eco-distress, climate grief or solastalgia (distress linked to environmental change). In a 2018 survey, 72% of people aged 18–34 said that negative environmental news stories affected their emotional well-being, such as by causing anxiety, racing thoughts or sleep problems (see go.nature.com/3vbbt7p ). A 2020 survey 6 in the United Kingdom found that young people aged 16–24 reported more distress from climate change than from COVID-19.

A few years ago, such ‘eco-emotions’ were sometimes dismissed as fretting of the ‘worried-well’ in high-income countries, Lawrance says. But research that shows the global reach of these feelings is challenging that view. The 2021 survey 1 was the biggest so far on climate anxiety and included 10,000 children and young people in 10 countries. More than 45% of respondents said that worry about climate change had a negative impact on eating, working, sleeping or other aspects of their daily lives. Reports of climate change affecting people’s ability to function were highest in the Philippines, India and Nigeria and lowest in the United States and United Kingdom — contradicting the idea that eco-anxiety is just a rich-country problem (see ‘Climate anxiety around the world’).

Source: Ref. 1

For some, eco-anxiety might be linked to first-hand experience of climate-related devastation. The fact that young people in the Philippines reported some of the highest levels of worry was no surprise to John Jamir Benzon Aruta, an environmental psychologist at De La Salle University in Manila. In 2013, he saw first-hand the devastation and trauma caused in the Philippines by Typhoon Haiyan — one of the most powerful tropical cyclones ever recorded. “You see houses, communities devastated. You also see corpses all over the place,” he says. “Just witnessing the aftermath made me feel traumatized.”

But the 2021 survey documented widespread distress that went beyond those who were immediately affected by extreme climate events. Around 75% of respondents said that climate change made them think the future is frightening and 56% said that it made them think that humanity is doomed. People who felt their government was failing to act on climate issues were more likely to feel eco-distress.

Are we all doomed? How to cope with the daunting uncertainties of climate change

Climate change isn’t the first existential crisis that humanity has faced. But researchers point out that it is different from some other threats: it is happening now rather than being a future risk, such as a nuclear war ; it’s affecting the entire globe at once; and many people feel angry that they have to bear the brunt of climate change that other people have caused.

Feelings of eco-anxiety are not necessarily a sign of dysfunction. “If you are under immediate threat, it is a realistic, rational, healthy survival instinct to react by being anxious or to experience fear,” says Elizabeth Marks, a clinical psychologist at the University of Bath, UK, and one of the survey’s lead authors. It could even be harmful to think of these feelings as a disorder. “If we think of it as a diagnosable condition, that risks placing the blame on the individual as having an unhealthy response,” she says. That said, some people might become so impaired by their eco-distress that they would benefit from psychological help.

Social media is being used to monitor negative feelings linked to climate change. In 2023, Kelton Minor, a research scientist at Columbia University’s Data Science Institute in New York and Nick Obradovich, a climate mental-health researcher at the Laureate Institute for Brain Research in Tulsa, Oklahoma, reported an analysis of more than eight billion posts on Twitter (now known as X) that appeared between 2015 and 2022 from people who had opted to share their geolocation data. (The analysis was part of a wider report on health and climate change 7 .) The researchers analysed the tweets for positive words (such as good, well, new and love) and negative ones (bad, wrong, hate and hurt), and linked them to climate data from the tweeters’ locations. Perhaps unsurprisingly, the team found that heatwaves and extreme rainfall increased negative feelings and decreased positive ones compared with control days without extreme weather in the same place and time of year. They also found that these negative reactions became worse over the years (see ‘Eco-anxiety on social media’).

Source: Ref. 7

Beyond the Western view

The full effects of climate change on mental health are hard to measure. A combination of factors, including the stigma around mental health and lack of access to health-care services, mean that many people with mental-health concerns go undiagnosed. When Wamaitha talked to her family in Kenya about how worried she was, they’d say: “It’s not a big deal, it’s part of life,” she says. Anxiety and depression are barely recognized as disorders in her region, she says. Mental-health services are scarce and older people just “think that you’re very sensitive” because they survived droughts in the past. In the 2021 survey, nearly 40% of young people worldwide said their concerns about climate change had been ignored or dismissed.

Climate change is also a health crisis — these 3 graphics explain why

Researchers are particularly worried that countries and regions that experience the harshest effects of climate change are where the least climate mental-health research has been done. In her studies, Uchendu found that most research was Western-centric. “Not a lot of people were talking about these issues in Africa,” she says. In 2022, she started the Eco-anxiety in Africa Project, which, in collaboration with the University of Nottingham, UK, has documented the emotional turmoil that heat and erratic weather has created for people living in five African cities.

Another question researchers have is how context and culture affect climate anxiety. Some studies have shown that “connection to country” — through cultural practices such as hunting and gathering food — is important to the mental health and well-being of some Aboriginal Australians and Torres Strait Islander communities 8 , says Michelle Dickson, who studies the mental health of Indigenous Australians at the University of Sydney, Australia. But rising sea levels, drought and bushfires threaten those practices. Tools used in health-care settings “rarely take into account the important cultural values that underpin Indigenous mental health”, says Dickson, who is a Darkinjung/Ngarigo Australian Aboriginal.

Dickson is now co-leading a project to empower communities to design their own climate action plans — allowing researchers to test whether doing this could improve people’s mental health.

Heatwaves — such as one that hit New Delhi in 2022 — can worsen mental disorders and are linked to increased negative feelings. Credit: Kabir Jhangiani/Pacific Press/LightRocket via Getty

Overcoming eco-distress

Addressing climate-fuelled mental-health conditions will be a colossal task when mental-health care globally is already poor: only around 3% of people with depression receive adequate treatment in low- and lower-middle-income countries, and 23% in high-income countries 9 . Lawrance says that many communities are finding their own ways to cope, but that the effectiveness of these efforts is rarely studied and shared. “There’s a massive gap around evaluation,” she says.

Some evidence suggests that taking action to combat climate change can help people to manage eco-anxiety . “There does seem to be an argument for supporting people to take collective action,” says Marks, such as joining campaign groups with like-minded people. It’s also important to “recognize that I feel this way because I care”, she says. “These climate emotions are actually something to be honoured and allowed, not pushed away.” Marks also suggests that some people who are feeling eco-distress limit the amount of time they spend ‘doom-scrolling’ through climate news.

Extreme heat harms health — what is the human body’s limit?

Researchers are starting to take collective action themselves. Last month, the Connecting Climate Minds project, one of the most ambitious research efforts in the field of climate-related mental health 10 , released a series of regional ‘research and action’ priorities, including, for example, to understand how climate change compounds the stress of wars, violence and disease epidemics in sub-Saharan Africa . The project includes researchers, policymakers and people with first-hand experience of climate change. Uchendu says that in one of the meetings, someone joining remotely was standing in flood water in their room. “It was mind-blowing,” she says.

Wamaitha, who along with Burrows is one of many people who shared their experiences with Connecting Climate Minds, has turned some of her concerns into action. Last year, after trying and failing to grow drought-resistant crops, she quit farming and is now working at a non-governmental organization in Bura, Kenya, that is focused on poverty relief. She is earning enough to study for a master’s degree in public health, and she raises awareness of global health on the social-networking site LinkedIn. But she is anxious about the future and worries about whether to have children. “I don’t think I am in a good environment to be able to bring kids into this particular place,” she says. “That is the saddest thing when I think about it.”

Burrows, who is studying medicine at the University of the West Indies in Saint Augustine, Trinidad and Tobago, says she chooses to be positive and does small things to help the environment, such as walking instead of driving. She says that she prays that wealthy countries and companies “will really, truly understand what is happening and not just say smooth words to try to pacify us in the moment”. They should act to “help the smaller countries and the world at large”, she says.

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Generalized Anxiety Disorder Case Study: James

A paper on case studies.

If you are seeking help in this area, please let one of our therapists know. Theravive has thousands of licensed counselors available to help you right away. The following article may have multiple collaborators and thus, parts of it may not represent the official positions of Theravive.

Generalized anxiety disorder, (GAD) is a traumatic illness, and is hard to understand unless you are experiencing it yourself. While specific anxiety disorders are complicated by panic attacks or other features of the disorder, GAD has no specific focus. (Durand, 2007 p.130). The person constantly worries about everyday life; not being able to figure out what to do with their worries. All the while making themselves and everyone around them miserable. (p.130). The worries seem to take over control of one's life, almost to the point of not being able to function at all.

It seems that GAD tends to run in families based on studies conducted, and seems to happen more to women than men. (Durand, 2007 p.132). And evidence shows that GAD may be proved to be just as heritable, the same as other anxiety disorders. (p.133). The textbook states that this disorder originated in 1980, however therapists were working with patients with anxiety way before the criteria was developed. (p.133). For many years, clinicians believed that people who were generally anxious just didn't seem to have anything specific to focus on, thus calling it the 'free floating' disorder. (p.133).

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) has specific criteria that characterized GAD. As stated in our textbook, the features are:

• Excessive anxiety and worry for 6 months or more about a number of events or activities. • Difficulty in controlling the worry. • At least three of these symptoms: (1) restlessness of feeling all keyed up; (2) becoming fatigues easily; (3) difficulty concentrating; (4) irritability; (5) muscle tension; (6) sleep disturbance. • Significant distress or impairment. • Anxiety is not limited to one specific issue. (Durand, 2007 p.131).

Generalized anxiety disorder has been studied using various criteria. The National Comorbidity Survey (NCS) focused on noninstitutionalized American civilians ages 15 to 54. The results were reported and found there was a clear predominance of women with GAD, with a 2:1 female/male ratio. It was lowest among the younger age group but increased with age. (NA, 1997). 'There was a significant regional difference in GAD as well, with a higher lifetime prevalence in the Northeast than in other parts of the country.' (1997). Studies have shown that many people could not really pinpoint a clear age of onset of GAD or an onset dating back to childhood. (Barlow, 1993 p.156). There have also been twin studies which conclude that GAD is somewhat greater for identical female twins than for non-identical twins, but only if one twin already had generalized anxiety disorder. (Durand, 2007 p.132). But later researched showed that what seemed to be inherited was the ability to become anxious rather than GAD itself. (p.132). It's amazing to know that people with GAD seem to show less responsiveness on most physiological measures, such as heart rate, blood pressure, skin conductance and respiration rate than do people with other anxiety disorders. (p.133).

Although it seems to prove that GAD is quite common, I am amazed that more people don't have this disorder. I think that many people have general anxieties on a daily basis, but most people are able to handle them successfully. I did not realize that most people with GAD have usually had symptoms of anxiety or feelings of being worried throughout life, but just didn't know when it all started. The criterion has changed over the years as well as doctors have become more knowledgeable about this disorder. I first had knowledge of this disease in 1997 when I noticed strange things happening.

He was not really watching as he stared directly at the television set. I would notice that he had no expressions at all; nothing during the humorous scenes, or the dramatic ones. He once told me that it was as if he was someone else, watching himself try to crawl out of his own skin. That was 10 years ago when I was married to this man who was suffering from generalized anxiety disorder. I didn't understand and I really didn't want to. I thought he was just being lazy and unmotivated. Although this disorder seems to be simple to others, it is quite alarming to the person who is suffering from it, and the onset is rather quick, whereas, treatments are difficult. Everyone experiences anxiety, but in most people, it does not last for months at a time.

The case study I am choosing is about James who is a doctor suffering from generalized anxiety disorder. At 31 years of age and living in New York, he is unemployed because of his constant anxiety, even at the thought of working. He now lives with his parents off a small trust fund set up for him by an uncle. Although he was an overachiever throughout his academic career, James is having a hard time keeping it together, while his parents are somewhat supportive but disappointed with his medical career. Let's see what we can learn about this horrible and crippling disorder. 'Generalized anxiety disorder is associated with irregular neurotransmitters in the brain. Neurotransmitters are chemicals that carry signals across nerve endings. Neurotransmitters that seem to involve anxiety include norepinephrine, GABA (gamma-aminobutyric acid), and serotonin.' (na, 2001). So it was thought that reduced levels of GABA initiated excessive anxiety, although neurotransmitters are much to complex to be interpreted that simply. (Durand, 2007 p.45).

The brain is a very fascinating and intricate part of who we are and if the brain is not functioning properly, then our reactions to certain situations are not in balance. This is why some people still believe that undeniable psychological disorders are said to be caused by biochemical imbalances. (Durand, 2007 p.50). So in James' case, his brain was not functioning right and he was experiencing an unnatural balance of change within his various neurotransmitters, causing him to become anxious, easily irritated, distracted and quite tense. He also complained of headaches, body aches and pains and always feeling tired.

Genetics does play a major role is determining whether a person will or will not have a psychological disorder. The textbook states that the research is beginning to acknowledge genes that relate to some psychological disorders. (Durand, 2007 p.70). I feel that genetics does contribute to some disorders, but I also think that the environment and society can cause debilitating stress to induce certain disorders, such as anxiety. If the gene linked to the disorder is dormant, a stress related incident can bring it to the surface, thus bringing on the disorder. My research has shown that there are brain abnormalities indicated with generalized anxiety disorder. A study of 30 patients displayed that compared to 20 healthy volunteers, 11 patients had significant brain abnormalities mainly in the right temporal lobe. (Nutt, 2003 p.209). The temporal lobe controls the processes of recognizing various sights and sounds and long term memory storage. (Durand, 2007 p.48). However there are two temporal lobes on each side of the brain, located at the level of the ears. The lobes help a person distinguish one sound from another as well as one smell from the other. The right lobe controls visual memory while the left lobe controls verbal memory. (Johnson, 2006) So this would explain why James kept making mistakes because he was probably having a hard time remembering simple procedures.

The first thing James would need to do would be to seek professional help and see if he has this disorder, although being a medical doctor, he may have self diagnosed himself, however he should see a psychiatrist. There are no laboratory tests that can determine if a person has anxiety or a mental illness, but a doctor will perform a battery of tests to weed out other illnesses, such as an overactive thyroid gland, which can produce anxiety and its symptoms. (NA, 2007 WebMD). James' next plan of attack would be to discuss the different types of medications that are available for providing relief from this disorder. Since James has generalized anxiety disorder, which has been called a 'free-floating' disorder because of his constant worrying and nervousness, as stated earlier, he would need a medication that treats low levels of GABA. (Roberts, ch.17 p.6). The textbook states that the drub benzodiazepine (minor tranquilizers) is the most frequently prescribed. (Durnad, 2007 p.134). The drug is used for short-term relief and can be hard to stop taking because of dependence issues. One such drug in particular is called Xanax, which is shown to enhance the function of GABA in the brain. It also slows down the central nervous system. This drug is extremely addicting; it's the drug my ex-husband did not want to give up, so we got a divorce.

There is also evidence that antidepressants can be used for GAD and may be a better choice. (p.134) The most common antidepressants are prozac and zoloft. 'These drugs are shown to affect the concentration and activity of the neurotransmitter serotonin, a chemical in the brain thought to be linked to anxiety disorders.' (na, 2004). Some of these drugs that I have researched for GAD, are also used for treating migraines, because I was prescribed some for headaches. No wonder I was always in a good mood, even though it felt like my head was about to explode.

Because the drugs prescribed for this disorder are recommended to be taken for short periods of time, therapy should be initialized as well. The side effects of these drugs are: Xanax (benzodiazepines): drowsiness, fatigue, decreased concentration, confusion, blurred vision, pounding or irregular heartbeat, impaired coordination, short term memory problems, dizziness. (Smith et al, 2006).

Prozac (Selective Serotonin reuptake inhibitors): nausea, insomnia, headaches, decreased sex drive, dizziness, weight gain or loss, nervousness, sweating, drowsiness/fatigue, dry mouth, diarrhea or constipation, skin rashes. (Smith et al, 2006) These medications offer so many side effects, it's a wonder anyone wants to take them at all. But I guess for the person who is suffering from anxiety attacks or generalized anxiety disorder, the side effects may be a welcomed relief There are also natural remedies to help with GAD such as valerian root and kava kava, which has been treating anxiety for years, but the results are not well documented. (Smith et al, 2006) Some natural remedies can actually make anxiety worse and taking supplements may interact with the prescription anxiety medications, so it's a good idea to discuss this with a doctor.

Another approach to treatment is to help James with therapy sessions to try to figure out why he is experiencing all this anxiety and worry. One session may include showing James pictures of things that may make him anxious and then teaching him how to relax deeply to fight his tension. It's called cognitive behavioral treatment, developed in the early 1990s, and is quite successful; however we need both medications and therapy to treat GAD. (Durand, 2007 p.134).

Acupuncture, which is one medical treatment that does no harm to the body, only releases energy and gets it moving in the system; (NA, 2007) biofeedback, which is the ability to allow the patient hear or see feedback of their body's physiological state while relaxing;(Grohol, 2004) and hypnotherapy shown as an appropriate treatment modality for those individuals who are highly suggestible, have also been used to treat anxiety. (Grohol, 2004).

So which treatments work the best? That is hard to say because everyone is different and will react differently to each treatment. As stated in the textbook, a combined treatment of therapy and medications suggested there were no advantages for both, and that people did better in the long run when having psychological treatments only. (Durand, 2007 p.144). So it's suggested to start with psychological treatment first and then followed by drug treatments for the patients who are not responding to therapy. (p.144).

How does environment influence our behavior? Do we imitate what we see around us? Are we simply looking for acceptance, thereby, acting or saying what we think society expects? Who decides what acceptable behavior is? Although the environment may affect a person's behavior, there are many other elements to explore that influence the way we are.

James is coping with generalized anxiety disorder, as was stated earlier. At 31, he is allowing this disorder to control his life which is leading to being emotionally and physically drained. Although he realizes that he is an intelligent and capable person, he knows to avoid any situation that may exacerbate the anxieties that he is experiencing. With minimal support from his family and friends, James feels that he is dealing with this all alone and just wants to lead a normal life. Perhaps the stress and strain of becoming a doctor led to James' anxiety disorder as it may have been dormant within his genetic makeup, and is now just surfacing.

Many people develop generalized anxiety disorder (GAD) during adolescence, but do not seek professional help until they are adults. (NA, 2001). When they do finally get help, they claim they have been anxious and nervous all their lives. (2001). These people cannot just 'get over it' but society seems to not grasp that concept. Some of the environmental influences that could lead to general anxiety are: • Work. This would affect James immensely because his whole life has been based around his becoming a doctor. Even his father wanted him to follow in his footsteps and have a prestigious career. • School. Although James did not experience anxieties until after he graduated from medical school, I'm sure he still felt anxious with tests and schoolwork. • Relationships. This would be dealing with James' parents as they are somewhat supportive but disappointed that his career has not been progressing. He also lost his relationship with his girlfriend of three years because of the stress. • Health. Because James is dealing with this disorder, his health is rapidly declining. He is having headaches, body aches and pains and is always tired. His emotional health is affected as well with feelings of laziness and worthlessness. • Financial. James is realizing that if he cannot work, he cannot earn a paycheck. He is living off a small trust fund set up for him by his great uncle, but that won't last forever. All of these things are considered threats and can cause James to worry excessively which is interfering with his life.

Is the environment to blame for James' anxiety or is it more biological? I think that genetics and the environment work together to produce this disorder. I feel that if a person is genetically prone to have anxiety and fear; if the person never leaves the house, then what does he/she have to worry about? The environment has to play a role in the mobility of this disorder. If James were to isolate himself from the world, he would still have anxiety; however he would not be able to face his fears, thus restricting his life. His thought process would be 'what if this happened, or what if that happened?' He would always be having threatening thoughts and images playing over and over in his mind. (Alloy, 2006 p.189).

Our textbook states that GAD generally runs in families, which I mentioned earlier. (Durand, 2007 p.132). With all the research and studies that are performed, it will show that generalized anxiety disorder is inherited. So genetics and biology has to be the most important because people who aren't suffering from anxiety will react more favorable to a stressful situation, than someone who is suffering from GAD. It seems that we all have to face the same environmental influences, but the threat of each situation interacts with the biological aspect of a person, thus bringing on the symptoms of the disorder. (p.133).

James needs to be treated by a psychiatrist, not a family physician. He needs to be seen by someone who deals with psychological disorders daily and is educated with the treatments available. Psychological treatments work better in the long run and work just as well as prescription medication. Our textbook states that, 'as we learn more about generalized anxiety, we may find that helping people with this disorder to focus on what is actually threatening is useful.' (Durand, 2007 p.134).

Research has indicated that psychological treatments work very well for children who suffer from GAD. (Durand, 2007 p.135). But I feel that unless a child is diagnosed early in life, the treatments won't be as effective. I'm sure that James was experiencing some form of anxiety as a child, but children are difficult to diagnose, and if the parents don't know what to look for, they won't know the child needs help. But children respond to cognitive-behavioral treatments along with family therapy. (p.135).

I feel that psychosocial treatments would be the best way to start with a patient. In James' case, I think he should start with therapy for at least three months. He needs to confront the fear, phobias and anxieties head on to figure out what's making him feel emotionally and physically drained. I would also suggest to James that he should educate and read everything he can on this disorder. Having this knowledge will benefit him so he may get the most out of his treatments. If I had a disorder, I would want to know everything about it. And I would be asking a million questions. Sometimes I feel that everyone in society could use some form of therapy to deal with the stressors of life.

Next, I would try medications in addition to therapy to help James with possible other symptoms of GAD, such as depression. (Smith et al, 2006). The medication, however, would only be used on a temporary basis, as addiction can occur. My ex-husband was on medication for his GAD, but he was not seeing anyone for therapy. I think that was the biggest problem. He was increasing his dosage without telling his doctor, thus becoming extremely dependent on the drugs. As a doctor, James should know that some of the medications used for GAD are very addictive and hopefully would only be used as directed.

There are certain beliefs about thoughts and thought processes that are included in cognitive forms. (Papageorgiou, 2004 p.228). 'There are two types of worries; Type 1 and Type 2. Type 1 worries deal with external daily events such as the welfare of a partner, and non-cognitive internal events such as concerns about bodily sensations. Type 2 worries are focused on the nature and occurrence of thoughts themselves such as worrying that worry will lead to insanity. It's basically worry about worry.' (Wells, 1997 p.202). The cognitive model claims that the varieties of worry are typically type 2 worries in which the patients negatively appraise the activity of worrying. (p 202). I feel that the cognitive psychological model best applies to understanding and treating this disorder. I believe that by using cognitive therapies and similar research studies, we can begin to know what it takes to treat the people who are suffering with better results now and in the future. There are new medications that can help people with GAD, but there are side effects that may be too harsh or severe. I believe that more psychosocial therapies may need to be developed in order to help these people, so they can live a normal life without medications, because of the problems they present to the body.

I believe that James could once again become a successful doctor if and when he gets his generalized anxiety disorder under control. The treatments are available; all he has to do is seek them out. I feel that with therapy coupled with medications would benefit James tremendously. Eventually he will be able to stop taking the medications and perhaps enjoy a fairly normal life. The good news is that only 4% of the population meets the criteria for GAD during a given one-year period. However it is still one of the most common anxiety disorders. (Durand, 2007 p.132). . My research for this paper has helped me so far in understanding what a person is going through with crippling anxiety. It's not something that a person can just 'get over' and I know I wanted to tell my ex-husband that many, many times. However, he became addicted to the prescriptions drugs, and became a drug addict in about two weeks. Because of my first hand experience with this disorder, I chose to do my projects on it.

References N.A. (1997) Retrieved Oct. 20, 2007 from The Natural History of Generalized Anxiety Disorder website: www.medscape.com N.A. (2001). Retrieved Sept. 16, 2007 from General Anxiety Disorder website: http://www.mentalhealthchannel.net N.A. (2004). Retrieved Sept. 13, 2007 from Anxiety Disorders Association of America website: http://www.adaa.org N.A. (2007) Retrieved Sept. 17, 2007 from Anxiety Panic Guide website: http://www.webmd.com N.A. (2007). Retrieved Oct. 21, 2007 from Acupuncture for Generalized Anxiety Disorder website: www.revelutionhealth.com Barlow, D. (1993) Clinical Handbook of Psychological Disorders: A step-by-step treatment Manual 3rd ed. Guilford Press Retrieved Oct. 20, 2007 from libsys.uah.edu. Durand, V. & Barlow, D. (2007) Essentials of Abnormal Psychology: Mason, OH. Thomson/Wadsworth Publishing. Grohol, J. (2004) Retrieved Oct. 20, 2007 from generalized anxiety disorder treatment website: www.psychentral.com/disorders Johnson, G. (2006) Retrieved Sept. 15, 2007 from A Guide to Brain Anatomy website: http://www.waiting.com/brainanatomy Nutt, D. & Ballenger, J. (2003). Anxiety Disorders. Malden, Ma: Blackwell Publishers Retrieved Sept. 18, 2007 from Net library search: libsys.uah.edu Papageorgiou, C. & Wells, A. (2004). Depressive Rumination Nature, Theory and Treatment. Hoboken, NJ: John Wiley & Sons, LTD. Roberts, M. (nd). Introductory Guide to Psychology Kaplan University Class SS-124 Alloy, L. & Riskind, J. (2006). Cognitive Vulnerability to Emotional Disorders. Mahwah, NJ: Lawrence Erlbaum Associates Inc. Smith, M., Kemp, G., Larson, H., Jaffe, J., Segal, J. (2006). Retrieved Oct.8, 2007 from Anxiety Attacks and Disorders website: http://www.helpguide.org Wells, A. (1997). Cognitive therapy of Anxiety Disorders: A practice manual and conceptual guide. Chichester, NY: John Wiley & Sons, LTD.

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• Social Phobia/Anxiety Case Study: Jim

Jim was a nice looking man in his mid-30’s.  He could trace his shyness to boyhood and his social anxiety to his teenage years.  He had married a girl he knew well from high school and had almost no other dating history.  He and his wife, Lesley, had three children, two girls and a boy.

At our first meeting, Jim was very shy and averted his eyes from me, but he did shake hands, respond, and smile a genuine smile.  A few minutes into our session and Jim was noticeably more relaxed.  "I’ve suffered with this anxiety for as long as I can remember", he said.  "Even in school, I was backward and didn’t know what to say.  After I got married, my wife started taking over all of the daily, family responsibilities and I was more than glad to let her."

If there was an appointment to be made, Lesley made it.  If there was a parent-teacher conference to go to, Lesley went to it.  If Jim had something coming up, Lesley would make all the social arrangements.  Even when the family ordered takeout food, it was Lesley who made the call.  Jim was simply too afraid and shy.

Indeed, because of his wife, Jim was able to avoid almost all social responsibility -- except at his job.  It was his job and its responsibilities that brought Jim into treatment.

Years earlier, Jim had worked at a small, locally-owned record and tape store, where he knew the owner and felt a part of the family.  The business was slow and manageable and he never found himself on display in front of lines of people.  Several years previously, however, the owner had sold his business to a national record chain, and Jim found himself a lower mid-range manager in a national corporation, a position he did not enjoy.

"When I have to call people up to tell them that their order is in," he said, "I know my voice is going to be weak and break, and I will be unable to get my words out.  I’ll stumble around and choke up....then I’ll blurt out the rest of my message so fast I’m afraid they won’t understand me.  Sometimes I have to repeat myself and that is excruciatingly embarrassing........"

Jim felt great humiliation and embarrassment about this afterwards: he couldn’t even make a telephone call to a stranger without getting extremely anxious and giving himself away.  That was pretty bad!  Then he would beat himself up.  What was wrong with him?  Why was he so timid and scared?  No one else seemed to be like he was.  He simply must be crazy!  After a day full of this pressure, anxiety and negative thinking, Jim would leave work feeling fatigued, tired, and defeated.

Meanwhile, his wife, being naturally sociable and vocal, continually enabled Jim not to have to deal with any social situations.  In restaurants, his wife always ordered.  At home, she answered the telephone and made all the calls out.  He would tell her things that needed to be done and she would do them.

He had no friends of his own, except for the couples his wife knew from her work.  At times when he felt he simply had to go to these social events, Jim was very ill-at-ease, never knew what to say, and felt the silences that occurred in conversation were his fault for being so backward.  He knew he made everyone else uncomfortable and ill-at-ease.

Of course, the worst part of all was the anticipatory anxiety Jim felt ahead of time – when he knew he had to perform, do something in public, or even make phone calls from work.  The more time he had to worry and stew about these situations, the more anxious, fearful and uncomfortable he felt.

REMARKS: Jim presented a very typical case of generalized social phobia/social anxiety.  His strong anticipation and belief that he wouldn’t do well at social interactions and in social events became a self-fulfilling prophecy, and his belief came true: he didn’t do well.  The more nervous and anxious he got over a situation, and the more attention he paid to it, the more he could not perform well.  This was a very negative paradox or "vicious cycle" that all people with social anxiety get stuck in.  If your beliefs are strong that you will NOT do well, then it is likely you will not do well.  Therefore, thoughts, beliefs, and emotions need to be changed.

The depression (technically "dysthymia") that comes about after the anxious event continued to fuel the fire.  "I’ll never be able to deal with this," Jim would tell himself, thus constantly reinforcing the fact that he saw himself as a failure and a loser.

Unusual in this situation is that Jim’s wife remained loyal to him, understood his problem to some extent, and even seemed to enjoy her role as the family’s "social director".  The more and more she did for Jim, the more and more he could avoid.  It got so bad that Jim, who loved to listen to new albums and read new books -- could not even go to stores or to the library.  He would tell his wife what to buy and she would buy it.  She even kept track of when the library books were due and made sure she took them back on time.

This family situation is unusual because most people with social anxiety/social phobia have an extremely difficult time making and continuing personal relationships -- because of self-consciousness and the need for more privacy than most other people.  In fact, social phobia ranks among one of the highest psychological disorders when it comes to failed relationships, divorce, and living alone.

TREATMENT for Jim consisted of the normal course of cognitive strategies so that he would relearn and rethink what he was doing to himself.  He was cooperative from the beginning, and progressed nicely doing therapy.  He took each of the practice handouts and spent time each day practicing.  He made a "special time" for himself that his family respected and he used this place and time to practice the cognitive strategies his mind had to learn.

His biggest real-life fear, speaking to another person in public, was not really a speaking problem; it was an anxiety problem.  There was nothing wrong with Jim’s voice, his reading ability, or his speaking ability.  Jim was a bright man who had associated great anxiety around these social events in public situations.

The course of treatment here is NOT to practice!  In fact, practicing would just draw attention to what Jim perceived was the problem: his voice, his awkwardness, his perceived inability to speak to others.  Thus, it would reinforce the very behaviors we do not want to reinforce.

Instead, Jim worked on paradoxes.  We deliberately goofed-up.  We tried to make as many mistakes as possible.  We injected humor into the situation and found that when he exaggerated his fears, he thought this was funny.  Although more is involved than just this, the concept here is to de-stress the situation and enable the person to see it for what it is: NO BIG DEAL!  If you make a mistake, SO WHAT?  Everyone else does too!

Over the weeks, before group therapy began, Jim did a number of interesting things in public that began proving to him that he was NOT the center of attention, and it just didn’t matter if he made a mistake or two.  After all, he was human just like everyone else.  It’s this idea of perfectionism, of always having to "do your best" that must be broken down.  Jim was human; humans make mistakes; so what?  It was certainly nothing to get upset about.  In fact, as time went by, it become even more funny and humorous, rather than humiliating or embarrassing.

After completion of the behavioral group therapy, Jim had an opportunity for advancement in his company, which he now felt comfortable to take.  The promotion entailed holding weekly meetings in which he was in charge.  He would have to do some public speaking and respond to his employees’ questions.  By this time, Jim was feeling much more comfortable and much less anxious about the whole situation.  "I think I’ll deliberately goof up," he joked to me before the start of his new job.  "It would be interesting to see how everyone else responds."

To say that Jim did not have any anticipatory anxiety before taking this position or before making his weekly presentations would be inaccurate.  The difference was now they were manageable.  They were simply minor roadblocks that could be overcome.  Jim’s thinking about social events and activities had changed a great deal since the first day I saw him in therapy.

I talked to Jim a few months ago and everything was going well.  His responsibilities at work had increased slightly, but Jim now had the ability and beliefs to deal with them.  He was much more confident and had a feeling of being in control.  He was doing more around the house and his wife was a little surprised at his metamorphosis.  Luckily, this did not change the marriage dynamics adversely, and the last time I talked with him, Jim had become a father again: another little boy.

"He’s the last," Jim said, laughing over the phone, "I can’t get too distracted.  I’ve got too many speeches to give now."

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• The Scorpion's Sting: An Anxiety Parable
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The Anxiety Network began in 1995 due to growing demand from people around the world wanting help in understanding and overcoming their anxiety disorder.  The Anxiety Clinic of Arizona and its website, The Anxiety Network, received so much traffic and requests for help that we found ourselves spending much of our time in international communication and outreach.  Our in-person anxiety clinic has grown tremendously, and our principal internet tool, The Anxiety Network, has been re-written and re-designed with focus on the three major anxiety disorders: panic, social anxiety, and generalized anxiety disorder.  

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The Social Anxiety Institute , the largest site on the internet for information and treatment of social anxiety, has maintained an active website since 1998.  Continuous, ongoing therapy groups have helped hundreds of people overcome social anxiety since 1994.  

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• v.176(4); 2002 Sep

Case-Based Reviews

Anxiety disorders, jian-ping chen.

1 Charles B Wang Community Health Center 125 Walker St New York, NY 10013

Leonard Reich

2 Health Insurance Plan of Greater New York 7 West 34th St New York, NY10001

Henry Chung

3 Pfizer, Inc. 235 East 42nd St. New York, NY 10017

see also p 239, 257

Summary points

• Careful evaluation of an anxious patient will help to determine if thecause of the anxiety is organic or psychological
• Use of herbal and over-the-counter substances should be determined becausesome herbal products (eg, ginseng, ma huang , and certain coughmedicines) contain stimulants that cause symptoms of anxiety
• Anxiety is often associated with one or more other mood disorders that mayrequire management and treatment
• Primary care practitioners should incorporate psychological techniques intheir medical management of Asian patients with anxiety

Ms M is a 60-year-old widowed Chinese woman with a 6-month history ofepisodic chest tightness, shortness of breath, pain that “moves all overmy body,” and numbness in her legs. These attacks, which occur once ortwice weekly, occur suddenly, reaching peak intensity within a few minutes.During an attack, pain travels from her chest to her abdomen, groin, and legs.The pain is often accompenied by a sensation of intermittent “hotQi” (air) coming from her abdomen to her throat, making her believe thatshe is being choked. She also describes feeling as if she is in a closed roomor small space. Ms M is anxious and frustrated about her symptoms and thinks she might havea serious medical problem. She has had frequent medical evaluations by herprimary care physician and second opinions from various specialists. Ms Mconsulted a doctor of traditional Chinese medicine and tried some herbalmedications, but has had no relief. She has refused to see a psychiatrist.

ANXIETY DISORDERS IN THE PRIMARY CARE SETTING

Anxiety disorders are a group of mental disturbances characterized byanxiety as a core symptom. In this article, we discuss anxiety disorderscommon to primary care, specifically panic disorder, generalized anxietydisorder (GAD), and posttraumatic stress disorder (PTSD).

The diagnosis is made when the constellation of symptoms are consistentwith the diagnostic criteria for each disease listed in the Diagnostic andStatistical Manual of Mental Disorders, 4th edition (DSM-IV) (see Tablelinked to this article on our web site). When symptoms of anxiety becomepervasive, have signs and symptoms consistent with DSM-IV criteria, and affectthe patient's ability to function, the presumed diagnosis is an anxietydisorder.

Which organic illnesses can cause anxiety symptoms?

Some of the disease states associated with prominent anxiety are shown in box 1 . These diseases, however,are rare explanations for anxiety and anxiety disorders. Clinicalinvestigations to identify a particular disease entity should only beundertaken if the pre-test probability of the disease is high.

Disease states associated with anxiety

What features are suggestive of an organic cause of anxiety?

An organic cause of anxiety should be suspected when the onset of symptomsis sudden, changes have recently occurred in the patient's medication, or thepatient has specific signs and symptoms suggestive of a new organic diseaseprocess.

When a patient presents with anxiety, the following features should promptclinicians to suspect an underlying nonpsychiatric disorder is thecause 1 :

• Onset of anxiety symptoms after the age of 35
• Lack of personal or family history of an anxiety disorder
• Lack of childhood history of significant anxiety, phobias, or separationanxiety
• Absence of significant life events generating or exacerbating the anxietysymptoms
• Lack of avoidance behavior
• Poor response to anxiolytic agents

How do you evaluate an anxious patient?

The medical evaluation of anxious patients should include a completehistory and physical examination. Features of the history that merit specialattention are:

• Substance use/abuse (eg, caffeine, amphetamines, marijuana, cocaine) andwithdrawal (eg, from alcohol or sedative-hypnotics)—both of these cancause anxiety symptoms
• Use of medications with anxiogenic effects (β-adrenergic agonists,theophylline, corticosteroids, thyroid hormone, sympathomimetics,psychostimulants)

Asking Asian patients if they are using any herbs or medicines given byfriends or relatives is important because some may contain ma huang (a stimulant) or ginseng. These substances may cause or exacerbate anxiety(see below).

Laboratory and medical tests should be performed only as indicated bysymptom constellation and clinical judgment.

Which cultural issues are important to consider?

Issues that are important in diagnosing anxiety include the following:

• Many Asian patients do not use the word anxiety. Instead, they discuss“nervousness,” “tension,” or “beingtense”
• Because being anxious is viewed as being weak or incompetent, many Asianpatients with anxiety disorders tend to present with physical complaints. Aphysical problem often is seen as a more legitimate reason to get help and togain sympathy and support from family members and friends
• Many patients with anxiety disorders also have depression. As many as 50%of patients with anxiety will have an episode of major depression at some timein their life 2
• Often patients may understand their symptoms as a defined illness that isknown only to the specific native culture. Examples include neurasthenia (a“nerve weakness,” see p 257), pa-leng (Chinese for“fear of cold”), hwa byung (Korean for “fireillness”) and taijin kyofusho (Japanese for “fear oflosing face and facing situations)
• Psychosocial issues encountered by new immigrants can exacerbate or createnew anxiety
• Some Chinese pharmaceuticals can cause or worsen anxiety. Ma-huang contains ephedrine, a common ingredient in cold medication or diet pills,which increases heart rate, blood pressure, and sweating, all markers ofanxiety. Ginseng possibly increases the basal metabolic rate and increasesheart rate, which may trigger anxiety

Treating anxiety with medication may be consistent with an Asian patient'sview that anxiety is a medical issue rather than a psychological one. Inaddition, adherence to a medical regimen hinges less on a good language matchbetween patient and physician than would be the case with a psychologicaltreatment program. Medication also has the benefit of relieving distressingphysical symptoms and rapidly returning patients to pre-existing functionallevels.

A major limitation of treating anxiety with medication alone is thatpatients do not evaluate their conditioned patterns, coping strategies, orenvironmental circumstances, which may be the root cause of their anxietydisorder. Failing to address these issues increases the risk of relapse whenmedication is discontinued.

Therefore, clinicians in primary care settings should emphasizepsychological treatments with the same conviction as medical ones. Researchfindings show thatpsychopharmacologic 3 , 4 and cognitive behavioralpsychotherapeutic 5 , 6 , 7 interventions individually are effective in the treatment of approximately 60to 90% of patients with various forms of anxiety disorders. The combination ofmedication and psychotherapy produces the most effective long-termresults. 8 , 9 , 10

SPECIFIC DISORDERS

Panic disorder, clinical assessment.

We have found that some Asian patients present with panic attacks that havestrong cultural overtones, characterized by only one or two predominantclassic symptoms. Our Chinese American patients with anxiety commonly complainof “hot and cold” symptoms (such as pa-leng ). Despite aconsistent environment, they describe sensations of hot or cold Qi (air) going up and down their body, along with other bodily discomforts.

“ Hwa byung ” is also a common cultural idiom ofdistress seen in Koreanpatients. 11 Lin andcolleagues describe this syndrome as highly somatized with anxiety, insomnia,sensations of heat in the body and the impulse to “get out of thehouse.” 11 Patients with these symptoms often recognize that the symptoms arepsychological and result from suppressing anger.

Obtaining a brief history of the patient's experience with panic attacks isuseful because panic attacks and agoraphobia (fear of being placed insituations where obtaining help is difficult, such as lonely open spaces ortraveling alone) may seriously limit the patient's ability to travel toappointments and comply with aftercare. If panic disorder with or withoutagoraphobia is diagnosed in Asian patients, time may be required to assesspatients' travel patterns and their ability to travel beyond their immediatecommunity.

Psychological treatments

Psychological treatments for panic have proven effective both independentlyand as an adjunct to medication. In a recent randomized controlled trial,investigators compared the effectiveness of cognitive-behavioral therapy,imipramine, or their combination, against placebo in the treatment of panicdisorder. 12 Eachtreatment individually was better than placebo, and the combination treatmentwas more effective than individual treatments at preventing relapse.

Cognitive-behavioral therapy is the psychological treatment of choice forpanic disorder. A protocol developed by Barlow and Craske, which involvesexposure, cognitive restructuring, breathing retraining, and relaxationtraining ( box 2 ), has beenwell-validated. 13 We have found these treatments are effective in Asian American patients, yettheir use may be limited by a lack of bilingual therapists.

Psychological therapies for panic disorder

Suggestions for practitioners

• Provide a medical explanation that gives patients an understanding of theirphysical symptoms. Acknowledge that the symptoms are physical but are notrelated to a serious medical condition, such as heart disease
• Instruct the patient on how to use abdominal breathing (breathingretraining) at the first sign of hyperventilation, anxiety, or a panicattack
• Suggest that the patient use relaxation techniques
• Encourage the patient to practice breathing retraining and relaxationtechniques during non-panic anxiety states
• Provide helpful literature and/or relaxation tapes that reinforcerelaxation techniques

Generalized anxiety disorder (GAD)

Generalized anxiety disorder is defined as excessive anxiety or worry inthe absence of, or out of proportion to, situational factors. The symptoms ofthis disorder are restlessness or feeling on edge, being easily fatigued,difficulty concentrating or the patient's mind going blank, irritability,muscle tension, and sleep disturbance. The diagnosis requires that symptomshave been present for more than 6months. 14

Pharmacotherapy

The treatment of GAD is similar to treatment for all other anxietydisorders. A selective serotonin reuptake inhibitor (SSRI) may be administeredat low doses and adjusted upward for a full therapeuticresponse. 4 Psychotherapy for patients with GAD has not been well studied.

Posttraumatic stress disorder (PTSD)

Posttraumatic stress disorder occurs after exposure to an event involvingdeath, serious injury, or a threat to the physical integrity of self orothers. Patients with the condition persistently re-experience the event, suchas through dreams and flashbacks; show persistent avoidance behavior, such asdiminished involvement in usual activities or relationships; and persistentsymptoms of increased arousal, such as irritability andhypervigilance. 14 Events that trigger the disorder include war; torture; natural disaster;violence to self or others, including rape; serious illness; surgery; andevents that have an idiosyncratic impact on a given patient.

Immigrants from the Pacific Rim may be at a higher risk of having beenexposed to traumatic events related to their journey to the United States orto their reasons for wanting to leave their home country. For example, someimmigrants from China have been tortured for political reasons or sufferedfrom enforcement of birth control policy resulting in forced terminations ofpregnancies. The prevalence of PTSD is high among Southeast Asianrefugees. 15

Posttraumatic stress disorder is often associated with depression, otheranxiety disorders, and substance abuse. Clinicians should assess for theseother conditions in patients with PTSD because substance abuse and depressionincrease suicidal risk. The National Women's Study found that 31% of women whoare raped develop PTSD and that 13% of rape victims make a suicideattempt. 16

The treatment of choice for PTSD is SSRI medication and cognitivebehavioral psychotherapy, along with therapy for any associated psychiatricillness, such as depression.

• If you suspect that a patient has PTSD, assess for substance abuse. Ifpatients are abusing or misusing substances, you should explain what resourcesare available to help them and discuss the particular risks of using drugsthat may cause dependence, such as short-acting benzodiazepines
• Encourage patients to use relaxation techniques
• Explain that the physical symptoms they experience are common to manypeople who have experienced a traumatic event. One statement might be:“Sometimes symptoms such as chronic fatigue, headaches, and stomachaches are the body's communication for posttraumatic stress”
• Identify feelings such as fear, anger, guilt, and helplessness, which mighthelp to alleviate the patient's physical symptoms

When Ms M experienced an attack of severe pain in the office of her primarycare practitioner, her physician contacted a psychiatrist for an immediateconsultation. The psychiatrist rendered the diagnosis of panic disorder andrecommended a treatment regimen involving an antidepressant agent, abenzodiazepine, and biweekly supportive and cognitive therapy. After 3 monthsof therapy, Ms M no longer had symptoms. The dosage of the benzodiazepine was tapered and she continued to be wellfor another 6 months while taking the antidepressant alone. Belleving that shewas cured, Ms M then discontinued the use of the antidepressant against theadvice of her psychiatrist. Two months later, her symptoms recurred and sheresumed taking the antidepressant. ​ antidepressant. Table 3 DSM-IV diagnostic criteria for anxiety disorder Panic disorders Rapid onset of fear, terror, or discomfort PLUS at least four of thefollowing: Palpitations Sweating Trembling or shaking Shortness of breath Choking Chest pain or tightness Nausea Hot flashes or chills Dizziness or lightheadedness Fear of dying or going crazy Feelings of unreality or depersonalization Generalized anxiety disorder Excessive anxiety and worry (apprehensive expectation occurring more daysthan not for at least 6 months) about events or activities, such as work orschool performance The patient finds it difficult to control the worry Anxiety and worry are associated with three or more of the followingsymptoms (at least one of which must be present more days than not for the 6months); Restlessness or feeling keyed up or on edge Being easily fatigued Difficulty concentrating or mind going blank Irritability Muscle tension Sleep disturbance (difficulty falling or staying asleep or restlessunsatisfying sleep) The focus of the anxiety and worry is not about having a panic attack,social phobia, obsessive-compulsive disorder, separation anxiety, gainingweight, having multiple physical complaints, or having serious illness; itnoes not occur exclusively during posttraumatic stress disorder Anxiety, worry, or physical symptoms cause clinically significant distressor impairment in social, occupational, or other important areas offunctioning The disturbance is not due to the direct physiologic effects of a substanceor a general medical condition and does not occur exclusively during a mood,psychotic, or a pervasive developmental disorder Posttraumatic stress disorder The person has been exposed to a traumatic event in which both of thefollowing were present: The person experienced, witnessed, or was confronted with an event orevents that involved actual or threatened death or serious injury or a threatto the physical integrity of self or others The person's response involved intense fear, helplessness, or horror. Inchildren, this may be expressed instead by disorganized or agitatedbehavior The traumatic event is persistently re-experienced in one (or more) of thefollowing ways: Recurrent and intrusive distressing recollections of the event, includingimages, thoughts, or perceptions. In young children, repetitive play may occurin which themes or aspects of the trauma are expressed Recurrent distressing dreams of the event. Children may have frighteningdreams without recognizable content Acting or feeling as if the traumatic event were recurring (includes asense of reliving the experience, illusions, hallucinations, and dissociativeflashback episodes, including those that occur on awakening or whenintoxicated). In young children, trauma-specific reenactment may occur Intense psychological distress at exposure to internal or external cuesthat symbolize or resemble an aspect of the traumatic event Physiologic reactivity on exposure to internal or external cues thatsymbolize or resemble an aspect of the traumatic event Persistent avoidance of stimuli associated with the trauma and numbing ofgeneral responsiveness (not present before the trauma), as indicated by three(or more) of the following: Efforts to avoid thoughts, feelings, or conversations associated with thetrauma Efforts to avoid activities, places, or people that arouse recollections ofthe trauma Inability to recall an important aspect of the trauma Diminished interest or participation in significant activities Feeling of detachment or estrangement from others Restricted range of affect (eg, unable to have loving feelings) Sense of a foreshortened future (eg, does not expect to have a career,marriage, children or a normal life span) Persistent symptoms of increased arousal (not present before the trauma) asindicated two (or more) of the following: Difficulty falling or staying asleep Irritability of outbursts of anger Difficulty concentrating Hypervigilance Exaggerated startle response Duration of the disturbance is more than 1 month. The disturbance causes clinically significant distress or impairment insocial, occupational, or other areas of functioning The condition is: Acute if duration of symptoms is less than 3 months Chronic if duration of symptoms is 3 months or more With delayed onset if onset of symptoms is at least 6 months after thestressor Open in a separate window

Dwarf ginseng ( Panax trifolius L.). The physiologic effects ofginseng may trigger or worsen anxiety

ROC/Taiwan Government Information Office

Difficulty concentrating and muscle tension are common signs of generalizedanxiety disorder

Competing interests: J-P Chen received speaker's fees from GlaxoSmith Kline and Pfizer, Inc; H Chung is Medical Director, Depression andAnxiety Management Team, Pfizer, Inc.

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Hannah, an anxious child

Hannah (not a real person) was a 10-year-old girl from a close, supportive family who was described as 'anxious from birth'. She had been a shy, reserved young girl at pre-school, but she integrated well in grade 1 and began making friends and succeeding academically. She complained several times of severe abdominal pain that was worst in the morning and never present at night. She had missed about 20 days of school during the previous year because of the pain. She also avoided school excursions, fearing the bus would crash. She had difficulty falling asleep and frequently asked her parents for their reassurance.

Hannah was worried that she and members of her family might die. She was unable to sleep at all before a test. She could not tolerate having her parents on a different floor of the house from herself, and she insisted on securing the house to an unnecessary extent in the evenings, fearing intruders. Her insecurity, need for constant reassurance, and school absenteeism were frustrating and upsetting for her parents.

Hannah had no personal history of traumatic events. She exhibits symptoms typical of childhood anxiety disorder, which is thought to occur in about 10% of children, equally in boys and girls before puberty. This type of disorder is diagnosed when anxiety is sufficient to interfere with daily functioning, for example Hannah's school attendance and sleep. These effects can increase and interfere to a progressively greater extent with age-appropriate functioning at home, at school and with peers, and also places sufferers at risk of developing mood disorders or substance abuse disorders in the future.

Many children experience fears; fears that are developmentally normal. Children with anxiety disorders, however, experience persistent fears or other symptoms of anxiety for months. Children can experience all the anxiety disorders experienced by adults. However, they can also experience separation anxiety disorder and selective mutism (failure to speak in certain social situations, thought to be related to social anxiety), which are unique to children. The duration of Hannah's difficulties and the symptoms, including inability to sleep, attend school regularly, go on school excursions, or face tests without extreme distress are all developmentally inappropriate, suggesting an anxiety disorder.

There is a range of common symptoms seen in anxious children. Symptoms involving thoughts include worrying, requests for reassurance, 'what if.' questions, and upsetting obsessive thoughts. Common symptoms involving behaviours include difficulty in separation, avoiding feared situations, tantrums when faced with fear, 'freezing' or mutism in feared situations, and repetitive rituals, or compulsions. Common symptoms involving feelings include panic attacks, hyperventilation, stomachaches, headaches and insomnia.

To screen quickly for one or more anxiety disorders in children, four questions are often useful:

• Does the child worry or ask for parental reassurance almost every day?
• Does the child consistently avoid certain age-appropriate situations or activities, or avoid doing them without a parent?
• Does the child frequently have stomachaches, headaches, or episodes of hyperventilation?
• Does the child have daily repetitive rituals?

These questions address the main thoughts, behaviours and feelings related to anxiety seen in children.

Megan Rodgers wishes to acknowledge an article entitled 'Childhood Anxiety Disorders' written by Dr Manassis, a Staff Psychiatrist at the Hospital for Sick Children and the Center for Addiction and Mental Health in Toronto, Ontario, on which this article is based.

Written by Megan Rodgers ADAVIC Volunteer June 2004

Potential of niacin skin flush response in adolescent depression identification and severity assessment: a case-control study

Affiliations.

• 1 Department of Psychosomatics, School of Medicine, Sichuan Provincial Center for Mental Health, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, No. 32, West second Section, 1st Ring Road, 610041, Chengdu, Sichuan, China.
• 2 Key Laboratory of Psychosomatic Medicine, Chinese Academy of Medical Sciences, Chengdu, China.
• 3 Bio-X Institutes, Key Laboratory for the Genetics of Developmental and Neuropsychiatric Disorders, Ministry of Education, Shanghai Jiao To ng University, Shanghai, China.
• 4 Sichuan Provincial Center for Mental Health, Sichuan Academy of Medical Science & Sichuan Provincial People's Hospital, No. 33, Section 2, Furong Avenue, Wenjiang District, 611135, Chengdu, Sichuan, China.
• 5 School of Nursing, Chengdu Medical College, Chengdu, China.
• 6 Department of Psychosomatics, School of Medicine, Sichuan Provincial Center for Mental Health, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, No. 32, West second Section, 1st Ring Road, 610041, Chengdu, Sichuan, China. [email protected].
• 7 Key Laboratory of Psychosomatic Medicine, Chinese Academy of Medical Sciences, Chengdu, China. [email protected].
• PMID: 38632560
• PMCID: PMC11025263
• DOI: 10.1186/s12888-024-05728-w

Background: The diagnosis of adolescent Depressive Disorder (DD) lacks specific biomarkers, posing significant challenges. This study investigates the potential of Niacin Skin Flush Response (NSFR) as a biomarker for identifying and assessing the severity of adolescent Depressive Disorder, as well as distinguishing it from Behavioral and Emotional Disorders typically emerging in childhood and adolescence(BED).

Methods: In a case-control study involving 196 adolescents, including 128 Depressive Disorder, 32 Behavioral and Emotional Disorders, and 36 healthy controls (HCs), NSFR was assessed. Depressive symptoms were measured using the Patient Health Questionnaire-9 (PHQ-9) and anxious symptoms with the Generalized Anxiety Disorder 7-item scale (GAD-7). Pearson correlation analysis determined the relationships between NSFR and the severity of depression in DD patients. Receiver Operating Characteristic (ROC) was used to identify DD from BED integrating NSFR data with clinical symptom measures.

Results: The adolescent Depressive Disorder group exhibited a higher rate of severe blunted NSFR (21.4%) compared to BED (12.5%) and HC ( 8.3%). Adolescent Depressive Disorder with psychotic symptoms showed a significant increase in blunted NSFR (p = 0.016). NSFR had negative correlations with depressive (r = -0.240, p = 0.006) and anxious (r = -0.2, p = 0.023) symptoms in adolescent Depressive Disorder. Integrating NSFR with three clinical scales improved the differentiation between adolescent Depressive Disorder and BED (AUC increased from 0.694 to 0.712).

Conclusion: The NSFR demonstrates potential as an objective biomarker for adolescent Depressive Disorder, aiding in screening, assessing severity, and enhancing insights into its pathophysiology and diagnostic precision.

Keywords: Adolescent depressive disorder; Behavioral and emotional disorders typically emerging in childhood and adolescence; Biomarker; Niacin skin flush response; Precision diagnosis.

© 2024. The Author(s).

• Anxiety Disorders / psychology
• Case-Control Studies

Grants and funding

• 2022NSFSC1550/the Youth Fund Project of Sichuan Provincial Science and Technology Department