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ANXIETY

Have you ever experienced anxiety? Chances are you have.

    Anxiety disorders are one of the most common reasons for visits to psychologists and other practitioners in the field of mental health. More than 23 million Americans suffer from a diagnosable and treatable form of anxiety.
    Almost everyone experiences anxiety to some degree at some point in his/her life, and there are times when anxiety becomes a cause for concern. An important question to be answered regarding anxiety, therefore, is "How can I know if I should be concerned about my anxiety?" The answer to this question is - any degree of anxiety that causes you concern or distress warrants therapeutic attention. Therapeutic services can serve to decrease or eliminate any level of anxiety, whether it is moderate or severe, so that you can function more effectively and comfortably in your daily life.
    Students can experience anxiety when facing situations such as beginning a new career, experiencing relational problems, or preparing for that dreaded final exam. There are times, however, when anxiety becomes extreme and distressful, preventing one from functioning adequately at school or work; or from engaging in satisfying social interactions. Whenever this happens, your anxiety may meet the criteria for being considered a disorder.
    This leads to the question, "What type of anxiety disorder do my symptoms of distress indicate?" There are several anxiety disorders that vary according to the type and severity of symptoms one experiences, as well as the focus of the anxiety. The following sections will describe the different anxiety disorders recognized in the DSM-IV (1997, American Psychiatric Association). If you do realize that you are suffering from an anxiety disorder please remember that anxiety is treatable and that help is available. The Counseling Center has a variety of resources to help you.

CONTENTS

Generalized Anxiety Disorder	Panic Disorder
Phobias	Posttraumatic Stress Disorder
Obsessive Compulsive Disorder	Acute Stress Disorder
Panic Attacks

Generalized Anxiety Disorder

John, a 22 year-old student, began experiencing chronic anxiety after he failed his freshmen year courses. He blamed himself for his academic failure; sure that his lack of regard for the course's required readings and assignments had led to his low grades. He was also worrying because he had let down his parents and his girlfriend, who had so much confidence in him making it through college. For weeks, John was unable to sleep well; spending long hours lying in bed at night worrying about his grades. He could not think clearly enough to do well on his tests, and felt like he was "blanking-out". on one occasion when he could not remember some of the materials he had studied and memorized the day before. He felt insecure most of the time and did not follow through on several commitments he had made. He was contemplating dropping out of college when he learned about the Counseling Center and came for help. *

The primary feature of this disorder is an unrelenting preoccupation with, or worry about a number of life issues. Approximately 5% of people meet the criteria for this disorder at some point in their life; women receiving diagnosis twice as often as men. The events that lead to this constant worry are usually related to everyday matters. For instance, you may feel constantly "stressed" about school, the health of your parents, and your current relationship with a boyfriend or girlfriend. These worries may seem to consume a large amount of your time and the enduring distraction may keep interfering with daily tasks that need to be completed. The anxiety experienced, although pervasive, is usually mild to moderate in intensity. As its name suggests, it is best described as a general worry extending into several dimensions of one's life. At least three, of several specific symptoms, are experienced by persons with this disorder, including; feelings of restlessness or "edginess", fatigue, problems with concentration and distraction from tasks, irritability, muscle tension, and sleep disturbances (difficulty falling or staying asleep or poor quality of sleep).

Generalized anxiety disorder specific criteria:

Extreme anxiety and worry, that persists for the majority of days within at least a 6 month period, about several events or activities (such as school or dating)
The worry is persistent and feels out of ones control
The anxiety and worry are accompanied by at least three of the following six symptoms:

(1) restlessness or "edginess"

(2) fatigue

(3) problems with concentration

(4) irritability or moodiness

(5) tension

(6) problems associated with sleep

The anxiety or worry causes mental anguish or disruption in areas related to work, social life, or other personally meaningful activities

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Phobias

Mary was a senior in college when she came to counseling. Her primary concern was her fear of heights. She could not go to the library because the main area faced the backyard that was two-stories below. She felt fearful of crossing the covered walkways connecting different buildings. She avoided the elevators and did not take classes that were given on or above the second floor of a building. Outside school she avoided high buildings and even high seats at the football stadiums. When she came to counseling for help she felt ridiculous. She could not understand why she was so afraid of heights, nor what counseling could do to help her. Fortunately, her needs to overcome her anxiety were more powerful than her doubts about undergoing therapy. After approximately three months, Mary was able to reach every place on campus. Soon thereafter, she attended some of the best football games of the season, sat in the highest places, and enjoyed the games.

In contrast to Generalized Anxiety Disorder, in which the focus of anxiety encompasses several broad areas of one's life, the focus of a phobia is much more specific and usually limited to one particular object or activity. Around 4 to 5% of Americans experience this disorder. If you suffer from a phobia, anxiety or panic-like symptoms arise immediately when you are confronted with the object or activity that you find frightening, and you will usually go out of your way to avoid coming into contact with it. Occasionally, you may manage to confront the phobic situation, but will continue to be extremely anxious. Although you realize that your fear is either unreasonable or excessive, a pattern develops in which you avoid many situations or objects that are somewhat similar to or related to your original phobia. It is easy to see how this may lead to significant disruptions in your daily functioning at work, school, or in social interactions. Usually the fear and anxiety associated with a phobic object or situation increases the nearer it is, and the less likely escape from it may be. Phobic disorders are divided into three general categories: Specific Phobia, Social Phobia, and Agoraphobia.

I. Specific Phobia is an irrational fear or avoidance of a specific object or situation. This disorder is seen among approximately 11% of the population at some point during their lifetime. If you have a specific phobia, you may fear being harmed in some way by a particular object; this is the case if you have a spider phobia and fear being bitten and dying from the spider's poison. Alternatively, your fear may center around your reaction to an object. For instance, you may be afraid of heights due to a fear of fainting because high altitudes make you dizzy, rather than fearing injuries due to a fall.
In order to be diagnosed with a specific phobia, your fear and avoidance must cause you extreme distress or interfere with your participation or performance in important areas of your daily life. For instance, if you are a student who has a fear of enclosed places, you may find it impossible to attend classes that are on the fifth floor of a building because a fear of elevators or stairwells prevents you from getting to the classroom, or because the classroom itself feels too "closed in." Some common specific phobias include:

Animal Type -the focus of the phobia are animals or insects (snakes and spiders)
Natural Environment Type -the focus of the phobia is an object in nature (storms, heights, water)
Blood-Injection-Injury Type -the focus of the phobia is the experience of seeing blood or an injury or by getting an injection or other medical procedure.
Situational Type -the focus of the phobia is a specific situation (public transportation, elevators, flying, enclosed places, or driving)
Other Type - the focus of the phobia is something other than those listed above (choking, vomiting, or falling down without some means of support)

Specific criteria for a specific phobia include:

A. Extreme, continuous, and irrational fear when exposed to a specific object or situation
B. Confrontation with the feared object or situation almost inevitably and immediately produces anxiety, which may be experienced as a situationally-bound or situationally-predisposed panic attack
C. The individual is aware that the fear is extreme and irrational
D. The feared object or situation is avoided or confronted with extreme anguish or anxiety
E. This avoidance response or the experience of anxiety when confronted with the object or situation leads to significant disruptions in the individual's daily routine, work or school performance, or social relationships, or there is extreme anguish associated with the phobia
F. For persons under age 18, these symptoms have lasted at least 6 months

II. Social Phobia is a fear of being in certain types of social or performance situations where you may be easily embarrassed. Social phobias are evidenced in 3 to 13 % of persons at some time during their lives. It usually occurs in situations where you must interact with and be evaluated by people who are unfamiliar. Social phobias fall into one of two categories (generalized or performance-oriented) that are based on the pervasiveness and specificity, of symptoms. If you suffer from a generalized social phobia, you often feel shy and inhibited in social situations. This "social shyness" usually poses a problem for you in many types of situations. If you suffer from a performance-oriented social phobia, you will experience anxiety only in situations where you are subjected to evaluation by others. Again, the anxiety you experience, regardless of which category, is so extreme that it interferes with your normal functioning. For example, a social phobia, characterized as a general pattern of social inhibition and shyness, would have very upsetting consequences for a CEO of a big corporation who had to regularly conduct meetings, give presentations, and meet with clients for lunch. Either this CEO would lose his/her job for refusing to perform these job duties, or he/she would have to suffer through them in misery.
Similarly, a marketing student burdened by a performance-oriented social phobia, whose classes necessitated frequent presentations and/or speeches in front of a group of peers, would be likely to experience a significant impairment in his academic functioning. In fact, a fear of public speaking is the most common expression of social phobia.

Specific criteria for Social Phobia include:

A. Extreme, continuous and irrational fear when exposed to one or more social or performance situations in which the individual is evaluated or introduced to people who are unfamiliar. Particularly, the individual fears that he/she will be suffer extreme embarrassment or humiliation
B. Confrontation with the feared social situation almost inevitably produces anxiety that may occur in the intense form of a situationally bound or situationally predisposed Panic Attack
C. The individual is aware that his/her fear is irrational and extreme
D. The feared social or performance situations are avoided or confronted with extreme anxiety or anguish
E. This avoidance reaction or experience of anxiety when confronted with the feared situation produces a significant disruption in one's daily activities, work or school performance, or social relationships, or experiences severe anguish concerning the phobia
F. For persons under age 18, the symptoms have lasted for a minimum of 6 months
G. The fear or avoidance is not a direct consequence of the effects of a substance

III. Agoraphobia is a fear of being in places or situations where it would be difficult for you to obtain help or where you could be easily embarrassed while trying to escape the situation. If you suffer from agoraphobia you may avoid traveling long distances from home by yourself, or sitting in the middle row of chairs in a crowded classroom. You may sometimes feel anxious being in a place where help would not be available in the event of having a panic attack or panic-like symptoms, in which you may experience shortness of breath, racing heart, sweating, chest pain, dizziness, and an overwhelming urge to get away from the current situation.
Unlike the other two phobias, where there are just one or a few areas to avoid, as an agoraphobic individual you will avoid a variety of situations; since the focus of your fear is on any place in which escape would be problematic or help unavailable. As is the case with certain phobias, this avoidance can lead to severe disruptions in your daily life and may become so extreme you can not leave your house. You may feel more comfortable going out when you are with a friend or family member. If you are a student, you may never even be able to attend classes or may only attend classes when accompanied by a classmate.
There are two distinct patterns of agoraphobia, characterized by fundamental differences in the focus of fear. If you experience sudden and severe bursts of fear; known as panic attacks, when you are in a public place, the agoraphobic pattern is labeled panic disorder with agoraphobia because your fear is mainly due to having a panic attack sometime in the future. When the focus of your fear primarily centers on being away from home and having a few panic-like symptoms, you would be diagnosed with agoraphobia without history of panic disorder.

Specific criteria for Agoraphobia:

A. Anxiety related to being in places from which escape would be difficult or embarrassing or in which help may be unavailable in the event of experiencing an unexpected or situationally-predisposed Panic Attack
B. The situations are routinely avoided or confronted with a great degree of anguish or anxiety about having a Panic Attack or panic-like symptoms or necessitate being accompanied by a friend

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Obsessive Compulsive Disorder

Chuck experienced all the symptoms of an obsessive-compulsive person. He was obsessed with order and could not spend less than 30 minutes straightening everything up in his desk at the bank in the mornings. He was also the last one to leave his office at night because he needed to make sure that everything was completely organized on his desk (the same things he will organize again on the following morning!) At school he could not turn in his class assignments because they were never organized to his satisfaction. Taking tests was very difficult because he spent most of his testing time making sure everything was ready for him to start and then obsessing about possible mistakes in choosing his answers. He was unable to turn in his tests unless he had checked his answers several times. He was also compelled to recheck his scantron choice to make sure he had marked the right choice.

    Obsessive Compulsive Disorder has two basic components: (1) obsessions, and (2) compulsions. Obsessions are constant ideas, thoughts, or images that keep intruding into your mind and cause you a great deal of anxiety and distress. Compulsions are specific and repetitive behaviors that you use in an effort to reduce the anxiety or distress produced by your obsession. Although you are aware that these obsessions or compulsions are unreasonable or excessive, you can't resist performing repetitive acts, and you feel driven to perform these behaviors in order to reduce your mental anguish or prevent some dreaded event from taking place. For instance, if you suffer from obsessive compulsive disorder you may constantly call to check on a relative to make sure they are safe because you have constant obsessions about your relative being killed, feel responsible for these thoughts, and, consequently, the safety of your relative.
    You may experience some of the most common obsessions, which involve thoughts about contamination from dirt or germs; repeated doubts, such as whether you left the oven on; and sexual imagery. Common compulsions you may experience involve checking things repeatedly, repeating verbal chants or mantras, counting, repeatedly rearranging and ordering items, and praying. These behaviors seem either extremely excessive or do not seem to be connected in any logical way to the obsession that you are attempting to cancel out or prevent.
    These activities usually consume a large amount of your time and interfere with your work, school, or social activities. It may take you hours to finish a simple project because you are constantly distracted by obsessions, or involved in performing compulsions. For instance, if you are trying to write a term paper, you may feel driven to perform a lengthy and detailed ritual of some kind after every line of writing.

Specific criteria for Obsessive Compulsive Disorder:

A. Either obsessions or compulsions:

Obsessions:

(1) repeated and insistent thoughts, urges, or images that feel intrusive and inappropriate and that cause significant anxiety or intrusiveness
(2) these thoughts, urges or images amount to more than disproportionate worries about realistic life events
(3) the individual tries to rid himself/herself of these intrusions or engages in some action intended to cancel them out
(4) the individual realizes that the obsessions originate from his/her own mind and are not thoughts transferred to their mind by external sources

Compulsions:

(1) continual behaviors or mental acts that a person feels urged to perform as a result of an obsession, or in compliance to a very specific and detailed set of rules
(2) these behaviors are motivated by a desire to prevent or cancel out a dreaded outcome or relieve the individual's distress; yet are not related in a realistic way to the outcome they are to affect.

B. The person has realized at some point that the obsessions or compulsions are irrational or extreme
C. The obsessions or compulsions cause significant anguish, are time-consuming (last more than one hour a day), or disrupt one's normal daily routine, performance at work or school or social activities
D. These problems are not attributable to the direct effects of a substance or general medical condition

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Panic Attacks

A panic attack is a very sudden rush of intense fear or terror, accompanied by a sense of impending doom and a frantic urge to flee. An estimated 36% of persons have experienced a Panic Attack at some point in their lives. You will experience a minimum of four out of 13 physical or cognitive symptoms, which come on almost instantly and reach a peak within 10 minutes. You may experience physical symptoms such as shortness of breath, racing heart, dizziness, and sweating. Cognitive symptoms of a panic attack involve fears of going crazy or dying.

There are three different types of panic attacks, which vary depending on the situation that triggers the onset of the attack:

unexpected (uncued) panic attacks do not have a specific situation that sets the panic symptoms in motion. They occur spontaneously or "out of the blue". For instance, you may experience an unexpected Panic Attack while you are taking notes in class and not thinking about anything in particular.
situationally bound (cued) panic attacks occur every time that you are in a particular situation. This specific situational "cue" almost never fails to trigger a panic attack. For example, you may panic every time that you are driving or taking an exam. situationally predisposed panic attacks are more likely to occur when you are in a particular situation, although the specific situation will not always trigger a panic attack. For instance, panic attacks may be more likely to occur when you are taking an exam, but there are times when you complete an exam without experiencing a panic attack.

A panic attack must have four of thirteen physical and/or cognitive symptoms:

heart palpitations, racing or pounding heart
sweating
trembling or shaking
shortness of breath or smothering
choking sensations
chest pain
nausea
dizziness, or feeling faint
depersonalization (feeling detached from one's body) or derealization (feelings of unreality)
fear of losing control or going crazy
fear of dying
numbness or tingling in the arms or legs
chills or hot flushes

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Panic Disorder

Mike came to the Counseling Center after being in college for two years. He described his panic attacks as terrifying. Sometimes he would be strong enough to leave his home only to return minutes later suffering intense fear. Most days he was not able to make it to school or work, and when he did, he could not stay for long. He spent most of his time at home, afraid that he would suffer another panic attack. His grades were suffering and he did not know what else he could do, since joining a study group or going to the university was not possible for him due to his panic. After working in counseling for one semester he wrote the following: "I found that...I no longer had the anxiety problem that I was originally seeking help for. What the method showed me was that it is possible for me to relax. It is possible...to alleviate and /or "head off" anxiety as or before it rears its ugly head...What I can tell you is that I am now able to work, live, and accomplish without the stumbling block of anxiety."

    You may meet the conditions for having a Panic Disorder if you have repeated, unexpected Panic Attacks and worry for some time afterwards that you will have another attack; or if you feel that the attacks represent something seriously wrong with you, or feel that they will be detrimental to some aspect of your life. Furthermore, you may begin to act differently because of the panic attacks you experience. For instance, you may tend to catastrophize the consequences of an attack, thinking "I am going to die", "I am going to go crazy" or "I am going to completely lose control and humiliate myself". For example, if you have had at least two Panic Attacks, you may become consumed with worry that you will have another one at some point, that you are going crazy because you experience these attacks for apparently no reason, and may begin to avoid social situations for fear of embarrassing yourself by having a Panic Attack. A key point in your experience of panic is that the attacks are not triggered by real threats to your safety or well being; that is, most people in an identical situation would not panic. You must have had at least two unexpected Panic Attacks, although situationally-predisposed and situationally-bound attacks are common as well. Panic Disorder can follow one of two distinct patterns:
    Panic Disorder without Agoraphobia is the repeated experience of unexpected panic attacks that is not accompanied by a fear of being away from home or in places where help may be unavailable.
    Panic Disorder with Agoraphobia is the repeated experience of unexpected panic attacks that is accompanied by a fear of being away from home or in places where help may be unavailable. Nearly 95% of people seeking treatment for Panic Disorder display this pattern. Approximately 3% of individuals are diagnosed with Panic Disorder at some point in their lives.

Specific criteria for Panic Disorder with Agoraphobia:

A. Both (1) and (2):
(1) the individual repeatedly experiences unanticipated Panic Attacks
(2) at least one of the attacks has been followed by at least one month of one (or more) of the following:
B. The presence of Agoraphobia (a fear and avoidance of being in places where escape might be problematic or help may not be available in the event of an unexpected or situationally-predisposed Panic Attack)
C. The attacks are not directly attributable to the effects of a substance or a general medical condition

Specific criteria for Panic Disorder without Agoraphobia:

A. Both (1) and (2):
(1) the individual repeatedly experiences unanticipated Panic Attacks
(2) at least one of the attacks has been followed by at least one month of one (or more) of the following:
B. The absence of Agoraphobia (See above criteria)
C. The attacks are not directly attributable to the effects of a substance or a general medical condition

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Posttraumatic Stress Disorder

After being involved in a major traffic accident the year before, Tracey could not get behind the wheel of a car anymore. She was very distressed by not being able to drive since she was a commuter. She had been carpooling with other people, but she was afraid of what might happen should her other classmate not be able to make it to school someday. Tracey's symptoms included shaking and sweating, and feeling helpless whenever she tried to start driving again. For this reason, she had not tried to drive for the last four months.

If you have ever endured a traumatic event in which you were seriously injured or threatened, or in which you witnessed the death or injury of another person, then it is possible that you may experience Posttraumatic Stress Disorder. A range of symptoms similar to Panic Disorder are also common to this disorder; however, in this case, the symptoms have been brought about by a real threat to your safety or well-being. Some examples of a real traumatic event include war, automobile accidents, acts of terrorism, or sexual assault. These are situations in which extreme anxiety would be a normal human reaction. Additionally, to be diagnosed with Posttraumatic Stress Disorder, you must have responded to these events with extreme fear, helplessness, or horror. Furthermore, you must have had episodes of reexperiencing the event, continuously avoiding situations or objects related to the event, continuously experiencing symptoms of heightened arousal or alertness, and a general emotional "numbness", that have lasted for longer than a month. Statistics for persons in general show that this disorder occurs in anywhere from 1 to 14% of the population, whereas at-risk groups, such as veterans of war, and victims of crime, show rates of 3 to 58%.

This disorder may follow one of three different courses:
It is labeled Acute if the symptoms last less than 3 months, Chronic if they last three months or longer, and Delayed Onset if the symptoms do not occur until 6 months after the traumatic event took place.

Specific criteria for Posttraumatic Stress Disorder:

A. The individual has experienced a traumatic event in which both of the following were present:
B. The process of reexperiencing the event may be manifested in one (or more) of the following ways:
C. Avoidance of event-related situations and general emotional numbing include three (or more) of the following:
D. Heightened symptoms of arousal are indicated by two (or more) of the following:
E. The above symptoms have occurred for at least a one-month period
F. The above symptoms cause significant anguish or disruption in one's activities

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Acute Stress Disorder

If you suffer from Acute Stress Disorder, a disorder that affects approximately 5% of persons at some point, you have probably shown many of the same symptoms as someone with Posttraumatic Stress Disorder. Having confronted a traumatic event in which you were either seriously injured, or witnessed another person being injured or killed, you most likely have responded with extreme fear, helplessness, or horror during or shortly after it occurred. Additionally, you must have experienced a range of symptoms similar to those of Posttraumatic Stress Disorder that have lasted for at least 2 days and no longer than 4 weeks, occurred within one month of the traumatic event, and interfered significantly with your job or social interactions, or other important areas of your life.

Specific criteria for Acute Stress Disorder include:

A. The individual has experienced a traumatic event in which both of the following were present:
B. The process of reexperiencing the event may be manifested in one (or more) of the following ways:
C. The traumatic event is repeatedly reexperienced in the form of: continuous images, thoughts, dreams, illusions, flashback episodes, or a reliving of the event; or anguish is associated with reminders of the event
D. Pronounced avoidance of objects or situations reminiscent of the event
E. Pronounced symptoms of anxiety or heightened arousal (e.g., sleep problems, irritable mood, difficulty with concentration, startle response, restlessness, and extreme alertness)
F. These symptoms cause mental anguish or disruptions in performance for an important area of one's life
G. The symptoms persist for at least 2 days and no more than 4 weeks and occurs within 4 weeks of the traumatic event
H. The symptoms are not directly attributable to the effects of a substance

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* All case descriptions are fictional

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The Help Screens (HS) & the Counseling Center Help Screens (CCHS) were created by Carlos P. Zalaquett, Ph.D.

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