By Sarah Jo Lorenz

S E R I E S C O N S U L T A N T Anne S. Walters, Ph.D. Emma Pendleton Bradley Hospital Warren Alpert Medical School of Brown University

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Foreword: Dr. Anne S. Walters, Ph.D.. ......................................... 6 Chapter 1: Introduction to Anxiety Disorders. ........................... 11 Chapter 2: Understanding the History of Anxiety Disorders. ....... 23 Chapter 3: Understanding Causes of Anxiety Disorders. ............. 35 Chapter 4: Treatment Options for Anxiety Disorders. ................. 49 Chapter 5: How Anxiety Disorders Affect Adults......................... 67 Chapter 6: How Families Can Cope With Anxiety Disorders. ........ 81 Chapter Notes. ..................................................................... 100 Series Glossary of Key Terms. ................................................ 102 Further Reading. .................................................................. 104 Internet Resources................................................................ 105 Organizations to Contact....................................................... 106 Index................................................................................... 108 Author’s Biography / Credits................................................. 112 CONTENTS KEY ICONS TO LOOK FOR: Words to Understand: These words with their easy-to-understand definitions will increase the reader’s understanding of the text while building vocabulary skills. Sidebars: This boxed material within the main text allows readers to build knowledge, gain insights, explore possibilities, and broaden their perspectives by weaving together additional information to provide realistic and holistic perspectives. Educational videos: Readers can view videos by scanning our QR codes, providing them with additional educational content to supplement the text. Examples include news coverage, moments in history, speeches, iconic sports moments, and much more! Text-Dependent Questions: These questions send the reader back to the text for more careful attention to the evidence presented there. Research Projects: Readers are pointed toward areas of further inquiry connected to each chapter. Suggestions are provided for projects that encourage deeper research and analysis. Series Glossary of Key Terms: This back-of-the-book glossary contains terminology used throughout this series. Words found here increase the reader’s ability to read and comprehend higher-level books and articles in this field.


Dr. Anne S. Walters, Ph.D.

Almost one in seven children and adolescents in the United States has a diagnosable mental illness, according to the National Institute of Mental Health (NIMH), the leading federal agency for research on mental disorders. That’s more than the number of children and adolescents suffering from cancer, AIDS, and diabetes combined. NIMH

research has found that almost 50 percent of these young people will experience an episode of mental illness before the age of eighteen. The rate of mental illness is even higher among young adults between the ages of eighteen and twenty-five. This is not a uniquely American problem, however. The World Health Organization (WHO) reports that mental disorders are the leading cause of disability among young people in all regions of the world.


The most common behavioral health diagnoses in children include attention deficit hyperactivity disorder (ADHD), behavior problems, anxiety, and depression. Some of these conditions commonly occur together. For example, about three in four children (73.8 percent) between the ages of three and seventeen who have been diagnosed with depression also suffer from anxiety, and almost one in two (47.2 percent) exhibit behavioral problems, according to the Centers for Disease Control and Prevention. What do these numbers mean? To start, it means that mental illness is very common. Most of you reading this will have at least one friend or family member who either is currently struggling or has struggled in the past with a psychiatric illness. That number may even include you and may mean that you have symptoms of both anxiety and depression. In addition, mental illness is becoming more common. Suicide rates have increased in children and adolescents over the past ten years, and this is a major concern at present for professionals in the behavioral health field. No one is sure what has caused these increases, though some speculate it is related to “cultural trends.” A combination of factors such as social media and technology advances or the opioid crisis may all play contributing roles. Other professionals have wondered about how violence in our schools might impact youth


mental health, and still others have pointed to the potential effects of decreased sleep on these illnesses. Despite there being more widespread information about the prevalence of mental health issues for children and adolescents, only slightly more than half of these children receive treatment. What gets in the way? One of the barriers to seeking treatment is the fear that others will find out. Children, adolescents, and even parents fear the stigma of being identified as having a mental illness. Despite progress in the diagnosis and treatment of these illnesses, the stigma that surrounds mental illness is still very profound, even today. Parents fear that their children will experience shame. As long as this stigma exists, it affects the likelihood that children or their families will seek help. Other barriers include doctor and hospital wait lists, concern about medical expense, a shortage of available mental health providers, and lack of knowledge about treatment options. Some of the movements toward reducing stigma have been helpful in this regard. Notable examples are actress Glenn Close and her foundation aimed at reducing the stigma for those with bipolar disorder, or Olympic athlete Michael Phelps speaking out about his own depression. The good news in all of this is that in recent years, evidence-based treatment has become available. The term “evidence based” refers to treatment that has been tested via research and


proven to be effective for various types of mental illness. For example, we know that a form of treatment called “Coping Cat,” utilizes a cognitive behavioral form of treatment that is effective for childhood anxiety, and that effectiveness is improved with the use of certain medications as well. Cognitive behavioral therapy (CBT) targets the way that we negatively interpret or perceive situations, and teaches us to “restructure” those thoughts, leading to different feelings and experiences. We know CBT is helpful because researchers have performed studies comparing patients who get this form of treatment with patients that receive other forms of treatment. Our readers will learn more about all these topics in the volumes ahead. We hope that having more information will help you to combat the stigma that surrounds mental illness, and therefore reduce the length of time it takes a child and family to seek treatment. Our hope is that this series will spark conversation and provide important information for children, parents, and school personnel about the various diagnoses that are most common in childhood and adolescence. With this series, we hope you will understand much more about mental illnesses, what is involved, and what to do to help those who might be suffering like family, friends, or even you.



anxiety: a general feeling of uneasiness, worry, or fear that is usually fleeting but can become a mental disorder that affects normal life NED: a term used in medical diagnosis and testing that means “no evidence of disease” and that treatments have worked at removing the illness or disease panic: extreme feelings of fear that can result in visible physical symptoms as well as mental and emotional conditions that cause severe disruptions to normal activities phobias: extreme and often irrational fears of normal, everyday, or truly harmless places and things, causing sufferers to avoid them or to panic when exposed to them psychiatric disorders: conditions that are related to mental disorders or conditions that affect the workings of the brain, mental processes, and normal thought abilities


1 chapter

Introduction to Anxiety DISORDERS

When it comes to the different types of mental illnesses that are commonly seen today, anxiety should be one of the easiest to understand. Everyone, at some point in their lives, has experienced some form of anxiety or has some instance of feeling panicked and out of control. If you were to ask the average person on the street whether he or she has ever felt butterflies in their stomach or tightness in their chest, that person will likely have had these experiences on multiple occasions. That is anxiety—the feeling you might get right before taking a big test, speaking in public, having a medical procedure, or going on a date. Feeling a small amount of brief anxiety is common in these situations, but anxiety felt at larger levels is classified as a disorder. An Insider’s Look at Anxiety Disorders Despite how common general anxiety is, this disorder is still hard for people to fully comprehend. While most people have experienced mild anxiety, few have felt the true panic that characterizes an anxiety disorder. Some people face significant anxiety on a daily basis, even in the most normal situations or trivial circumstances. Panic goes far beyond a feeling of uneasiness and is considered an extreme form


of general anxiety. Normal levels of anxiety, like stomach flutters before a speech, are expected, but severe anxiety can include sweating palms, shortness of breath, and feelings of nausea that interfere with the person’s ability to function. Imagine going through normal everyday life with uncontrolled anxiety. Here is how “Kenny” describes what it is like to live with a severe anxiety disorder: Hello. My name is Kenny, and I have been a cancer survivor for four years now, and I think what I’m about to describe about anxiety is very important. For as long as I can remember, I have always had anxiety about needles, injections, and blood draws. Scans, x-rays, and other medical things like that never really phased me, that is, until mid-2015, when I went into the ER for kidney stones and found out I had a large mass on my kidney. The mass turned out to be cancer. I joined some cancer-support groups, and they talked about a thing called “scanxiety” —a cute little name that cancer patients have to describe anxiety from getting medical scans. I kind of laughed it off at first, but then I started my first scans since my cancer diagnosis. Thinking of the scans gave me panic attacks. The anxiety kicked in, and negative thoughts about my disease just wouldn’t stop coming. What if the medicine wasn’t working? What if I end up dying? What would my wife and two-year-old son do without me? I would cry, hyperventilate, and seclude myself in the house. For days, I barely got any sleep. Three months later, I had my kidney and cancer surgically removed, and I thought, “Good! Now I can relax!” but anxiety disorders don’t work that way. When you have cancer, you get scans every couple of months for many years to check the progression of your disease. Every time a scan came up, the anxiety would really kick into high gear again. It would start as a feeling in the back of my mind. I could sometimes ignore it, but soon the anxiety would turn into a crying fit or full blown panic attack. “What if the cancer has come back? What if it


Behavioral Disorders: Anxiety Disorders

has spread to other places? I can’t afford to lose my other kidney! The medication’s side effects are bad enough already, so what if they have to increase my doses? I don’t want my young son to grow up without his daddy around!” These thoughts and more would keep me in a state of panic for weeks before a scan. The night before the scan, I couldn’t sleep. The morning of the scan, I would vomit in the bathroom until we had to go to the appointment. The fear never left until the doctor told us that I was still in NED status (no evidence of disease), but this could be days or weeks after the scans. For me, this ebb and flow of mild-to-severe anxiety came every three months or so and lasted for three years before the cancer came back. Now that I am officially in stage 4 cancer, the old anxieties are back. Now, I find myself in a state of panic until Some patients feel tremendous anxiety each time they have a medical scan. Everyone has anxiety from time to time, but anxiety felt all the time is classified as a disorder.


Introduction to Anxiety Disorders

we see if the medicines are still working. Between my scans, the anxiety calms somewhat, but I live in a constant state of wondering just how long I may have with my family. I wonder how long until the medicines stop working or until they wear down my body so much that I can’t keep fighting. I live in a constant state of fear, and anything can set off a full-fledged panic attack. This is my reality. This is what my life is like living with the anxiety disorder that cancer brought on. I wish more people understood what it is like. Even though I may put on a smile and act positively on the outside, on the inside I am still scared, panicked, and worried. 1 Anxiety disorders are serious mental illnesses. Some people master the art of hiding some of the symptoms and learn to hide behind a mask of smiles and happy faces. However, most people who have this disorder have underlying symptoms that have been present for a long time. These symptoms occur when a person has persistent or long lasting anxiety that leads to extreme distress and greatly interferes with the ability to live a normal life and engage in normal activities. Common symptoms that people experience when having anxiety are: • Feelings of panic, danger, fear, confusion, and uneasiness • Problems sleeping (e.g., getting to sleep and staying asleep) • Cold and sweaty hands and feet • Tightness in the chest or shortness of breath • Heartbeat skipping, racing, or pounding • An inability to be still and calm • Dry mouth and difficulty speaking • Numbness or tingling, especially in the face, hands, or feet • Nausea, indigestion, vomiting, or bloating What Anxiety Disorder Symptoms Look Like


Behavioral Disorders: Anxiety Disorders

• Muscle tension and cramping in the legs, back, or neck • Anticipation of passing out or changes in vision • Dizziness, confusion, loss of balance, or increased clumsiness Anxiety is sometimes complicated, because it often occurs along with other disorders. Anxiety can even cause other disorders to develop. General anxiety can cause someone to go into seclusion, and that can lead to social anxiety or the development of other disorders such as agoraphobia, an extreme and irrational fear of leaving one’s own home. When disorders such as these go untreated, they can quickly get out of hand. Depression is likely to develop and make the anxiety symptoms more pronounced and more devastating. These factors make anxiety disorders a challenge to diagnose, live with, and treat.

People with anxiety experience trouble sleeping and many other symptoms. People with general anxiety often have social anxiety and perhaps even extreme fears.


Introduction to Anxiety Disorders

A phobia is a deep fear of a situation, such as claustrophobia, the extreme fear of being trapped in a closed space like an elevator. There are many phobias, including agoraphobia, a fear of leaving your house.

Types of Anxiety Disorders There are different classifications of anxiety disorders, which can vary in severity: panic disorder, social anxiety disorder, phobias , post traumatic stress disorder (PTSD), separation anxiety, and generalized anxiety disorder. • Generalized anxiety disorder (GAD). GAD is characterized by an enhanced feeling of worry and apprehension that extends beyond normal anxiety and nervousness. Feeling sick for hours before or after a speech, being so worried you can’t focus on a task, and anxiety to the level of crying are all examples of GAD. • Panic disorder. This is a severe form of anxiety that causes extreme levels of panic, often over events and things that most people would not find at all distressing. Running out of a crowded grocery store because it is hard to breathe, or shaking, sweating, and hyperventilating simply by standing


Behavioral Disorders: Anxiety Disorders

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