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Why is anger a common response to trauma?

Anger is usually a central feature of a survivor's response to trauma because it is a core component of the survival response in humans. Anger helps people cope with life's adversities by providing us with increased energy to persist in the face of obstacles. However, uncontrolled anger can lead to a continued sense of being out of control of oneself and can create multiple problems in the personal lives of those who suffer from PTSD.

One theory of anger and trauma suggests that high levels of anger are related to a natural survival instinct. When initially confronted with extreme threat, anger is a normal response to terror, events that seem unfair, and feeling out of control or victimized. It can help a person survive by mobilizing all of his or her attention, thought, brain energy, and action toward survival. Recent research has shown that these responses to extreme threat can become "stuck" in persons with PTSD. This may lead to a survival mode response where the individual is more likely to react to situations with "full activation," as if the circumstances were life threatening, or self-threatening. This automatic response of irritability and anger in individuals with PTSD can create serious problems in the workplace and in family life. It can also affect the individuals' feelings about themselves and their roles in society.

Another line of research is revealing that anger can also be a normal response to betrayal or to losing basic trust in others, particularly in situations of interpersonal exploitation or violence.

Finally, in situations of early childhood abuse, the trauma and shock of the abuse has been shown to interfere with an individual's ability to regulate emotions, which leads to frequent episodes of extreme or out of control emotions, including anger and rage.

How can posttraumatic anger become a problem?

Researchers have described three components of posttraumatic anger that can become maladaptive or interfere with one's ability to adapt to current situations that do not involve extreme threat:

• Arousal: Anger is marked by the increased activation of the cardiovascular, glandular, and brain systems associated with emotion and survival. It is also marked by increased muscle tension. Sometimes with individuals who have PTSD, this increased internal activation can become reset as the normal level of arousal and can intensify the actual emotional and physical experience of anger. This can cause a person to feel frequently on-edge, keyed-up, or irritable and can cause a person to be more easily provoked. It is common for traumatized individuals to actually seek out situations that require them to stay alert and ward off potential danger. Conversely, they may use alcohol and drugs to reduce overall internal tension.
• Behavior: Often, the most effective way of dealing with extreme threat is to act aggressively, in a self-protective way. Additionally, many people who were traumatized at a relatively young age do not learn different ways of handling threat and tend to become stuck in their ways of reacting when they feel threatened. This is especially true of people who tend to be impulsive (who act before they think). Again, as stated above, while these strategies for dealing with threat can be adaptive in certain circumstances, individuals with PTSD can become stuck in using only one strategy when others would be more constructive. Behavioral aggression may take many forms, including aggression toward others, passive-aggressive behavior (e.g., complaining, "backstabbing," deliberately being late or doing a poor job), or self-aggression (self-destructive activities, self-blame, being chronically hard on oneself, self-injury).
• Thoughts and Beliefs: The thoughts or beliefs that people have to help them understand and make sense of their environment can often overexaggerate threat. Often the individual is not fully aware of these thoughts and beliefs, but they cause the person to perceive more hostility, danger, or threat than others might feel is necessary. For example, a combat veteran may become angry when others around him (wife, children, coworkers) don't "follow the rules." The strength of his belief is actually related to how important it was for him to follow rules during the war in order to prevent deaths. Often, traumatized persons are not aware of the way their beliefs are related to past trauma. For instance, by acting inflexibly toward others because of their need to control their environment, they can provoke others into becoming hostile, which creates a self-fulfilling prophecy. Common thoughts people with PTSD have include: "You can't trust anyone," "If I got out of control, it would be horrible/life-threatening/intolerable," "After all I've been through, I deserve to be treated better than this," and "Others are out to get me, or won't protect me, in some way."

How can individuals with posttraumatic anger get help?

In anger management treatment, arousal, behavior, and thoughts/beliefs are all addressed in different ways. Cognitive-behavioral treatment, a commonly utilized therapy that shows positive results when used to address anger, applies many techniques to manage these three anger components:

• For increased arousal, the goal of treatment is to help the person learn skills that will reduce overall arousal. Such skills include relaxation, self-hypnosis, and physical exercises that discharge tension.
• For behavior, the goal of treatment is to review a person's most frequent ways of behaving under perceived threat or stress and help him or her to expand the possible responses. More adaptive responses include taking a time out; writing thoughts down when angry; communicating in more verbal, assertive ways; and changing the pattern "act first, think later" to "think first, act later."
• For thoughts/beliefs, individuals are given assistance in logging, monitoring, and becoming more aware of their own thoughts prior to becoming angry. They are additionally given alternative, more positive replacement thoughts for their negative thoughts (e.g., "Even if I am out of control, I won't be threatened in this situation," or "Others do not have to be perfect in order for me to survive/be comfortable"). Individuals often role-play situations in therapy so they can practice recognizing their anger-arousing thoughts and applying more positive thoughts.

There are many strategies for helping individuals with PTSD deal with the frequent increase of anger they are likely to experience. Most individuals have a combination of the three anger components listed above, and treatment aims to help with all aspects of anger. One important goal of treatment is to improve a person's sense of flexibility and control so that he or she does not feel re-traumatized by his or her own explosive or excessive responses to anger triggers. Treatment is also meant to have a positive impact on personal and work relationships.

References

Chemtob, C.M., Novaco, R.W., Hamada, R.S., Gross, D.M., & Smith, G. (1997). Anger regulation deficits in combat-related posttraumatic stress disorder. Journal of Traumatic Stress, 10(1), 17-35.

Source: National Center for PTSD
Updated October 2003

Page last modified or reviewed by athealth on January 29, 2013

Events That Trigger Anger

When you get angry, it is because an event has provoked your anger. For example, you may get angry when the bus is late, when you have to wait in line at the grocery store, or when a neighbor plays his stereo too loud. Everyday events such as these can provoke your anger. Many times, specific events touch on sensitive areas in your life. These sensitive areas or "red flags" usually refer to long-standing issues that can easily lead to anger. For example, some of us may have been slow readers as children and may have been sensitive about our reading ability. Although we may read well now as adults, we may continue to be sensitive about this issue. This sensitivity may be revealed when someone rushes us while we are completing an application or reviewing a memorandum and may trigger anger because we may feel that we are being criticized or judged as we were when we were children. This sensitivity may also show itself in a more direct way, such as when someone calls us "slow" or "stupid."

In addition to events experienced in the here-and-now, you may also recall an event from your past that made you angry. You might remember, for example, how the bus always seemed to be late before you left home for an important appointment. Just thinking about how late the bus was in the past can make you angry in the present. Another example may be when you recall a situation involving a family member who betrayed or hurt you in some way. Remembering this situation, or this family member, can raise your number on the anger meter. Here are examples of events or issues that can trigger anger:

• Long waits to see your doctor
• Traffic congestion
• Crowded buses
• A friend joking about a sensitive topic
• A friend not paying back money owed to you
• Being wrongly accused
• Having to clean up someone else's mess
• Having an untidy roommate
• Having a neighbor who plays the stereo too loud
• Being placed on hold for long periods of time while on the telephone
• Being given wrong directions
• Rumors being spread about you that are not true
• Having money or property stolen from you.

Cues to Anger

A second important aspect of anger monitoring is to identify the cues that occur in response to the anger-provoking event. These cues serve as warning signs that you have become angry and that your anger is continuing to escalate. They can be broken down into four cue categories: physical, behavioral, emotional, and cognitive (or thought) cues.

Physical Cues. Physical cues involve the way our bodies respond when we become angry. For example, our heart rates may increase, we may feel tightness in our chests, or we may feel hot and flushed. These physical cues can also warn us that our anger is escalating out of control or approaching a 10 on the anger meter. We can learn to identify these cues when they occur in response to an anger-provoking event. Can you identify some of the physical cues that you have experienced when you have become angry?

Behavioral Cues. Behavioral cues involve the behaviors we display when we get angry, which are observed by other people around us. For example, we may clench our fists, pace back and forth, slam a door, or raise our voices. These behavioral responses are the second cue of our anger. As with physical cues, they are warning signs that we may be approaching a 10 on the anger meter. What are some of the behavioral cues that you have experienced when you have become angry?

Emotional Cues. Emotional cues involve other feelings that may occur concurrently with our anger. For example, we may become angry when we feel abandoned, afraid, discounted, disrespected, guilty, humiliated, impatient, insecure, jealous, or rejected. These kinds of feelings are the core or primary feelings that underlie our anger. It is easy to discount these primary feelings because they often make us feel vulnerable. An important component of anger management is to become aware of, and to recognize, the primary feelings that underlie our anger. Can you identify some of the primary feelings that you have experienced during an episode of anger?

Cognitive Cues. Cognitive cues refer to the thoughts that occur in response to the anger provoking event. When people become angry, they may interpret events in certain ways. For example, we may interpret a friend's comments as criticism, or we may interpret the actions of others as demeaning, humiliating, or controlling. Some people call these thoughts "self-talk" because they resemble a conversation we are having with ourselves. For people with anger problems, this self-talk is usually very critical and hostile in tone and content. It reflects beliefs about the way they think the world should be; beliefs about people, places, and things. Closely related to thoughts and self-talk are fantasies and images. We view fantasies and images as other types of cognitive cues that can indicate an escalation of anger. For example, we might fantasize about seeking revenge on a perceived enemy or imagine or visualize our spouse having an affair. When we have these fantasies and images, our anger can escalate even more rapidly. Can you think of other examples of cognitive or thought cues?

Strategies for Controlling Anger.

In addition to becoming aware of anger, you need to develop strategies to effectively manage it. These strategies can be used to stop the escalation of anger before you lose control and experience negative consequences. An effective set of strategies for controlling anger should include both immediate and preventive strategies.

Immediate strategies include taking a timeout, deep-breathing exercises, and thought stopping. Preventive strategies include developing an exercise program and changing your irrational beliefs. One example of an immediate anger management strategy worth exploring at this point is the timeout. The timeout can be used formally or informally. For now, we will only describe the informal use of a timeout. This use involves leaving a situation if you feel your anger is escalating out of control. For example, you may be a passenger on a crowded bus and become angry because you perceive that people are deliberately bumping into you. In this situation, you can simply get off the bus and wait for a less crowded bus.

The informal use of a timeout may also involve stopping yourself from engaging in a discussion or argument if you feel that you are becoming too angry. In these situations, it may be helpful to actually call a timeout or to give the timeout sign with your hands. This lets the other person know that you wish to immediately stop talking about the topic and are becoming frustrated, upset, or angry.

Anger Management: The A-B-C-D Model*

Albert Ellis developed a model that is consistent with the way we conceptualize anger management treatment. He called his model the A-B-C-D or rational-emotive model.

• A = Activating Situation or Event
• B = Belief System
  What you tell yourself about the event (your self-talk)
  Your beliefs and expectations of others
• C = Consequence
  How you feel about the event based on your self-talk
• D = Dispute
  Examine your beliefs and expectations. Are they unrealistic or irrational?

 *Based on the work of Albert Ellis, 1979, and Albert Ellis and R.A. Harper, 1975.

In A-B-C-D model, "A" stands for an activating event, what we have been calling the red-flag event.

"B" represents the beliefs people have about the activating event. Ellis claimed that it is not the events themselves that produce feelings such as anger, but our interpretations of and beliefs about the events.

"C" stands for the emotional consequences of events. In other words, these are the feelings people experience as a result of their interpretations of and beliefs concerning the event. According to Ellis and other cognitive behavioral theorists, as people become angry, they engage in an internal dialog, called "self-talk." For example, suppose you were waiting for a bus to arrive. As it approaches, several people push in front of you to board. In this situation, you may start to get angry. You may be thinking, "How can people be so inconsiderate! They just push me aside to get on the bus. They obviously don't care about me or other people." Examples of the irrational self-talk that can produce anger escalation are reflected in statements such as "People should be more considerate of my feelings," "How dare they be so inconsiderate and disrespectful," and "They obviously don't care about anyone but themselves."

Ellis says that people do not have to get angry when they encounter such an event. The event itself does not get them upset and angry; rather, it is people's interpretations of and beliefs concerning the event that cause the anger. Beliefs underlying anger often take the form of "should" and "must." Most of us may agree, for example, that respecting others is an admirable quality. Our belief might be, "People should always respect others." In reality, however, people often do not respect each other in everyday encounters. You can choose to view the situation more realistically as an unfortunate defect of human beings, or you can let your anger escalate every time you witness, or are the recipient of, another person's disrespect. Unfortunately, your perceived disrespect will keep you angry and push you toward the explosion phase. Ironically, it may even lead you to show disrespect to others, which would violate your own fundamental belief about how people should be treated.

Ellis' approach consists of identifying irrational beliefs and disputing them with more rational or realistic perspectives (in Ellis' model, "D" stands for dispute). You may get angry, for example, when you start thinking, "I must always be in control. I must control every situation." It is not possible or appropriate, however, to control every situation. Rather than continue with these beliefs, you can try to dispute them. You might tell yourself, "I have no power over things I cannot control," or "I have to accept what I cannot change." These are examples of ways to dispute beliefs that you may have already encountered in 12-Step programs such as Alcoholics Anonymous or Narcotics Anonymous.

People may have many other irrational beliefs that may lead to anger. Consider an example where a friend of yours disagrees with you. You may start to think, "Everyone must like me and give me approval." If you hold such a belief, you are likely to get upset and angry when you face rejection. However, if you dispute this irrational belief by saying, "I can't please everyone; some people are not going to approve of everything I do," you will most likely start to calm down and be able to control your anger more easily.

Another common irrational belief is, "I must be respected and treated fairly by everyone." This also is likely to lead to frustration and anger. Most folks, for example, live in an urban society where they may, at times, not be given the common courtesy they expect. This is unfortunate, but from an anger management perspective, it is better to accept the unfairness and lack of interpersonal connectedness that can result from living in an urban society. Thus, to dispute this belief, it is helpful to tell yourself, "I can't be expected to be treated fairly by everyone."

Other beliefs that may lead to anger include "Everyone should follow the rules," or "Life should be fair," or "Good should prevail over evil," or "People should always do the right thing." These are beliefs that are not always followed by everyone in society, and, usually, there is little you can do to change that. How might you dispute these beliefs? In other words, what thoughts that are more rational and adaptive and will not lead to anger can be substituted for such beliefs?

For people with anger control problems, these irrational beliefs can lead to the explosion phase (10 on the anger meter) and to the negative consequences of the post-explosion phase. It is often better to change your outlook by disputing your beliefs and creating an internal dialog or self-talk that is more rational and adaptive.

Anger Management: Thought Stopping

A second approach to controlling anger is called thought stopping. It provides an immediate and direct alternative to the A-B-C-D Model. In this approach, you simply tell yourself (through a series of self-commands) to stop thinking the thoughts that are getting you angry. For example, you might tell yourself, "I need to stop thinking these thoughts. I will only get into trouble if I keep thinking this way," or "Don't buy into this situation," or "Don't go there." In other words, instead of trying to dispute your thoughts and beliefs as outlined in the A-B-C-D Model described above, the goal is to stop your current pattern of angry thoughts before they lead to an escalation of anger and loss of control.

Adapted from: Reilly PM and Shopshire MS. Anger Management for Substance Abuse and Mental Health Clients: A Cognitive Behavioral Therapy Manual. DHHS Pub. No. (SMA) 02-3661. Rockville, MD: Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, 2002.

Page last modified or reviewed by athealth on January 29, 2014

Anger. Everybody experiences it and everybody expresses it. It is a natural and healthy human emotion when managed effectively. But it can be a source of various physical, mental, emotional, social, or legal problems when not managed effectively. It is often a problem in one of these areas that brings a client in for counseling, either on a voluntary or a mandated basis. As a counselor, there are numerous and varied options for intervention. And there are numerous and varied aspects to consider before selecting an appropriate intervention.

Defining Anger

There are many different views from which to consider the construct of anger. Dahlen and Deffenbacher (2001) identify three main ingredients to anger. First, there is an anger-eliciting stimulus, typically an easily-identifiable external source (e.g., somebody did something to me) or internal source (e.g., emotional wounds). Second, there is a pre-anger state, which includes one's cognitive, emotional, and physical state at the time of provocation; one's enduring psychological characteristics; and one's cultural messages about anger and about expressing anger. Third, there is one's appraisal of the anger-eliciting stimulus and one's ability to cope with the stimulus. All three of these ingredients interact to create a state of being angry.

Dahlen and Deffenbacher (2001) also identify four related domains in which anger exists. First, in the emotional and experiential domain, anger is a feeling state ranging in intensity from mild annoyance to rage and fury. Second, in the physiological domain, anger is associated with adrenal release, increased muscle tension, and activation of the sympathetic nervous system.

Third, in the cognitive domain, anger is associated with biased information processing. Fourth, in the behavior domain, anger can be either functional (e.g., being assertive, setting limits) or dysfunctional (e.g., being aggressive, withdrawing, using alcohol and drugs, etc.).

Rhoades (n.d.) provides additional ways to understand anger. What is the source and expression of the anger? Is it intense and situation-specific or chronic and generalized? What is the extent of the anger? Does it easily and quickly evolve into deep feelings of resentment? Is it coupled with intense aggression or explosiveness? Has it become uncontrollable? What is the anger hiding? Is it a cover-up for fear, being used as a shield to keep other people at a distance so they are unable to see one's insecurities and weaknesses?

Expressing Anger

The expression of anger can take many forms. Some common means of expressing anger include venting, resisting, seeking revenge, expressing dislike, avoiding the source of anger, and seeking help (Marion, 1997). However, in many cultures, people are taught that while expressing anxiety, depression or other emotions is acceptable, expressing anger is not (Controlling anger before it controls you, n.d.). As a result, many people never learn how to handle their own or others' anger effectively or to channel it constructively.

Gorkin (2000) distinguishes between the intention and the usefulness of anger expressions. In terms of intention, the expression of anger can be purposeful or spontaneous. The purposeful expression of anger is intentional, has a significant degree of consideration or calculation, and yields a high degree of self-control. The spontaneous expression of anger is immediate, has little premeditation, and yields little to moderate self-control.

In terms of usefulness, the expression of anger can be constructive or destructive. Constructive expression of anger affirms and acknowledges one's integrity and boundaries without intention to threaten another person. Destructive expression of anger defensively projects and rigidly fortifies one's vulnerable identity and boundaries. These distinctions provide for four basic expressions of anger. Purposeful and constructive expression leads to assertion. Purposeful and destructive expression leads to hostility. Spontaneous and constructive expression leads to passion and suffering. And spontaneous and destructive expression leads to rage, violence, screaming, and hitting. With respect to rage, one can be outraged, by a seemingly clear and external (sometimes criminal) target, or one can be "in-raged" (Gorkin, 2000), by a reaction to still unresolved internal hurts and humiliations (vs. actual, immediate stimulus-and-response provocation).

Although much of the work in anger management focuses on helping people understand what triggers their anger and on learning a healthier response, or expression, of that anger, the debate continues regarding the healthiest ways to express anger. Interestingly, some sources (e.g., Schwartz, 1990) indicate that repressing anger can be adaptive for coping with certain emotions. Other sources (e.g., Controlling anger before it controls you, n.d.) document that suppressing anger can lead to headaches, hypertension, high blood pressure, depression, emotional disturbances, gastrointestinal disorders, respiratory disorders, skin disorders, genitourinary disorders, arthritis, disabilities of the nervous system, circulatory disorders, and even suicide. It is important to learn to identify whether or not a client's reactions to and expressions of anger are a problem.

Assessing Anger

How does a client know when his or her anger is more of a problem than a help? Few formal assessments exist to quantifiably measure the level of one's anger. However, there are numerous qualitative indicators to review with clients to understand the extent of their concerns about their anger and anger management strategies.

• Is the anger chronic, long-lasting, too intense, or too frequent (Rhoades, n.d.)?
• Does the anger disrupt the client's thinking, affect the client's relationships (Rhoades, n.d.), or affect the client's school or work performance?
• Does the client exhibit frequent loss of temper at slight provocations, passive-aggressive behavior, a cynical or hostile personality, chronic irritability and grumpiness?
• Has the client begun to display low self-esteem, sulking, or brooding?
• Is the client withdrawing socially from family and friends?
• Is the client getting physically sick or doing damage to one's own or others' bodies or property?
• Is the client experiencing physical symptoms such as increased heart rate, increased blood pressure, or increased adrenaline flow (Controlling anger before it controls you, n.d.)?

Although some of these symptoms may be indicative of other issues, they are also often related to unresolved anger. The bottom line is that when a person becomes a victim to his or her anger, the anger is a problem.

Managing Anger

According to Wellness Reproductions (1991), there are three main methods of dealing with anger. First, there is "stuffing" one's anger, a process in which a person may or may not admit his or her anger to self or others and in which one avoids direct confrontations. A person may stuff his or her anger out of fear of hurting someone, fear of rejection, fear of damaging relationships or fear of losing control. Often, a person who stuffs anger is unable to cope with strong, intense emotions and thinks that anger is inappropriate or unacceptable. Stuffing one's anger typically results in impaired relationships and compromised physical and mental health.

Second, there is escalating one's anger, a process in which a person provokes blame and shame. The purpose is to demonstrate power and strength while avoiding the expression of underlying emotions. A person who escalates his or her anger is often afraid of getting close to other people and lacks effective communication skills. Escalating one's anger typically yields short-term results, impaired relationships, and compromised physical and mental health. Sometimes, escalating one's anger also leads to physical destruction of property or to abusive situations, thus adding the potential for legal ramifications.

Third, there is managing one's anger, a process in which a person is open, honest, and direct and in which one mobilizes oneself in a positive direction. The focus is on the specific behavior that triggered the anger and on the present (past issues are not brought into the current issue). A person who manages his or her anger avoids black and white thinking (e.g., never, always, etc.), uses effective communication skills to share feelings and needs, checks for possible compromises, and assesses what is at stake by choosing to stay angry versus dealing with the anger. Managing one's anger results in an increased energy level, effective communication skills, strengthened relationships, improved physical and mental health, and boosted self-esteem.

Summary

It is this process of managing one's anger that is the primary goal of counseling people to effectively deal with anger. The goal is not to eliminate anger. Anger is a natural and healthy emotion. After a client acknowledges he or she is angry, a counselor can help the client learn how to reduce the emotional and physiological arousal that anger causes and learn to control its effects on people and the environment. To be more effective, practitioners should attempt to understand the extent and expression of the anger, the specific problems resulting from the anger, the function the anger serves, the underlying source of the anger, and the domain the problems occur in (e.g. emotional, physiological, or cognitive) before choosing interventions for the client.

Specific strategies and skills as well as some additional considerations in helping clients manage anger are reviewed in Anger Management 2: Counseling Strategies and Skills.

References

Controlling anger before it controls you (n.d.). Retrieved July 23, 2003 from National Mental Health Association

Dahlen, E. R. & Deffenbacher, J. L. (2001). Anger management. In W. J. Lyddon. & J.

V. Jones, Jr. (Eds.), Empirically supported cognitive therapies: Current and future applications (pp. 163-181). New York: Springer Publishing Company.

Gorkin, M. (2000, August 17). The four faces of anger. Retrieved July 23, 2003

Marion, M. (1997). Guiding young children's understanding and management of anger. Young Children, 52(7), p. 62-67.

Rhoades, G. F. (n.d.) Anger management online conference transcript. Retrieved July 23, 2003

Schwartz, G. E. (1990). Psychobiology of repression and health: A systems approach. In J. L. Singer (Ed.), Repression and dissociation: Implications for personality theory, psychopathology, and health. Chicago: University of Chicago Press.

Wellness Reproductions. (1991). Anger management. Retrieved July 23, 2003

Source: ERIC Digest
ERIC Clearinghouse on Counseling and Student Services
ERIC Identifier: ED482766
2003-12-00
Author: Eileen K. Hogan

Page last modified or reviewed by athealth on January 29, 2014

Many different strategies and skills for anger management intervention have been tried and tested. Some of the most empirically supported interventions are cognitive-behavioral interventions including relaxation coping skills, cognitive interventions, behavioral coping and social skills training, and problem-solving skills training.

According to Dahlen and Deffenbacher (2001), relaxation coping skills target both the emotional and physiological arousal associated with anger with the intent being to lower the anger arousal. In contrast to targeting arousal, cognitive interventions target biases in information processing and cognitive appraisals. They help to identify distorted patterns of thinking, develop more reality-based and less anger-engendering cognitions, and free up problem-solving and coping resources.

Behavioral coping and social skills training target the actual expression of anger (vs. reducing anger arousal). Specific skills training that has been empirically supported includes direct coping skills (e.g., interpersonal communication, negotiation, feedback), related coping skills (e.g., parenting, budgeting and financial planning, assertive communication), and inductive social skills training (e.g., clients identify and explore effective behaviors for coping with anger) (Dahlen and Deffenbacher, 2001).

Problem-solving skills training is useful when there are no behavioral skill deficits (e.g., poor social skills) but there is a lack of general problem-solving skills with which to assess situations and to choose various coping skills. A basic problem-solving methodology is to identify the problem, generate alternative solutions, consider theconsequences of each solution, select an effective and appropriate response, and evaluate the outcomes of implementing the specific response (Skiba & McKelvey, 2000).

Additional strategies that have been found to be useful in managing anger effectively include avoiding situations that make one angry, changing environments, focusing on something positive, engaging in substitute positive activities, and improving communication and social skills. Humor has also been found to be helpful when it is used constructively to help face problems; sarcastic humor is just another form of unhealthy anger expression (Controlling anger before it controls you, n.d.).

Structured Programs

In addition to the strategies and skills highlighted above, there are numerous structured and pre-packaged programs for helping people learn to manage their anger more effectively. These programs vary in intended audience, theoretical basis, teaching method, and actual skills and techniques used. A summary of several programs can be found in Anger Management 3: Structured Interventions.

Additional Considerations in Anger Management Interventions

Cultural Impact of Client's Natural Environment

Howells and Day (2002) highlight the importance of understanding the culture a client returns to upon leaving a counseling or training session. Will the culture support the behavior changes and thinking processes that the client has been learning? In some cases (e.g., the gang a client hangs out with, incarcerated clients, institutionalized clients), the culture the client lives in day-to-day will not necessarily support the kinds of changes a client may be trying to make.

Indeed, daily survival may be based on vastly different modes of operation than a client may be practicing in counseling. It is important to clarify which culture is in charge of the client's daily life (e.g., the family and its subcultures? the street corner and friends? the neighborhood? the school and teachers?) and how it may affect a client's success in learning to manage anger more effectively.

Transferring Skills to the Classroom, Workplace, and Home

Another consideration is the adequate transfer of skills learned in counseling to one's natural environment. This could be the classroom, the workplace, or even one's home. Besley (1999) conducted an experiment on transferring skills to the classroom environment of a student client.

According to Besley (1999), change begins at a teachable moment, and four conditions are necessary for change:

• the person is in an environment where he or she feels safe,
• the person is supported and encouraged during the change process,
• the environment is relevant to the person, and
• the person is involved and has some degree of control in the change process.

In a school setting, when a counselor has been working with a student individually to develop more effective anger management skills, there still remains the issue of encouraging the student to use the new skills outside the counseling sessions (e.g., in the classroom, in the cafeteria, on the playground). One proven way to do this is to have the counselor sit in the classroom (or cafeteria or playground) with the student and be available to coach the student right at the moment(s) he or she becomes angry (Besley, 1999). The counselor can then coach the student's cognitive processes and help the student cope with impulsivity and, at the same time, model effective and useful skills for the other students and even the teacher.

Readiness for Anger Management Intervention

The best anger management training delivered by the most qualified counselor will be ineffective if the client is not ready for anger management training. According to Howells & Day (2003), there are several different things that can impact readiness for anger management.

Sometimes there are a complex array of factors presenting with the anger problem. People with certain mental and personality disorders may also have an anger management problem. Or anger management and control may be a symptom of a serious mental or personality disorder.

Existing client inferences about their anger "problem" can impact their readiness. Some clients may view anger as an appropriate response to many situations. Some clients may believe that catharsis is the best approach (expressing anger is considered better than controlling it) or that angry responses get results (in reality, although angry outbursts sometimes generate desired short- term results, they rarely result in long-term change). Attitudes of self-righteousness, low personal responsibility, blaming others, and condemning others also reduce readiness. For some clients, anger may not even be considered a problem. In fact, anger may be adaptive in certain settings for the client: it may bring with it many social benefits such as perceptions of higher status, strength, and competence. Unfortunately, these types of beliefs and perceptions can be difficult to uncover and assess.

The client's skill level also impacts readiness for effective treatment. People need certain cognitive processes with which to think about consequences and choices in order to improve anger management skills. Sometimes a person's impulsive nature will interfere with the application of such cognitive processes. Other issues that impact a client's readiness are difficulty judging the intent of others, underestimating one's own reaction to anger-provoking situations, wanting to blame conflict on others, an inability to distinguish one's feelings, and poor social and problem-solving skills.

Finally, the client's beliefs about treatment impact readiness. Even in coerced or mandatory treatment, if the client concurs with the need for treatment and perceives the treatment as likely to be helpful in meeting his or her goals, then coercion is not as big an issue. However, if the client believes the treatment is not likely to fulfill his or her personal goals, then coercion could definitely impact readiness.

How does a counselor positively influence the readiness variables? Counselors can explore the personal goals of the client and help the client become aware of any discrepancies between the actual social consequences of their anger expression and the pursuit of their personal goals. Counselors can work to incorporate the client's goals and treatment plan into the values and goals of the existing informal culture of the client.

Counselors can also help clients build appropriate interpersonal and cognitive skills and develop an appropriate vocabulary for communicating triggers, thoughts, emotions, and behaviors.

Variables that Influence Effective Treatment

In studies on the effect of anger management interventions with student populations, Skiba and McKelvey (2000) found three variables to have the most influence. First, the length of treatment: typically, more sessions yield stronger initial outcomes and booster sessions (e.g., annually) improve long-term outcomes. Second, proper framing: the more the training is made relevant to the student and the environments in which he or she lives on a daily basis, the stronger the initial outcomes. Finally, supplemental interventions (e.g., utilizing weekly goals, utilizing components of Aggression Replacement Training) help improve initial outcomes. Although these factors were studied specifically in reference to student populations, they are likely applicable to other client bases as well.

Summary

Anger. Everybody experiences it and everybody expresses it. Some people manage their anger in healthy ways. Other people are managed by their anger in unhealthy ways. Although there are many skills, strategies, and structured programs (see Anger Management 3: Structured Interventions) known to help people improve how they deal with anger, there are many factors to consider when selecting an effective intervention. In addition to understanding the expression, function, source, and resulting problems of a client's anger (see Anger Management 1: An Overview for Counselors), practitioners can also attempt to understand the client's cultural needs with respect to dealing with the problem, the ability of the client to transfer new skills to their daily environments, and the client's readiness and skill level for dealing with the problem. Only then can the practitioner choose an intervention that will be truly effective for the client.

For more information please see: Anger Management 1: An Overview for Counselors

References

Besley, K. R. (1999). Anger management: Immediate intervention by counselor coach. Professional School Counseling, 3(2), pp. 81-90.

Controlling anger before it controls you (n.d.). Retrieved July 23, 2003 from National Mental Health Association.

Dahlen, E. R. & Deffenbacher, J. L. (2001). Anger management. In W. J. Lyddon. & J. V. Jones, Jr. (Eds.), Empirically supported cognitive therapies: Current and future applications (pp. 163-181). New York: Springer Publishing Company.

Howells, K. & Day, A. (2003). Readiness for anger management: clinical and theoretical issues. Clinical Psychology Review, 23. pp. 319-337.

Skiba, R. & McKelvey, J. (2000). What works in preventing school violence: The safe and responsive fact sheet series - Anger management. Retrieved July 23, 2003 from What works in preventing school violence

Source: ERIC Digest
ERIC Clearinghouse on Counseling and Student Services
ERIC Identifier: ED482767
2003-12-00
Author: Eileen K. Hogan

Page last modified or reviewed by athealth on August 27, 2018

by James Lehman, MSW

Many parents make the mistake of assuming that since their child's behavior is connected to their feelings, fixing the feelings will fix the behavior. Unfortunately, nothing could be further from the truth. It's critical for parents to understand that processing your child's feelings while they are happening is not constructive. Children become overwhelmed with emotions, and by the time they're feeling angry or resentful, you're already way into a negative situation. The time to teach kids about fire safety is not when the curtains are burning. In the same way, appropriate behavior is best learned before the crisis. And make no bones about it, if your child is screaming, yelling or punching things, you are already in crisis mode. I like to remind parents that the Chinese symbol for crisis is a combination of the characters for "danger" and "opportunity." So when your child acts out, although it's a dangerous situation, also remember that it presents a good opportunity for learning to take place.

Many parents try to deal with their child's emotions first because they believe that's where the bad behavior is coming from. If your child gets angry and smashes his sister's dollhouse, asking him, "Why did you get angry?" or "Why did you do that?" is ineffective. It focuses on the emotion or the act itself, not the child's thinking behind the behavior, which is what you really need to address. Your goal is to help your child solve the problem from which his feelings emanate, the thinking that sparks the emotion. The key is to focus on the underlying thinking and the faulty problem-solving that triggers the whole crisis.

It's important to acknowledge that most kids solve problems by being compliant. For instance, when you tell one child, "You can't ride your bike, it's too close to dinner," that child might shrug and say, "OK," and come into the house. But some kids solve problems by being defiant. If you tell another child exactly the same thing, he might answer you with, "I don't care. Ben rides his bike! Why do I have to do this?" He starts raising his voice, getting more and more frustrated and angry. The underlying thought for the kid who acts out is probably something like, "This isn't fair, you don't have the right to stop me, other parents let their kids do it," or some other thought which triggers a negative emotional response. Focusing this kid on his feelings of anger and frustration will not change his behavior.

Instead, you have to focus him on the original thought or perception that made him think your direction wasn't fair, and the inappropriate behavior he used to solve the problem of "fairness." In life, the problem for everyone - including your child - is that things are not always going to feel fair. There's injustice in life, and injustice leads to frustration. Or there are times when you want to do something, but it's just not the right time. And that can lead to frustration and anger for your child if he doesn't process it the right way.

How do you start effecting this change in your child's perceptions? The next time your child acts out, instead of asking him why he did it, try saying, "Let's look at what you do when you get angry." That way, you're teaching him that he's angry and getting him to look at what he's doing with the anger. The primary goal of behavioral change is to get people to do something different when they're upset, angry, or afraid. The next step is to ask, "The next time this happens, what can you do differently?" Don't try to tell him, "You shouldn't feel this way," or "Those feelings aren't valid." Just say, "The next time you feel this way, what can you do differently?" It's a very different process than the one that begins with "Why do you feel that way?" or "Why did you do that?" When you ask those questions, you're going to get all the excuses and justifications which are so detrimental to actual problem-solving.

Make the shift. Focus on your child's thinking, not his emotions. This is the most powerful step you can make toward changing his behavior.

Angry Child? Fix the Behavior, Not the Feelings reprinted with permission from Empowering Parents.

Author: James Lehman is a behavioral therapist and the creator of The Total Transformation® Program for parents. He has worked with troubled children and teens for three decades. James holds a Masters Degree in Social Work from Boston University.

Page last modified or reviewed by athealth on January 29, 2014

What is anorexia?

Anorexia, or anorexia nervosa, is an eating disorder. Anorexics have a problem keeping their body weight in a normal range or even above a minimal weight level considered to be healthy.

There are two types of anorexia:

• Restricting Type: The first type of anorexia, called restricting, is found in those anorexics who severely limit their caloric intake and/or who exercise to excess to cause weight loss.
• Binge-Eating/Purging Type: The second type of anorexia, called binge-eating/purging, is found in those anorexics who eat in binges and then purge the body of the ingested food either by self-induced vomiting, the ingestion of large quantities of laxatives, the overuse of diuretics and enemas to rid the body of food.

What characteristics are associated with anorexia?

Anorexics do not accurately see, or perceive, their body's shape and weight. They fear weight gain, and they work hard to stay thin.

In most cases anorexics actually lose weight. Weight loss usually occurs because of a severe reduction in caloric intake. In addition, weight loss is achieved by self-induced vomiting, the use of diuretics (water pills), and the use of laxatives. Many anorexics also exercise to excess in an attempt to burn calories.

Some anorexics develop anorexia during their growing period by failing to gain weight properly.

Young women with this disorder sometimes fail to have their regular menstrual cycles.

Are there genetic factors associated with anorexia?

The person with a family member who has had an eating disorder is at higher risk for developing anorexia. Also, mood disorders are seen more frequently in families where someone has anorexia.

Does anorexia affect males, females, or both?

Anorexia is primarily a disorder of females. Only rarely is it found in males.

At what age does anorexia appear?

Anorexia is usually diagnosed when the young person is between the ages of 15 and 20 years. It is quite common for the first signs of anorexia to appear following a personally stressful event during adolescence. People in their 20's and 30's may have anorexia however, it is rare to see anorexia in an individual over 40 years of age.

How often is anorexia seen in our society?

In the United States approximately 7 out of every 100 females have some form of eating disorder. Research shows that anorexia is found in about one percent (1%) of young women in their late adolescence or early adulthood.

How is anorexia diagnosed?

Individuals with anorexia do not worry about their weight loss. Therefore, they generally do not seek professional help. Parents, other relatives, or friends are often responsible for getting the necessary help for the family member suffering from anorexia.

The diagnosis of anorexia is made when the anorexic either loses fifteen percent (15%) of their weight or when the growing child fails to acquire eighty-five percent (85%) of the minimal weight for their particular age and height. As mentioned above, young people with anorexia do not see themselves as overly thin, and they gain a great sense of achievement by keeping themselves trim. A history of excessive exercise, self-induced vomiting, and the overuse of laxatives or diuretics helps the mental health professional make a diagnosis of anorexia.

How is anorexia treated?

Individual and/or group therapy is important for those with anorexia. Group members can offer each other valuable support in monitoring eating and weight gain and in dealing with such issues as self-esteem. Most people with anorexia can be treated as outpatients. However, if the anorexic has lost too much weight and their health is in danger, hospitalization is necessary.

Various medications have been tried in the treatment of anorexia, and none are considered to be very effective. However, medications can be quite helpful for those with anorexia who also have anxiety and/or depression.

A major focus of treatment is to help the anorexic begin to develop normal eating habits and to work toward the goal of achieving a healthy, normal weight. The person with anorexia must learn about the detrimental effects of starvation on the body. And, it is important for the anorexic to learn about the harmful effects of frequent vomiting and/or excessive use of laxatives.

What happens to someone with anorexia?

Anorexia has a wide spectrum of outcomes. It is not unusual for a young person to have only one brief episode of anorexia lasting a few weeks to several months. However, it is also not uncommon for a person to suffer from the illness during most of adolescence and into early adulthood. It is very important to recognize that up to five percent (5%) of those with anorexia actually die of their illness.

What can people do if they need help?

If you, a friend, or a family member would like more information and you have a therapist or a physician, please discuss your concerns with that person.

Page last modified or reviewed by athealth on January 29, 2014

Depression is a serious disorder that can cause significant problems in mood, thinking, and behavior at home, in school, and with peers. It is estimated that major depressive disorder (MDD) affects about 5 percent of adolescents.

Research has shown that, as in adults, depression in children and adolescents is treatable. Certain antidepressant medications, called selective serotonin reuptake inhibitors (SSRIs), can be beneficial to children and adolescents with MDD. Certain types of psychological therapies also have been shown to be effective. However, our knowledge of antidepressant treatments in youth, though growing substantially, is limited compared to what we know about treating depression in adults.

Recently, there has been some concern that the use of antidepressant medications themselves may induce suicidal behavior in youths. Following a thorough and comprehensive review of all the available published and unpublished controlled clinical trials of antidepressants in children and adolescents, the U.S. Food and Drug Administration (FDA) issued a public warning in October 2004 about an increased risk of suicidal thoughts or behavior (suicidality) in children and adolescents treated with SSRI antidepressant medications. In 2006, an advisory committee to the FDA recommended that the agency extend the warning to include young adults up to age 25.

More recently, results of a comprehensive review of pediatric trials conducted between 1988 and 2006 suggested that the benefits of antidepressant medications likely outweigh their risks to children and adolescents with major depression and anxiety disorders. The study, partially funded by NIMH, was published in the April 18, 2007, issue of the Journal of the American Medical Association.¹

What Did the FDA Review Find?

In the FDA review, no completed suicides occurred among nearly 2,200 children treated with SSRI medications. However, about 4 percent of those taking SSRI medications experienced suicidal thinking or behavior, including actual suicide attempts - twice the rate of those taking placebo, or sugar pills.

In response, the FDA adopted a "black box" label warning indicating that antidepressants may increase the risk of suicidal thinking and behavior in some children and adolescents with MDD. A black-box warning is the most serious type of warning in prescription drug labeling.

The warning also notes that children and adolescents taking SSRI medications should be closely monitored for any worsening in depression, emergence of suicidal thinking or behavior, or unusual changes in behavior, such as sleeplessness, agitation, or withdrawal from normal social situations. Close monitoring is especially important during the first four weeks of treatment. SSRI medications usually have few side effects in children and adolescents, but for unknown reasons, they may trigger agitation and abnormal behavior in certain individuals.

What Do We Know About Antidepressant Medications?

The SSRIs include:

• fluoxetine (Prozac)
• sertraline (Zoloft)
• paroxetine (Paxil)
• citalopram (Celexa)
• escitalopram (Lexapro)
• fluvoxamine (Luvox)

Another antidepressant medication, venlafaxine (Effexor), is not an SSRI but is closely related.

SSRI medications are considered an improvement over older antidepressant medications because they have fewer side effects and are less likely to be harmful if taken in an overdose, which is an issue for patients with depression already at risk for suicide. They have been shown to be safe and effective for adults.

However, use of SSRI medications among children and adolescents ages 10 to 19 has risen dramatically in the past several years. Fluoxetine (Prozac) is the only medication approved by the FDA for use in treating depression in children ages 8 and older. The other SSRI medications and the SSRI-related antidepressant venlafaxine have not been approved for treatment of depression in children or adolescents, but doctors still sometimes prescribe them to children on an "off-label" basis. In June 2003, however, the FDA recommended that paroxetine not be used in children and adolescents for treating MDD.

Fluoxetine can be helpful in treating childhood depression, and can lead to significant improvement of depression overall. However, it may increase the risk for suicidal behaviors in a small subset of adolescents. As with all medical decisions, doctors and families should weigh the risks and benefits of treatment for each individual patient.

What Should You Do for a Child With Depression?

A child or adolescent with MDD should be carefully and thoroughly evaluated by a doctor to determine if medication is appropriate. Psychotherapy often is tried as an initial treatment for mild depression. Psychotherapy may help to determine the severity and persistence of the depression and whether antidepressant medications may be warranted. Types of psychotherapies include "cognitive behavioral therapy," which helps people learn new ways of thinking and behaving, and "interpersonal therapy," which helps people understand and work through troubled personal relationships.

Those who are prescribed an SSRI medication should receive ongoing medical monitoring. Children already taking an SSRI medication should remain on the medication if it has been helpful, but should be carefully monitored by a doctor for side effects. Parents should promptly seek medical advice and evaluation if their child or adolescent experiences suicidal thinking or behavior, nervousness, agitation, irritability, mood instability, or sleeplessness that either emerges or worsens during treatment with SSRI medications.

Once started, treatment with these medications should not be abruptly stopped. Although they are not habit-forming or addictive, abruptly ending an antidepressant can cause withdrawal symptoms or lead to a relapse. Families should not discontinue treatment without consulting their doctor.

All treatments can be associated with side effects. Families and doctors should carefully weigh the risks and benefits, and maintain appropriate follow-up and monitoring to help control for the risks.

What Does Research Tell Us?

An individual's response to a medication cannot be predicted with certainty. It is extremely difficult to determine whether SSRI medications increase the risk for completed suicide, especially because depression itself increases the risk for suicide and because completed suicides, especially among children and adolescents, are rare. Most controlled trials are too small to detect for rare events such as suicide (thousands of participants are needed). In addition, controlled trials typically exclude patients considered at high risk for suicide.

One major clinical trial, the NIMH-funded Treatment for Adolescents with Depression Study (TADS)², has indicated that a combination of medication and psychotherapy is the most effective treatment for adolescents with depression. The clinical trial of 439 adolescents ages 12 to 17 with MDD compared four treatment groups - one that received a combination of fluoxetine and CBT, one that received fluoxetine only, one that received CBT only, and one that received a placebo only. After the first 12 weeks, 71 percent responded to the combination treatment of fluoxetine and CBT, 61 percent responded to the fluoxetine only treatment, 43 percent responded to the CBT only treatment, and 35 percent responded to the placebo treatment.

At the beginning of the study, 29 percent of the TADS participants were having clinically significant suicidal thoughts. Although the rate of suicidal thinking decreased among all the treatment groups, those in the fluoxetine/CBT combination treatment group showed the greatest reduction in suicidal thinking.

Researchers are working to better understand the relationship between antidepressant medications and suicide. So far, results are mixed. One study, using national Medicaid files, found that among adults, the use of antidepressants does not seem to be related to suicide attempts or deaths. However, the analysis found that the use of antidepressant medications may be related to suicide attempts and deaths among children and adolescents.³

Another study analyzed health plan records for 65,103 patients treated for depression.⁴ It found no significant increase among adults and young people in the risk for suicide after starting treatment with newer antidepressant medications.

A third study analyzed suicide data from the National Vital Statistics and commercial prescription data. It found that among children ages five to 14, suicide rates from 1996 to 1998 were actually lower in areas of the country with higher rates of SSRI antidepressant prescriptions. The relationship between the suicide rates and the SSRI use rates, however, is unclear.⁵

New NIMH-funded research will help clarify the complex interplay between suicide and antidepressant medications. In addition, the NIMH-funded Treatment of Resistant Depression in Adolescents (TORDIA) study, will investigate how best to treat adolescents whose depression is resistant to the first SSRI medication they have tried. Finally, NIMH also is supporting the Treatment of Adolescent Suicide Attempters (TASA) study, which is investigating the treatment of adolescents who have attempted suicide. Treatments include antidepressant medications, CBT or both.

Resources

Bridge JA, Iyengar S, Salary CB, Barbe RP, Birmaher B, Pincus HA, Ren L, Brent DA, MD. Clinical Response and Risk for Reported Suicidal Ideation and Suicide Attempts in Pediatric Antidepressant Treatment: A Meta-analysis of Randomized Controlled Trials. JAMA. 2007;297:1683-1696.

Treatment for Adolescents with Depression Study (TADS) Team. Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: Treatment for Adolescents with Depression Study (TADS) randomized controlled trial. Journal of the American Medical Association, 2004 Aug 18; 292(7):807-20.

Olfson M, Marcus SC, Shaffer D. Antidepressant Drug Therapy and Suicide in Severely Depressed Children and Adults. Archives of General Psychiatry. 2006 Aug. 63:865-72

Simon GE, Savarino J, Operskalski B, Wang P. Suicide Risk During Antidepressant Treatment. American Journal of Psychiatry. 2006. 163 (1): 41-47.

Gibbons RD, Hur K, Bhaumik DK, Mann JJ. The relationships between antidepressant prescription rates and rate of early adolescent suicide. American Journal of Psychiatry 2006. 163 (11): 1898-1904

National Institute of Mental Health (NIMH)
Page last reviewed by NIMH: January 05, 2011

Page last modified or reviewed by athealth on January 29, 2014

Antisocial personality disorder (APD) is a psychiatric disorder characterized by chronic and pervasive patterns of behavior that disregard and violate the rights of others. These patterns of behavior begin in childhood or early adolescence and continue into adulthood.

Individuals with APD exhibit signs of antisocial behavior such as unlawful behavior, deceitfulness, consistent irresponsibility, physical fighting, disregard for the safety of self and others, and lack of guilt or remorse. The diagnosis requires that the individual be at least 18 years of age and have had a history of some symptoms of conduct disorder before the age of 15.

Individuals with antisocial personalty disorder frequently lack empathy and tend to show contempt for the feelings and suffering of others. They may have an inflated self-opinion and can display superficial charm to gain money, sex, or power.

People with APD often use faulty rationalizations to justify their behavior. Examples include excuse making, blaming someone or something else for causing the behavior, lying, thinking that they're special and that the rules don't apply to them, victim playing, grandiosity, and using power plays to get their way.

More men than women are diagnosed with APD, although some women with APD may be misdiagnosed as borderline personality disorder (BPD). Determining the type and extent of antisocial symptoms for women is not easy ( Rutherford et al. 1999), but it is important because of the high prevalence of neglectful parenting in women with substance use disorders and APD ( Goldstein et al. 1999).

Substance Use Among People with Antisocial Personality Disorder

Many people with APD use substances in a polydrug pattern involving alcohol, marijuana, heroin, cocaine, and methamphetamine. The illicit drug culture can correspond with their view of the world as fast-paced and dramatic, which supports their need for a heightened self-image. Consequently, they may be involved in crime and other sensation-seeking, high-risk behavior.

APD appears to be a failure to attach. The people with this diagnosis appear deficient in their ability to experience shared or reciprocal emotions such as guilt or love. Individuals with APD disdain society's rules; they know right from wrong but they do not care. They may be excited by the illicit drug culture and may have considerable pride in their ability to thrive in the face of the dangers of that culture. They are often in trouble with the law. If they are more effective, they may limit themselves to exploitive or manipulative behavior that does not make them so vulnerable to spending time in jail.
Treatment

Antisocial personality disorder is difficult to treat. Individual treatment for the disorder is often mandated by a court.

Clients with APD are often said to "act out" tension or conflict. Behaviors that interfere with treatment, which might even result in a client being sent immediately to jail, are seen by therapists as a form of resistance to whatever happens to be the focus of therapy at the time. Substance abuse treatment counselors working with clients with APD often sense resistance to substance abuse treatment and its goals.

In addition to an objective psychosocial and criminal history, the following steps may be useful in assessing the antisocial client:

• Taking a thorough family history.
• Finding out whether the client set fires as a child, abused animals, or was a bed-wetter.
• Taking a thorough sexual history that includes questions about animals and objects. Asking about any unusual or out-of-the-ordinary sexual experiences may serve as a lead-in and as a means to gauge how the client responds to questions about such personal areas.
• Taking a history of the client's ability to bond with others. Counselors can ask, "Who was your first best friend?" "When was the last time you saw him or her?" "Do you know how he or she is?" "Is there any authority figure who has ever been helpful to you?"
• Asking questions to find out about possible parasitic relationships and taking a history of exploitation of self and others. In this context, parasitic refers to a relationship in which one person uses and manipulates another until the first has gotten everything he or she wants, then abandons the relationship.
• Taking a history of head injuries, fighting, and being hit. It may be useful to refer for neuropsychological testing.
• Testing urine for recent substance use.
• HIV testing.

The assessment should consider criminal thinking patterns, such as rationalization and justification for maladaptive behaviors. There is a special need to establish collateral contacts and to assess for criminal history and the relationship of substance use to behavior.

References:

Ball SA. Manualized treatment for substance abusers with personality disorders: Dual Focus Schema Therapy. Addictive Behaviors. 23((6)):883-891; 1998. (PubMed)

Ball SA, Young JE. Dual focus schema therapy for personality disorders and substance dependence: Case study results. Cognitive and Behavioral Practice. 7((3)):270-281; 2000.

Barley, W.D. Behavioral and cognitive treatment of criminal and delinquent behavior. In: Reid, W.H., Dorr, D., Walker, J.I., and Bonner, J.W., III, eds. Unmasking the Psychopath: Antisocial Personality and Related Syndromes. New York: W.W. Norton, 1986. pp. 159-190.

Carlson MJ, Baker LH. Difficult, dangerous, and drug seeking: The 3D way to better patient care. American Journal of Public Health. 88((8)):1250-1252; 1998. (PubMed)

Doren, D.M. Understanding and Treating the Psychopath. New York: John Wiley and Sons, 1987.

Evans, K., and Sullivan, J.M. Step Study Counseling with the Dual Disordered Client. Center City, MN: Hazelden Educational Materials, 1990.

Fisher MS. Group therapy protocols for persons with personality disorders who abuse substances: Effective treatment alternatives. Social Work With Groups. 18((4)):71-89; 1995.

Goldstein RB, Powers SI, McCusker J. Erratum to "Antisocial behavioral syndromes among residential drug abuse treatment clients". Drug & Alcohol Dependence. 53((2)):171-187; 1999. (PubMed)

Greene DC, McVinney LD. Outpatient group psychotherapy with chemically dependent and cluster-B personality disordered male clients. Journal of Chemical Dependency Treatment. 7((1/2)):81-96; 1997.

Hare RD. The Hare PCL-R: Some issues concerning its use and misuse. Legal and Criminological Psychology. 3((Part 1)):99-119; 1998.

Messina NP, Wish ED, Nemes S. Therapeutic community treatment for substance abusers with antisocial personality disorder. Journal of Substance Abuse Treatment. 17((1-2)):121-128; 1999. (PubMed)

Nadeau L, Landry M, Racine S. Prevalence of personality disorders among clients in treatment for addiction. Canadian Journal of Psychiatry. 44((6)):592-596; 1999.

O'Connell, D.F. Dual Disorders: Essentials for Assessment and Treatment. New York: Haworth Press, 1998.

Raine, A., Lencz, T., Bihrle, S., LaCasse, L., and Colletti, P. Reduced prefrontal gray matter volume and reduced autonomic activity in antisocial personality disorder. Archives of General Psychiatry 57(2):119-127; discussion 128-129, 2000.

Rutherford MJ, Cacciola JS, Alterman AI. Antisocial personality disorder and psychopathy in cocaine-dependent women. American Journal of Psychiatry. 156((6)):849-856; 1999. (PubMed)

Seivewright N, Daly C. Personality disorder and drug use: A review. Drug & Alcohol Review. 16((3)):235-250; 1997. (PubMed)

Vaillant, G.E. The Natural History of Alcoholism Revisited. Cambridge: Harvard University Press, 1995.

Windle M. Psychopathy and antisocial personality disorder among alcoholic inpatients. Journal of Studies on Alcohol. 60((3)):330-336; 1999. (PubMed)

Adapted from Substance Abuse Treatment for Persons with Co-Occurring Disorders:
Treatment Improvement Protocol 42
DHHS Publication No. (SMA) 05-3922

Page last modified or reviewed by athealth on January 29, 2014

Introduction

Anxiety Disorders affect about 40 million American adults age 18 years and older (about 18%) in a given year,¹ causing them to be filled with fearfulness and uncertainty. Unlike the relatively mild, brief anxiety caused by a stressful event (such as speaking in public or a first date), anxiety disorders last at least 6 months and can get worse if they are not treated. Anxiety disorders commonly occur along with other mental or physical illnesses, including alcohol or substance abuse, which may mask anxiety symptoms or make them worse. In some cases, these other illnesses need to be treated before a person will respond to treatment for the anxiety disorder.

Effective therapies for anxiety disorders are available, and research is uncovering new treatments that can help most people with anxiety disorders lead productive, fulfilling lives. If you think you have an anxiety disorder, you should seek information and treatment right away.

This booklet will

• describe the symptoms of anxiety disorders,
• explain the role of research in understanding the causes of these conditions,
• describe effective treatments,
• help you learn how to obtain treatment and work with a doctor or therapist, and
• suggest ways to make treatment more effective.

The following anxiety disorders are discussed in this brochure:

• panic disorder
• obsessive-compulsive disorder (OCD)
• post-traumatic stress disorder (PTSD)
• social phobia (or social anxiety disorder)
• specific phobias and
• generalized anxiety disorder (GAD)

Each anxiety disorder has different symptoms, but all the symptoms cluster around excessive, irrational fear and dread.

Panic Disorder

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

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

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

Panic disorder is a real illness that can be successfully treated. It is characterized by sudden attacks of terror, usually accompanied by a pounding heart, sweatiness, weakness, faintness, or dizziness. During these attacks, people with panic disorder may flush or feel chilled; their hands may tingle or feel numb; and they may experience nausea, chest pain, or smothering sensations. Panic attacks usually produce a sense of unreality, a fear of impending doom, or a fear of losing control.

A fear of one's own unexplained physical symptoms is also a symptom of panic disorder. People having panic attacks sometimes believe they are having heart attacks, losing their minds, or on the verge of death. They can't predict when or where an attack will occur, and between episodes many worry intensely and dread the next attack.

Panic attacks can occur at any time, even during sleep. An attack usually peaks within 10 minutes, but some symptoms may last much longer.

Panic disorder affects about 6 million American adults ¹ and is twice as common in women as men.² Panic attacks often begin in late adolescence or early adulthood,² but not everyone who experiences panic attacks will develop panic disorder. Many people have just one attack and never have another. The tendency to develop panic attacks appears to be inherited.³

People who have full-blown, repeated panic attacks can become very disabled by their condition and should seek treatment before they start to avoid places or situations where panic attacks have occurred. For example, if a panic attack happened in an elevator, someone with panic disorder may develop a fear of elevators that could affect the choice of a job or an apartment, and restrict where that person can seek medical attention or enjoy entertainment.

Some people's lives become so restricted that they avoid normal activities, such as grocery shopping or driving. About one-third become housebound or are able to confront a feared situation only when accompanied by a spouse or other trusted person.² When the condition progresses this far, it is called agoraphobia, or fear of open spaces.

Early treatment can often prevent agoraphobia, but people with panic disorder may sometimes go from doctor to doctor for years and visit the emergency room repeatedly before someone correctly diagnoses their condition. This is unfortunate, because panic disorder is one of the most treatable of all the anxiety disorders, responding in most cases to certain kinds of medication or certain kinds of cognitive psychotherapy, which help change thinking patterns that lead to fear and anxiety.

Panic disorder is often accompanied by other serious problems, such as depression, drug abuse, or alcoholism.^4,5 These conditions need to be treated separately. Symptoms of depression include feelings of sadness or hopelessness, changes in appetite or sleep patterns, low energy, and difficulty concentrating. Most people with depression can be effectively treated with antidepressant medications, certain types of psychotherapy, or a combination of the two.

Obsessive-Compulsive Disorder

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

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

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

People with obsessive-compulsive disorder (OCD) have persistent, upsetting thoughts (obsessions) and use rituals (compulsions) to control the anxiety these thoughts produce. Most of the time, the rituals end up controlling them.

For example, if people are obsessed with germs or dirt, they may develop a compulsion to wash their hands over and over again. If they develop an obsession with intruders, they may lock and relock their doors many times before going to bed. Being afraid of social embarrassment may prompt people with OCD to comb their hair compulsively in front of a mirror-sometimes they get "caught" in the mirror and can't move away from it. Performing such rituals is not pleasurable. At best, it produces temporary relief from the anxiety created by obsessive thoughts.

Other common rituals are a need to repeatedly check things, touch things (especially in a particular sequence), or count things. Some common obsessions include having frequent thoughts of violence and harming loved ones, persistently thinking about performing sexual acts the person dislikes, or having thoughts that are prohibited by religious beliefs. People with OCD may also be preoccupied with order and symmetry, have difficulty throwing things out (so they accumulate), or hoard unneeded items.

Healthy people also have rituals, such as checking to see if the stove is off several times before leaving the house. The difference is that people with OCD perform their rituals even though doing so interferes with daily life and they find the repetition distressing. Although most adults with OCD recognize that what they are doing is senseless, some adults and most children may not realize that their behavior is out of the ordinary.

OCD affects about 2.2 million American adults,¹ and the problem can be accompanied by eating disorders,⁶ other anxiety disorders, or depression.^2,4 It strikes men and women in roughly equal numbers and usually appears in childhood, adolescence, or early adulthood.² One-third of adults with OCD develop symptoms as children, and research indicates that OCD might run in families.³

The course of the disease is quite varied. Symptoms may come and go, ease over time, or get worse. If OCD becomes severe, it can keep a person from working or carrying out normal responsibilities at home. People with OCD may try to help themselves by avoiding situations that trigger their obsessions, or they may use alcohol or drugs to calm themselves.^4,5

OCD usually responds well to treatment with certain medications and/or exposure-based psychotherapy, in which people face situations that cause fear or anxiety and become less sensitive (desensitized) to them. NIMH is supporting research into new treatment approaches for people whose OCD does not respond well to the usual therapies. These approaches include combination and augmentation (add-on) treatments, as well as modern techniques such as deep brain stimulation.

Post-Traumatic Stress Disorder (PTSD)

"I was raped when I was 25 years old. For a long time, I spoke about the rape as though it was something that happened to someone else. I was very aware that it had happened to me, but there was just no feeling."

"Then I started having flashbacks. They kind of came over me like a splash of water. I would be terrified. Suddenly I was reliving the rape. Every instant was startling. I wasn't aware of anything around me, I was in a bubble, just kind of floating. And it was scary. Having a flashback can wring you out."

"The rape happened the week before Thanksgiving, and I can't believe the anxiety and fear I feel every year around the anniversary date. It's as though I've seen a werewolf. I can't relax, can't sleep, don't want to be with anyone. I wonder whether I'll ever be free of this terrible problem."

Post-traumatic stress disorder (PTSD) develops after a terrifying ordeal that involved physical harm or the threat of physical harm. The person who develops PTSD may have been the one who was harmed, the harm may have happened to a loved one, or the person may have witnessed a harmful event that happened to loved ones or strangers.

PTSD was first brought to public attention in relation to war veterans, but it can result from a variety of traumatic incidents, such as mugging, rape, torture, being kidnapped or held captive, child abuse, car accidents, train wrecks, plane crashes, bombings, or natural disasters such as floods or earthquakes.

People with PTSD may startle easily, become emotionally numb (especially in relation to people with whom they used to be close), lose interest in things they used to enjoy, have trouble feeling affectionate, be irritable, become more aggressive, or even become violent. They avoid situations that remind them of the original incident, and anniversaries of the incident are often very difficult. PTSD symptoms seem to be worse if the event that triggered them was deliberately initiated by another person, as in a mugging or a kidnapping.

Most people with PTSD repeatedly relive the trauma in their thoughts during the day and in nightmares when they sleep. These are called flashbacks. Flashbacks may consist of images, sounds, smells, or feelings, and are often triggered by ordinary occurrences, such as a door slamming or a car backfiring on the street. A person having a flashback may lose touch with reality and believe that the traumatic incident is happening all over again.

Not every traumatized person develops full-blown or even minor PTSD. Symptoms usually begin within 3 months of the incident but occasionally emerge years afterward. They must last more than a month to be considered PTSD. The course of the illness varies. Some people recover within 6 months, while others have symptoms that last much longer. In some people, the condition becomes chronic.

PTSD affects about 7.7 million American adults,1but it can occur at any age, including childhood.⁷ Women are more likely to develop PTSD than men,⁸ and there is some evidence that susceptibility to the disorder may run in families.⁹ PTSD is often accompanied by depression, substance abuse, or one or more of the other anxiety disorders.⁴

Certain kinds of medication and certain kinds of psychotherapy usually treat the symptoms of PTSD very effectively.

Social Phobia (Social Anxiety Disorder)

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

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

Social phobia, also called social anxiety disorder, is diagnosed when people become overwhelmingly anxious and excessively self-conscious in everyday social situations. People with social phobia have an intense, persistent, and chronic fear of being watched and judged by others and of doing things that will embarrass them. They can worry for days or weeks before a dreaded situation. This fear may become so severe that it interferes with work, school, and other ordinary activities, and can make it hard to make and keep friends.

While many people with social phobia realize that their fears about being with people are excessive or unreasonable, they are unable to overcome them. Even if they manage to confront their fears and be around others, they are usually very anxious beforehand, are intensely uncomfortable throughout the encounter, and worry about how they were judged for hours afterward.

Social phobia can be limited to one situation (such as talking to people, eating or drinking, or writing on a blackboard in front of others) or may be so broad (such as in generalized social phobia) that the person experiences anxiety around almost anyone other than the family.

Physical symptoms that often accompany social phobia include blushing, profuse sweating, trembling, nausea, and difficulty talking. When these symptoms occur, people with social phobia feel as though all eyes are focused on them.

Social phobia affects about 15 million American adults.¹ Women and men are equally likely to develop the disorder,¹⁰ which usually begins in childhood or early adolescence.² There is some evidence that genetic factors are involved.¹¹ Social phobia is often accompanied by other anxiety disorders or depression,^2,4 and substance abuse may develop if people try to self-medicate their anxiety.^4,5

Social phobia can be successfully treated with certain kinds of psychotherapy or medications.

Specific Phobias

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

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

Specific phobias affect an estimated 19.2 million adult Americans¹ and are twice as common in women as men.¹⁰ They usually appear in childhood or adolescence and tend to persist into adulthood.¹² The causes of specific phobias are not well understood, but there is some evidence that the tendency to develop them may run in families.¹¹

If the feared situation or feared object is easy to avoid, people with specific phobias may not seek help; but if avoidance interferes with their careers or their personal lives, it can become disabling and treatment is usually pursued.

Specific phobias respond very well to carefully targeted psychotherapy.

Generalized Anxiety Disorder

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

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

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

People with generalized anxiety disorder (GAD) go through the day filled with exaggerated worry and tension, even though there is little or nothing to provoke it. They anticipate disaster and are overly concerned about health issues, money, family problems, or difficulties at work. Sometimes just the thought of getting through the day produces anxiety.

GAD is diagnosed when a person worries excessively about a variety of everyday problems for at least 6 months.13 People with GAD can't seem to get rid of their concerns, even though they usually realize that their anxiety is more intense than the situation warrants. They can't relax, startle easily, and have difficulty concentrating. Often they have trouble falling asleep or staying asleep. Physical symptoms that often accompany the anxiety include fatigue, headaches, muscle tension, muscle aches, difficulty swallowing, trembling, twitching, irritability, sweating, nausea, lightheadedness, having to go to the bathroom frequently, feeling out of breath, and hot flashes.

When their anxiety level is mild, people with GAD can function socially and hold down a job. Although they don't avoid certain situations as a result of their disorder, people with GAD can have difficulty carrying out the simplest daily activities if their anxiety is severe.

GAD affects about 6.8 million American adults,¹ including twice as many women as men.² The disorder develops gradually and can begin at any point in the life cycle, although the years of highest risk are between childhood and middle age.² There is evidence that genes play a modest role in GAD.¹³

Other anxiety disorders, depression, or substance abuse^2,4 often accompany GAD, which rarely occurs alone. GAD is commonly treated with medication or cognitive-behavioral therapy, but co-occurring conditions must also be treated using the appropriate therapies.

Treatment of Anxiety Disorders

In general, anxiety disorders are treated with medication, specific types of psychotherapy, or both.¹⁴ Treatment choices depend on the problem and the person's preference. Before treatment begins, a doctor must conduct a careful diagnostic evaluation to determine whether a person's symptoms are caused by an anxiety disorder or a physical problem. If an anxiety disorder is diagnosed, the type of disorder or the combination of disorders that are present must be identified, as well as any coexisting conditions, such as depression or substance abuse. Sometimes alcoholism, depression, or other coexisting conditions have such a strong effect on the individual that treating the anxiety disorder must wait until the coexisting conditions are brought under control.

People with anxiety disorders who have already received treatment should tell their current doctor about that treatment in detail. If they received medication, they should tell their doctor what medication was used, what the dosage was at the beginning of treatment, whether the dosage was increased or decreased while they were under treatment, what side effects occurred, and whether the treatment helped them become less anxious. If they received psychotherapy, they should describe the type of therapy, how often they attended sessions, and whether the therapy was useful.

Often people believe that they have "failed" at treatment or that the treatment didn't work for them when, in fact, it was not given for an adequate length of time or was administered incorrectly. Sometimes people must try several different treatments or combinations of treatment before they find the one that works for them.

Medication

Medication will not cure anxiety disorders, but it can keep them under control while the person receives psychotherapy. Medication must be prescribed by physicians, usually psychiatrists, who can either offer psychotherapy themselves or work as a team with psychologists, social workers, or counselors who provide psychotherapy. The principal medications used for anxiety disorders are antidepressants, anti-anxiety drugs, and beta-blockers to control some of the physical symptoms. With proper treatment, many people with anxiety disorders can lead normal, fulfilling lives.

Antidepressants Antidepressants were developed to treat depression but are also effective for anxiety disorders. Although these medications begin to alter brain chemistry after the very first dose, their full effect requires a series of changes to occur; it is usually about 4 to 6 weeks before symptoms start to fade. It is important to continue taking these medications long enough to let them work.

SSRIs Some of the newest antidepressants are called selective serotonin reuptake inhibitors, or SSRIs. SSRIs alter the levels of the neurotransmitter serotonin in the brain, which, like other neurotransmitters, helps brain cells communicate with one another.

Fluoxetine (Prozac®), sertraline (Zoloft®), escitalopram (Lexapro®), paroxetine (Paxil®), and citalopram (Celexa®) are some of the SSRIs commonly prescribed for panic disorder, OCD, PTSD, and social phobia. SSRIs are also used to treat panic disorder when it occurs in combination with OCD, social phobia, or depression. Venlafaxine (Effexor®), a drug closely related to the SSRIs, is used to treat GAD. These medications are started at low doses and gradually increased until they have a beneficial effect.

SSRIs have fewer side effects than older antidepressants, but they sometimes produce slight nausea or jitters when people first start to take them. These symptoms fade with time. Some people also experience sexual dysfunction with SSRIs, which may be helped by adjusting the dosage or switching to another SSRI.

Tricyclics Tricyclics are older than SSRIs and work as well as SSRIs for anxiety disorders other than OCD. They are also started at low doses that are gradually increased. They sometimes cause dizziness, drowsiness, dry mouth, and weight gain, which can usually be corrected by changing the dosage or switching to another tricyclic medication.

Tricyclics include imipramine (Tofranil®), which is prescribed for panic disorder and GAD, and clomipramine (Anafranil®), which is the only tricyclic antidepressant useful for treating OCD.

MAOIs Monoamine oxidase inhibitors (MAOIs) are the oldest class of antidepressant medications. The MAOIs most commonly prescribed for anxiety disorders are phenelzine (Nardil®), followed by tranylcypromine (Parnate®), and isocarboxazid (Marplan®), which are useful in treating panic disorder and social phobia. People who take MAOIs cannot eat a variety of foods and beverages (including cheese and red wine) that contain tyramine or take certain medications, including some types of birth control pills, pain relievers (such as Advil®, Motrin®, or Tylenol®), cold and allergy medications, and herbal supplements; these substances can interact with MAOIs to cause dangerous increases in blood pressure. The development of a new MAOI skin patch may help lessen these risks. MAOIs can also react with SSRIs to produce a serious condition called "serotonin syndrome," which can cause confusion, hallucinations, increased sweating, muscle stiffness, seizures, changes in blood pressure or heart rhythm, and other potentially life-threatening conditions.

Anti-Anxiety Drugs High-potency benzodiazepines combat anxiety and have few side effects other than drowsiness. Because people can get used to them and may need higher and higher doses to get the same effect, benzodiazepines are generally prescribed for short periods of time, especially for people who have abused drugs or alcohol and who become dependent on medication easily. One exception to this rule is people with panic disorder, who can take benzodiazepines for up to a year without harm.

Clonazepam (Klonopin®) is used for social phobia and GAD, lorazepam (Ativan®) is helpful for panic disorder, and alprazolam (Xanax®) is useful for both panic disorder and GAD.

Some people experience withdrawal symptoms if they stop taking benzodiazepines abruptly instead of tapering off, and anxiety can return once the medication is stopped. These potential problems have led some physicians to shy away from using these drugs or to use them in inadequate doses.

Buspirone (Buspar®), an azapirone, is a newer anti-anxiety medication used to treat GAD. Possible side effects include dizziness, headaches, and nausea. Unlike benzodiazepines, buspirone must be taken consistently for at least 2 weeks to achieve an anti-anxiety effect.

Beta-Blockers Beta-blockers, such as propranolol (Inderal®), which is used to treat heart conditions, can prevent the physical symptoms that accompany certain anxiety disorders, particularly social phobia. When a feared situation can be predicted (such as giving a speech), a doctor may prescribe a beta-blocker to keep physical symptoms of anxiety under control.

Taking Medications

Before taking medication for an anxiety disorder:

• Ask your doctor to tell you about the effects and side effects of the drug.
• Tell your doctor about any alternative therapies or over-the-counter medications you are using.
• Ask your doctor when and how the medication should be stopped. Some drugs can't be stopped abruptly but must be tapered off slowly under a doctor's supervision.
• Work with your doctor to determine which medication is right for you and what dosage is best.
• Be aware that some medications are effective only if they are taken regularly and that symptoms may recur if the medication is stopped.

Psychotherapy

Psychotherapy involves talking with a trained mental health professional, such as a psychiatrist, psychologist, social worker, or counselor, to discover what caused an anxiety disorder and how to deal with its symptoms.

Cognitive-Behavioral Therapy

Cognitive-behavioral therapy (CBT) is very useful in treating anxiety disorders. The cognitive part helps people change the thinking patterns that support their fears, and the behavioral part helps people change the way they react to anxiety-provoking situations.

For example, CBT can help people with panic disorder learn that their panic attacks are not really heart attacks and help people with social phobia learn how to overcome the belief that others are always watching and judging them. When people are ready to confront their fears, they are shown how to use exposure techniques to desensitize themselves to situations that trigger their anxieties.

People with OCD who fear dirt and germs are encouraged to get their hands dirty and wait increasing amounts of time before washing them. The therapist helps the person cope with the anxiety that waiting produces; after the exercise has been repeated a number of times, the anxiety diminishes. People with social phobia may be encouraged to spend time in feared social situations without giving in to the temptation to flee and to make small social blunders and observe how people respond to them. Since the response is usually far less harsh than the person fears, these anxieties are lessened. People with PTSD may be supported through recalling their traumatic event in a safe situation, which helps reduce the fear it produces. CBT therapists also teach deep breathing and other types of exercises to relieve anxiety and encourage relaxation.

Exposure-based behavioral therapy has been used for many years to treat specific phobias. The person gradually encounters the object or situation that is feared, perhaps at first only through pictures or tapes, then later face-to-face. Often the therapist will accompany the person to a feared situation to provide support and guidance.

CBT is undertaken when people decide they are ready for it and with their permission and cooperation. To be effective, the therapy must be directed at the person's specific anxieties and must be tailored to his or her needs. There are no side effects other than the discomfort of temporarily increased anxiety.

CBT or behavioral therapy often lasts about 12 weeks. It may be conducted individually or with a group of people who have similar problems. Group therapy is particularly effective for social phobia. Often “homework” is assigned for participants to complete between sessions. There is some evidence that the benefits of CBT last longer than those of medication for people with panic disorder, and the same may be true for OCD, PTSD, and social phobia. If a disorder recurs at a later date, the same therapy can be used to treat it successfully a second time.

Medication can be combined with psychotherapy for specific anxiety disorders, and this is the best treatment approach for many people.

How to Get Help for Anxiety Disorders

If you think you have an anxiety disorder, the first person you should see is your family doctor. A physician can determine whether the symptoms that alarm you are due to an anxiety disorder, another medical condition, or both.

If an anxiety disorder is diagnosed, the next step is usually seeing a mental health professional. The practitioners who are most helpful with anxiety disorders are those who have training in cognitive-behavioral therapy and/or behavioral therapy, and who are open to using medication if it is needed.

You should feel comfortable talking with the mental health professional you choose. If you do not, you should seek help elsewhere. Once you find a mental health professional with whom you are comfortable, the two of you should work as a team and make a plan to treat your anxiety disorder together.

Remember that once you start on medication, it is important not to stop taking it abruptly. Certain drugs must be tapered off under the supervision of a doctor or bad reactions can occur. Make sure you talk to the doctor who prescribed your medication before you stop taking it. If you are having trouble with side effects, it’s possible that they can be eliminated by adjusting how much medication you take and when you take it.

Most insurance plans, including health maintenance organizations (HMOs), will cover treatment for anxiety disorders. Check with your insurance company and find out. If you don’t have insurance, the Health and Human Services division of your county government may offer mental health care at a public mental health center that charges people according to how much they are able to pay. If you are on public assistance, you may be able to get care through your state Medicaid plan.

Ways to Make Treatment More Effective

Many people with anxiety disorders benefit from joining a self-help or support group and sharing their problems and achievements with others. Internet chat rooms can also be useful in this regard, but any advice received over the Internet should be used with caution, as Internet acquaintances have usually never seen each other and false identities are common. Talking with a trusted friend or member of the clergy can also provide support, but it is not a substitute for care from a mental health professional.

Stress management techniques and meditation can help people with anxiety disorders calm themselves and may enhance the effects of therapy. There is preliminary evidence that aerobic exercise may have a calming effect. Since caffeine, certain illicit drugs, and even some over-the-counter cold medications can aggravate the symptoms of anxiety disorders, they should be avoided. Check with your physician or pharmacist before taking any additional medications.

The family is very important in the recovery of a person with an anxiety disorder. Ideally, the family should be supportive but not help perpetuate their loved one’s symptoms. Family members should not trivialize the disorder or demand improvement without treatment. If your family is doing either of these things, you may want to show them this booklet so they can become educated allies and help you succeed in therapy.

Role of Research in Improving the Understanding and Treatment of Anxiety Disorders

NIMH supports research into the causes, diagnosis, prevention, and treatment of anxiety disorders and other mental illnesses. Scientists are looking at what role genes play in the development of these disorders and are also investigating the effects of environmental factors such as pollution, physical and psychological stress, and diet. In addition, studies are being conducted on the “natural history” (what course the illness takes without treatment) of a variety of individual anxiety disorders, combinations of anxiety disorders, and anxiety disorders that are accompanied by other mental illnesses such as depression.

Scientists currently think that, like heart disease and type 1 diabetes, mental illnesses are complex and probably result from a combination of genetic, environmental, psychological, and developmental factors. For instance, although NIMH-sponsored studies of twins and families suggest that genetics play a role in the development of some anxiety disorders, problems such as PTSD are triggered by trauma. Genetic studies may help explain why some people exposed to trauma develop PTSD and others do not.

Several parts of the brain are key actors in the production of fear and anxiety.15 Using brain imaging technology and neurochemical techniques, scientists have discovered that the amygdala and the hippocampus play significant roles in most anxiety disorders.

The amygdala is an almond-shaped structure deep in the brain that is believed to be a communications hub between the parts of the brain that process incoming sensory signals and the parts that interpret these signals. It can alert the rest of the brain that a threat is present and trigger a fear or anxiety response. It appears that emotional memories are stored in the central part of the amygdala and may play a role in anxiety disorders involving very distinct fears, such as fears of dogs, spiders, or flying.

The hippocampus is the part of the brain that encodes threatening events into memories. Studies have shown that the hippocampus appears to be smaller in some people who were victims of child abuse or who served in military combat.^16,17 Research will determine what causes this reduction in size and what role it plays in the flashbacks, deficits in explicit memory, and fragmented memories of the traumatic event that are common in PTSD.

By learning more about how the brain creates fear and anxiety, scientists may be able to devise better treatments for anxiety disorders. For example, if specific neurotransmitters are found to play an important role in fear, drugs may be developed that will block them and decrease fear responses; if enough is learned about how the brain generates new cells throughout the lifecycle, it may be possible to stimulate the growth of new neurons in the hippocampus in people with PTSD.¹⁸

Current research at NIMH on anxiety disorders includes studies that address how well medication and behavioral therapies work in the treatment of OCD, and the safety and effectiveness of medications for children and adolescents who have a combination of anxiety disorders and attention deficit hyperactivity disorder.

References

1. Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Archives of General Psychiatry, 2005 Jun;62(6):617-27.

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

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

4. Regier DA, Rae DS, Narrow WE, et al. Prevalence of anxiety disorders and their comorbidity with mood and addictive disorders. British Journal of Psychiatry Supplement, 1998; (34): 24-8.

5. Kushner MG, Sher KJ, Beitman BD. The relation between alcohol problems and the anxiety disorders. American Journal of Psychiatry, 1990; 147(6): 685-95.

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

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

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

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

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

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

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

13. Kendler KS, Neale MC, Kessler RC, et al. Generalized anxiety disorder in women. A population-based twin study. Archives of General Psychiatry, 1992; 49(4): 267-72.

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

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

16. Bremner JD, Randall P, Scott TM, et al. MRI-based measurement of hippocampal volume in combat-related posttraumatic stress disorder. American Journal of Psychiatry, 1995; 152: 973-81.

17. Stein MB, Hanna C, Koverola C, et al. Structural brain changes in PTSD: does trauma alter neuroanatomy? In: Yehuda R, McFarlane AC, eds. Psychobiology of posttraumatic stress disorder. Annals of the New York Academy of Sciences, 821. New York: The New York Academy of Sciences, 1997.

18. Molavi DW. The Washington University School of Medicine Neuroscience Tutorial for First-Year Medical Students. (1997) Washington University Program in Neuroscience. Retrieved November 16, 2005, from http://thalamus.wustl.edu/course.

NIH Publication No. 09 3879
Page last reviewed by NIH: November 02, 2010

Reviewed by athealth on January 29, 2014

What is anxiety?

Anxiety is a feeling of tension associated with a sense of threat of danger when the source of the danger is not known. In contrast, fear is a feeling of tension that is associated with a known source of danger. It is normal for us to have some mild anxiety present in our daily lives. Anxiety warns us and enables us to get ready for the ‘fight or flight’ response. However, heightened anxiety is emotionally painful. It disrupts a person's daily functioning.

Anxiety can be seen with several other emotional disorders including the following:

• Acute Stress Disorder
• Panic Attack
• Agoraphobia
• Phobia
• Anxiety Disorder Due to Medical Condition
• Post-traumatic Stress Disorder
• Generalized Anxiety Disorder
• Substance-Induced Anxiety Disorder
• Obsessive-Compulsive Disorder

What characteristics are associated with anxiety?

Frequently, people with anxiety experience tightness in their chest, a racing or pounding heart, and a pit in their stomach. Anxiety causes some people to get a headache, to sweat, and/or to have the urge to urinate.

Severe anxiety, which can be described as an episode of terror, is referred to as a panic attack. Panic attacks can be extremely frightening. People who experience panic attacks over a prolonged time period may become victims of agoraphobia and fear leaving home or going into crowded places.

Is there a genetic basis for anxiety disorder?

Research shows strong evidence for a genetic basis for anxiety. If a person has anxiety, more than 10% of his/her relatives will also suffer from some form of anxiety.

Do anxiety disorders affect males, females, or both?

Females are twice as likely to suffer from anxiety than males. However, an equal number of males and females are seen for treatment of their anxiety.

At what age does anxiety disorder appear?

Anxiety problems commonly begin when people are in their 20’s. However, people of any age can suffer from and require treatment for anxiety.

How common are anxiety disorders in our society?

Anxiety disorders are very common. At least three percent (3%) of the population has had or will be diagnosed with some form of abnormal anxiety.

How are anxiety disorders diagnosed?

A mental health professional may diagnose an anxiety disorder after taking a careful personal history from the client/patient. It will be important to the therapist to learn the details of that person's life. It is also very important not to overlook a physical illness that might mimic or contribute to this psychological disorder since some medical illnesses can cause anxiety-like symptoms. For instance, a person with an overactive thyroid, known as hyperthyroidism, may have symptoms similar to anxiety.

If there is any question whether the individual might have a physical problem, the mental health professional should recommend a complete physical examination by a medical doctor. People examined during an anxiety attack usually have rapid pulse, rapid breathing, dry mouth, and sweating palms. They might also complain of dizziness or numbness or tingling in their extremities. Laboratory tests might be necessary as a part of the physical workup.

How are anxiety disorders treated?

Psychotherapy is recommended for someone with moderate to severe anxiety.

Antianxiety medications can be used effectively to reduce severe anxiety. For example, sometimes people experiencing a panic attack think they are having a heart attack, and they worry that they might die. Therefore, they go to a hospital emergency room to be evaluated. Once they are evaluated and diagnosed with anxiety, they are given reassurance that they are not going to die, and they may be treated with medications to lessen their anxious symptoms.

What happens to people with an anxiety disorder?

Some forms of anxiety are short-lived. However, many people with anxiety battle the disorder for years.

The prognosis for the recovery from anxiety is variable. With treatment, however, many people learn to live with or control their anxiety so that they can continue to be fully functioning.

What can people do if they need help?

If you, a friend, or a family member would like more information and you have a therapist or a physician, please discuss your concerns with that person.

Page last modified or reviewed by athealth on January 29, 2014