SW26 • Social Workers 2026-2027

Table of Contents

SW26 • Social Workers 2026-2027

How to Receive Credit

NetCE 5 Hour Course #76703 • Understanding and Treating Spiritual Abuse

76703 • Understanding and Treating Spiritual Abuse

1. INTRODUCTION

2. FOUNDATIONS: DEFINING SPIRITUAL ABUSE

3. COMMON THEMES IN SPIRITUAL ABUSE

4. ASSESSING FOR SPIRITUAL ABUSE

5. TREATING SPIRITUAL ABUSE

6. PROFESSIONAL DEVELOPMENT ISSUES

7. CONCLUSION

8. GLOSSARY

Works Cited

NetCE 6 Hour Course #77042 • Setting Ethical Limits: For Caring and Competent Professionals

77042 • Setting Ethical Limits: For Caring and Competent Professionals

1. INTRODUCTION

2. COMPETENCE

3. CULTURAL COMPETENCE

4. THE THERAPEUTIC RELATIONSHIP

5. THE COSTS OF CARING

6. TRANSFERENCE AND COUNTERTRANSFERENCE

7. BOUNDARIES AND LIMITS

8. BOUNDARY CROSSINGS AND VIOLATIONS

9. MULTIPLE RELATIONSHIPS

10. GIFTS

11. TECHNOLOGY AND DISTANCE THERAPY

12. CONCLUSION

13. RESOURCES

Works Cited

NetCE 15 Hour Course #76183 • Anxiety Disorders

76183 • Anxiety Disorders

1. INTRODUCTION

2. BACKGROUND

3. OVERALL PREVALENCE, RISK FACTORS, AND CLINICAL COURSE

4. ETIOLOGY AND PATHOPHYSIOLOGY

5. CLINICAL AND DIAGNOSTIC FEATURES

6. ASSESSMENT

7. GENERAL TREATMENT CONSIDERATIONS

8. TREATMENT OF GENERALIZED ANXIETY DISORDER

9. TREATMENT OF PANIC DISORDER

10. TREATMENT OF AGORAPHOBIA

11. TREATMENT OF SOCIAL ANXIETY DISORDER

12. TREATMENT OF SPECIFIC PHOBIA

13. TREATMENT OF SEPARATION ANXIETY DISORDER

14. EMERGING THERAPIES AND NOVEL TREATMENT APPROACHES

15. COMPLEMENTARY/ALTERNATIVE THERAPIES

16. CONCLUSION

Works Cited

Evidence-Based Practice Recommendations Citations

SW26 • Social Workers 2026-2027

Jamie Marich, PhD, LPCC-S, REAT, RYT-500, RMT

Lisa Hutchison, LMHC

www.netce.com

Copyright © 2026 NetCE, All rights reserved.

SW26 • Social Workers 2026-2027

Expiration Date: 06/30/2027

How to Receive Credit

To complete this Special Offer for continuing education credit please go to http://www.netce.com/specials in your browser.

For assistance with receiving continuing education credit, please contact us at help@netce.com.

76703 • Understanding and Treating Spiritual Abuse

Jamie Marich, PhD, LPCC-S, REAT, RYT-500, RMT

www.netce.com

Copyright © 2024 NetCE, All rights reserved.

Spiritual abuse is not just relevant for those who have been members of cults. It is a very real condition that often occurs in individuals who have been abused or who struggle with addiction issues. In this course, theories of spiritual abuse and approaches to understanding it are explored through pastoral, developmental, and clinical lenses. Generally defined as the use of God/a higher power or religion as a tool to gain power and control by the abuser, spiritual abuse is one of the most overlooked forms of abuse in clinical settings. However, the willingness to address it will give clinicians added insight into many of their clients and how to more effectively and holistically address treatment. Case studies, personal reflection, and other critical thinking activities will help participants understand how the construct of spiritual abuse is relevant to clinical practice and apply this knowledge to assessment and treatment planning.

Table of Contents

76703 • Understanding and Treating Spiritual Abuse

Course Overview

Audience

Accreditations & Approvals

Designations of Credit

Individual State Behavioral Health Approvals

Course Objective

Learning Objectives

Faculty

Faculty Disclosure

Division Planners

Division Planners Disclosure

Director of Development and Academic Affairs

Director Disclosure Statement

About the Sponsor

Disclosure Statement

Implicit Bias in Health Care

1. INTRODUCTION

2. FOUNDATIONS: DEFINING SPIRITUAL ABUSE

SOCIOLOGIC PERSPECTIVES

PASTORAL PERSPECTIVES

DEVELOPMENTAL PERSPECTIVES

CLINICAL PERSPECTIVES

3. COMMON THEMES IN SPIRITUAL ABUSE

TRAITS OF SPIRITUAL ABUSERS

TRAITS OF SPIRITUAL ABUSE VICTIMS

CASE EXAMPLE

4. ASSESSING FOR SPIRITUAL ABUSE

CASE EXAMPLE

5. TREATING SPIRITUAL ABUSE

GENERAL FRAMEWORK FOR TRAUMA TREATMENT

CULT RECOVERY

HEALTHY SPIRITUALITY AND SPECIFIC RECOVERY STRATEGIES

CASE EXAMPLE

6. PROFESSIONAL DEVELOPMENT ISSUES

7. CONCLUSION

8. GLOSSARY

Works Cited

76703 • Understanding and Treating Spiritual Abuse

Education Category. Psychiatric / Mental Health

Release Date. 09/01/2024

Expiration Date. 08/31/2027

Course Overview

Spiritual abuse is not just relevant for those who have been members of cults. It is a very real condition that often occurs in individuals who have been abused or who struggle with addiction issues. In this course, theories of spiritual abuse and approaches to understanding it are explored through pastoral, developmental, and clinical lenses. Generally defined as the use of God/a higher power or religion as a tool to gain power and control by the abuser, spiritual abuse is one of the most overlooked forms of abuse in clinical settings. However, the willingness to address it will give clinicians added insight into many of their clients and how to more effectively and holistically address treatment. Case studies, personal reflection, and other critical thinking activities will help participants understand how the construct of spiritual abuse is relevant to clinical practice and apply this knowledge to assessment and treatment planning.

Audience

This course is designed for professional clinicians of any kind who may encounter victims of spiritual abuse, including counselors, social workers, therapists, and psychologists.

Accreditations & Approvals

NetCE has been approved by NBCC as an Approved Continuing Education Provider, ACEP No. 6361. Programs that do not qualify for NBCC credit are clearly identified. NetCE is solely responsible for all aspects of the programs. As a Jointly Accredited Organization, NetCE is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved under this program. Regulatory boards are the final authority on courses accepted for continuing education credit. Continuing Education (CE) credits for psychologists are provided through the co-sponsorship of the American Psychological Association (APA) Office of Continuing Education in Psychology (CEP). The APA CEP Office maintains responsibility for the content of the programs. NetCE is accredited by the International Accreditors for Continuing Education and Training (IACET). NetCE complies with the ANSI/IACET Standard, which is recognized internationally as a standard of excellence in instructional practices. As a result of this accreditation, NetCE is authorized to issue the IACET CEU. NetCE is recognized by the New York State Education Department's State Board for Social Work as an approved provider of continuing education for licensed social workers #SW-0033. This course is considered self-study, as defined by the New York State Board for Social Work. NetCE is recognized by the New York State Education Department's State Board for Mental Health Practitioners as an approved provider of continuing education for licensed mental health counselors #MHC-0021. This course is considered self-study by the New York State Board of Mental Health Counseling. NetCE is recognized by the New York State Education Department's State Board for Mental Health Practitioners as an approved provider of continuing education for licensed marriage and family therapists. #MFT-0015.This course is considered self-study by the New York State Board of Marriage and Family Therapy. Materials that are included in this course may include interventions and modalities that are beyond the authorized practice of licensed master social work and licensed clinical social work in New York. As a licensed professional, you are responsible for reviewing the scope of practice, including activities that are defined in law as beyond the boundaries of practice for an LMSW and LCSW. A licensee who practices beyond the authorized scope of practice could be charged with unprofessional conduct under the Education Law and Regents Rules.

Designations of Credit

NetCE designates this continuing education activity for 2 NBCC clock hour(s). Social workers participating in this intermediate to advanced course will receive 5 Clinical continuing education clock hours. NetCE designates this continuing education activity for 5 credit(s). NetCE is authorized by IACET to offer 0.5 CEU(s) for this program.

Individual State Behavioral Health Approvals

In addition to states that accept ASWB, NetCE is approved as a provider of continuing education by the following state boards: Alabama State Board of Social Work Examiners, Provider #0515; Florida Board of Clinical Social Work, Marriage and Family Therapy and Mental Health Counseling, CE Broker Provider #50-2405; Illinois Division of Professional Regulation for Social Workers, License #159.001094; Illinois Division of Professional Regulation for Licensed Professional and Clinical Counselors, License #197.000185; Illinois Division of Professional Regulation for Marriage and Family Therapists, License #168.000190;

Course Objective

The purpose of this course is to provide clinicians with an appreciation for the impact of spiritual abuse on clients and the skills necessary to assess and address the experience of spiritual abuse.

Learning Objectives

Upon completion of this course, you should be able to:

1. Define spiritual abuse from a pastoral, developmental, and clinical perspective.

2. Identify the common traits among spiritually abusive persons and religious denominations as well as victims of spiritual abuse.

3. Assess for commonly encountered negative cognitions acquired by those who have been spiritually abused in the context of clinical symptomology.

4. Develop and implement treatment plans that are sensitive to the needs of clients who have experienced spiritual abuse.

5. Identify components of healthy spirituality that will assist in the recovery process.

6. Determine one's own strengths and weaknesses in clinically addressing spiritual abuse and its various clinical manifestations.

Faculty

Jamie Marich, PhD, LPCC-S, REAT, RYT-500, RMT, (she/they) travels internationally speaking on topics related to EMDR therapy, trauma, addiction, expressive arts, and mindfulness while maintaining a private practice and online education operation, the Institute for Creative Mindfulness, in her home base of northeast Ohio. She is the developer of the Dancing Mindfulness approach to expressive arts therapy and the developer of Yoga for Clinicians. Dr. Marich is the author of numerous books, including EMDR Made Simple, Trauma Made Simple, and EMDR Therapy and Mindfulness for Trauma Focused Care (written in collaboration with Dr. Stephen Dansiger). She is also the author of Process Not Perfection: Expressive Arts Solutions for Trauma Recovery. In 2020, a revised and expanded edition of Trauma and the 12 Steps was released. In 2022 and 2023, Dr. Marich published two additional books: The Healing Power of Jiu-Jitsu: A Guide to Transforming Trauma and Facilitating Recovery and Dissociation Made Simple. Dr. Marich is a woman living with a dissociative disorder, and this forms the basis of her award-winning passion for advocacy in the mental health field.

Faculty Disclosure

Contributing faculty, Jamie Marich, PhD, LPCC-S, REAT, RYT-500, RMT, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Division Planners

Alice Yick Flanagan, PhD, MSW

Margaret Donohue, PhD

Division Planners Disclosure

The division planners have disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Director of Development and Academic Affairs

Sarah Campbell

Director Disclosure Statement

The Director of Development and Academic Affairs has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

About the Sponsor

The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare.

Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.

Disclosure Statement

It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.

Implicit Bias in Health Care

The role of implicit biases on healthcare outcomes has become a concern, as there is some evidence that implicit biases contribute to health disparities, professionals' attitudes toward and interactions with patients, quality of care, diagnoses, and treatment decisions. This may produce differences in help-seeking, diagnoses, and ultimately treatments and interventions. Implicit biases may also unwittingly produce professional behaviors, attitudes, and interactions that reduce patients' trust and comfort with their provider, leading to earlier termination of visits and/or reduced adherence and follow-up. Disadvantaged groups are marginalized in the healthcare system and vulnerable on multiple levels; health professionals' implicit biases can further exacerbate these existing disadvantages.

Interventions or strategies designed to reduce implicit bias may be categorized as change-based or control-based. Change-based interventions focus on reducing or changing cognitive associations underlying implicit biases. These interventions might include challenging stereotypes. Conversely, control-based interventions involve reducing the effects of the implicit bias on the individual's behaviors. These strategies include increasing awareness of biased thoughts and responses. The two types of interventions are not mutually exclusive and may be used synergistically.

1. INTRODUCTION

In clinical discussions, we are used to talking about issues of sexual, physical, emotional, verbal, and even financial abuse, but the idea of spiritual abuse tends to be overlooked. Many professionals do not realize that spiritual abuse exists or are confused by its definition. Shortly, spiritual abuse is the use of God or religion as a tool to gain power and control by the abuser. Clients may relate their struggles with God or spirituality resulting from negative experiences with abusive religious leaders or parents/caregivers, and these struggles may keep them from accessing spiritual resources they inherently want to access for wellness. Dealing with "spiritual hang-ups" can enhance treatment of any clinical condition if a client is willing to have them addressed. If clinicians are serious about holistic, "body-mind-spirit" approaches to treatment, assessing for and addressing the experience of spiritual abuse and its impact on an individual is imperative.

This course will consider the foundations of spiritual abuse by first defining it through clinical, developmental, and pastoral lenses, then exploring the common themes in spiritually abusive dynamics that transcend religion or denomination. Next, the course will discuss how to assess for the presence of spiritual abuse in clients and how to provide in-depth treatment strategies, informed by trauma-sensitive treatment approaches, for healing the wounds of spiritual abuse. Finally, the course examines issues of professional development as it relates to spiritual abuse. This examination includes, but is not limited to, exploring one's own spiritual identities, hesitancies to address spirituality with clients, and strategies to help clients access the best healing possible.

A major premise in this course is that no religion, no denomination, and no spiritual practice is immune to the devastating effects of spiritual abuse. It can happen anywhere––in yoga schools, convents, Catholic churches, devout households, Evangelical "megachurches," tiny country church houses, synagogues, yeshivas, ashrams, temples, radical sects, meditation groups, and small community Bible studies. Whenever a leader or members usurp their power and use spiritual-based threats to keep people in place or wield power over vulnerable members of a group, then spiritual abuse is present. The notion that spiritual abuse does not discriminate is a key assumption of this course. In studying spiritual abuse, there is a chance that you will read something about your denomination or chosen belief system that is upsetting, but no offense is intended. With the exception of few groups that clearly meet the definition of a cult (explored later in this course) or an extremist sect that promotes hate speech, no denominations or spiritual practices are condemned. Rather, as a clinician who treats trauma, it is important to identify those individual groups, leaders, or members who use their power over people or the spiritual practices inherent in their faith system in an abusive way.

2. FOUNDATIONS: DEFINING SPIRITUAL ABUSE

Completing a literature search on spiritual abuse will not uncover as many entries as a search on sexual abuse or physical abuse. Many articles examine the spiritual implications of abuse or see spiritual wounding as a clear symptom of more "obvious" abuse that is more likely to present as a treatment issue. For example, there is clear documentation in scholarly literature discussing the spiritual implications of sexual abuse, and in the popular forum, many online support groups for spiritual abuse exist in conjunction with sexual abuse sites[1]. Another facet of the literature examines spiritual abuse as an issue in cultures in which forced assimilation and other religious discrimination occurred (e.g., Aboriginal, other indigenous cultures) [2]. The issue of spiritual abuse within subsystems meeting the definition of a cult is another major area of exploration, as is the examination of those who have survived clergy abuse [3,4,5].

It is important to realize that spiritual abuse is not limited to these more prominent examples—alongside sexual abuse or cases of religious persecution or cultic involvement. According to Dehan and Levi, spiritual abuse should be considered a separate category of abuse because its presence keeps the victim from realizing total spiritual fulfillment [6]. Spiritual abuse or other religious "hang-ups" can act as a barrier to people getting the help they need in terms of mental wellness [7]. In contrast, a healthy spiritual focus can be a major source of strength for a person seeking mental wellness, which makes resolving emotional issues connected to spiritual abuse imperative [8]. Literature findings regarding the treatment of spiritual abuse will be explored later in this course.

The vast majority of general literature on the topic of spiritual abuse is qualitative and experiential in nature. Books from multiple perspectives explore spiritual abuse and its effect. These writings are too numerous to catalogue in the scope of this article. Explanatory and definitional highlights from pastoral, developmental, and clinical perspectives are covered in this section.

SOCIOLOGIC PERSPECTIVES

As with many issues in psychology and religion, definitions are often personal and diverse. For the purposes of setting definitions in this course, it is imperative to explore the definition of a cult because much of the talk surrounding spiritual abuse is connected to cultic brainwashing and working to reintegrate people who escape from cults. The entomologic root of the word "cult" is the Latin cultus, simply meaning to tend or to worship; the same root also spawned the English word "cultivate," a verb that typically has positive connotations. In the modern era, the term "cult" has come to have a negative connotation. A succinct definition from the Oxford English Dictionary on modern usage is, "a new religious movement or other group whose beliefs or practices are considered abnormal or bizarre" [9]. This general definition, although accurate overall, is still open to interpretation and can even be used by spiritual abusers to denigrate other groups who are seen as a threat to their denominational superiority (e.g., in the Evangelical Church, Catholicism, Hinduism, Judaism, and Buddhism may all be considered negatively connoted cults). Thus, it is imperative to examine commonly agreed upon traits or characteristics of a cult.

An authority on cultic definition is Michael Langone, founder of the International Cultic Studies Association (ICSA). The ICSA does not publish a list of groups that they label to be cultic. Rather, they encourage those evaluating cultic behavior to make judgments for themselves, using certain criteria as a guideline to determine if a group is destructive or harmful to the people involved. Based on the work of Langone, Lalich and Tobias established the following list as an evaluative guideline [10]:

- The group displays excessively zealous and unquestioning commitment to its leader (whether alive or dead) and regards his/her belief system, ideology, and practices as the truth or law.

- Questioning, doubt, and dissent are discouraged or even punished.

- Mind-altering practices (such as meditation, chanting, speaking in tongues, denunciation sessions, and debilitating work routines) are used in excess and serve to suppress doubts about the group and its leader(s).

- The leadership dictates, sometimes in great detail, how members should think, act, and feel. For example, members may be required to obtain permission to date, change jobs, or marry—or leaders may prescribe what types of clothes to wear, where to live, whether or not to have children, how to discipline children, and so forth.

- The group is elitist, claiming a special, exalted status for itself, its leader(s), and its members. For example, the leader may be considered the Messiah, a special being, or an avatar, or the group and/or the leader may be on a special mission to save humanity.

- The group has a polarized us-versus-them mentality, which may cause conflict with the wider society.

- The leader is not accountable to any authorities (unlike, for example, teachers, military commanders, or ministers, priests, monks, and rabbis of mainstream religious denominations).

- The group teaches or implies that its supposedly exalted ends justify whatever means it deems necessary. This may result in members participating in behaviors or activities they would have considered reprehensible or unethical before joining the group (e.g., lying to family or friends, collecting money for bogus charities).

- The leadership induces feelings of shame and/or guilt in order to influence and/or control members. Often, this is done through peer pressure and subtle forms of persuasion.

- Subservience to the leader or group requires members to cut ties with family and friends and radically alter the personal goals and activities they had before joining the group.

- The group is preoccupied with bringing in new members.

- The group is preoccupied with making money.

- Members are expected to devote inordinate amounts of time to the group and group-related activities.

- Members are encouraged or required to live and/or socialize only with other group members.

- The most loyal members (the "true believers") feel there can be no life outside the context of the group; they believe there is no other way to be. Members often fear reprisals to themselves or others if they leave (or even consider leaving) the group.

In the spirit of ICSA's "evaluate for yourself" mentality, there is no certain number of criteria that should be fulfilled in order for the definition to be met. Rather, this list is offered as an evaluative guideline that can be especially useful for clinicians. The "evaluate for yourself" approach is a trait of healthy spirituality, a concept that will be discussed in greater depth in the section on treatment.

A critical aspect of working with spiritual abuse is to understand that it does not only occur in what society considers to be cults. It is easy to accept that a person emerging from a dangerous cult would be a clear victim of spiritual abuse, but what of the more subtle, yet equally dangerous manifestations? Hobson, although writing primarily from the pastoral perspective, offers a comprehensive definition of spiritual abuse [11]. Admitting that spiritual abuse is impossible to define in a sentence or two, he makes as concise of an attempt as possible [11]:

Spiritual abuse is the gross dereliction or neglect of a spiritual leader's responsibility to protect the basic rights of anyone under that leader's care. These basic rights include parishioners' spiritual, psychological, financial, and physical well-being. Spiritual abuse occurs when any spiritual leader violates these sacred trusts in any way, form, or fashion, thus causing any harm in regards to the aforementioned rights. Abuse occurs whenever a leader injures or takes advantage of anyone under his or her care at any time, in the following manner: physically, sexually, financially, emotionally, or psychologically, and any other similar acts…It occurs so frequently, most victims of it aren't even aware it has happened to them.

As explained, it is paramount to realize that spiritual abuse is a global phenomenon that transcends religious denomination or religious practice. Throughout history, if one person has been in the position to wield power over another person and chooses to use God, enlightenment, salvation, the threat of damnation, the promise of enlightenment, or other spiritual promise/threat to exert that power, a spiritually abusive relationship can exist. This relationship can occur between a spiritual leader (e.g., pastor, priest, guru, imam, rabbi) and his or her congregation, between parents/grandparents and their children, or between mentors/gurus and their disciples.

The term "guru" is worth exploring as well. Guru is the Sanskrit word meaning "teacher" or "master," literally translated as "one who casts out darkness." Although originating in Hinduism, many in the modern era use the term in reference to anyone whose teachings attract followers. For example, some consider the Dalai Lama to be a guru, and notable leaders in other disciplines not related to religion have even been referred to as gurus. Because of well-publicized scandals involving guru misconduct in the last several decades, especially in the areas of financial and sexual exploitation, many people in the United States attribute a negative connotation to the word "guru," similar to the negative, exploitative connotation associated with the term "cult."

One of the most well-known books on abusive power dynamics within Eastern and other spiritual practices that are not specifically Christian is The Guru Papers: Masks of Authoritarian Power [12]. In this book, "guru" (with editorial quotation marks) refers to anyone who manipulates others under the guise of knowing what is best for them. In this broad definition, almost anyone can meet the definition, whether it is a spiritual leader, a 12-step sponsor, a parent, a friend, a teacher, or a romantic partner.

PASTORAL PERSPECTIVES

Although spiritual abuse occurs in every religious denomination and no spiritual practice is immune to its effects, the greatest body of writing on the problem, from a religious perspective, is within Christianity. This section will explore how some of these seminal works define and explain spiritual abuse. Christian pastors or those in a position of ministry are the sources of all of these works, unless otherwise noted. Despite the overt Christian focus of this section, consider how any denomination, religion, or spiritual grouping could be inserted into these definitions and notice the similarities.

In their revolutionary work The Subtle Power of Spiritual Abuse, Jeff VanVonderen and former pastor David Johnson defined spiritual abuse as "the mistreatment of a person who is in need of help, support, or greater spiritual empowerment, with the result of weakening, undermining, or decreasing that person's spiritual empowerment" [13]. Many abuse survivors, with spiritual abuse being no exception, have a tendency to feel that they are somehow uniquely "crazy" for feeling a certain way. This doubt about the validity of experience can be an even greater factor with spiritual abuse because a great many people do not realize it is an actual form of abuse, as much as physical or sexual abuse.

Another leader in the pastoral community on the issue of spiritual abuse, Christian sociologist Ronald Enroth writes [14]:

Unlike physical abuse that often results in bruised bodies, spiritual and pastoral abuse leaves scars on the psyche and soul. It is inflicted by persons who are accorded respect and honor in our society by virtue of their role as religious leaders and models of spiritual authority. They base their authority on the Bible, the Word of God, and see themselves as shepherds with sacred trust. But when they violate that trust, when they abuse their authority and when they misuse ecclesiastical power to control and manipulate the flock, the results can be catastrophic.

Another Christian leader whose work emerged in the early 1990s was Ken Blue. He also drew comparisons between spiritual abuse and other types of abuse [15]:

Abuse of any type occurs when someone has power over another and uses that power to hurt. Physical abuse means that someone exercises physical power over another, causing physical wounds. Sexual abuse means that someone exercises sexual power over another, resulting in sexual wounds. And spiritual abuse happens when a leader with spiritual authority uses that authority to coerce, control, or exploit a follower, thus causing spiritual wounds.

Dale and Juanita Ryan, who worked closely with Ken Blue, put it in the simplest terms: "Spiritual abuse is a kind of abuse that damages the central core of who we are. It leaves us spiritually disorganized and emotionally cut off from the healing love of God" [16].

DEVELOPMENTAL PERSPECTIVES

The fields of psychology and related helping professions have a variety of developmental models to describe the human experience. A specific psychologic model of faith development also exists, attributed to developmental psychologist James W. Fowler and based on the works of Piaget, Erickson, and Kohlberg (who introduced the stages of moral development in human being) [17]. Examine this Faith Development Model and consider where spiritually abusive experiences might have their greatest impact [17]:

- Stage 0: Primal or undifferentiated faith (birth to 2 years of age) is characterized by an early learning of the safety of one's environment (i.e., warm, safe, and secure vs. hurt, neglect, and abuse). If consistent nurturing is experienced, one will develop a sense of trust and safety about the universe and the divine. Negative experiences will cause one to develop distrust with the universe and the divine.

- Stage 1: Intuitive-projective faith (3 to 7 years of age) is characterized by the psyche's unprotected exposure to the Unconscious.

- Stage 2: Mythic-literal faith (mostly school-age children) is characterized by a strong belief in the justice and reciprocity of the universe. During this stage, deities are almost always anthropomorphic (i.e., personified).

- Stage 3: Synthetic-conventional faith (12 years of age to adulthood) is characterized by conformity to religious authority and the development of a personal identity. Any conflicts with one's beliefs are ignored at this stage due to the fear of threat from inconsistencies.

- Stage 4: Individuative-reflective faith (usually mid-twenties to late thirties) is characterized as a stage of angst and struggle. The individual takes personal responsibility for his or her beliefs and feelings. As one is able to reflect on one's own beliefs, there is openness to a new complexity of faith, but this also increases the awareness of conflicts in one's belief.

- Stage 5: Conjunctive faith (mid-life) is characterized by the acknowledging of paradox and transcendence relating to the reality behind the symbols of inherited systems. The individual resolves conflicts from previous stages by a complex understanding of a multidimensional, interdependent "truth" that cannot be explained by any particular statement.

- Stage 6: Universalizing faith, or what some might call "enlightenment," is characterized by the individual treating any person with compassion as he or she views people as from a universal community and worthy of being treated with the universal principles of love and justice.

No perfect models exist within the psychologic professions, and this model is no exception. For instance, the quality of spiritual role models and sociocultural contexts can significantly impact the way a person moves through these stages. Moreover, the ages are meant to be approximate. Some would argue that the faith crises of the individuative-reflective stage are much more likely to happen in adolescence today than when the model was initially proposed in 1981. Despite its imprecisions, Fowler's model is highly regarded within the psychologic professions because its construction was strongly influenced by luminaries in developmental psychology and because empirical research supporting the model is extensive [18]. Having an understanding of this model becomes important when assessing for spiritual abuse because having a spiritually exploitative experience at an earlier stage can have different implications than abuse at a later stage. Moreover, healthy development in earlier stages may serve as a safeguard against the ill effects of a spiritually abusive experience in later stages.

Stein points to the role of disorganized attachment as a factor in the development or perpetuation of spiritual abuse [51]. In disorganized attachment, a person does not know what to expect, leading to a tendency to withdraw and to be anxious about attachment needs being met. Disorganized attachment styles can develop in highly vulnerable people, and if a spiritual abuse victim does not already operate in this style from early childhood wounding, a cultic or spiritually abusive system will work to create it [51].

CLINICAL PERSPECTIVES

Scholarly articles on spiritual abuse, as a clinical issue, began surfacing in the 1990s. The idea of spiritual abuse as an issue of clinical attention is not unique to the 1990s, but it is apparent that people began to speak up more about being spiritually abused during this period. Helping professionals who were savvy to working with the spiritual dimension of a human being continued the conversation and inquiry. One such author, Boyd Purcell, writes from two perspectives as a minister and as a doctoral-level clinical counselor. Purcell's insights on defining spiritual abuse are multifarious, and some are highlighted here to facilitate a discussion of clinical perspectives [19].

Purcell's succinct definition of spiritual abuse is "any unhealthy, mind-altering relationship with the God of a person's conception that has life-harmful consequences" [19]. He defines spiritual abuse among people as existing on a continuum from zero to terrorism.

Most people have experienced some form of spiritual abuse in their lifetime; however, the people who tend to suffer from it to the extent that clinical attention is required fall in the moderate-to-terrorism range. Purcell explains that when he began teaching the spiritual abuse continuum in the early 1990s, most clinicians responded that they had never heard of the terms or considered them to exist. But the ideas resonated and continue to be used today.

Purcell has identified three causes of spiritually abusive dynamics. Although he writes primarily from a Christian perspective, these causes clearly apply to abuse dynamics within other belief systems as well [19]:

- Legalism: A religious belief that people can please God or any chosen deity, even earning their way into heaven or an afterlife, by obeying specific rules. This is commensurate with a reward and punishment mentality, the lowest stage in Kohlberg's stages of moral development.

- Literalism: The belief that the Bible or other sacred texts must be interpreted literally, not symbolically, to be properly understood.

- Mixed messages: Receiving two contrasting viewpoints about God or spirituality (e.g., "God loves you unconditionally," vs. "But God will only love and accept you if you follow all of the rules").

Considering these dynamics, it becomes clear that people are often afraid to come forward to report spiritual abuse, fearing that they are somehow breaking the rules or displeasing God if they seek help. Although fear of speaking up is a common dynamic in many forms of abuse, it can take on a more damning implication for people if they believe that their soul may be in jeopardy.

Mixed messages are a causal factor in many issues presenting for clinical attention, and many people with personality disorders grow up in environments with severe mixed messaging. Clinicians who work in the field of recovery may know the colloquial expression "mixed messages are a recipe for crazy-making."

In terms of literalism and legalism, a parallel can be made to "living within the letter of the law" versus "living within the spirit of the law." People who have grown up with literalism and legalism often suffer from rigidity or black-and-white thinking. This type of thinking is difficult to work with and should be addressed as a treatment issue. If a client struggles with black-and-white thinking, consider exploring whether or not he or she grew up with legalism or literalism in their home of origin. Even if the client long abandoned the church or spiritual beliefs, the impact of such an upbringing on his or her thought system may be present.

Another causal factor is what is referred to as clericalism [52]. By definition, clericalism is when a small group of highly regarded leaders identified as special make all of the most important decisions in the organization. Although input might be taken from member of the congregation, it is not seriously regarded. Clericalism has been identified as a major causal and exacerbating factor in the abuse scandals within the Roman Catholic Church [52].

Another newer term is child abuse linked to faith or belief, or CALFB [53]. Child protective services workers may encounter this phenomenon used to justify other forms of abuse. In one survey of 1,300 child protective service workers, a need for further training in phenomenon around spiritual abuse and religious trauma was identified. The National Domestic Violence Hotline has also worked to raise awareness about the dynamics of spiritual abuse in intimate partner or other family violence.

Case Example

Client D grew up in a strict Baptist home. Her father was a Baptist minister who died when she was very young; her mother went on to remarry another Baptist minister. One of the teachings rigidly instilled in her developing mind was that she would "go to hell" if she had sex before marriage. So, after she chose to have sex with her boyfriend when she was 19 years of age, she felt that because she was doomed anyway, she might as well go all the way with her "sinning." D clearly identifies that this belief of being damned was a major factor in her developing sexual addiction and eventual dependency on food, alcohol, and cocaine. When she presented for treatment at 40 years of age, a significant belief that blocked her successful participation in treatment was, "I am unworthy of getting better because I am undeserving of God's love." In reflecting back on her treatment experience, eye movement desensitization and reprocessing (EMDR) therapy was needed to help her work on deservability issues, which were instilled by a spiritually abusive upbringing.

3. COMMON THEMES IN SPIRITUAL ABUSE

A desire for or a need to control is a common trait in those who abuse, typically because they are lacking an internal sense of security and stability. Those who work with trauma survivors typically assume that those who abuse others have been abused or mistreated themselves on some level. A trauma-sensitive perspective informs that if the original wound is not resolved, a person may act out in a maladaptive attempt to heal. The likelihood of a maladaptive, or unhealthy, response increases if the person is never shown healthier ways to resolve his or her wounding. This section will explore the traits of those who are likely to spiritually abuse—traits that are common regardless of the religious denomination or spiritual practice in question. In addition, some of the traits of those vulnerable to spiritual abuse will be discussed. Finally, the section will end with a discussion of the similarities and differences between those abuses that occur in religious or spiritual settings (e.g., churches, temples, ashrams) and those that occur within the home or family.

TRAITS OF SPIRITUAL ABUSERS

There are three major traits of those who spiritually abuse others:

- Narcissistic traits/tendencies, resulting from deep insecurity

- Usually a genuine belief that one is doing "the right thing" (rarely an intent to harm)

- Skilled in the language of love, emotions, trust, and intimacy

Narcissistic Traits/Tendencies

Just as clinicians tend to assume that those who abuse have been abused themselves, the assumption is often made that those with narcissistic traits and tendencies (even if criteria for full-blown narcissistic personality disorder are not met) are reacting to a deep sense of insecurity. For many who spiritually abuse, having spiritual knowledge to hold over people becomes a way to meet their need for inner security or self-esteem.

Genuine Belief in One's Righteousness

With the exception of a few extremists who fall into what might be considered cult leaders or who engage in what Purcell labels spiritual terrorism, there rarely is intent to harm [19]. Many who act out in spiritually abusive ways genuinely believe they have found some type of "answer" and desire to share it with others, likely unaware of the subconscious insecurities that drive them. In the case of Client D, discussed in the previous section, her parents likely believed they were doing the right thing by instructing her in the ways of their faith. The phrase, "I'm doing this for your own good" is a common statement uttered by those who spiritually abuse [11,19,50].

Skilled in the Language of Love, Emotions, Trust, and Intimacy

A very cynical way to explain this common trait is to think of manipulation. If abusers are not directly cruel, they are typically very manipulative, using the nuanced appeal of "I have what you really want deep down" to meet their own needs. Those who have experiences with abusive systems typically state that the church or spiritual community had a certain appeal to it, promising good things like love, camaraderie, or even healing and enlightenment. These positive appeals are fundamentally good and have nearly universal appeal. Those who spiritually abuse are masters at luring people in with these good points, but after spending some time with the church or faith community, followers are likely to become acquainted with the ugly realities of the system. In essence, all of this promised love, joy, and bliss comes with a price.

Certain gurus or spiritual teachers come across as very appealing at first, often attracting schools of followers. Then, the initial appeal of the practice may wear off when disciples realize that the leaders are asking more of them in terms of devotion or money than they initially presented. Or, in the worst cases, leaders may take advantage of their followers' desires for intimacy, motivation, and/or self-realization by promising it for a price, often one that is financial, sexual, or emotional in nature.

TRAITS OF SPIRITUAL ABUSE VICTIMS

People who are spiritually abused genuinely desire love, acceptance, intimacy, and the positive attributes of spiritual experiences. Many have been hurt in other areas of life and are seeking a spiritual connection. Abusers tend to sense this and take advantage of or exploit it. Commonly observed traits in people who are prone to being spiritually abused include:

- Deep insecurity and emotional sensitivity

- A genuine intent to pursue truth

- Deep longing for love, emotions, trust, and intimacy

- A belief that love is earned

- Periods of crisis or major life change

Insecurity, Sensitivity, and Longing

As discussed, those who spiritually abuse are often insecure. Those who are prone to being abused typically have the added dynamic of extreme sensitivity. Such sensitivity is like a fire in a fireplace. If it rages out of control, it can burn the house down, but if the fire dies (i.e., sensitive tendencies are numbed), the house will be freezing. The key is to keep a balance. Many sensitive people have the purest of intentions, as the traits suggest, to do the right thing and to live in truth, love, trust, and deep intimacy. Yet if this is not managed, it can make them vulnerable to a host of negative responses (e.g., addictive responses) or to being exploited emotionally, sexually, financially, physically, and spiritually.

Looking at these traits through the lens of Fowler's Faith Development Model, it is important to re-examine stage 0, or primal/undifferentiated faith. This period, from birth to 2 years of age, is characterized by an early learning of the safety of one's environment [17]. If consistent nurturing is experienced, one will develop a sense of trust and safety. Negative experiences will cause one to develop distrust with the universe and the divine. One could argue that people who have these negative experiences at this vulnerable, preverbal period are prone to developing insecurity, emotional sensitivity, and a longing for truth and intimacy.

Earned Love

The common belief that love is earned ties in to Purcell's descriptions of legalism and literalism [19]. This is exemplified by the idea that obedience results in God's love, entrance into heaven, a spiritual reward, or spiritual enlightenment (i.e., the truth, intimacy, and love one has been seeking). However, it is important to remember that even people who do not grow up in religious homes may develop this belief system. For example, in some homes the message of earning parental love through obedience is either implicitly or explicitly delivered. In alcoholic homes, young children may believe, albeit maladaptively, that their good behavior could stop their parent from drinking. Whenever a person receives any message along the lines of "love is earned" in the formative years and a newer, more adaptive message is never installed in its place, they are vulnerable to being abused, especially in a spiritual sense, later in life.

Periods of Crisis or Major Life Change

Abusers tend to prey on the weak, and people are most likely to feel weak during periods of crisis or life change, especially when an element of self-doubt is involved. In the popular understanding about cults, this trait is recognized in charismatic cult leaders: they prey on the weak. However, it does not take an extremist cult leader for this dynamic to take place.

In discussing spiritual abuse, it is not hard to see how it can manifest in spiritual systems (e.g., churches, communities) in which an abusive leader or leaders are at the helm. However, it is just as important to discuss when the abusive "leader" is a parent or family member. Research indicates that spiritual abuse is often perpetrated by a family member, commonly a parent who follows a literal, legalistic interpretation of fundamentalist religious teachings. Consider the case of Client D from the case example in the previous section. The messages she received about hellfire and damnation came in the home. One could argue that such messages are even more damaging to children when they come from a parent or primary attachment figure as opposed to a pastor or religious leader.

CASE EXAMPLE

Client J is a woman, 35 years of age. During a counseling session, J relates a key negative belief she received in childhood and internalized: "I am Satan's child." This belief was given to her by her father, a man whom she genuinely loved, in his attempt to "save her soul." Another negative message she received, one that accelerated her addictive responses, was that if she did not follow God's laws as written in her father's denomination's interpretation of the Bible, then the people who were close to her would be taken away. This message was relayed when she was 19 years of age, after her high school guidance counselor, a woman to whom she was very close, died unexpectedly of complications of pneumonia. Her death affected J very much, and her father's response to it was that her death was God's "warning sign" to Client J. Her father said that if she did not "straighten up" her ways (which meant getting back to church, an activity she abandoned when going to college), then God would begin to remove more people from her life, starting with her brother and mother. These words were very damaging, setting off a deep depression that lasted years.

4. ASSESSING FOR SPIRITUAL ABUSE

There is a very active online community of spiritual abuse survivors, discussion boards, and forums for people to share their stories about wounding and recovery. These online communities are usually the first places that spiritual abuse victims go in the modern era because of the anonymity they provide [20]. Such communities can provide victims with the initial validation of their experiences needed to begin recovery and transform into a survivor. One popular community, Kingdom Grace, offered the following insights regarding spiritual abuse [21]: Spiritual abuse is trauma. The three characteristics of trauma are:

- An external cause—Someone does it to you.

- Violation—You are violated by an unwelcome intrusion.

- Loss of control—It is unexpected and beyond your control.

The result is a shattering of the basic assumptions the person held about their world.

Trauma, which is based on a Greek word meaning wound, is defined as any experience a person endures that leaves a life-threatening or life-altering impact. If left unresolved, the effects can be devastating. Some experiences of trauma manifest as clinical post-traumatic stress disorder (PTSD). However, the helping professions are growing increasingly savvy to the notion that an event or experience does not have to meet PTSD criteria to be relevant. Many conditions that present for clinical attention, including, but not limited to, depression and mood disorders, anxiety disorders, adjustment disorders, and personality disorders, can have clear roots in traumatic experiences or can be exacerbated by the presence of unresolved trauma.

The same approaches that helping professionals use to assess for PTSD and trauma-related conditions can be used to assess for spiritual abuse, if spiritual abuse is accepted as a trauma like any other form of abuse. This section will focus on direct and indirect methods for assessing spiritual abuse as a trauma.

Providers who are not experienced in assessing for PTSD or trauma should start with a semi-standardized interview tool such as the Primary Care PTSD Screen (Table 1) [22]. The Primary Care PTSD Screen is not meant to be a diagnostic tool, but it is an effective screening tool, indicating whether or not further assessment is necessary. If a client answers "yes" to any of these questions, the results of the screening should be considered positive. A list of other screening tools or psychometric measures and instructions on their use in clinical settings is available at https://www.ptsd.va.gov/professional/provider-type/doctors/screening-and-referral.asp. Any trauma-related tool can be used to assess for the presence of spiritual abuse as long as it is appropriately modified.

Table 1: PRIMARY CARE PTSD SCREEN

In your life, have you ever had any experience that was so frightening, horrible, or upsetting that in the past month you:

1. Have had nightmares about it or thought about it when you didn't want to?

2. Tried hard not to think about it or went out of your way to avoid situations that remind you of it?

3. Were constantly on guard, watchful, or easily startled?

4. Felt numb or detached from others, activities, or your surroundings?

If you want to specifically tailor the tool to assess for spiritual abuse, you can modify the opening statement: In your life, have you ever had any spiritual or religious experiences that were so frightening, horrible, or upsetting?

Source: [22]

One of the sub-criteria of PTSD in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) is persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., "I am bad," "No one can be trusted," "The world is dangerous") [23]. Alternatively, this might be expressed as "I've lost my soul forever," or "My whole nervous system is permanently ruined." Although this symptom is officially listed under the criterion of negative alterations in cognitions and mood associated with the traumatic event(s) beginning or worsening after the traumatic event(s) occurred, this description has long been accepted as a part of trauma-related injuries.

These negative belief examples are one way to assess for trauma and its impact. In a clinical setting, a 30-item list called The Greatest Hits List of Negative Beliefs may be helpful [24]. This list contains 30 of the most common negative cognitions those who have been traumatized tend to believe about themselves. Common examples include:

- I am not good enough.

- I am permanently damaged.

- It is my fault.

- My body is ugly.

- I have to be perfect.

- I cannot trust anyone.

- I am not worthy.

- I am not safe.

- I cannot show my emotions.

These beliefs are rather general, but when identified, exploring them can lead to valuable clinical information. When working with survivors of spiritual abuse, a similar greatest hits list, specific to spiritually charged beliefs about the self, may be more helpful. Some of these beliefs include:

- I have to be perfect.

- I am defective.

- I am not deserving (of God's love/grace).

- I am a disappointment (in God's eyes).

- I cannot trust my judgment.

- I am demonic/possessed/"Satan's child."

- I am not safe in the world.

- I am cursed.

This list is not exhaustive, as it is not possible to capture every negative slur that a person received, with spiritual charge, from an abuser. However, it provides a solid place to begin. In some cases, the core event(s) causing the spiritual abuse reveal themselves during assessment with a general list, but if the trauma is suspected to be more spiritual or existential in nature, a simplified and specific list may be more helpful.

First, let the client see the list and ask if any of the eight beliefs on the list apply to him or her. Let the client know that he or she may have one, two, or even all eight beliefs that resonate. If more than two beliefs are checked, ask the client to re-review the list and try to rank or identify the one or two worst. In order to obtain additional information about a spiritually abusive experience, consider asking follow-up questions. For example, if a client's most charged cognition is "I'm a disappointment in God's eyes," ask:

- Thinking back over the course of your whole life, when did you first start to believe "I am a disappointment in God's eyes?" Or, thinking back over the course of your whole life, when did you first receive the message "I am a disappointment in God's eyes?"

- Thinking back over the course of your whole life, when was the worst time you believed "I am a disappointment in God's eyes?" Or, thinking back over the course of your whole life, when was the worst time you received the message "I am a disappointment in God's eyes?"

- Thinking back over the course of your whole life, when was the most recent time you believed "I am a disappointment in God's eyes?" Or, thinking back over the course of your whole life, when was the most recent time you received the message "I am a disappointment in God's eyes?"

The answers to these questions can provide a wealth of information to guide treatment planning. The decision of when during the treatment process to ask these questions is up to the clinician's discretion and the quality of the therapeutic relationship. These questions may be asked during an initial assessment if sufficient rapport has been established, or if a spirituality-related abuse issue arises, the questions may be used later in the treatment process.

The idea of observing and reacting to issues that come up during the treatment process is an important part of assessing for spiritual abuse. Many forms of trauma are not evident in the first session. Even if they are, it is generally not prudent to ask clients detailed questions about the trauma until sufficient rapport has been established and the client has sufficient stabilization, or coping, skills to deal with the distress that may manifest in his or her disclosures. Few clients will identify spiritual abuse as being a trauma or a form of abuse, even if asked during an initial assessment, because many people continue to be unaware of the possibility of this type of abuse. One potential avenue in the initial assessment is to ask a question about religious and/or cultural upbringing. Clients may respond with, "I grew up in a very devout (insert denomination or religion) home, so I was given a lot of negative messages about sex." Such responses provide an opportunity to follow-up or even educate clients on spiritual abuse.

Issues of spiritual abuse may also reveal themselves when working with a client to develop spiritual resources. This is a standard part of the treatment process in traditional substance use disorder treatment, especially those following a 12-step model. Founded in 1935, the 12 steps of Alcoholics Anonymous (AA) have been developed by many treatment centers as a philosophical approach. Part of 12-step philosophy is, after a person admits powerlessness over drugs or alcohol, to begin exploring a relationship with a Higher Power or power greater than oneself and to turn one's will and life over to the care of this power. The steps are not intended to demand devotion to a specific God or religion, but rather to allow addicts to develop their own conceptualization of God. Although many people find 12-step spirituality to be user-friendly and easily accessible to those who desire spirituality and not religion, others resist the 12-step model as being too "God-oriented." Others are able to express their belief in God, but find the idea of trusting a God of their understanding or turning their life over to a Higher Power scary. These resistances may be a natural part of addiction recovery, or they may be a sign that spiritual abuse occurred and is unresolved.

In 2022, Koch and Edstrom debuted a Spritual Abuse and Harm Scale [54]. They developed this tool from surveying over 3,000 Evangelical Christians, so the tool is limited to people from this experience. Six thematic factors comprise the 27-item scale: maintaining the system, internal distress, embracing violence, controlling leadership, harmful God image, and gender discrimination.

CASE EXAMPLE

Consider the case of Client E [24]. Several years ago, E presented for treatment services related to unresolved sexual trauma. She knew that she had PTSD, although the religious themes connected to her PTSD did not come to light immediately. One day, E declared, "There is something in me that is inherently spiritual. I want to be spiritual, but I resist, probably because of what happened to me growing up."

This statement may be viewed as a trigger. When a person say things like "I'm inherently spiritual, but…," or talks about wanting to do spiritual things (e.g., yoga class, church) without taking steps to do these activities, it is a sign that spiritual abuse may exist and should be explored further.

Upon questioning, E revealed she was raised in an Evangelical home with a strictly religious father and an alcoholic mother. She was sexually assaulted by another student at her father's church school as a pre-teen, and the school did not care to address it. In addition, she was sexually assaulted at one of her mother's AA meetings as a teenager, which understandably gave her a very low opinion of going to meetings in the community, even after she developed an issue with cannabis abuse in adulthood. E realized she was a lesbian during adolescence, and her father condemned her to hell when her same-sex desires came to the surface. For E, anything connected to God or religion had become equated with pain. Although she expressed interest in trying activities like yoga or meditation, Eastern practices that she knew would be more agreeable with her temperament, she resisted.

After being educated about the reality of spiritual abuse, E had no problem identifying as a spiritual abuse survivor, in addition to being an emotional abuse survivor. The next step was determining how to move forward with this knowledge.

5. TREATING SPIRITUAL ABUSE

As is the case when treating all forms of trauma, forging a solid therapeutic alliance is absolutely imperative when working with victims of spiritual abuse [19]. The importance of a solid therapeutic alliance is well-established by research in the field, and its implication in treating trauma is even more significant [25,26]. The literature addressing general traumatic stress indicates that the quality of the therapeutic alliance, as rated by clients, is the greatest predictor of facilitating meaningful change in clients with complex PTSD [27,28,29]. The Anaïs Nin quote,"Shame is the lie that someone told you about yourself" is often used to illustrate the effects of abuse on young children. Helping professionals are in a position of power, and this power may be used to continue reinforcing negative self-talk or to help a person start to see a new truth about himself or herself, which can hopefully assist that person in developing a healthier relationship with spirituality. The modeling process is the very essence of setting a crucible for change through the therapeutic alliance.

There are many possible approaches to treating spiritual abuse. Regardless of the chosen approaches, which should be tailored to meet the client where he or she is upon coming in to treatment, a strong therapeutic alliance is a constant. This section will review a general framework for treating all trauma and consider how spiritual abuse treatment can fit into this model. The available literature and evidence supporting spiritual abuse treatment approaches will be explored, including specific techniques that can be implemented into practice, regardless of the specific therapeutic modality.

GENERAL FRAMEWORK FOR TRAUMA TREATMENT

There is a general consensus in the traumatic stress literature that addressing trauma should occur in three stages [30,31,32,33]:

- Stabilization

- Working through of the trauma (reprocessing)

- Reintegration/reconnection with society

These stages are referred to by many names, including the consensus model, the three-stage consensus model, and the triphasic model.

Stage 1: Stabilization

During the stabilization stage, clients are equipped with the skills to make sure that they can regulate intense affect and remain stable when working on the past. One possible error is immediately attempting to address past issues/memories. When clients explore the past before they are ready to deal with it, more damage can result. Thus, stage one is just as important as stage two in trauma treatment; it provides clients with the skills necessary to stabilize and cope. Forging the therapeutic alliance and cultivating coping mechanisms (which may or may not include spiritual pathways) are essential parts of treatment.

Stage 2: Reprocessing

In stage two, a variety of therapeutic techniques or approaches can be implemented to help a person work through and resolve the trauma in a holistic, experiential way. It will not be enough to confront the negative thoughts and self-talk about the trauma(s), spiritual or not. Rather, the approach should help the person truly transform on all levels of the self, body, mind, and spirit. For example, if a client has the negative spiritual cognition "I'm a disappointment in God's eyes," a successful course of stage two treatment would allow her or him to develop a more positive core belief like "I am precious in God's eyes" in a total sense.

No one specific therapy is considered the most effective for reprocessing trauma [34,35]. The decision of which approach to use is based on a combination of factors, including the needs and strengths of the client, the experience and strengths of the therapist, the therapeutic alliance, and the choice of a method that engages and inspires the participants [25]. A wide variety of methods and approaches can help a person resolve trauma, including, but not limited to, psychoanalysis, experiential therapy, EMDR, trauma-focused cognitive-behavioral therapy, exposure therapy, stress inoculation therapy, somatic experiencing, narrative therapy, Gestalt therapy, and more innovative approaches like art therapy, music therapy, yoga therapy, dance therapy, and animal- or equine-assisted therapy. A combination of modalities is often necessary to help a client optimally heal, especially when issues connected to core identity are involved.

Stage 3: Reintegration

Reintegration is perhaps the most "common sense" stage of the entire consensus model, yet it is one that is often missed. The purpose of reintegration is to help clients transition into living their lives without the symptoms of trauma. At some point during treatment, clients often relate feeling like a burden has been lifted. Too often, work stops here, without considering that, after carrying a weight for such a long time, it may feel incredibly weird or even uncomfortable to maneuver through life without it. Continuing care and maintenance strategies are imperative.

There will be a great deal of overlap between stage 3 and stages 1 and 2, especially when trauma work is being done with a client in an outpatient setting. In fact, when working outpatient, reintegration is incorporated throughout treatment. The three-stage model is not meant to be a stepwise approach. If a client is working on trauma in stage two and finds him- or herself overwhelmed to the point of regressing dangerously, it is likely that he or she will need to step back to stage one work for a while. Whole sessions may be spent working on stage two material, but it can be good practice to close each session with stabilization strategies.

CULT RECOVERY

Interestingly, the literature on cult recovery offers a similar three-tiered model. Langone proposed the following three stages of recovery, with associated tasks for each stage [36]:

- Re-evaluation (focus on the past)

- Re-evaluate cult affiliation.

- Learn how one was under the influence of mind control.

- Help client to understand trauma and how to deal with "floating" or flashback episodes.

- Begin re-evaluating beliefs and value system before, during, and after the cult involvement.

- Reconciliation (focus on the present)

- Allow and encourage client to grieve losses.

- Expect emotional volatility, normalize, and offer support.

- Let the past re-emerge.

- Deal with arrests in the maturation process.

- Help the client regain purpose.

- Reintegration (focus on the future)

- Help plan and focus on the future.
-Encourage recovery of the whole self.

- Help clients integrate cult experience into their permanent identities.

The level of distress of those exiting cults has been noted to be comparable to patients in inpatient psychiatric treatment, so clinicians understanding these stages and how to work within them is important [37]. Although written for cult recovery, many of these suggestions can be applied to any manifestation of spiritual abuse that occurred within an unhealthy system; modifications will need to be made depending on the systems and, of course, the person.

Singer and Ofshe assert that it is important to normalize the sense of anxiety and trepidation a survivor experiences; it is further important to allow for a period of adjustment following abuse [38]. They discourage the use of hypnosis, cautioning that it may trigger dissociative experiences. Keeping this in mind, it is important to proceed with caution, even with guided meditations or relaxation techniques that may trigger a dissociative flashback. Trauma expert Judy Herman, who coined the term complex PTSD, states that clinicians should empower clients so they feel in control of their own recovery [39]. She also stresses the importance of screening for depression, anxiety, suicidality, and possible returns to the cult, especially in early treatment. Clinicians should refrain from making assumptions about those who enter a cult; for example, not all members have highly dependent personalities [40]. It is important to help victims recognize that they were ethically and morally wronged as a first step toward recovering their mental and emotional dignity [40].

Therapists who are accustomed to treating the whole person will be in a good position when it comes to treating spiritual abuse. Because spiritual abuse can affect multiple dimensions of a person's life, including physical, psychologic, emotional, relational, educational, vocational, sexual, financial, and spiritual realms, it is critical to assess which areas have been affected and address them accordingly within the three-stage consensus model [11,41]. First, clinicians should practice within a spiritually sensitive, reflective framework and not dismiss spiritual issues in the counseling process [42]. Second, especially in working with women, clinicians should help survivors connect with the full range of their emotional experience, which may be difficult because many traditional, orthodox religious groups promote emotional repression [43]. In the cases of spiritual abuse that happened as a result of oppression (e.g., in indigenous cultures), it can be critically important to bring in the respective culture's healing rituals, if the client is willing [2]. Narrative counseling, or affording oppressed survivors the chance to share their stories, is also a helpful tool [44].

One qualitative study specifically addressed the question of effective treatment for spiritual abuse recovery [20]. In this study, 100 spiritual abuse survivors in the Christian tradition from English-speaking countries throughout the world participated. The researcher concluded that four main steps were necessary in order for these survivors to heal from spiritual abuse:

- Sufficient time to grieve

- Forgiveness and release of the situation to God

- A suitable faith community

- Moving forward in Christ with the help of the Holy Spirit

Obviously, these steps can be modified to remove the Christian language if applied to other situations, and additional research investigating if similar dynamics are found in other denominations or faiths is necessary.

The definition of recovery may vary from survivor to survivor [20]. Regardless of how survivors choose to define their recovery, it becomes imperative that clinicians help them to define and work toward healthy spirituality as part of the treatment process.

HEALTHY SPIRITUALITY AND SPECIFIC RECOVERY STRATEGIES

The definition of spiritual abuse recovery can vary depending on the goals of each client and his or her situational factors, and the goals of recovery should be clearly delineated. Simply offering a client this choice of defining recovery can be a liberating gesture that enhances the therapeutic alliance; any chance to offer choice to a client is an opportunity for empowerment. There are various definitions of healthy spirituality and spiritual recovery available, but their often overtly Christian focus can be limiting for broader recovery. Much of the Christian pastoral literature on spiritual abuse, although revolutionary to jumpstarting the discussion on spiritual abuse, defines recovery in Christian-only terms. In a more liberal clinical view, attraction to other spiritual practices (e.g., Eastern, New Age) may be a manifestation of recovery; all practices that offer authentic expressions of religiosity/spirituality and yield healthy fruits for their followers are valid choices [45].

Spiritually and culturally inclusive counselors may appreciate the following list of traits of healthy spirituality and/or religion:

- Realization that spirituality is simply the search for meaning in everyday life

- Compassion, forgiveness, respect, and unconditional love as its foundation

- Individuals encouraged to look within to find the source of wisdom and knowledge

- Each person's path is accepted as right for them, and paths that are different from their own are not devalued

- Acknowledgement that each person alone contains everything needed for a fulfilling and successful spiritual existence

- The belief that spirituality arises from a personal relationship with God/the Universe and not from a relationship with any religious institution

- The spiritual/intuitive gifts of all individuals are recognized as divinely empowered

- Releasing judgment and acceptance of the connectedness and unity of all

If it is helpful, this list may be shared with clients.

Another way to conceptualize healthy spirituality is to look at the natural opposites of the negative beliefs covered in the previous section. These beliefs of healthy spirituality would read as such:

- It is okay to make mistakes.

- I am fine just as I am.

- I am deserving.

- I am perfect in God's/the Universe's eyes.

- I can trust my judgment/intuition.

- I am a child of God/the Universe/Earth.

- I can create safety in my world.

- I am blessed.

In working with clients, it is a solid first step, as part of stabilization, to determine if they have any of these positive beliefs, even if negative beliefs are also present. Time may then be spent working with that positive cognition.

If a client struggles with believing that he or she is shameful or undeserving, yet is somehow able to accept the belief that she is blessed, this positive cognition can be built on as a stabilization technique. Many clients with shame-based spiritual ideology are at least able to accept the "I am blessed" belief on some level, especially if they have worked steps two and three of a 12-step program (i.e., believing that Higher Power can restore to sanity and turning one's will and life over to the care of the Higher Power). Even if these steps have not been worked, "I am blessed" may be able to be accepted on gratitude alone. If this is the case, consider stating the following:

Right now, I would like you to just focus in on the statement "I am blessed." Stay with your breath, notice your body, and just say "I am blessed" either to yourself or aloud. Notice what that feels like in your body, to be blessed. If you can, bring up something in your mind that makes you connect with the statement "I am blessed." Maybe it is a song, or perhaps it is a memory, either in the distant past or recently, that really helped you to believe the truth that you are blessed.

At this point, the memory, the song, or any other information that comes up can be used to complete a spiritual guided imagery or guided meditation, inviting the client to stay focused on the positive elements of what is emerging, especially if he or she starts to entertain any negative spiritual cognitions.

Working with music, be it spiritual music or secular music with a spiritual theme, can be a powerful technique. If a client is clearly able to identify a special song that helps him or her to feel connected with a Higher Power, sense of spirit, or the universe, it can be incorporated into spiritual guided imagery or used as a focusing meditation technique. Encourage the client to stay attuned to any body sensations that may emerge as the song plays. Tuning in to these positive visceral sensations and inviting the client to really be with and notice them can be useful in the healing process. The client can then be encouraged to use this song (e.g., listening to it, singing it) as a coping skill to access when needed. Guided imagery and its multiple variations incorporating other sensory material can also help to build healthy spirituality. These techniques allow clients to begin experimenting with and rebuilding their own sense of spirituality.

Clinicians who are devout in the beliefs of one specific faith should feel free to tailor or modify the approaches discussed in this section, as long as it is clear that they are healthy for the client. It is only healthy for a clinician to be specific with her or his religion or faith if the client is seeking that specific care (e.g., Christian counseling). If a client is seeking a counselor of a specific faith, this is a way of indicating a desire to continue in that faith, so counselors should incorporate the healthiest elements of that faith. However, if a practitioner is working in a secular setting, it is her or his responsibility to refrain from pushing a specific faith and keep an open mind to the client's spiritual needs.

Some clients may be so scarred by spiritually abusive experiences that they want nothing to do with reconnection to a spiritual source. If this viewpoint is voiced, it should be respected. However, many who are spiritually abused have an innate drive to be spiritual. Thus, avoiding that part of the person is usually not optimal, and inquiry, curiosity, and experimentation should be encouraged, as appropriate. It can be healing for the client to find what works and is healthy and to make a connection that only spirituality will likely fulfill. A major part of recovery for any kind of abuse, but especially spiritual abuse, is negotiating what is healthy and authentic.

For some survivors of spiritual abuse, the process of recovery through discovery happens over a period of years and seasons of life. Even when survivors begin to find a path that feels genuine and healing for them, old messages, either directly or subtly delivered, must be confronted.

Because spiritual abuse is a form of trauma, it is clear that treatment will need to include reprocessing and reintegration components. As discussed, there is no gold-standard approach for reprocessing trauma. The keys are to make sure that proper stabilization is in place before proceeding with reprocessing activities and to discover with the client which methods or approaches will work best. For certain cases, EMDR can be a good fit [46]. Some specific pastoral techniques (e.g., transformational prayer) may also be used to treat spiritual abuse.

There are several techniques from the Gestalt approach that are useful for addressing spiritual abuse and its manifestations [47]. As long as a qualified professional who is comfortable dealing with trauma and intense affect uses these techniques with clients who are properly stabilized, they are generally safe. It is rarely productive for a survivor of abuse to confront the abuser (the only exceptions being when the abuser is in some form of active recovery and has an awareness of how they victimized others, or if the survivor is well-prepared to simply say what he/she has to say without engaging in extended attempts at reasoning). However, the empty chair technique can help survivors to release the feelings they have been holding in a dynamic, experiential way by imagining the abuser in an empty chair across from them.

Another similar technique is that of the unsent letter. In this approach, the client writes a letter to the person who abused him or her, or even to a Higher Power. The intention is not to send the letter to the abuser, but rather for the client to release his or her pain in a dynamic way, without censor. The client then decides how he or she is going to release the letter. Some will want to share the letter with their counselors so someone can witness their pain. Other clients may find it too dangerous to keep such a letter, so they destroy it after it is written, an act that can be very healing. Some may want to burn the letter, perhaps while saying some type of prayer or intention for release. Just as symbol and ritual can be used to hurt, it can also be used to heal.

Giving clients permission to vent their anger at the churches, groups, or entities that abused them is an important part of reprocessing the trauma of spiritual abuse. Anger toward God or the divine is an issue in treating all types of trauma (e.g., "How could God let this happen?"). Clearly, that anger can have an even more pervasive impact for survivors of spiritual abuse, as their trauma was perpetrated "in the name of God." Allowing clients to work through their anger with the abuser, Higher Power, or spiritual organization in a supportive manner is an effective component of stage two reprocessing. This spirit of non-judgment, even if the client seems stuck in her or his anger and resentment for quite a while, is critical when working with survivors of spiritual abuse.

Not all helping professionals can work with stage two reprocessing. Many clinicians are well-suited to deal with stage one and stage three work, but recognize that they cannot handle stage two. Comfort with trauma and intense affect is perhaps the most important quality of an effective trauma therapist [48,49]. The missing piece for many helping professionals is not lack of specific, technical training, but a general uneasiness with trauma in general. Often, this uneasiness results from unresolved countertransference issues or an unwillingness to address one's own traumatic wounds as a helping professional. The proverb "Healer, heal thyself" should be embraced in order for a clinician to work with trauma in an optimally effective manner.

Recovery from spiritual abuse can be a long-term process that continues to take place after formal counseling terminates, which is why the reintegration process is a necessary part of the healing process. Clinicians should work with clients on using the skills they developed in therapy to continue addressing pain as it arises in life, especially pain connected to spirituality. Clients who are able to foster connection with a healthier spiritual system, be that in the form of a new church group, a meditation group, yoga studio, Bible study, faith-sharing group, or simply a solid group of friends that honors tolerant, integrated approaches to spirituality, are at an advantage when it comes to reintegration. If contextually appropriate (based on clinical discretion), clinicians may work with the new spiritual group or that group's leader (with appropriate consent from the client) for enhanced, collaborative care.

CASE EXAMPLE

Let's return to Client E, the young woman discussed in a previous section. E knew immediately that she desired to be spiritual, but any time she tried, the images and early memories from her negative experiences at home and in the church blocked her. Although it became clear that reprocessing some of these memories would be an important part of her treatment, it was also critical to first build on the positive cognition, "There is something in me that wants to be spiritual."

Her counselor begins working with E on using some standard breathing, lightstream visualization, and muscle relaxation techniques. These helped her to achieve a sense of visceral calm and ease sitting in the office. Upon relaxing, the counselor asks E to keep an open mind to the spiritual realm and invites her to notice what emerges in terms of a spiritual figure or a spiritual source. Almost instantaneously, E smiles. She reports that she began to see a little creature that looked half like the character Yoda from the Star Wars movies and half like Mr. Miagi from The Karate Kid movies. The counselor prompts E to stay with that image and notice what happens. With a continued smile, she explains that he was playing a drum, and when he stopped, he invited her to come and sit with him and the two of them talked about all things related to life. As she stays with this experience, she reports feeling a sense of total love and acceptance. Clearly, this figure is a Higher Power that worked for her. As a take away, her counselor encourages E to continue working with this image on a daily basis. He also suggests that she begin by working with her breath, as she had in the office, and then allow the image to come up and notice what happens the longer she stays with the image. This technique is one that allows her to keep building her relationship with her Higher Power and her newfound spirituality.

6. PROFESSIONAL DEVELOPMENT ISSUES

Many helping professionals are reticent to explore issues of spirituality with clients, especially spiritual abuse, because they have not explored their own spiritual identities or are afraid of being perceived as "pushing spirituality" on clients. Although pushing spirituality is never appropriate, counselors are committing a disservice if they do not at least ask questions about the client's spiritual self. If clients are uninterested in addressing spirituality in counseling, that is their choice. If a client is willing to explore it, counselors should be willing to guide him or her.

This is why it is important for clinicians to assess their own spirituality. Some do not identify as a spiritual person or understand why anyone would be drawn to spirituality, and knowing this is a first step. These counselors should determine if this state of being inhibits them from being effective with clients who deeply desire to be spiritual. If a clinician dismisses spiritual abuse as related to church corruption or religious superstition, clinical relationships can be damaged.

Many counselors who work with spiritual abuse or trauma have had negative personal experiences with spirituality. If unresolved, this state tends to manifest as not wanting to explore spirituality with clients. If addressed, it can make counselors more effective in working with survivors. Not only can this effectiveness be used to help clients, but it can help to raise awareness about the realities of spiritual abuse. As discussed, many people are unaware that spiritual abuse exists, including colleagues, and education is important. Helping professionals may also be hesitant to address spiritual abuse because they are unsure of what to do with the issues that may come up in sessions. Thus, education about the experiences of people who go through spiritual abuse and trauma is a valuable part of enhancing treatment. This education should be more than just technical; it should include information about what people experience and how to build the understanding, empathetic relationships that can facilitate people growing into their authentic selves.

Part of being an effective helper is recognizing when one is beyond his or her area of competence or comfort. Having a referral network is vital. An Internet search of spiritual abuse counselors by geographical area may not retrieve a great deal of results. Instead, a pastor or religious leader who is known for her or his tolerance may be a good source. Working through one of the many books on the topic of spiritual abuse and personally reflecting upon the content may also provide guidance. For many clients, acknowledging that spiritual abuse is real can be a powerful validation.

7. CONCLUSION

Just as the specific definitions of spiritual abuse differ, so can the varieties of the recovery experience. Above all, helping professionals should realize that spiritual abuse is a form of abuse. Spiritual abuse is trauma, and it can manifest and cause problems in human experiences. Helping professionals can help clients to heal from its wounds. As discussed, having spiritual abuse validated as a legitimate form of abuse by a helping professional can commence the healing process in a very powerful way.

This course has outlined spiritual abuse, in general, as the use of God or religion as a tool to gain power and control. The primary assumption is that spiritual abuse is not unique to any one religion or faith; it can happen in every faith and in every spiritual practice. The specific definitions of and literature on spiritual abuse were explored from sociologic, pastoral, developmental, and clinical perspectives. Common themes apparent in spiritual abuse, specifically commonalities between those who abuse and those who are vulnerable to being spiritually abused, were outlined. Issues in assessing spiritual abuse, specifically assessing it as a trauma issue, were described, followed by issues in treatment. The three-stage consensus model of trauma treatment was presented as a framework for healing spiritual abuse in a clinically sensitive manner. Finally, the course concluded with issues of professional development and honing one's own sense of spiritual awareness in order to optimally serve clients.

8. GLOSSARY

12-step model: The 12-steps of Alcoholics Anonymous have been developed by many treatment centers as a philosophical approach. Part of the 12-step philosophy is to begin exploring a relationship with a power greater than oneself and to turn one's will and life over to the care of this power.

CALFB: Child abuse linked to faith or belief.

Conjunctive faith: Stage 5 in Fowler's Faith Development Model (mid-life), characterized by acknowledging paradox and transcendence relating to the reality behind the symbols of inherited systems. The individual resolves conflicts from previous stages by a complex understanding of a multidimensional, interdependent "truth" that cannot be explained by any particular statement.

Cult: From the Latin meaning "to worship," in the modern era, the definition takes on a negative connotation, generally described as a new religious movement or other group whose beliefs or practices are considered abnormal or bizarre [9]. Various organizations and scholars have published lists or guidelines to identify cultic groups, a common consensus being that cults have a destructive impact on their members.

Disorganized attachment: An attachment style characterized from unpredictable tendencies to withdraw and then to anxious engage with an attachment figure. Largely caused by inconsistency in attachment needs being met.

Fowler's Faith Development Model: A seven-stage model explaining faith development in humans across the lifespan, influenced by the work of Piaget, Erickson, and Kohlberg [17].

Guru: A Sanskrit word meaning "teacher" or "master," literally one who can cast out the darkness. Although originating in Hinduism, many in the modern era use the term in reference to anyone whose teachings attract followers. It has negative connotation in some circles because of scandals involving financial or sexual exploitation.

Individuative-reflective faith: Stage 4 in Fowler's Faith Development Model, characterized as a stage of angst and struggle. The individual takes personal responsibility for his or her beliefs and feelings. As one is able to reflect on one's own beliefs, there is an openness to a new complexity of faith, but this also increases the awareness of conflicts in one's belief.

Intuitive-projective faith: Stage 1 in Fowler's Faith Development Model, characterized by the psyche's unprotected exposure to the Unconscious.

Legalism: A religious belief that people can please God or any chosen deity, even earning their way into heaven or an afterlife, through obeying the rules.

Literalism: The belief that the Bible or other sacred text(s) must be interpreted literally, not symbolically, to be properly understood.

Mixed messages: Receiving two contrast viewpoints.

Mythic-literal faith: Stage 2 in Fowler's Faith Development Model, characterized by a strong belief in the justice and reciprocity of the universe; deities are almost always anthropomorphic (i.e., personified).

Primal or undifferentiated faith: Stage 0 in Fowler's Faith Development Model, characterized by an early learning of the safety of one's environment. If consistent nurturing is experienced, one will develop a sense of trust and safety about the universe and the divine; negative experiences will cause one to develop distrust.

Ritual abuse: An extreme, sadistic form of abuse of children and nonconsenting adults. It is methodical, systematic sexual, physical, emotional, and spiritual abuse, which often includes mind control, torture, and highly illegal and immoral activities such as murder, child pornography, and prostitution. The abuse is justified by a religious or political ideology.

Spiritual abuse: Succinctly described as the use of God or religion as a tool to gain power and control.

Synthetic-conventional faith: Stage 3 in Fowler's Faith Development Model, characterized by conformity to religious authority and the development of a personal identity. Any conflicts with one's beliefs are ignored at this stage due to the fear of threat from inconsistencies.

Three-stage (or triphasic) consensus model: refers to the three main stages that should guide trauma treatment—stabilization, reprocessing (working through of the trauma), and reintegration/reconnection with society. This model has emerged from a general consensus in the trauma literature of how treatment should be framed.

Universalizing faith: Stage 6 in Fowler's Faith Development Model, what some might call "enlightenment." Characterized by the individual believing everyone should be treated with the universal principles of love and justice.

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15. Blue K. Healing Spiritual Abuse. Downers Grove, IL: InterVarsity Publishing; 1993.

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20. Orlowski BM. Spiritual Abuse Recovery: Dynamic Research on Finding a Place of Wholeness. Eugene, OR: Wipf and Stock; 2010.

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77042 • Setting Ethical Limits: For Caring and Competent Professionals

Lisa Hutchison, LMHC

www.netce.com

Copyright © 2024 NetCE, All rights reserved.

Without proper self-care, boundaries, and awareness (transference), therapists become vulnerable to burnout and vicarious traumatization. This can result in a risk of therapeutic effectiveness, loss of trust with clients, and possible ethical crossings or violations. This course supports professionals practicing competence, while utilizing self-care and boundaries to minimize burnout while practicing compassion for the clients that they serve.

Table of Contents

77042 • Setting Ethical Limits: For Caring and Competent Professionals

Course Overview

Audience

Accreditations & Approvals

Designations of Credit

Individual State Behavioral Health Approvals

Special Approvals

Course Objective

Learning Objectives

Faculty

Faculty Disclosure

Division Planners

Division Planners Disclosure

Director of Development and Academic Affairs

Director Disclosure Statement

About the Sponsor

Disclosure Statement

Implicit Bias in Health Care

1. INTRODUCTION

2. COMPETENCE

APA'S ETHICAL PRINCIPLES OF PSYCHOLOGISTS AND CODE OF CONDUCT

2014 ACA CODE OF ETHICS

CODE OF ETHICS OF THE NASW

3. CULTURAL COMPETENCE

CODE OF ETHICS OF THE NASW

CHARACTERISTICS OF A CULTURALLY COMPETENT COUNSELOR

4. THE THERAPEUTIC RELATIONSHIP

CONGRUENCE

EMPATHY

5. THE COSTS OF CARING

STRESS

COMPASSION FATIGUE, VICARIOUS TRAUMA, AND BURNOUT

MITIGATING THE COSTS OF CARING

6. TRANSFERENCE AND COUNTERTRANSFERENCE

REFLECTION

SELF-AWARENESS

7. BOUNDARIES AND LIMITS

BUILDING TRUST

THE VALUE OF FLEXIBILITY

EMPOWERING AND PROTECTING THE CLIENT

PROTECTING THE PROFESSIONAL

8. BOUNDARY CROSSINGS AND VIOLATIONS

9. MULTIPLE RELATIONSHIPS

BOUNDARY VIOLATIONS WITHIN MULTIPLE RELATIONSHIPS

10. GIFTS

THE GIFT OF SELF-DISCLOSURE

11. TECHNOLOGY AND DISTANCE THERAPY

LEGAL AND ETHICAL CONSIDERATIONS

SOCIAL MEDIA

12. CONCLUSION

13. RESOURCES

Works Cited

77042 • Setting Ethical Limits: For Caring and Competent Professionals

Education Category. Ethics - Human Rights

Release Date. 12/01/2024

Expiration Date. 11/30/2027

Course Overview

Without proper self-care, boundaries, and awareness (transference), therapists become vulnerable to burnout and vicarious traumatization. This can result in a risk of therapeutic effectiveness, loss of trust with clients, and possible ethical crossings or violations. This course supports professionals practicing competence, while utilizing self-care and boundaries to minimize burnout while practicing compassion for the clients that they serve.

Audience

This course is designed for social workers, counselors, and marriage and family therapists in all practice settings.

Accreditations & Approvals

NetCE has been approved by NBCC as an Approved Continuing Education Provider, ACEP No. 6361. Programs that do not qualify for NBCC credit are clearly identified. NetCE is solely responsible for all aspects of the programs. As a Jointly Accredited Organization, NetCE is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved under this program. Regulatory boards are the final authority on courses accepted for continuing education credit. Continuing Education (CE) credits for psychologists are provided through the co-sponsorship of the American Psychological Association (APA) Office of Continuing Education in Psychology (CEP). The APA CEP Office maintains responsibility for the content of the programs. NetCE is accredited by the International Accreditors for Continuing Education and Training (IACET). NetCE complies with the ANSI/IACET Standard, which is recognized internationally as a standard of excellence in instructional practices. As a result of this accreditation, NetCE is authorized to issue the IACET CEU. NetCE is recognized by the New York State Education Department's State Board for Social Work as an approved provider of continuing education for licensed social workers #SW-0033. This course is considered self-study, as defined by the New York State Board for Social Work. NetCE is recognized by the New York State Education Department's State Board for Mental Health Practitioners as an approved provider of continuing education for licensed mental health counselors #MHC-0021. This course is considered self-study by the New York State Board of Mental Health Counseling. NetCE is recognized by the New York State Education Department's State Board for Mental Health Practitioners as an approved provider of continuing education for licensed marriage and family therapists. #MFT-0015.This course is considered self-study by the New York State Board of Marriage and Family Therapy. Materials that are included in this course may include interventions and modalities that are beyond the authorized practice of licensed master social work and licensed clinical social work in New York. As a licensed professional, you are responsible for reviewing the scope of practice, including activities that are defined in law as beyond the boundaries of practice for an LMSW and LCSW. A licensee who practices beyond the authorized scope of practice could be charged with unprofessional conduct under the Education Law and Regents Rules.

Designations of Credit

NetCE designates this continuing education activity for 2.5 NBCC clock hour(s). Social workers participating in this intermediate to advanced course will receive 6 Ethics continuing education clock hours. NetCE designates this continuing education activity for 6 credit(s). NetCE is authorized by IACET to offer 0.6 CEU(s) for this program.

Individual State Behavioral Health Approvals

In addition to states that accept ASWB, NetCE is approved as a provider of continuing education by the following state boards: Alabama State Board of Social Work Examiners, Provider #0515; Florida Board of Clinical Social Work, Marriage and Family Therapy and Mental Health Counseling, CE Broker Provider #50-2405; Illinois Division of Professional Regulation for Social Workers, License #159.001094; Illinois Division of Professional Regulation for Licensed Professional and Clinical Counselors, License #197.000185; Illinois Division of Professional Regulation for Marriage and Family Therapists, License #168.000190;

Special Approvals

This course meets the requirement for 3 hours of Ethics continuing education as required by the Pennsylvania State Board of Social Worker, Marriage and Family Therapists and Professional Counselors. This course has been approved by NetCE, as a NAADAC Approved Education Provider, for educational credits, NAADAC Provider #97847. NetCE is responsible for all aspects of their programming. NetCE is approved as a provider of continuing education by the California Consortium of Addiction Programs and Professionals. Provider Number 5-08-151-0624. NetCE is approved as a provider of continuing education by the California Association of DUI Treatment Programs (CADTP). Provider Number 185. NetCE is approved as a provider of continuing education by the California Association for Alcohol/Drug Educators. Provider Number CP40 889 H 0626. NetCE designates this continuing education activity for 6 continuing education hours for addiction professionals.

Course Objective

The purpose of this course is to educate helping professionals on how to provide compassionate care ethically to those they serve without causing burnout.

Learning Objectives

Upon completion of this course, you should be able to:

1. Define professional competence.

2. Describe the importance of cultural competence.

3. Outline components of the therapeutic relationship.

4. Define empathy and describe the difference between empathy and sympathy.

5. Identify compassion fatigue, vicarious trauma, and burnout and describe their impact on mental health professionals.

6. Define transference and countertransference and discuss their implications for the mental health professional.

7. Identify the functions of professional boundaries in the therapeutic relationship and multiple relationships.

8. Discuss the guidance on giving and receiving gifts provided by professional ethics codes.

9. Discuss the legal and ethical considerations of providing distance therapy.

Faculty

Lisa Hutchison, LMHC, has more than 20 years of experience providing individual and group counseling with adults. She specifically focuses on teaching assertiveness, stress management, and boundary setting for empathic helpers. Ms. Hutchison graduated from the University of Massachusetts, Boston, with a Master’s degree in education for mental health counseling.

Faculty Disclosure

Contributing faculty, Lisa Hutchison, LMHC, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Division Planners

Alice Yick Flanagan, PhD, MSW

Margaret Donohue, PhD

Division Planners Disclosure

The division planners have disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Director of Development and Academic Affairs

Sarah Campbell

Director Disclosure Statement

The Director of Development and Academic Affairs has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

About the Sponsor

The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare.

Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.

Disclosure Statement

It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.

Implicit Bias in Health Care

The role of implicit biases on healthcare outcomes has become a concern, as there is some evidence that implicit biases contribute to health disparities, professionals' attitudes toward and interactions with patients, quality of care, diagnoses, and treatment decisions. This may produce differences in help-seeking, diagnoses, and ultimately treatments and interventions. Implicit biases may also unwittingly produce professional behaviors, attitudes, and interactions that reduce patients' trust and comfort with their provider, leading to earlier termination of visits and/or reduced adherence and follow-up. Disadvantaged groups are marginalized in the healthcare system and vulnerable on multiple levels; health professionals' implicit biases can further exacerbate these existing disadvantages.

Interventions or strategies designed to reduce implicit bias may be categorized as change-based or control-based. Change-based interventions focus on reducing or changing cognitive associations underlying implicit biases. These interventions might include challenging stereotypes. Conversely, control-based interventions involve reducing the effects of the implicit bias on the individual's behaviors. These strategies include increasing awareness of biased thoughts and responses. The two types of interventions are not mutually exclusive and may be used synergistically.

1. INTRODUCTION

Counselors can make a significant, positive impact in the lives of those with whom they work, and the practice of therapy can be highly rewarding and gratifying. However, it can also be emotionally demanding, challenging, and stressful. Counselors are at risk for occupational stress from a variety of sources, including[1]:

- The demands of clinical and professional responsibility

- The challenges of managing the client/counselor relationship

- The role characteristics that make counselors prone to burnout (e.g., high level of involvement)

- Vulnerability to vicarious traumatization

- The changing standards and business demands of the profession (e.g., increased documentation requirements, increased intrusion of legal/business concerns into therapeutic practice)

- The intersection of personal and professional demands

Healthy boundaries are a critical component of self-care. Setting boundaries can help counselors manage occupational stressors and maintain the delicate balance between their personal and professional lives. Boundaries also demonstrate competency in clinical practice and help counselors avoid ethical conflicts [2].

Please note, throughout this course the term "counselor" is used to refer to any professional providing mental health and/or social services to clients, unless otherwise noted.

2. COMPETENCE

Professional associations representing the various fields of clinical practice have codes of ethics that provide principles and standards to guide and protect both the mental health professional and the individuals with whom they work. For example, the American Psychological Association (APA), the American Counseling Association (ACA), the National Association of Social Workers (NASW), the National Board of Certified Counselors (NBCC), and the National Certification Commission for Addiction Professionals (NCCAP) each has an ethics code created to identify core values, inform ethical practice, support professional responsibility and accountability, and ensure competency among its members [3,4,5,6,7].

Competency is defined as "the extent to which a therapist has the knowledge and skill required to deliver a treatment to the standard needed for it to achieve its expected effects" [8]. It is the scope of the professional's practice. According to the ethics codes of the APA, the ACA, and the NASW, members are to practice only within their boundaries of competence [3,4,5].

APA'S ETHICAL PRINCIPLES OF PSYCHOLOGISTS AND CODE OF CONDUCT

2.01 Boundaries of Competence

(a) Psychologists provide services, teach, and conduct research with populations and in areas only within the boundaries of their competence, based on their education, training, supervised experience, consultation, study, or professional experience.

(b) Where scientific or professional knowledge in the discipline of psychology establishes that an understanding of factors associated with age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language, or socioeconomic status is essential for effective implementation of their services or research, psychologists have or obtain the training, experience, consultation, or supervision necessary to ensure the competence of their services, or they make appropriate referrals, except as provided in Standard 2.02, Providing Services in Emergencies.

(c) Psychologists planning to provide services, teach, or conduct research involving populations, areas, techniques, or technologies new to them undertake relevant education, training, supervised experience, consultation, or study.

(d) When psychologists are asked to provide services to individuals for whom appropriate mental health services are not available and for which psychologists have not obtained the competence necessary, psychologists with closely related prior training or experience may provide such services in order to ensure that services are not denied if they make a reasonable effort to obtain the competence required by using relevant research, training, consultation, or study.

(e) In those emerging areas in which generally recognized standards for preparatory training do not yet exist, psychologists nevertheless take reasonable steps to ensure the competence of their work and to protect clients/patients, students, supervisees, research participants, organizational clients, and others from harm.

(f) When assuming forensic roles, psychologists are or become reasonably familiar with the judicial or administrative rules governing their roles.

2.03 Maintaining Competence

Psychologists undertake ongoing efforts to develop and maintain their competence.

2014 ACA CODE OF ETHICS

C.1. Knowledge of and Compliance with Standards

Counselors have a responsibility to read, understand, and follow the ACA Code of Ethics and adhere to applicable laws and regulations.

C.2. Professional Competence

C.2.a. Boundaries of Competence

Counselors practice only within the boundaries of their competence, based on their education, training, supervised experience, state and national professional credentials, and appropriate professional experience. Whereas multicultural counseling competency is required across all counseling specialties, counselors gain knowledge, personal awareness, sensitivity, dispositions, and skills pertinent to being a culturally competent counselor in working with a diverse client population.

C.2.b. New Specialty Areas of Practice

Counselors practice in specialty areas new to them only after appropriate education, training, and supervised experience. While developing skills in new specialty areas, counselors take steps to ensure the competence of their work and protect others from possible harm.

C.2.c. Qualified for Employment

Counselors accept employment only for positions for which they are qualified given their education, training, supervised experience, state and national professional credentials, and appropriate professional experience. Counselors hire for professional counseling positions only individuals who are qualified and competent for those positions.

C.2.d. Monitor Effectiveness

Counselors continually monitor their effectiveness as professionals and take steps to improve when necessary. Counselors take reasonable steps to seek peer supervision to evaluate their efficacy as counselors.

C.2.e. Consultations on Ethical Obligations

Counselors take reasonable steps to consult with other counselors, the ACA Ethics and Professional Standards Department, or related professionals when they have questions regarding their ethical obligations or professional practice.

C.2.f. Continuing Education

Counselors recognize the need for continuing education to acquire and maintain a reasonable level of awareness of current scientific and professional information in their fields of activity. Counselors maintain their competence in the skills they use, are open to new procedures, and remain informed regarding best practices for working with diverse populations.

C.4. Professional Qualifications

C.4.a. Accurate Representation

Counselors claim or imply only professional qualifications actually completed and correct any known misrepresentations of their qualifications by others. Counselors truthfully represent the qualifications of their professional colleagues. Counselors clearly distinguish between paid and volunteer work experience and accurately describe their continuing education and specialized training.

C.4.b. Credentials

Counselors claim only licenses or certifications that are current and in good standing.

C.4.c. Educational Degrees

Counselors clearly differentiate between earned and honorary degrees.

C.4.d. Implying Doctoral-Level Competence

Counselors clearly state their highest earned degree in counseling or a closely related field. Counselors do not imply doctoral-level competence when possessing a master's degree in counseling or a related field by referring to themselves as "Dr." in a counseling context when their doctorate is not in counseling or a related field. Counselors do not use "ABD" (all but dissertation) or other such terms to imply competency.

C.4.e. Accreditation Status

Counselors accurately represent the accreditation status of their degree program and college/university.

C.4.f. Professional Membership

Counselors clearly differentiate between current, active memberships and former memberships in associations. Members of ACA must clearly differentiate between professional membership, which implies the possession of at least a master's degree in counseling, and regular membership, which is open to individuals whose interests and activities are consistent with those of ACA but are not qualified for professional membership.

CODE OF ETHICS OF THE NASW

1.04 Competence

(a) Social workers should provide services and represent themselves as competent only within the boundaries of their education, training, license, certification, consultation received, supervised experience, or other relevant professional experience.

(b) Social workers should provide services in substantive areas or use intervention techniques or approaches that are new to them only after engaging in appropriate study, training, consultation, and supervision from people who are competent in those interventions or techniques.

(c) When generally recognized standards do not exist with respect to an emerging area of practice, social workers should exercise careful judgment and take responsible steps (including appropriate education, research, training, consultation, and supervision) to ensure the competence of their work and to protect clients from harm.

(d) Social workers who use technology in the provision of social work services should ensure that they have the necessary knowledge and skills to provide such services in a competent manner. This includes an understanding of the special communication challenges when using technology and the ability to implement strategies to address these challenges.

(e) Social workers who use technology in providing social work services should comply with the laws governing technology and social work practice in the jurisdiction in which they are regulated and located and, as applicable, in the jurisdiction in which the client is located.

3. CULTURAL COMPETENCE

A general (aspirational) principle articulated in the APA's ethics code addresses respect for people's rights and dignity. The principle states, in part, that [3]:

Psychologists are aware of and respect cultural, individual, and role differences, including those based on age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language, and socioeconomic status and consider these factors when working with members of such groups. Psychologists try to eliminate the effect on their work of biases based on those factors, and they do not knowingly participate in or condone activities of others based upon such prejudices.

CODE OF ETHICS OF THE NASW

1.05 Cultural Competence

(a) Social workers should demonstrate understanding of culture and its function in human behavior and society, recognizing the strengths that exist in all cultures.

(b) Social workers should demonstrate knowledge that guides practice with clients of various cultures and be able to demonstrate skills in the provision of culturally informed services that empower marginalized individuals and groups. Social workers must take action against oppression, racism, discrimination, and inequities, and acknowledge personal privilege.

(c) Social workers should demonstrate awareness and cultural humility by engaging in critical self-reflection (understanding their own bias and engaging in self-correction), recognizing clients as experts of their own culture, committing to lifelong learning, and holding institutions accountable for advancing cultural humility.

(d) Social workers should obtain education about and demonstrate understanding of the nature of social diversity and oppression with respect to race, ethnicity, national origin, color, sex, sexual orientation, gender identity or expression, age, marital status, political belief, religion, immigration status, and mental or physical ability.

(e) Social workers who provide electronic social work services should be aware of cultural and socioeconomic differences among clients' use of and access to electronic technology and seek to prevent such potential barriers. Social workers should assess cultural, environmental, economic, mental or physical ability, linguistic, and other issues that may affect the delivery or use of these services.

Although counselors are not expected to know about every nuance of each culture they serve, it is important to be open to learning about diverse cultural backgrounds in order to provide empathic, competent care. It is also important to be aware of culture-specific religious or spiritual practices that are regarded as healing forces in the client's world. Achieving this awareness may involve researching the client's culture and inquiring about their culture-specific healing practices in a manner that respects the client's dignity and privacy [3]. It is always the professional's goal to do no harm. As previously stated, professionals must "try to eliminate the effect on their work of [their] biases" and address them outside the therapeutic time with a trusted colleague or supervisor [3].

CHARACTERISTICS OF A CULTURALLY COMPETENT COUNSELOR

Three characteristics of a culturally competent counselor have been described. First, a culturally competent counselor is actively engaged in the process of becoming aware of his or her assumptions about human behavior, values, biases, preconceived notions, and personal limitations [9]. This is an ongoing process of self-discovery that requires the willingness to address any issues that may arise. For example, because the concept of boundaries varies across cultures, therapeutic elements related to boundaries should be modified to adapt to this variance. The expectation of confidentiality also varies, so the counselor should not assume that confidentiality is implicitly restricted to the counselor and client. In many cultures, confidentiality is neither expected nor therapeutic [10]. Being culturally competent also requires vigilance and an understanding that referral to another counselor might be necessary in some circumstances (i.e., when working with a particular client is beyond the counselor's boundaries of competence) [9].

Next, a culturally competent counselor actively attempts to understand the worldview of a culturally different client by employing empathy and avoiding negative judgments [9]. This involves becoming familiar with the culture, subculture, and political history of the client when these differ from those of the counselor. This yields valuable rewards and is useful in avoiding the common therapeutic blunder of overgeneralization [10]. For example, knowing the client's ethnicity, political affiliation in their country of origin, religious beliefs, and expectations of gender roles all contribute to providing the counselor a more precise framework from which therapy can be applied. Clients usually recognize and appreciate the counselor's attempts to learn about their culture, which can enhance the therapeutic alliance [10]. It is also important to recognize that the client is part of a larger cultural system that may include family members, societal elders, or others of significance to the client. These others can impact the client's therapy, with positive or negative outcomes, depending on whether they are enlisted as therapeutic allies or alienated [10].

Last, a culturally competent counselor actively develops and practices appropriate, relevant, and sensitive intervention strategies and skills when working with culturally different clients. In order to keep abreast of new interventions and strategies, the counselor may need to acquire additional education, training, and supervised experience (Resources) [9].

Common issues in the therapeutic relationship (e.g., gifts, touch, eye contact, medication compliance, choice of vocabulary) are all influenced by culture. Rather than adhere to a rigid theoretical approach to dealing with these issues, it is best to seek out their cultural meaning on a case-by-case basis. Enlist the expertise of a "cultural informant" if one is available. This person is generally from the same culture as the client, is not an active participant in the therapy, and functions as a consultant to the professional by interpreting or identifying culture-specific issues. The therapeutic paradigm should be flexible. The degree of active intervention by the mental health professional, definition of therapeutic goals, techniques used, and outcome measures should all be modified to reflect cultural differences in the therapy. Also, transference and countertransference interactions influenced by culture will occur and require that professionals become familiar with the types of culturally influenced reactions that can occur in therapy. Phenomena such as cultural stereotyping often occur even when the counselor and client share the same ethno-cultural background [10].

4. THE THERAPEUTIC RELATIONSHIP

Many situations that occur in the counseling office are not written about in text books or taught in a classroom setting. Counselors learn through hands-on experience, intuition, ongoing supervision, and continuing education. One constant is the therapeutic relationship. Every therapeutic relationship is built on trust and rapport. Counselors teach their clients what a healthy relationship is through the compassionate care and limit setting that occurs within the therapeutic context. Counselors model acceptable behavior in the office so their clients are equipped to emulate and apply that behavior in the outside world. In many cases, counselors are teaching self-regulation to clients who are learning how to control impulses or regulate behavior in order to improve their connection to other people.

Bandura has described self-regulation as a self-governing system that is divided into three major subfunctions [11]:

- Self-observation: We monitor our performance and observe ourselves and our behavior. This provides us with the information we need to set performance standards and evaluate our progress toward them.

- Judgment: We evaluate our performance against our standards, situational circumstances, and valuation of our activities. In the therapeutic setting, the counselor sets the standard of how to interact by setting limits and upholding professional ethics. The client then compares the counselor's (i.e., "the expert's") modeled behavior with what they already have learned about relationship patterns and dynamics (i.e., referential comparisons).

- Self-response: If the client perceives that he or she has done well in comparison to the counselor's standard, the client gives him- or herself a rewarding self-response. The counselor should reinforce this response by delivering positive reinforcement and affirmation for the newly learned behavior. For example, if the client arrives to therapy habitually late and then makes an effort to arrive on time, the counselor can remark, "I notice that you are working hard to arrive on time for session. That is great." The counselor's positive reinforcement and acknowledgment can have a positive impact on the client's self-satisfaction and self-esteem.

According to Rogers, "individuals have within themselves vast resources for self-understanding and for altering their self-concepts, basic attitudes, and self-directed behavior" [12]. To facilitate a growth-promoting climate for the client, the counselor should accept, care for, and prize the client. This is what Rogers refers to as "unconditional positive regard," and it allows the client to experience whatever immediate feeling is going on (e.g., confusion, resentment, fear, anger, courage) knowing that the professional accepts it unconditionally [12]. In addition to unconditional positive regard, a growth-promoting therapeutic relationship also includes congruence and empathy.

CONGRUENCE

Trust is built and sustained over time through consistent limits that are maintained within the sacred space of each therapeutic hour. When a counselor is observed as consistent and congruent, the client notices. Being authentic is part of being compassionate and empathic. Clients know when a counselor's words and actions do not match. These actions can be overt, such as cutting short the therapeutic time or going over the time allotted. They also can be subtle, as when leaked out and expressed through a stressed vocal tone, facial expression, or other body language indicator (e.g., arms folded across the chest). To the highly aware client, these actions can result in a loss of trust.

Nevertheless, counselors are not perfect and can err from time to time. This is why it is important for counselors to be self-aware, acknowledge when their words and actions do not match, and discuss that within the therapeutic relationship. If a client notices one of these cues of incongruence and expresses it to the counselor, it is essential that the counselor listen openly and validate the client's experience. Any defensiveness on the part of the counselor will decrease relationship trust. Conversely, this admission of human failure can actually build a stronger bond of trust. Clients see that counselors are, like themselves, human and imperfect. This presents an opportunity for clients to learn and then model this type of integrity in their own relationships. "Congruence for the therapist means that he (or she) need not always appear in a good light, always understanding, wise, or strong" [12]. It means that the therapist is his or her actual self during encounters with clients. Without façade, he or she openly has the feelings and attitudes that are flowing at the moment [12]. The counselor's being oneself and expressing oneself openly frees him or her of many encumbrances and artificialities and makes it possible for the client to come in touch with another human being as directly as possible [12]. As discussed, this involves self-observation and self-awareness on the counselor's part.

This does not mean that counselors burden clients with overt expression of all their feelings. Nor does it mean that counselors disclose their total self to clients. It means that the counselor is transparent to the client so that the client can see him or her within the context of the therapeutic relationship [13]. It also means avoiding the temptation to present a façade or hide behind a mask of professionalism, or to assume a confessional-professional attitude. It is not easy to achieve such a reality, as it involves "the difficult task of being acquainted with the flow of experiencing going on within oneself, a flow marked especially by complexity and continuous change" [12].

EMPATHY

There is great power in empathy. It breaks down resistance and allows clients to feel safe and able to explore their feelings and thoughts. It is a potent and positive force for change [12]. Empathy serves our basic desire for connection and emotional joining [14]. Empathy may be defined as the action of understanding, being aware of, being sensitive to, and vicariously experiencing the feelings, thoughts, and experience of another. It is a deeper kind of listening in which the counselor senses accurately the feelings and personal meanings that the client is experiencing and communicates this understanding to the client [12]. Empathy is not parroting back the client's words or reflecting only the content of those words. It entails capturing the nuances and implications of what the client is saying, and reflecting this back to the client for their consideration using clear, simply connotative language in as few words as possible [15]. Counselors also can show empathy in nonverbal ways to their clients by, for example, looking concerned, being attentive, leaning forward, and maintaining eye contact [15].

Empathy is a multi-level process of relating to others. It encompasses both an emotive experience and a cognitive one. It includes an intellectual component (namely, understanding the cognitive basis for the client's feelings), and it implies the ability to detach oneself from the client's feelings in order to maintain objectivity [16]. While engaged in empathic listening, mental health professionals should remain responsive to feedback and alter their perspective or understanding of the client as they acquire more information [16]. Empathy may be summarized by the ability to [17]:

- See the world as others see it.

- Be nonjudgmental.

- Understand another person's feelings.

- Communicate your understanding of that person's feelings.

Empathy should not be confused with sympathy, which may be defined as an affinity, association, or relationship between persons wherein whatever affects one similarly affects the other. Compared with empathy, sympathy is a superficial demonstration of care. With sympathy, you feel sorry for the client; with empathy, you feel the client's pain. Although a counselor can get caught up in the client's feelings, he or she should always strive to empathically understand what the client is experiencing while maintaining emotional detachment. This potentially provides a broader perspective that extends beyond the client's situational distress. Mental health professionals want to employ the best tools in order to affect change in their clients without causing harm, and empathy surpasses sympathy in terms of effectiveness. Research has validated the importance of empathy, unconditional positive regard, and congruence for achieving an effective therapeutic relationship [18].

Compassion-focused therapy is a rapidly growing, evidence-based form of psychotherapy that pursues the alleviation of human suffering through psychological science and engaged action [19]. According to Gilbert, the following are attributes of compassion-focused therapy [20]:

- Sensitivity: Responsive to distress and needs; able to recognize and distinguish the feelings and needs of the client.

- Sympathy: Being emotionally moved by the feelings and distress of the client. In the therapeutic relationship, the client experiences the counselor as being emotionally engaged with their story as opposed to being emotionally passive or distant.

- Distress tolerance: Able to contain, stay with, and tolerate complex and high levels of emotion, rather than avoid, fearfully divert from, close down, contradict, invalidate, or deny them. The client experiences the counselor as able to contain her/his own emotions and the client's emotions.

- Empathy: Working to understand the meanings, functions, and origins of another person's inner world so that one can see it from her/his point of view. Empathy takes effort in a way that sympathy does not.

- Nonjudgment: Not condemning, criticizing, shaming, or rejecting. It does not mean nonpreference. For example, nonjudgment is important in Buddhist psychology, which emphasizes experiencing the moment "as it is." This does not mean an absence of preferences.

Empathic Boundaries

Counselors strive to achieve empathy with their clients while maintaining boundaries that protect their own energies. Professionals should ''sense the client's private world as if it were [their] own, without ever losing the 'as if' quality,'' and while not becoming entangled with their perception of the client [12; 21]. It takes work to maintain a healthy distance emotionally while feeling and intuiting what the client is saying.

Too much sympathy, or working with empathy without proper boundaries in the therapeutic relationship, drains the counselor of energy and leads to burnout. In a study of 216 hospice care nurses from 22 hospice facilities across Florida, it was found that trauma, anxiety, life demands, and excessive empathy (leading to blurred professional boundaries) were key determinants of compassion fatigue risk [22]. In other words, there can be too much of a good thing. In order to motivate client change, there should be a limit to the use of empathy in therapy. Empathy is but one tool that a compassionate mental health professional can use to ensure client growth.

5. THE COSTS OF CARING

Humans need humans and heal best with compassionate care. However, mental health professionals must guard against caring too much. While hearing about and sharing the joyous parts of a client's life is wonderful, most therapeutic work involves listening to a client's emotional pain, which can take its toll on even the most seasoned professional.

STRESS

Stress is a warning sign that indicates that self-care needs to be increased. Stress tells you that something is not right. It is like the "check engine" light on your car's dashboard, which, if ignored, can lead to major engine malfunction. Stress that is left unchecked or poorly managed is known to contribute to high blood pressure, heart disease, obesity, diabetes, and suicide [23]. Stress reminds us that we are human and that we have limits. The symptoms of stress include [23]:

- Headaches, muscle tension, neck or back pain

- Upset stomach

- Dry mouth

- Chest pains, rapid heartbeat

- Difficulty falling or staying asleep

- Fatigue

- Loss of appetite or overeating "comfort foods"

- Increased frequency of colds

- Lack of concentration or focus

- Memory problems or forgetfulness

- Jitters, irritability, short temper

- Anxiety

Other warning signs that more self-care is needed include outbursts, depression, anxiety, and lowered tolerance to frustration. Fatigue, whether physical, emotional, mental, or spiritual, can lead to reactivity and poor judgment. Little or no self-care can contribute to burnout, illness, and even addiction. It can also leave the professional vulnerable to crossing or violating boundaries.

A counselor's job is stressful for many reasons, including working in isolation; shouldering the burden of a client's depression, anxiety, apathy, and suicidality; witnessing slow, gradual progress in the therapeutic process; and managing increasing administrative demands (e.g., insurance claims, documentation). These demands can often lead to increased stress and frustration for the counselor.

Self-care includes stress management and vice versa. Self-care should be part of your preventative wellness routine, not instituted only when signs of illness or breakdown are already occurring. Activities that one recommends to clients to decrease their stress will also work for professionals. This includes healthy eating, time management, relaxation techniques, adequate sleep, and maintaining hobbies and outside interests.

COMPASSION FATIGUE, VICARIOUS TRAUMA, AND BURNOUT

When work-related stress is combined with a lack of self-care and support, more serious stress reactions can occur. Compassion fatigue can develop when a mental health professional cares too much or carries too much material [24]. Chronic day-to-day exposure to clients and their distress (e.g., sexual and physical abuse, military combat, community disaster) can be emotionally taxing for the helping professional and can result in compassion fatigue, vicarious trauma, or, ultimately, professional burnout [24,25]. Vicarious trauma describes a profound shift in worldview that occurs in helping professionals when they work with clients who have experienced trauma; the professional's fundamental beliefs about the world are altered by repeated exposure to traumatic material. Burnout describes the physical and emotional exhaustion that helping professionals can experience when they have low job satisfaction and feel powerless and overwhelmed at work. It is not the same as being depressed or overworked. It is a subtle process in which an individual is gradually caught in a state of mental fatigue and is completely drained of all energy. However, burnout does not necessarily indicate a change in worldview or a loss of the ability to feel compassion for others [26,27,28].

The chronic use of empathy combined with day-to-day bureaucratic hurdles (e.g., agency stress, billing difficulties, balancing clinical work with administrative work) can generate the experience of compassion fatigue [29,30]. This type of listening and exposure can take its toll on mental health professionals, particularly when combined with the need to maintain strong limits and boundaries both inside and outside the office. Yet, no matter how well-defined the boundaries are, there will be times when the professional will be affected by listening to what the client has lived through in order to survive; it can be very difficult to hear. This is why peer supervision is necessary. The professional benefits from having a place to offload and receive support following an intense client session in order to mitigate the risk of negative consequences, such as post-traumatic stress disorder, which can be an indirect response to clients' suffering. Compassion fatigue can also cause professionals to lose touch with their own empathy. Strong emotions, as evoked by traumatic material, may strain the empathic ability of the therapist [31]. Symptoms of compassion fatigue result in a loss of interest toward holding empathic response to others due to feeling overwhelmed and burdened by the client's trauma and illnesses. Caregivers with compassion fatigue may develop a preoccupation with re-experiencing clients' trauma; they can develop signs of persistent arousal and anxiety as a result of this secondary trauma. Examples of this arousal can include difficulty falling or staying asleep, irritability or outbursts of anger, and/or exaggerated startle responses. Most importantly, these caregivers ultimately experience a reduced capacity for or interest in being empathic toward the suffering of others [32]. Overlap can occur between compassion fatigue, vicarious trauma, and burnout, with the mental health professional experiencing more than one emotional state.

Some causes of burnout and compassion fatigue can result in part from the personality characteristics of the professional (e.g., perfectionism, overinvolvement with clients) [33]. Because burnout is largely identified in young, highly educated, ambitious professionals, many consider the conflict between an individual's expectations and reality as one of the main characteristics of burnout [27]. Additionally, the professional's attitudes, beliefs, and assumptions can have an impact on performance (e.g., "I must get all my clients better'') and may lead to irritation, a sense of failure, or burnout. Some attitudinal issues are specific to particular client groups (e.g., people who get hostile or perpetrators of sexual assault) or to particular elements of the therapy process (e.g., "I must be available for all of my clients all the time'') [34]. In order to prevent or decrease cases of burnout, compassion fatigue, and vicarious traumatization among professionals, it is important that they receive education on the signs and symptoms of each and that they have access to an open and supportive environment in which to discuss them.

MITIGATING THE COSTS OF CARING

Disengage

As noted, counselors are at increased risk for compassion fatigue, burnout, and/or vicarious trauma when the majority of their caseload involves trauma cases; when there is a lack of balance between work, rest, and play; and when there is a lack of attention to spiritual needs. To reduce their risk, counselors should learn to let go and leave work at work—they should learn to disengage. Disengagement can lower or prevent compassion stress by allowing counselors to distance themselves from the ongoing misery of clients between sessions. The ability to disengage demands a conscious, rational effort to recognize that one must "let go" of the thoughts, feelings, and sensations associated with client sessions in order to live one's own life. Disengagement is the recognition of the importance of self-care and of the need to carry out a deliberate program of self-care [30]. When counselors employ self-care, they model for their clients what mental health looks like. When clients know that counselors have done their own therapeutic or healing work, it instills in them a sense of hope. They see results that indicate the process can work for them, too.

Seek Support

Research indicates that encouraging peer support groups, providing education on the impact of client traumas on mental health professionals, diversifying caseloads, encouraging respite and relaxation, and encouraging a sense of spirituality and wellness are several means of providing support for at-risk professionals [35]. Counselors can be more resilient, accomplish more, and feel more worthwhile when they have close, supportive relationships. Support acts as a buffer against the effects of stress and burnout [36]. Counselors with a larger sense of meaning and connection who practice self-care and work in collaboration with others are less likely to experience vicarious traumatization [37,38].

Set Self-Care Boundaries

In addition to setting and maintaining boundaries with clients, counselors also should set and maintain self-care boundaries to avoid burnout. When setting self-care boundaries, counselors may consider some of the following habits [24,39]:

- Leave work at the office. Avoid conducting research, making telephone calls, and catching up on record keeping at home. Set office hours, publish them on your answering machine, and adhere to those hours.

- Have a procedure for after-hours emergency calls. For example, many counselors instruct clients to call the nearest hospital or go to the local emergency room. Other offices may have an on-call clinician dedicated to responding to emergency calls. The important thing is that there be a clear policy in place for after-hours calls and that clients are aware of and understand the policy.

- Do not skip meals to see an extra client. Include regularly scheduled breaks as part of each work day.

- Schedule and take vacations. Do not check your messages while on vacation. Ask another counselor to see clients in cases of emergency. Most clients can tolerate their counselor's absence for a week or two.

- Live a well-rounded life beyond the office. Make time for friends and family and engage in interests that renew you.

- Educate yourself about trauma and its effects. If you are a supervisor, consider using instruments that measure stress with supervisees. The Maslach Burnout Inventory (MBI) and the Professional Quality of Life (ProQOL) scale should be administered on a regular basis to assess both organizational and individual risk of burnout and trauma-related conditions in high-risk settings.

- Increase your capacity for awareness, containment, presence, and integration. Awareness can be encouraged through meditation, visualization, yoga, journal keeping, art, other creative activities, and personal psychotherapy. Containment abilities can be built through self-care efforts and a balanced life that includes time spent in activities unrelated to work.

Mental health professionals should strive to maintain a balance between giving and getting, between stress and calm, and between work and home. These stand in clear contrast to the overload, understaffing, over-commitment, and other imbalances of burnout. To give and give until there is nothing left to give means that the professional has failed to replenish his or her resources [28].

Practice Mindfulness

Helping professionals often feel like they have to fix others or have all the answers. This is a faulty cognition. Oftentimes, the most healing and powerful act a counselor can do is being in the moment with the client, holding the space for his or her feelings and thoughts. Mindfulness practice can facilitate this. The practice of mindfulness (i.e., present-focused attending to ongoing shifts in mind, body, and the surrounding world), integrated into daily life, can help counselors to develop enhanced patience, presence, and compassion [38]. It can help counselors to stay calmly focused and grounded, which allows them to be less reactive and engage with greater equanimity [38].

One study investigated how the use of dialectical behavioral therapy (DBT) in working with young, self-harming women with borderline personality disorder affected the occupational stress and levels of burnout among psychiatric professionals [40]. DBT was stressful in terms of learning demands, but it decreased the experience of stress in actual treatment of clients. Participants felt that mindfulness training, which was one aspect of DBT, improved their handling of work stressors not related to DBT [40]. Counselors were better able to accept feelings of frustration, cope with stress, and be more patient and relaxed [40]. Mindfulness has been found to decrease stress, increase concentration, and increase the counselor's ability to detach from the client's material. It also assists a counselor's empathy and boundary setting [41]. Mindfulness, attention, empathy, and counseling self-efficacy have been found to be significantly related to one another [41].

One study explored the impact of Buddhist mindfulness (meditation) practice on the attitude, work, and lived experience of counselors and their self-reported experiences of working with clients [42]. Findings suggest that a long-term mindfulness meditation practice can positively impact counselors' ability to distinguish their own experiences from their clients' experiences, can enrich clarity in their work with clients and may help them develop self-insight [42]. Mindfulness may also help to increase patience, intentionality, gratitude, and body awareness [43]. It is an excellent tool for caring, compassionate professionals to use to maintain their own energies and support their clients' growth.

Expand Your Professional World

Symptoms of burnout or compassion fatigue can be signs of a need to grow professionally. This might mean branching out from individual therapy sessions to include group therapy, teaching at local colleges, supervising other professionals, developing continuing education units, or providing consultations. In some instances, it might mean changing careers or exploring other ways to use your licensure and experience.

6. TRANSFERENCE AND COUNTERTRANSFERENCE

The term transference was coined by Freud to describe the way that clients "transfer" feelings about important persons in their lives onto their counselor. As Freud said, "a whole series of psychological experiences are revived, not as belonging to the past but applying to the person of the physician at the present moment" [44]. The client's formative dynamics are recreated in the therapeutic relationship, allowing clients to discover unfounded or outmoded assumptions about others that do not serve them well, potentially leading to lasting positive change [45]. Part of the counselor's work is to "take" or "accept" the transferences that unfold in the service of understanding the client's experience and, eventually, offer interpretations that link the here-and-now experience in session to events in the client's past [46]. The intense, seemingly irrational emotional reaction a client may have toward the counselor should be recognized as resulting from projective identification of the client's own conflicts and issues. It is important to guard against taking these reactions too personally or acting on the emotions in inappropriate ways [47]. Therapists' emotional reactions to their patients (countertransference) impact both the treatment process and the outcome of psychotherapy.

REFLECTION

It also is important to be reflective rather than reactive in words and actions. Use of the mindfulness technique can help counselors to become reflective rather than reactive and can help counselors unhook from any triggering material and maintain appropriate limits and boundaries. Reflection demands a reasonable level of awareness of one's thoughts and feelings and a sound grasp of whether they deviate from good professional behavior. Reflection includes [48]:

- A questioning attitude towards one's own feelings and motives

- The recognition that we all have blind spots

- An understanding that staff are affected by clients

- An understanding that clients are affected by staff behavior

- A recognition that clients often have strong feelings toward staff

Clients are more accepting of transference interpretations in an environment of empathy. Transference interpretation is most effective when the road has been paved with a series of empathic, validating, and supportive interventions that create a holding environment for the client [50].

Freud believed transference to be universal, with the possibility of occurring in the counselor as well as the client. He described this "countertransference" as "the unconscious counter reaction to the client's transference, indicative of the therapist's own unresolved intrapsychic conflicts" [51]. Freud felt that countertransference could interfere with successful treatment [45]. Since the 1950s, the view of countertransference has evolved. It is no longer believed to be an impediment to treatment. Instead, it is viewed as providing important information that the professional can use in helping the client [45].

Empathy allows the counselor to experience and thus know what the client is experiencing. Countertransference emerges when the client's transference reactions touch the counselor in an unresolved area, resulting in conflictual and irrational internal reactions [52]. Good indicators of countertransference are feelings of irritability, anger, or sadness that seem to arise from nowhere. Countertransference frequently originates in counselors' unresolved conflicts related to family issues, needs, and values; therapy-specific areas (e.g., termination, performance issues); and cultural issues [53]. When feelings have intensity or when they persist, this is an indicator for future work and healing.

The counselor's work is to bear the client's transferences and interpret them. When the counselor refuses the transference, there is often a mutual projective identification going on, in which both counselor and client project part of themselves onto the other. Refusal may also mean that one of the counselor's own blind spots has been engaged. As Shapiro explains, "a rough edge of our character has been 'hooked' by a bit of what the patient is struggling with, and we act out a bit of countertransference evoked in us by the transference" [54]. In a group therapy setting, family dynamic re-enactments can emerge as transferences. Managing these complex dynamics can raise the counselor's anxiety and mobilize his or her defenses, compromising a usually thoughtful stance. When counselors experience intense reactions in trauma groups that pull them out of the present moment, they should investigate whether they are responding to traumatic content, personal unresolved issues, or individual or collective transference [55]. Counselors who find themselves ruminating about a previous session's content, a client's welfare, or their own issues should talk with a trusted, objective colleague. Countertransference issues for the mental health professional should be resolved apart from the therapeutic environment to avoid burdening and potentially harming clients [51]. One study of countertransference found that therapists' self-reported disengaged feelings over a treatment period adversely impacted the effect of transference work for all patients, but especially for patients with a history of poor, nonmutual, complicated relationships [48].

SELF-AWARENESS

Problems arise when the professional lacks awareness or refuses to devote the necessary time to process the personal emotions and thoughts that arise within the therapeutic relationship. Feelings of anger, grief, jealousy, shame, injustice, trauma, and even attraction can, when they touch a wound from the past, trigger reactions within even experienced professionals. Clients' experiences can replicate the professional's past relationships and trigger emotions that have not been worked on or addressed. If this occurs, the professional can, without disrupting the client's session, make a mental note of the feelings. This allows the professional to attend to the present moment. After the client's session has ended, the professional can arrange to talk to a colleague or supervisor for processing. If the countertransference continues, it may be necessary for the professional to seek counseling. Self-awareness helps the professional to reflect back to the client's true emotions. It also is an important component of training, development, and effectiveness [56]. Mental health professionals need to possess certain values, qualities, and sensitivities, and should be open-minded and have an awareness of their comfort levels, values, biases, and prejudices [57].

As stated in the ethics codes of the ACA [4]:

Therapists are aware of—and avoid imposing—their own values, attitudes, beliefs, and behaviors. They respect the diversity of clients, trainees, and research participants and seek training in areas in which they are at risk of imposing their values onto clients, especially when their values are inconsistent with the client's goals. They refrain from initiating an activity when they know or should know that there is a substantial likelihood that their personal problems will prevent them from performing their work-related activities in a competent manner. When they become aware of personal problems that may interfere with their performing work-related duties adequately, they take appropriate measures, such as obtaining professional consultation or assistance and determine whether they should limit, suspend, or terminate their work-related duties.

7. BOUNDARIES AND LIMITS

Generally speaking, a boundary indicates where one area ends and another begins. It indicates what is "out of bounds" and acts to constrain, constrict, and limit. In the therapeutic relationship, a boundary delineates the "edge" of appropriate behaviors and helps to rule in and out what is acceptable, although the same behaviors might be acceptable or even desirable in other relationships [58,59]. Boundaries have important functions in the therapeutic relationship, helping to build trust, empower and protect clients, and protect the professional.

BUILDING TRUST

An inherent power differential exists in the therapeutic relationship between the client, who is placed in a position of vulnerability as she or he seeks help, and the practitioner, who is placed in a position of power because of her or his professional status and expertise [59]. When the client sees the counselor sitting in a chair, with a diploma or licensure on the wall, it can be intimidating. To help mitigate these feelings with the client, it is important to maintain a sense of professionalism while working to build trust and rapport. Part of that professionalism includes setting limits and explaining what they are in the context of therapy.

The familiarity, trust, and intensity of the therapeutic relationship create a powerful potential for abuse that underscores the need for careful attention to the ethical aspects of professional care [59]. Trust is the cornerstone of the therapeutic relationship, and counselors have the responsibility to respect and safeguard the client's right to privacy and confidentiality [4]. Clients have expressed what they believe to be essential conditions for the development of trust in the therapeutic relationship. These include that the clinician [60]:

- Is perceived as available and accessible

- Tries to understand by listening and caring

- Behaves in a professional manner (evidenced by attributes such as honesty in all interactions)

- Maintains confidentiality

- Relates to the client as another adult person rather than as an "expert"

- Remains calm and does not over-react to the issue under discussion

Only when satisfied that the clinician is sufficiently experienced, professional, flexible, and empathic can a foundation for therapy be laid. Clients acknowledge that this takes time and that the trustworthiness of the therapeutic relationship may be tested. If the relationship is perceived to be wanting, clients indicate that they would have difficulty continuing it [60].

THE VALUE OF FLEXIBILITY

Rigid boundaries can negatively reinforce the power differential that exists between the client and the counselor. Rigid boundaries may serve the fears and needs of counselors who are new to the profession and/or concerned with the implications of boundary violations. However, rigid boundaries can lead to harm for the client who perceives that the "rules" are more important than his or her welfare. While rigidity and remoteness on the counselor's part may help ensure that boundaries are intact, they do not accurately reflect the intended role of boundaries in clinical practice. Boundaries should never imply coldness or aloofness. As stated, clients value flexibility, caring, and understanding. Within conditions that create a climate of safety, flexible boundaries can accommodate individual differences among clients and counselors and allow them to interact with warmth, empathy, and spontaneity [61]. Firm, intractable boundaries may be a comfort to the helping professional; however, fixed rules cannot capture the complex reality of the therapeutic relationship [59].

EMPOWERING AND PROTECTING THE CLIENT

Boundaries and effective limit setting in sessions help to empower and protect clients by teaching and reinforcing the skills they need to become healthy. Boundaries set the parameters and expectations of therapy, so it is important to articulate them in such a way that each client's understanding of them is clear. Counselors should constantly and actively make judgements about where to draw lines that are in the client's best interests [62].

Boundaries begin the moment a client enters the room. Indicate which chair is yours and where it is acceptable for the client to sit. Take note of where your seat is in relation to the door should an emergency arise. Be sure to maintain an appropriate amount of space between yourself and the client. Too much space can feel impersonal and too little can feel invasive. Consider the décor of the setting. Clients may become distracted by the counselor's personal artifacts and family photographs and may place their focus on the counselor rather than on their own therapeutic work. Some clients with poor boundaries may become preoccupied with the counselor's family, which can become a source of transference.

Clients often enter therapy with a history of prior boundary violations (e.g., childhood sexual abuse, domestic violence, inappropriate boundary crossings with another professional) that leave them with persisting feelings and confusion regarding roles and boundaries in subsequent intimate relationships [63]. Consequently, they may test the boundaries as children do. The counselor should recognize these boundary dilemmas and manage them by reiterating the boundaries calmly and clearly [62]. The counselor must also set and maintain boundaries even if the client threatens self-harm or flight from therapy. This can be extremely challenging when faced with a client's primitively motivated, intense demands. However, counselors should recall that one description of the tasks with clients with primitive tendencies is to resist reinforcing primitive strivings and to foster and encourage adult strivings [64]. Winnicott refers to this as a "holding relationship," wherein the counselor acts as a "container" for the strong emotional storms of the client. The act of holding helps reassure the client that the clinician is there to help the client retain control and, if necessary, assume control on his or her behalf [65].

Due to the potential issues and challenges that the client brings to therapy (e.g., cognitive deficits, substance abuse/addictions, memory issues, personality disordered manipulations), it is important to maintain a record of instances when the articulated boundaries and limits have been ignored or violated. For example, a client is habitually late, despite knowing that it is unacceptable to arrive more than 10 minutes late to session. The first instance of a late arrival might simply warrant a reminder of the 10-minute limit, whereas repeated instances would require that the limit be enforced. The clinician who overidentifies with a client might experience a need to do things for the client rather than help the client learn to do things for him- or herself. While this behavior may appear relatively harmless, it suggests overinvolvement with a client and potential boundary problems [66]. Such behavior inhibits the client's ability to learn personal responsibility and how to resolve conflict [67]. It also may impede the reflective and investigative character of an effective helping process [39]. Mental health professionals should take reasonable steps to minimize harm to clients where it is foreseeable and unavoidable [3,4]. They also should facilitate client growth and development in ways that foster the interest and welfare of the client and promote the formation of healthy relationships [4].

PROTECTING THE PROFESSIONAL

As stated, professional associations that represent the various fields of clinical practice have codes of ethics that provide principles and standards to guide and protect the professional and the individuals with whom they work [3,4,5,6,7]. Client welfare and trust in the helping professions depend on a high level of professional conduct [3,4]. Professional values, such as managing and maintaining appropriate boundaries, are an important way of living out an ethical commitment [4].

Some situations in therapy are clear with regard to boundaries (e.g., no sexual relationships with clients). Other situations may be not as clear or may be ambiguous (e.g., receiving gifts from clients). When faced with such situations, professionals should engage in an ethical decision-making process that includes an evaluation of the context of the situation and collaboration with the client to make decisions that promote the client's growth and development [4]. Supervision and colleague support also may be necessary to reach the best decision. Such a process helps clinicians maintain justice and equity and avoid implications of favoritism in dealing with all of their clients [68].

Professionals who deliver services in nontraditional settings, such as those who have home-based practices, face unique challenges related to boundaries and limit setting. As with office-based therapy, some situations cannot be prepared for and will need to be addressed in the moment. While delivering services in nontraditional settings may benefit some clients, when working in homes or residences, the professional is advised to emphasize informed consent, particularly with regard to therapeutic boundaries. Whenever possible, the impact of crossing boundaries on therapy and on the therapeutic relationship should be considered ahead of time [69].

8. BOUNDARY CROSSINGS AND VIOLATIONS

A boundary crossing is a departure from commonly accepted practices that could potentially benefit clients; a boundary violation is a serious breach that results in harm to clients and is therefore unethical [70]. Professional risk factors for boundary violations include [71]:

- The professional's own life crises or illness

- A tendency to idealize a "special" client, make exceptions for the client, or an inability to set limits with the client

- Engaging in early boundary incursions and crossings or feeling provoked to do so

- Feeling solely responsible for the client's life

- Feeling unable to discuss the case with anyone due to guilt, shame, or the fear of having one's failings acknowledged

- Realization that the client has assumed management of his or her own case

Denial about the possibility of boundary problems (i.e., "This couldn't happen to me") also plays a significant role in the persistence of the problem [71]. Lack of self-care and self-awareness also can leave the mental health professional vulnerable to boundary crossings and/or violations.

Whatever the reason the professional has to cross a boundary, it is of utmost importance to ensure that it will not harm the client. Each boundary crossing should be taken seriously, weighed carefully in consultation with a supervisor or trusted colleague, well-documented, and evaluated on a case-by-case basis. Intentional crossings should be implemented with two things in mind: the welfare of the client and therapeutic effectiveness. Boundary crossing, like any other intervention, should be part of a well-constructed and clearly articulated treatment plan that takes into consideration the client's problem, personality, situation, history, and culture as well as the therapeutic setting and context [72]. Boundary crossings with certain clients (e.g., those with borderline personality disorder or acute paranoia) are not usually recommended. Effective therapy with such clients often requires well-defined boundaries of time and space and a clearly structured therapeutic environment. Dual or multiple relationships, which always entail boundary crossing, impose the same criteria on the professional. Even when such relationships are unplanned and unavoidable, the welfare of the client and clinical effectiveness will always be the paramount concerns [72].

Some counselors may consider a boundary crossing when it provides a better firsthand sense of the broader clinical context of their client, such as visiting the home of a client that is ailing, bedridden, or dying; accompanying a client to a medically critical but dreaded procedure; joining a client/architect on a tour of her latest construction; escorting a client to visit the gravesite of a deceased loved one; or attending a client's wedding [72]. Many mental health professionals will not cross these boundaries and will insist that therapy occur only in the office. Each professional should operate according to the parameters with which he or she is comfortable. As stated, the best interests of the client, including client confidentiality, and the impact to therapy should be of paramount importance when considering whether to cross a boundary.

To be in the best position to make sound decisions regarding boundary crossings, mental health professionals should develop an approach that is grounded in ethics; stay abreast of evolving legislation, case law, ethical standards, research, theory, and practice guidelines; consider the relevant contexts for each client; engage in critical thinking and personal responsibility; and, when a mistake is made or a boundary decision has led to trouble, use all available resources to determine the best course of action to respond to the problem [73]. The risk management strategy also should include discussions with supervisors, colleagues, and the client. Each step should be documented and should include supervisory recommendations and client discussion regarding the benefits versus the risks of such actions. Although minor boundary violations may initially appear innocuous, they may represent the foundation for eventual exploitation of the client. If basic treatment boundaries are violated and the client is harmed, the professional may be sued, charged with ethical violations, and lose his/her license [74].

9. MULTIPLE RELATIONSHIPS

Examples of multiple relationships include being both a client's counselor and friend; entering into a teacher/student relationship; becoming sexually involved with a current or former client; bartering services with a client; or being a client's supervisor. Even when entering into a multiple relationship seems to offer the possibility of a better connection to a client, it is not recommended. Multiple relationships can cause confusion and a blurring of boundaries and risk exploitation of the client.

The issue of multiple relationships is addressed by the codes of ethics of mental health professions. According to the APA's ethics code [3]:

A multiple relationship occurs when a psychologist is in a professional role with a person and (1) at the same time is in another role with the same person, (2) at the same time is in a relationship with a person closely associated with or related to the person with whom the psychologist has the professional relationship, or (3) promises to enter into another relationship in the future with the person or a person closely associated with or related to the person. A psychologist refrains from entering into a multiple relationship if the multiple relationships could reasonably be expected to impair the psychologist's objectivity, competence or effectiveness in performing his or her functions as a psychologist, or otherwise risks exploitation or harm to the person with whom the professional relationship exists.

The ethics code of the NASW defines dual or multiple relationships as occurring "when social workers relate to clients in more than one relationship, whether professional, social, or business. Dual or multiple relationships can occur simultaneously or consecutively." [5]. It also states that "social workers should not engage in dual or multiple relationships with clients or former clients in which there is a risk of exploitation or potential harm to the client. In instances when dual or multiple relationships are unavoidable, social workers should take steps to protect clients and are responsible for setting clear, appropriate, and culturally sensitive boundaries" [5]. The code further states that it is the professional's responsibility to "be alert to and avoid conflicts of interest that interfere with the exercise of professional discretion and impartial judgment" and that counselors should "inform clients when a real or potential conflict of interest arises and take reasonable steps to resolve the issue in a manner that makes the clients' interests primary and protects clients' interests to the greatest extent possible" [5]. In some instances, this may require "termination of the professional relationship with proper referral of the client" [5].

The ACA ethics code states that [4]:

Counselors are prohibited from engaging in counseling relationships with friends or family members with whom they have an inability to remain objective. . .They also are prohibited from engaging in a personal virtual relationship with individuals with whom they have a current counseling relationship (e.g., through social and other media). . .When a counselor agrees to provide counseling services to two or more persons who have a relationship, the counselor clarifies at the outset which person or persons are clients and the nature of the relationships the counselor will have with each involved person. If it becomes apparent that the counselor may be called upon to perform potentially conflicting roles, the counselor will clarify, adjust, or withdraw from roles appropriately.

Mental health professionals who practice in small, rural communities face special problems in maintaining neutrality, fostering client separateness, protecting confidentiality, and managing past, current, or future personal relationships with clients [75]. Whether the practice is located in a small town or a big city, there will be times when counselors and clients will encounter one another outside the office. To ignore a client who is reaching out in a social setting may cause the client harm. However, it also is important to avoid violating the client's privacy. The best way to minimize the potential awkwardness of such an encounter is to prepare ahead of time. For example, a counselor might incorporate a conversation about such an encounter into the initial evaluation process by telling the client: "If I happen to be at a store or a restaurant and see you, I won't say hello because I respect your confidentiality and want to protect your privacy. However, if you want to smile or say hello to me, I will respond in kind." Explain to the client that the conversation or acknowledgment must be brief to prevent any violation of the client's privacy. After an encounter in public, address the event in your next session, discuss any feelings the client had about the encounter, and note the discussion in the client record. Such an encounter would not fall under the category of dual/multiple relationships unless, for example, the counselor and client went grocery shopping at the same time every week and interacted each time. In this instance, the counselor is advised to change his or her shopping day and/or time in order to avoid risking loss of client confidentiality.

BOUNDARY VIOLATIONS WITHIN MULTIPLE RELATIONSHIPS

Mental health professionals are forbidden to exploit any person over whom they have supervisory, evaluative, or other similar authority. This includes clients/patients, students, supervisees, research participants, and employees [3,4]. Professional ethics codes outline specific instances of behaviors and actions (some that are expressly prohibited) that have exploitative potential, including [3,4,5]:

- Bartering with clients

- Sexual relationships with students or supervisees

- Sexual intimacies with current or former clients

- Sexual intimacies with relatives/significant others of current therapy clients

- Therapy with former sexual partners or partners of a romantic relationship

- Romantic interactions or relationships with current clients, their romantic partners, or their family members, including electronic interactions or relationships

- Physical contact with clients (e.g., cradling or caressing)

There are times when a client has an emotional session and hugs the counselor unexpectedly before leaving the office. This physical contact should be noted in the client's record along with what precipitated it. It should be revisited with the client at the next session, with this discussion recorded in the client's record. While you may prefer no physical contact, you can try to respond positively to the desire for closeness. For example, make personal contact with your hand as you hold the client at a distance, make eye contact, and tell the client that while physical reaching out is positive and welcome, you cannot allow it [12].

The ACA ethics code prohibits sexual and/or romantic counselor/client interactions or relationships with former clients, their romantic partners, or their family members for a period of five years following the last professional contact. This prohibition applies to both in-person and electronic interactions or relationships [4]. The APA ethics code indicates that this period should be "at least two years after cessation or termination of therapy," and that "psychologists do not engage in sexual intimacies with former clients/patients even after a two-year interval except in the most unusual circumstances" [3]. Mental health professionals who choose to engage in relationships with former clients have the burden of demonstrating that there has been no exploitation, in light of all relevant factors [3]. Factors to consider include the amount of time passed since termination of therapy; the client's personal history and mental status; the likelihood of an adverse impact on the client; and statements or actions made by the counselor during therapy suggesting or inviting a possible sexual or romantic relationship with the client [3].

Standards regarding sexual relationships and physical contact also are addressed by the NASW ethics code [5]:

1.09 Sexual Relationships

(a) Social workers should under no circumstances engage in sexual activities, inappropriate sexual communications through the use of technology or in person, or sexual contact with current clients, whether such contact is consensual or forced.

(b) Social workers should not engage in sexual activities or sexual contact with clients' relatives or other individuals with whom clients maintain a close personal relationship when there is a risk of exploitation or potential harm to the client. Sexual activity or sexual contact with clients' relatives or other individuals with whom clients maintain a personal relationship has the potential to be harmful to the client and may make it difficult for the social worker and client to maintain appropriate professional boundaries. Social workers—not their clients, their clients' relatives, or other individuals with whom the client maintains a personal relationship—assume the full burden for setting clear, appropriate, and culturally sensitive boundaries.

(c) Social workers should not engage in sexual activities or sexual contact with former clients because of the potential for harm to the client. If social workers engage in conduct contrary to this prohibition or claim that an exception to this prohibition is warranted because of extraordinary circumstances, it is social workers—not their clients—who assume the full burden of demonstrating that the former client has not been exploited, coerced, or manipulated, intentionally or unintentionally.

(d) Social workers should not provide clinical services to individuals with whom they have had a prior sexual relationship. Providing clinical services to a former sexual partner has the potential to be harmful to the individual and is likely to make it difficult for the social worker and individual to maintain appropriate professional boundaries.

1.10 Physical Contact

Social workers should not engage in physical contact with clients when there is a possibility of psychological harm to the client as a result of the contact (such as cradling or caressing clients). Social workers who engage in appropriate physical contact with clients are responsible for setting clear, appropriate, and culturally sensitive boundaries that govern such physical contact.

The safest course of action is to continue to maintain established boundaries and limits indefinitely after therapy ends. In addition to the noted relevant factors, counselors should keep in mind that the client may return for further treatment. If the counselor has become involved in a business or social relationship with a former client, he or she deprives the client of the opportunity to return for additional treatment. It is vital to be mindful of the potential to exploit the client's vulnerability in a post-termination relationship [76].

Mental health professionals who find themselves attracted to a client should seek supervision around this issue. It is normal for feelings to develop in any type of relational context. It is not the feelings of attraction that are the problem, but rather actions taken. Mental health professionals should never act on these feelings, but instead discuss them with a trusted supervisor or colleague, exploring the possibility of countertransference as well as the potential trigger for the attraction. If the attraction causes intense feelings, it is advisable to seek personal therapy. If the feelings interfere with one's ability to treat a client, the client should be transferred to another professional, and work with the client terminated.

10. GIFTS

It is not unusual during the course of therapy for a client to present a counselor with a token of appreciation or a holiday gift, and receiving gifts from clients is not strictly prohibited by professional ethics codes. Instead, the ethics codes advise professionals to consider a variety of factors when deciding whether to accept a client's gift.

Section A.10.f (Receiving Gifts) of the 2014 ACA Code of Ethics states that [4]:

Counselors understand the challenges of accepting gifts from clients and recognize that, in some cultures, small gifts are a token of respect and gratitude. When determining whether to accept a gift from clients, counselors take into account the therapeutic relationship, the monetary value of the gift, the client's motivation for giving the gift, and the counselor's motivation for wanting to accept or decline the gift.

The National Board for Certified Counselors Code of Ethics: Directive #21 provides similar guidance to its members [6]:

Counselors shall not accept gifts from clients except in cases when it is culturally appropriate or therapeutically relevant. Counselors shall consider the value of the gift and the effect on the therapeutic relationship before accepting. Acceptance of a gift shall be documented in the client's record.

In the code of ethics of the Association for Addiction Professionals, Principle I-40: The Counseling Relationship states that [7]:

Addiction professionals recognize that clients may wish to show appreciation for services by offering gifts. Providers shall take into account the therapeutic relationship, the monetary value of the gift, the client's motivation for giving the gift, and the counselor's motivation for wanting to accept or decline the gift.

As noted in these excerpts, the effect on the therapeutic relationship should be a primary consideration when considering whether to accept a gift. Gifts can mean many things and also can fulfill social functions. The counselor's task is to identify the contextual meaning of the gift and determine when the gift is not merely a gift. To do so, the counselor must draw out from the client information to discern the possibility of a metaphorical or culturally significant meaning for the gift giving [77]. Counselors should consider the client's motivation for gift-giving as well as the status of the therapeutic relationship. Gifts that may seem intended to manipulate the counselor are probably best refused, whereas rejection of a gift intended to convey a client's appreciation may harm the relationship [78].

If the counselor is most comfortable with a "no-gift policy," it is best that the policy be discussed at the beginning of therapy. To wait until a client is presenting a gift to state that it is your policy to decline gifts may harm the client and damage the therapeutic relationship. Clear communication, both written and spoken, of the policy with clients as they enter therapy may help avert difficult later interactions around gifts. If clients have an understanding as they begin therapy what the counselor's approach will be, misunderstandings may be avoided [79]. While restrictive guidelines might be unhelpful, confusion surrounding gifts seems to be exacerbated by a lack of professional discussion about the topic [80].

Many professionals try to keep gifts "alive" throughout client sessions. This often involves putting the gift "on hold" (including decisions about acceptance and rejection) until the best moment for exploration with the client occurs. This allows that gifts given during therapy (where possible) remain part of therapy (i.e., they stay in the room and are available for future sessions) [80]. When considering whether to discuss the gift as part of therapy, the counselor should evaluate pertinent factors, such as the client's time in therapy, the context and frequency of gifts, and client dynamics. While not all gifts warrant full discussion (e.g., those given to show appreciation or of modest financial value), some, such as repeated or expensive gifts, do. Although counselors should be careful not to make too much of a gift, especially those that clients at least initially see as being given simply as a way to say thank you, such conversations may enable both members of the dyad to attain greater insight into the gift's intention and meaning and thereby prove helpful to the continued therapy work [81].

Gifts can range from physical objects, to symbols or gestures. As stated, consider the monetary value of the gift, the client's motivation for giving the gift, and the counselor's motivation for wanting to accept or decline the gift [4,5,7]. If there are concerns about any of these factors, it may be best to explore the intent of the gift in session. If a gift is deemed inappropriate, the counselor is advised to decline to accept it. In these cases, counselors should express appreciation for the thought and gesture, explain why they are unable to accept the gift, return it with kindness, and note the encounter in the client's record.

Professionals who work with children have unique challenges regarding gifts. Rejecting a child's gift or trying to explain a "no-gift policy" can cause the child to feel confused or rejected; children do not have the same levels of cognition and understanding that adults have. For play counselors, potential compromises include incorporating the gift into the other materials and toys in the playroom or directly sharing the gift with the child [81]. An important factor affecting the decision to accept a gift is the kind of gift presented by the child. Artwork or something created by the child is an extension of the child and therefore can be viewed as an extension of emotional giving. Accepting non-purchased items (e.g., a flower picked by a child or a child's drawing) would be acceptable in most cases [82].

Clients with personality disorders present unique challenges regarding the issue of gifts. Generally, these clients exhibit manipulation, poor boundaries, and fixed or rigid patterns of relating, and gift giving can be a feature of the clinical picture for such clients. Accepting a gift from such a client may reinforce patterns of manipulative or self-debasing behaviors that are symptomatic of the problematic levels of functioning. In such instances, counselors should discern which course of action is truly in the client's best interests [77].

Often, a small token may be given or received at the termination of therapy for a long-term client. A touchstone that has meaning for the client, such as a meditation CD, book, or greeting card, is appropriate. As with all gifts, the gift and the context in which the gift was given or received should be noted in the client's record, along with your own intent and how you think the client perceived the gift.

THE GIFT OF SELF-DISCLOSURE

Self-disclosure can be considered another type of gift; however, it is best saved for a special occasion, shared deliberately, and always with the client's welfare first and foremost in mind. Self-disclosure is useful when it benefits the client, not the counselor. Although self-disclosure may cause no problems in therapy, it may intrude on the client's psychic space or replace a client's rich and clinically useful fantasy with dry fact, stripped of meaningful affect [71].

Humanistic theorists openly embrace counselor self-disclosure, asserting that such interventions demonstrate counselors' genuineness and positive regard for clients [83]. It is not surprising that professionals with behavioral and cognitive orientations view professional self-disclosures positively, especially when these interventions are intended to serve as a model for client self-disclosure [84]. And there will be times that self-disclosure is helpful in therapy. For example, it may serve as a vehicle for transmitting feminist values, equalizing power in the therapy relationship, facilitating client growth, fostering a sense of solidarity between counselor and client, helping clients view their own situations with less shame, encouraging clients' feelings of liberation, and acknowledging the importance of the real relationship between counselor and client. It also may enable clients to make informed decisions about whether or not they choose to work with a counselor [84].

According to one study, the content areas clinical social workers felt most comfortable self-disclosing about were loneliness, relationship status, aging, and other developmental issues of adulthood. Many talked freely about their marital status, the composition of their families, their parenting, their education, and their work. The most significant content area for sharing was grief work around significant losses either through separation, divorce, or death [85]. In these cases, counselor self-disclosure can help clients feel less alone and can normalize an emotional experience. It can give a client hope to learn that a trusted counselor has gone through the same situation.

Cautions Regarding Self-Disclosure

The power differential in the therapeutic relationship gives the professional access to a great deal of information about the client, which is transmitted in a one-way direction from client to counselor. Occasionally, a client will ask personal questions of the counselor. The questions may arise simply out of curiosity, but they also may arise when a client is attempting to gain a feeling of control, as seen in individuals with personality disorders. Personal questions also may signal a client's wish to avoid feeling uncomfortable with emerging feelings/thoughts. Acknowledging and showing compassion for the client's curiosity while maintaining professional boundaries will satisfy most clients. While it is normal for clients to be curious, it is important to remind them that they are the focus of session. Gently redirect the conversation with comments such as, "Let's get back to you," or "What were you thinking or feeling before you asked me about myself?" It is important that professionals keep their sharing limited, even when the client asks for them to self-disclose.

No matter how on guard one is, there will be times when personal information makes its way to clients. Accidental self-disclosures may include extra-therapeutic encounters, slips of the tongue, or public notices of events or lectures. Personal aspects of the counselor's life may come to light if he or she calls a client by another client's name, a newspaper prints an obituary of the counselor's spouse, or the counselor is seen entering a place of worship [86]. Most clients who learn a bit of personal information about their counselor will mention it only to express care or concern, as when they learn of a death. Clients are generally satisfied with a brief acknowledgement of the disclosure and an appreciation for the client's expressed feelings about it.

As stated, mental health professionals' primary concern is to avoid burdening or overwhelming clients. Professionals should generally avoid using disclosures that are for their own needs, that remove the focus from the client, that interfere with the flow of the session, that burden or confuse the client, that are intrusive, that blur the boundaries between the professional and client, or that contaminate transference [84].

11. TECHNOLOGY AND DISTANCE THERAPY

We live in a rapidly changing world, especially where technology is concerned. In the past, therapy was offered only through in-person interaction in an office setting. Then, gradually, some professionals began to offer telephone sessions. Today, counseling is offered through video conferencing and other forms of telepsychology, and paper client records are being replaced with electronic records. Competent counseling includes maintaining the knowledge and skills required to understand and properly use treatment tools, including technology, while adhering to the ethical code of one's profession.

The APA has created guidelines to address the developing area of psychologic service provision commonly known as telepsychology [87]. The APA defines telepsychology as the "delivery of psychological services using telecommunication technologies…Telecommunication technologies include, but are not limited to synchronous (i.e., live and real-time interaction, e.g., videoconferencing, audio-only telephone) and asynchronous (i.e., store-and forward, non-live; e.g., text, email, messaging program, data-tracking smartphone applications) methods of healthcare-related communication and transmission of healthcare-related information. Transmitted information may include text, image, audio, interactive videoconferencing, remote patient monitoring, or other data related to patient care" [89]. The APA guidelines are informed by its ethics code and record-keeping guidelines as well as its guidelines on multicultural training, research, and practice.

The guidelines allow that telecommunication technologies may either augment traditional in-person services or be used as stand-alone services. However, the guidelines are intended to "help psychologists apply best professional practices when using telecommunication technologies" and not to "contravene any limitations set on psychologists' activities based on ethical standards; federal, state, provincial, and territorial laws; and other organizational regulations" [87]. When one set of considerations may suggest a different course of action than another, the professional should balance them appropriately, with the aid of the guidelines, while holding to all current legal and ethical standards of practice [87]. The complete guidelines are available online at https://www.apa.org/about/policy/telepsychology-revisions.

The 2014 ACA Code of Ethics also addresses distance counseling, technology, and social media. It states [4]:

Counselors understand that the profession of counseling may no longer be limited to in-person, face-to-face interactions. Counselors actively attempt to understand the evolving nature of the profession with regard to distance counseling, technology, and social media and how such resources may be used to better serve their clients. Counselors strive to become knowledgeable about these resources. Counselors understand the additional concerns related to the use of distance counseling, technology, and social media and make every attempt to protect confidentiality and meet any legal and ethical requirements for the use of such resources.

The ACA code also addresses legal considerations, informed consent and disclosure, confidentiality, security, and multicultural and disability considerations as they relate to technology.

The NBCC recognizes that distance counseling presents unique ethical challenges to professional counselors; related technology continues to advance and be used by more professionals; and that the use of technology by professionals continues to evolve. In light of this information, the NBCC Code of Ethics includes an updated and expanded section on telemental health, social media, and technology. The revised policy advises in detail about privacy concerns, legal considerations, obtaining the necessary information and consent from the client, and social media best practices [6].

According to the NASW ethics code, "Social workers should take reasonable steps to protect the confidentiality of electronic communications, including information provided to clients or third parties. Social workers should use applicable safeguards (such as encryption, firewalls, and passwords) when using electronic communications such as e-mail, online posts, online chat sessions, mobile communication, and text messages" [5]. Professionals are advised to "comply with the laws governing technology and social work practice in the jurisdiction in which they are regulated and located and, as applicable, in the jurisdiction in which the client is located" [5]. In general, the NASW Code of Ethics advises that "Social workers should develop and inform clients about their policies, consistent with prevailing social work ethical standards, on the use of electronic technology" [5]. Professionals who are involved in discoverable (by the client) "electronic communication with groups based on race, ethnicity, language, sexual orientation, gender identity or expression, mental or physical ability, religion, immigration status, and other personal affiliations may affect their ability to work effectively with particular clients" [5].

Professionals interested in providing online interventions also should consider the potential for boundary confusion, inappropriate dual relationships, or harm to clients [5]. For example, instant message systems can alert clients each time the professional is online, allowing the client to send chat requests. Clients might access a professional's personal webpage or sign onto online discussion groups to which the professional also belongs. Some may continue to send the professional emails after the termination of the relationship. E-counselors should consider their response to such ongoing contact. Potentially more seriously, clients may use the Internet to harass or stalk current or former counselors [88]. The best way to prevent potential problems is to discuss the boundaries with clients during the initial assessment. Being up front and clear with clients about limits and policies regarding the use of technology and social networking is recommended [89].

Miscommunication is a commonplace occurrence in the online world. Even the simplest things (e.g., punctuation marks) can be misinterpreted. Studies reveal that 7% of any message is conveyed through words, 38% through certain vocal elements, and 55% through nonverbal elements (e.g., facial expressions, gestures, posture) [90]. Some technology-based forms of communication can result in the loss of important nonverbal and vocal cues, leading to an increased risk for miscommunication between client and counselor. Interactive communication, such as texting and email, involves the loss of nonverbal social cues that provide valuable contextual information and interpretation of meaning. Loss of these physical social cues may also increase the client's tendency to project personal psychologic material onto the blankness of the communication. While this may be helpful in some forms of psychotherapeutic interventions and it may offer advantages over in-person communication, it also presents a potential risk for increased miscommunication [88].

The compassionate professional strives to communicate nonverbally to clients that he or she is listening to and in the moment with the client. Physical cues, such as nodding and eye contact, have been shown to be positively associated with the degree that clients feel the counselor is respectful and genuine [91,92]. Much attention also is paid to the voice, as it carries the verbal message and people often believe the voice to be a more reliable indicator of one's true feelings [93]. Because research exploring how empathy is experienced in an online environment is minimal, counselors should check with their clients to determine if the empathy is being transmitted in their text-based communications [12].

No matter what type of counseling is offered, a thorough initial evaluation should be completed to assess whether a client is appropriate for distance counseling. Practicing within recommended guidelines does not release counselors from the personal responsibility to be aware of, and to independently evaluate, the variety of ethical issues involved in the practice of online therapy [88]. Certain clients (e.g., those with suicidal, homicidal, or substance abuse history, clients with personality disorders) would not be suited to online therapy.

LEGAL AND ETHICAL CONSIDERATIONS

The challenges of online therapy lead to legal and ethical concerns associated with the delivery of mental health services via the Internet. Those opposed to online or distance therapy worry about licensure issues related to doing therapy across jurisdictional boundaries, legal responsibility in the event of a crisis, and the appropriateness of client anonymity [94].

Providing services across state lines is one of the biggest unresolved issues. Although communication technologies allow counselors to reach clients anywhere, state licensing laws generally do not permit out-of-state counselors to provide services via these methods. Some states offer guest licensure provisions, but most states require that the counselor hold a license in his or her own state and in the client's state. Providing distance therapy within one's own state is simpler, and it allows mental health professionals to reach people who would not otherwise have access to services (e.g., rural residents, people with certain disabilities) as well as those who want to receive services from home. To confidently provide distance services [95]:

- Abide by all applicable licensing requirements and professional standards of care.

- Understand the technology being used.

- Periodically check your state legislature's website for the latest telehealth laws and regulations.

- Check for a board policy statement that provides guidance on telepractice.

- Check whether your state licensing board has issued policies related to telepractice.

- Confirm that telehealth services (both in-state and across jurisdictional lines) are covered under your malpractice policy.

The COVID-19 public health emergency increased demand for mental and behavioral health services while driving most of those services to telehealth platforms. In response to this, in 2020, the APA led a campaign to maximize the availability of telepsychology services [96]. In March 2020, the federal government designated psychologists as critical, essential workers, and the Centers for Medicare and Medicaid Services (CMS) improved access to care for Medicare beneficiaries. CMS issued further guidance to waive key telehealth requirements. Because the new legislation cannot supersede state licensing laws (e.g., those that prohibit psychologists from using telehealth to provide services across state lines), the APA drafted letters to governors in all 50 states urging them to temporarily suspend state licensing laws and regulations regarding telepsychology services to ensure continuity of care. Within weeks of receiving the APA letter [96]:

- 12 states issued executive orders calling for expansion of telehealth service rates.

- 14 states issued executive orders allowing patients to receive telehealth services in their own homes.

- 16 states temporarily lifted licensing requirements.

- 22 states either expanded their policies for out-of-state providers to temporarily practice in their states or instituted emergency expedited registration for out-of-state providers.

However, the COVID-19 public health emergency ended in August 2023, and professionals offering telehealth services must use fully HIPAA-compliant software. Some options include Skype for Business, Updox, VSee, Zoom for Healthcare, and others [97]. More information can be found at https://www.hhs.gov/hipaa/for-professionals/security/laws-regulations/index.html [98]. The APA also advises professionals to review individual payer's policies to confirm what telehealth services are covered and to determine the requirements for coding and billing telehealth services. Depending on the state, telehealth services may be limited to videoconferencing or include asynchronous communications or audio-only phone. It is also important to determine if there are originating site restrictions for where the patient may receive services or if coverage of telehealth services is limited to in-network providers or telehealth-only providers [97]. Emergency licensing provisions enacted during the COVID-19 pandemic have also ended.

SOCIAL MEDIA

With the advent of social media, clients can now search for and find the Facebook or Twitter page of their counselor, if one exists. Counselors who accept a client's "friend request" are in essence agreeing that the counselor and client are now friends, creating a multiple relationship. As discussed, when clients have access to their counselor's social media sites, both intentional and unintentional self-disclosures can occur. Modern social networking systems (e.g., Facebook, Instagram) exemplify intentional self-disclosure without a particular client focus. In contrast, Internet search engines (e.g., Google, LexisNexis) may allow unintended disclosure of personal details of the professional's life. Professionals should be aware and cognizant of social media involvement, including what information is public. Many sites offer ways to post minimal information if a connection to other professionals is desired. Avoid posting a profile photo that includes your family or other personal details, as these are public [86].

12. CONCLUSION

Competent counselors are well-educated and well-versed in the ethics of their profession. They understand that trust is built over time in the therapeutic relationship, with the help of limits and boundaries, and that it is reinforced by empathic response. Competent, compassionate professionals are both self- and other-aware and able to seek appropriate supervision and consultation when necessary. They establish self-care boundaries in order to protect their own compassionate, empathic response as well as their physical, emotional, and spiritual well-being. This enables counselors to most effectively help their clients.

13. RESOURCES

Administration for Community Living

Diversity and Cultural Competency

https://www.acl.gov/programs/strengthening-aging-and-disability-networks/diversity-and-cultural-competency

Office of Minority Health

Cultural and Linguistic Competency

https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=1&lvlid=6

Health Resources and Services Administration

Culture, Language and Health Literacy

https://www.hrsa.gov/about/organization/bureaus/ohe/health-literacy/culture-language-and-health-literacy

APA Ethical Principles of Psychologists and Code of Conduct

https://www.apa.org/ethics/code

ACA Code of Ethics

https://www.counseling.org/docs/default-source/default-document-library/ethics/2014-aca-code-of-ethics.pdf

NAADAC Code of Ethics

https://www.naadac.org/code-of-ethics

NBCC Code of Ethics

https://www.nbcc.org/Assets/Ethics/NBCCCodeofEthics.pdf

NASW Code of Ethics

https://www.socialworkers.org/About/Ethics/Code-of-Ethics

Substance Abuse and Mental Health Services Administration Cultural Competence

https://www.samhsa.gov/capt/applying-strategic-prevention/cultural-competence

HelpGuide: Benefits of Mindfulness

https://www.helpguide.org/harvard/benefits-of-mindfulness.htm

Mindfulnet.org

http://www.mindfulnet.org

Plum Village Mindfulness Practice Center

https://plumvillage.org/mindfulness-practice

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76183 • Anxiety Disorders

Mark Rose, BS, MA, LP

www.netce.com

Copyright © 2025 NetCE, All rights reserved.

Anxiety disorders are characterized by states of chronic, excessive dread or fear of everyday situations. The fear and avoidance can be life-impairing and disabling. Anxiety disorders result from the interaction of biopsychosocial factors, whereby genetic vulnerability interacts with situations, stress, or trauma to produce clinically significant syndromes. The influence from hereditary factors and adverse psychosocial experiences on anxiety disorder pathogenesis and pathophysiology is complex, but neuroscience advances have greatly improved the understanding of the underlying factors in the development and maintenance of anxiety disorders.

Table of Contents

76183 • Anxiety Disorders

Course Overview

Audience

Accreditations & Approvals

Designations of Credit

Individual State Behavioral Health Approvals

Special Approvals

Course Objective

Learning Objectives

Faculty

Faculty Disclosure

Division Planners

Division Planners Disclosure

Director of Development and Academic Affairs

Director Disclosure Statement

About the Sponsor

Disclosure Statement

Implicit Bias in Health Care

1. INTRODUCTION

2. BACKGROUND

SAFETY BEHAVIORS AND SIGNALS

PRIMARY FEATURES OF ANXIETY AND RELATED DISORDERS

3. OVERALL PREVALENCE, RISK FACTORS, AND CLINICAL COURSE

PAST YEAR AND LIFETIME PREVALENCE

OVERALL RISK FACTORS

CLINICAL COURSE

COMORBID DEPRESSION

SPECIFIC DISORDERS

4. ETIOLOGY AND PATHOPHYSIOLOGY

ANXIETY DISORDERS IN GENERAL

GENERALIZED ANXIETY DISORDER

PANIC DISORDER

AGORAPHOBIA

SOCIAL ANXIETY DISORDER

SPECIFIC PHOBIA

ADULT SEPARATION ANXIETY DISORDER

5. CLINICAL AND DIAGNOSTIC FEATURES

GENERALIZED ANXIETY DISORDER

PANIC ATTACKS

PANIC DISORDER

AGORAPHOBIA

SOCIAL ANXIETY DISORDER

SPECIFIC PHOBIA

SEPARATION ANXIETY DISORDER

SELECTIVE MUTISM

6. ASSESSMENT

SCREENING FOR ANXIETY DISORDERS IN THE PRIMARY CARE SETTING

SCREENING TOOLS

IDENTIFYING PATIENTS WHO REQUIRE TREATMENT

PATIENT HISTORY

PHYSICAL EXAMINATION

DIFFERENTIAL DIAGNOSIS

7. GENERAL TREATMENT CONSIDERATIONS

PREDICTORS OF WORSE TREATMENT RESPONSE AND OUTCOMES

OVERLAPPING PSYCHOLOGIC AND DRUG THERAPY MECHANISMS

PSYCHOTHERAPIES: OVERVIEW

PHARMACOTHERAPY: OVERVIEW

CLINICAL ISSUES

8. TREATMENT OF GENERALIZED ANXIETY DISORDER

PSYCHOTHERAPY

PHARMACOTHERAPY

9. TREATMENT OF PANIC DISORDER

PSYCHOTHERAPY

PHARMACOTHERAPY

SSRI/SNRI

10. TREATMENT OF AGORAPHOBIA

PSYCHOTHERAPY

PHARMACOTHERAPY

CONTRIBUTING FACTORS TO PANIC DISORDER WITH AGORAPHOBIA TREATMENT RESPONSE

11. TREATMENT OF SOCIAL ANXIETY DISORDER

PSYCHOTHERAPY

PHARMACOTHERAPY

12. TREATMENT OF SPECIFIC PHOBIA

PSYCHOTHERAPY

PHARMACOTHERAPY

A NOVEL APPROACH COMBINING MEDICATION AND EXPOSURE THERAPY

13. TREATMENT OF SEPARATION ANXIETY DISORDER

PSYCHOTHERAPY

PHARMACOTHERAPY

14. EMERGING THERAPIES AND NOVEL TREATMENT APPROACHES

NEUROENHANCING AGENTS TO AUGMENT EXPOSURE THERAPY

CAPNOMETRY-ASSISTED RESPIRATORY TRAINING

NEUROMODULATION THERAPIES

NEW OR NOVEL ANXIOLYTIC AGENTS

15. COMPLEMENTARY/ALTERNATIVE THERAPIES

HERBAL PRODUCTS AND SUPPLEMENTS

EXERCISE THERAPY

YOGA

16. CONCLUSION

Works Cited

Evidence-Based Practice Recommendations Citations

76183 • Anxiety Disorders

Education Category. Psychiatric / Mental Health

Release Date. 05/01/2025

Expiration Date. 04/30/2028

Course Overview

Anxiety disorders are characterized by states of chronic, excessive dread or fear of everyday situations. The fear and avoidance can be life-impairing and disabling. Anxiety disorders result from the interaction of biopsychosocial factors, whereby genetic vulnerability interacts with situations, stress, or trauma to produce clinically significant syndromes. The influence from hereditary factors and adverse psychosocial experiences on anxiety disorder pathogenesis and pathophysiology is complex, but neuroscience advances have greatly improved the understanding of the underlying factors in the development and maintenance of anxiety disorders.

Audience

This course is designed for behavioral and mental health providers involved in the identification, treatment, and care of patients with anxiety disorder.

Accreditations & Approvals

NetCE has been approved by NBCC as an Approved Continuing Education Provider, ACEP No. 6361. Programs that do not qualify for NBCC credit are clearly identified. NetCE is solely responsible for all aspects of the programs. As a Jointly Accredited Organization, NetCE is approved to offer social work continuing education by the Association of Social Work Boards (ASWB) Approved Continuing Education (ACE) program. Organizations, not individual courses, are approved under this program. Regulatory boards are the final authority on courses accepted for continuing education credit. Continuing Education (CE) credits for psychologists are provided through the co-sponsorship of the American Psychological Association (APA) Office of Continuing Education in Psychology (CEP). The APA CEP Office maintains responsibility for the content of the programs. NetCE is recognized by the New York State Education Department's State Board for Social Work as an approved provider of continuing education for licensed social workers #SW-0033. This course is considered self-study, as defined by the New York State Board for Social Work. NetCE is recognized by the New York State Education Department's State Board for Mental Health Practitioners as an approved provider of continuing education for licensed mental health counselors #MHC-0021. This course is considered self-study by the New York State Board of Mental Health Counseling. NetCE is recognized by the New York State Education Department's State Board for Mental Health Practitioners as an approved provider of continuing education for licensed marriage and family therapists. #MFT-0015.This course is considered self-study by the New York State Board of Marriage and Family Therapy. Materials that are included in this course may include interventions and modalities that are beyond the authorized practice of licensed master social work and licensed clinical social work in New York. As a licensed professional, you are responsible for reviewing the scope of practice, including activities that are defined in law as beyond the boundaries of practice for an LMSW and LCSW. A licensee who practices beyond the authorized scope of practice could be charged with unprofessional conduct under the Education Law and Regents Rules.

Designations of Credit

NetCE designates this continuing education activity for 6.5 NBCC clock hour(s). Social workers participating in this intermediate to advanced course will receive 15 Clinical continuing education clock hours. NetCE designates this continuing education activity for 15 credit(s).

Individual State Behavioral Health Approvals

In addition to states that accept ASWB, NetCE is approved as a provider of continuing education by the following state boards: Alabama State Board of Social Work Examiners, Provider #0515; Florida Board of Clinical Social Work, Marriage and Family Therapy and Mental Health Counseling, CE Broker Provider #50-2405; Illinois Division of Professional Regulation for Social Workers, License #159.001094; Illinois Division of Professional Regulation for Licensed Professional and Clinical Counselors, License #197.000185; Illinois Division of Professional Regulation for Marriage and Family Therapists, License #168.000190;

Special Approvals

This course has been approved by NetCE, as a NAADAC Approved Education Provider, for educational credits, NAADAC Provider #97847. NetCE is responsible for all aspects of their programming. NetCE is approved as a provider of continuing education by the California Consortium of Addiction Programs and Professionals. Provider Number 5-08-151-0626. NetCE is approved as a provider of continuing education by the California Association of DUI Treatment Programs (CADTP). Provider Number 185. NetCE is approved as a provider of continuing education by the California Association for Alcohol/Drug Educators. Provider Number CP40 889 H 0626. NetCE designates this continuing education activity for 15 continuing education hours for addiction professionals.

Course Objective

The purpose of this course is to provide mental health professionals with the knowledge and skills necessary to appropriately identify and treat patients with anxiety disorders, addressing knowledge gaps, enhancing clinical skills, and improving patient outcomes.

Learning Objectives

Upon completion of this course, you should be able to:

1. Review basic concepts related to anxiety disorders, including safety behaviors/signals and primary features.

2. Outline the epidemiology of anxiety disorders in the United States.

3. Describe general risk factors for and comorbidities of anxiety disorders.

4. Describe risk factors for and the clinical course of specific anxiety disorders.

5. Discuss the pathogenesis of anxiety disorders in relation to contributing genetic, physiologic, and psychologic factors.

6. Review the pathophysiology of specific anxiety disorders, including social anxiety disorder, agoraphobia, and specific phobia.

7. Apply the clinical and diagnostic criteria for anxiety disorders presented in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

8. Analyze key components of screening and select appropriate screening tools for identification of anxiety disorders.

9. Conduct an informed clinical evaluation and select laboratory testing, in consideration of the differential diagnosis of anxiety disorders.

10. Describe general treatment considerations for anxiety disorders, including predictors of response or nonresponse to therapy.

11. Discuss the role and efficacy of psychotherapy approaches in the treatment of anxiety disorders.

12. Select a pharmacotherapy option appropriate to a given patient's specific diagnosis, age, and comorbidities.

13. Devise a strategy for management and follow-up designed to improve outcomes.

14. Provide patient education more effectively, in relation to specific anxiety disorders.

15. Address the efficacy, safety and limitations of novel, emerging, and alternative/complementary approaches to the treatment of anxiety disorders.

Faculty

Mark Rose, BS, MA, LP, is a licensed psychologist in the State of Minnesota with a private consulting practice and a medical research analyst with a biomedical communications firm. Earlier healthcare technology assessment work led to medical device and pharmaceutical sector experience in new product development involving cancer ablative devices and pain therapeutics. Along with substantial experience in addiction research, Mr. Rose has contributed to the authorship of numerous papers on CNS, oncology, and other medical disorders. He is the lead author of papers published in peer-reviewed addiction, psychiatry, and pain medicine journals and has written books on prescription opioids and alcoholism published by the Hazelden Foundation. He also serves as an Expert Advisor and Expert Witness to law firms that represent disability claimants or criminal defendants on cases related to chronic pain, psychiatric/substance use disorders, and acute pharmacologic/toxicologic effects. Mr. Rose is on the Board of Directors of the Minneapolis-based International Institute of Anti-Aging Medicine and is a member of several professional organizations.

Faculty Disclosure

Contributing faculty, Mark Rose, BS, MA, LP, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Division Planners

Alice Yick Flanagan, PhD, MSW

Margaret Donohue, PhD

Division Planners Disclosure

The division planners have disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Director of Development and Academic Affairs

Sarah Campbell

Director Disclosure Statement

The Director of Development and Academic Affairs has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

About the Sponsor

The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare.

Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.

Disclosure Statement

It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.

Implicit Bias in Health Care

The role of implicit biases on healthcare outcomes has become a concern, as there is some evidence that implicit biases contribute to health disparities, professionals' attitudes toward and interactions with patients, quality of care, diagnoses, and treatment decisions. This may produce differences in help-seeking, diagnoses, and ultimately treatments and interventions. Implicit biases may also unwittingly produce professional behaviors, attitudes, and interactions that reduce patients' trust and comfort with their provider, leading to earlier termination of visits and/or reduced adherence and follow-up. Disadvantaged groups are marginalized in the healthcare system and vulnerable on multiple levels; health professionals' implicit biases can further exacerbate these existing disadvantages.

Interventions or strategies designed to reduce implicit bias may be categorized as change-based or control-based. Change-based interventions focus on reducing or changing cognitive associations underlying implicit biases. These interventions might include challenging stereotypes. Conversely, control-based interventions involve reducing the effects of the implicit bias on the individual's behaviors. These strategies include increasing awareness of biased thoughts and responses. The two types of interventions are not mutually exclusive and may be used synergistically.

1. INTRODUCTION

Anxiety is an extreme form of worry, life's adaptative response to perceived impending physical and emotional threats both large and small; as such, anxiety focuses attention and, if necessary, prompts one to prepare for "fight or flight." Small moments of anxiety are useful and expected in the course everyday life; such experiences are transient, having no significant impact on social and occupational activities. Anxiety disorders are maladaptive forms of excessive apprehension and fearfulness—taxing, counter-productive, robbing life of its productivity and joy.

Anxiety disorders are characterized by several distinct clinical patterns that share a common refrain: acute exacerbation and chronic states of excessive worry and apprehension around otherwise normal circumstance and everyday situations. Anxiety syndromes include fearfulness in response to social and performance expectations, situational and triggered panic attacks, general (anticipatory) anxiety states, and avoidance (safety) behaviors. The diagnosis of anxiety disorder requires that the patient has experienced a certain number of symptoms or symptomatic episodes for more than a minimum specified period, causing significant personal distress and impairing everyday function [3,350].

Anxiety disorders are thought to develop from the interaction of genetic predisposition in the face of perceived overwhelming challenges to self—biopsychosocial stress or trauma that leads to clinically significant syndromes. The influence of hereditary factors and adverse psychosocial experiences on pathogenesis and pathophysiology is complex, but neuroscience advances have greatly improved the understanding of the underlying factors in the development and maintenance of anxiety disorders.

2. BACKGROUND

SAFETY BEHAVIORS AND SIGNALS

Safety behaviors are coping tactics used by persons with anxiety disorders to prevent, escape from, or diminish the severity of a perceived threat. Safety behaviors are particularly common in persons with panic disorder, agoraphobia, and social anxiety disorder. These behaviors emerge in response to external (e.g., situations, persons, activities) and/or internal (e.g., thoughts, emotions, memories) foci of perceived threat and are either anticipatory (avoidant) or consequential (escape) [1]. While safety behaviors may provide some measure of immediate relief, they have no impact on the individual's propensity for anxiety, nor do they diminish the frequency and severity of future symptomatic events. However, assessment of safety behavior provides guidance for implementing targeted interventions, and accurate assessment and elimination of safety behaviors is often necessary to maximize treatment of clinical anxiety [351].

Another coping mechanism observed in persons with anxiety disorder is safety signals, defined as the people or objects used to diminish distress in situations that elicit anxiety. Safety signals are also potentially counterproductive; they offer immediate relief but facilitate persistence of the anxiety disorder over time by preventing direct confrontation of feared stimuli in the absence of "safe" objects/people and by maintaining perceptions of risk/harm and coping inability. A patient's continued use of safety signals impedes therapeutic progress, in particular the response to exposure therapy. However, safety behaviors may be helpful early in treatment by making exposure therapy more tolerable and less threatening [1].

PRIMARY FEATURES OF ANXIETY AND RELATED DISORDERS

The distinguishing features of specific anxiety disorders are summarized in the following section. Related conditions of post-traumatic stress disorder (PTSD) and obsessive-compulsive disorder (OCD) are included because, although no longer classed as anxiety disorders by the 2013 Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), they are often included in research that pre-dates 2013 and can co-occur with anxiety disorders [2]. Situations or objects that evoke intense anxiety in patients with agoraphobia, social anxiety disorder, or specific phobia are either avoided or endured with significant personal distress.

Generalized Anxiety Disorder

Generalized anxiety disorder (GAD) is characterized by repetitive thinking and intrusive worrying about potentially harmful future events that is persistent (lasting more than a few months) and not restricted to circumstances [3]. While recognizing that some degree of worry may be helpful, patients with GAD report experiencing excessive, uncontrollable worry causing distress or impairment. These patients have physical anxiety symptoms and key psychologic symptoms (i.e., restlessness, fatigue, difficulty concentrating, irritability, muscle tension, and disturbed sleep). GAD is often comorbid with major depression, panic disorder, phobic anxiety disorders, health anxiety, and OCD [3].

Panic Disorder

Panic disorder is characterized by recurrent unexpected surges of severe anxiety ("panic attacks"), with varying degrees of anticipatory anxiety between attacks [3]. Panic attacks are characterized by sudden onset of intense fear (terror) accompanied by such symptoms as uncontrollable trembling, sweating, palpitations, dizziness, shortness of breath, numbness and tingling, and chest pain. These attacks are often incapacitating, typically peak within 10 minutes and last around 30 to 45 minutes. Most patients also develop a fear of having future panic attacks, which is considered a key element in classifying such episodes as panic disorder [3].

Agoraphobia

Around two-thirds of patients with panic disorder develop agoraphobia, defined as fear or avoidance of places or situations from which escape might be difficult or where help might not be available in the event of a panic attack [3]. These places or situations can include crowds, public transportation, or being alone outside of the home [2].

Social Anxiety Disorder

Social anxiety disorder (SAD) is characterized by excessive worry and apprehension in anticipation of social interactions and situations, specifically a fear of being negatively evaluated/judged by others (resulting in embarrassment or humiliation) in social group settings [3]. It is associated with physical and psychologic anxiety symptoms.

Specific Phobia

Specific, simple, or isolated phobia is excessive and unreasonable fear/avoidance of specific objects or situations such as animals (e.g., snakes, insects); the natural environment (e.g., heights, storms); closed spaces (e.g., elevators, caves); or procedures (e.g., venipuncture, dental examination) [3]. Individuals with specific phobia disorder recognize that their specific fear/avoidance reaction is unreasonable but find it intensely distressing or interfering with everyday life. The most common phobias reported by adults involve animals, heights, and flying.

Separation Anxiety Disorder

Adult separation anxiety disorder (SEPAD) is characterized by fear or anxiety concerning separation from those to whom an individual is attached. Common features include excessive distress when experiencing or anticipating separation from home and persistent and excessive worries about potential harms to attachment figures or untoward events that might result in separation [3].

Post-Traumatic Stress Disorder

PTSD is the persistent fear or episodic severe emotional distress that follows actual or threatened death, serious injury, or psychological shock to the physical integrity of self or others (the trauma), with ongoing intrusive symptoms related to the traumatic event. Exacerbations are often triggered by recollections, flashbacks, or dreams; manifestations include avoidance symptoms (e.g., efforts to avoid activities or thoughts associated with the trauma), negative alterations in cognition and mood, and hyper-arousal symptoms (e.g., disturbed sleep, hypervigilance, exaggerated startle response) [2].

Obsessive-Compulsive Disorder

OCD is characterized by recurrent uncontrollable thoughts and ruminations (obsessions) that lead to restlessness and anxiety, followed by impulsive/repetitive physical or mental rituals (compulsions) to alleviate distress. The obsessive-compulsive behaviors are destressing and time-consuming, which impedes normal social and occupational function. Common obsessions relate to fear of personal contamination, accidents, and religious or sexual matters; common rituals include washing, checking, cleaning, counting, and touching [3].

Illness Anxiety Disorder

Illness anxiety disorder is a somatic-symptom related disorder characterized by excessive or disproportionate preoccupations with having or acquiring a serious illness. This includes excessive health-related behaviors and high levels of alarm about personal health status [3].

3. OVERALL PREVALENCE, RISK FACTORS, AND CLINICAL COURSE

Taken together, anxiety disorders (DSM-5 plus PTSD and OCD) have a 12-month prevalence of approximately 19% in the United States, and a lifetime prevalence of approximately 29% [4,5]. The pattern of sex distribution is consistent among anxiety disorders, and the prevalence of any anxiety disorder is higher for girls/women (23%) than for boys/men (14%) [5,6]. Anxiety disorder is more prevalent among adolescents 13 to18 years of age (32%) but less severe, with only 8% having experienced severe impairment. The prevalence of anxiety disorder gradually declines with age, from a high of 23% among all persons 30 to 44 years of age to 9% among those older than 60 years of age. Among surveyed adults having any anxiety disorder, the proportional severity of impairment associated with symptomatic episodes occurring in the previous year was 43% mild, 34% moderate, and 23% serious [5].

PAST YEAR AND LIFETIME PREVALENCE

The reported data on anxiety disorders in the United States include 12-month prevalence, lifetime prevalence, and lifetime morbid risk (Table 1). The two lifetime measures differ. Lifetime prevalence measures the proportion of the population currently or previously diagnosed with the disorder, while lifetime morbid risk measures the proportion who may develop the disorder at some point, independent of their lifetime history at the time of assessment. By including future cases, lifetime morbid risk is believed to be more accurate. Lifetime prevalence and lifetime morbid risk are usually equivalent for disorders with early-life onset, but diverge for disorders with increasingly later onset. The ratio of lifetime prevalence to lifetime morbidity risk falls below 1.0 in disorders with increasingly later onset; the further the ratio values fall below 1.0, the later the median age of onset [7].

Table 1: COMPARISON OF PREVALENCE, MORBID RISK, AND RATIO OF LIFETIME PREVALENCE TO MORBID RISK FOR ANXIETY DISORDERS

Anxiety Disorder

12-month

Lifetime

Lifetime Morbid Risk

Lifetime/Lifetime Morbid Risk

Generalized anxiety disorder

2.0%

4.3%

9.0%

0.5

Panic disorder

2.4%

3.8%

6.8%

0.5

Agoraphobia

1.7%

2.5%

3.7%

0.7

Social anxiety disorder

7.4%

10.7%

13.0%

0.8

Specific phobia

12.1%

15.6%

18.4%

0.8

Separation anxiety disorder

1.2%

6.7%

8.7%

0.8

Source: [7]

Anxiety disorders with earlier median age of onset are phobias and separation anxiety disorder (15 to 17 years of age), and those with latest age of onset are panic disorder and generalized anxiety disorder (23 to 30 years of age). Lifetime morbid risk is considerably higher than lifetime prevalence for most anxiety disorders, with magnitude of difference much higher for disorders with later than earlier age of onset. Also, the ratio of 12-month to lifetime prevalence roughly reflects persistence but varies meaningfully in ways consistent with differential persistence of these disorders [7].

OVERALL RISK FACTORS

Demographic

The odds for a lifetime diagnosis of any anxiety disorder were calculated, and the same pattern was found for past 12 month diagnosis [8]. These odds are organized according to sex, socioeconomic status, education level, and age. Overall, the risk of developing an anxiety disorder is greater for women/girls than men/boys.

Persons in lower income brackets also incur an increased odds of developing an anxiety disorder compared with those in higher income brackets (48% increased risk with $35,000 to $69,000; 52% with $20,000 to $34,000; 100% with $19,000 or less). Lower educational attainment is also a risk factor. Compared with college graduates, the odds of developing an anxiety disorder are increased 44% with 13 to 15 years of education, 76% with 12 years of education, and 86% with 0 to 11 years of education. These disorders are also 40% more likely in persons 15 to 24 years of age compared with older adults (45 to 54 years of age) [8].

Behavioral Inhibition and Temperament

Behavioral inhibition has been defined as a childhood temperament characterized by high levels of caution, avoidance, and fearful response to unfamiliar people, objects, and situations [352]. Children who display behavioral inhibition may exhibit limited ability to handle stress as they mature and are at increased risk of developing anxiety disorders later in life. A study of heightened anxiety in young adults during the COVID-19 pandemic found that behavioral inhibition in childhood was linked to worry dysregulation in adolescence, which in turn predicted elevated anxiety during the pandemic when participants had reached young adulthood [352,353]. Behavioral inhibition and introversion are also strongly linked to later development and severity of situational avoidance, which is a core feature and risk factor in agoraphobia and SAD [9].

CLINICAL COURSE

Anxiety disorders in the aggregate show a U-shaped age of onset—higher in childhood and young adulthood and lower in adolescence. The greatest concentration occurs during transition to early adulthood. Unlike biologically driven pubertal transitions, adulthood transitions involve distinct psychosocial events (e.g., independent living, full-time employment), and this represents a key period for understanding the development of adult anxiety disorders such as panic disorder and agoraphobia [10].

Community studies of persons with sub-diagnostic anxiety symptoms over time often show episodic symptoms and prolonged periods of remission, with symptoms reappearing or worsening during adverse life events and psychosocial stressors. In contrast, studies of clinical anxiety disorder populations typically show a chronic course with fluctuating symptom severity between periods of remission and relapse, with long-term course varying by disorder [3].

Healthcare Utilization

Distressing anxiety symptoms oftentimes consist of somatic complaints, prompting patients to visit an emergency facility or seek out a primary care provider. If anxiety disorder goes unrecognized or is considered a secondary issue, costly medical testing and delay in effective care may result. Societal costs resulting from misdiagnosis, ineffective treatment and work absenteeism attributable to anxiety disorders are substantial. The direct medical expenditure associated with anxiety in adults, including inpatient visits, prescription costs, and office-based visits is estimated at $33.7 billion annually [354]. Recognition of the patient with a pattern of subjective worrying and anxiety, coupled with validated screening, targeted examination and selective testing enhances diagnosis. Effective treatment with pharmacotherapy or cognitive-behavioral therapy (CBT) can be expected to relieve symptoms and minimize costs [2,3].

COMORBID DEPRESSION

Anxiety symptoms often co-occur with other psychologic symptoms. Depressive symptoms are highly prevalent with more severe anxiety symptoms, with anxiety and depressive symptom severity strongly correlated. Patients with anxiety disorder have high comorbidity rates of major depressive disorder (almost 50%), schizophrenia, substance use disorders, and physical illness [3,11]. Overlapping symptoms of anxiety and depression, such as sleep disturbance, fatigue, and difficulty concentrating, make differentiation challenging. Depressive disorders are sometimes termed "anxious-misery" when high levels of sadness and anhedonia are present [2]. Suicidal ideation and rates of suicide attempts are elevated in persons with anxiety disorders, and the suicide risk among patients has been reported as increased by a factor of 10 compared with the general population [54].

SPECIFIC DISORDERS

Generalized Anxiety Disorder

Epidemiology

Studies show that GAD has a 6.2% lifetime prevalence and a 2.0% to 3.1% past-year prevalence in the U.S. population [350]. The lifetime and past-year prevalences are 3.6% and 2.0% in men/boys and 6.6% and 4.3% in women/girls. Most persons with GAD diagnoses are female. The reported prevalence for GAD in primary care patient panels range 3.7% to 14.8% [54]. Childhood or adolescent onset was found in more than 50% of those seeking help for anxiety, reflecting the chronicity of the disease [2].

Risk Factors

No single etiology has been identified for GAD, but it likely involves the interaction of multiple familial/genetic and environmental risk factors. A review of twin and family studies found significant associations between GAD, other anxiety disorders, and depression, suggesting a common underlying genetic basis. A significant number of patients and their first-degree relatives develop GAD (odds ratio 6:1) [12]. Civilian trauma (e.g., motor vehicle accidents, physical or sexual assault, sudden unexpected loss of a loved one, bullying or peer victimization in childhood or adolescence) is a risk factor for GAD [13]. The presence of another anxiety disorder (e.g., panic disorder, SAD, specific phobia) is another possible factor. Panic disorder is comorbid in 25% of patients with GAD [13].

Older adults are the fastest-growing age demographic in the United States. Although late-onset GAD (on or after 65 years of age) is uncommon, clinicians should bear in mind that age-related propensity for anxiety, including the emergence of anxiety disorder, may change over the course of a lifetime. The concerns of aging that may lead to excessive worrying include personal health, the welfare of loved ones, dwindling income, loss of independence, and ability to manage one's affairs at home. The primary predictors of anxiety in the elderly include female sex, recent adverse life events, and chronic physical (e.g., respiratory and cardiac disorders, dyslipidemia, cognitive impairment) or mental health (e.g., depression, phobia, past GAD) disorders. Other risk factors include poverty, parental loss/separation or low emotional support during childhood, and history of parental mental health problems. Late-onset GAD is described as a multifactorial, stress-related affective disorder resulting from proximal and distal risk factors of which some are potentially modifiable by healthcare intervention [14].

Clinical Course

The course of GAD tends to be chronic with fluctuating symptom severity, and GAD may "switch" to other diagnoses, particularly depression and somatoform disorders [15,16]. GAD is associated with impairments in psychosocial functioning, role functioning, work productivity, and health-related quality of life comparable to major depressive disorder or panic disorder. Patients with GAD and comorbid major depression show significantly greater impairment in health-related quality of life than in either disorder alone. Primary care patients with GAD showed significantly higher annual medical costs than patients without GAD (median $2,375 versus $1,448) and higher mean annual medical costs ($2,138) than patients with other anxiety disorders. GAD is frequently under-recognized in primary care, and only 20% to 32% of patients receive adequate treatment. Suboptimal treatment adds to the health-related quality of life burden of this disorder [17].

Panic Disorder

Epidemiology

In the United States, 4% to 28% of the population experience panic attacks at some time during life. The 2.4% 12-month prevalence of panic disorder in the United States is among the highest worldwide [7,18].

Panic disorder prevalence in primary care is approximately 7%, and substantially higher in patients presenting with cardiac or gastrointestinal symptoms. Relative to white patients, the odds of developing panic attacks and panic disorder are higher in Native Americans, and lower in Asian, Hispanic, and black patients [18,19].

Panic attacks are most likely to develop in patients who are in their mid-20s and slightly earlier in men than women. Panic disorder age of onset is usually between late adolescence and 35 years of age, while the age of onset for panic disorder with agoraphobia spans the early 20s to early 30s. Panic disorder is more common among women, with a 2:1 ratio and increasing to 3:1 with panic disorder with agoraphobia. Panic symptoms during adolescence elevate risks for other anxiety and mood disorders in adulthood. Depressive disorders are highly comorbid (33% to 85%), especially among those with agoraphobia [2,20]. Panic disorder is highly comorbid with other anxiety, mood, and substance use disorders, including nicotine dependence, and cigarette smoking may increase the risk for later-onset panic disorder [21].

Risk Factors

As with GAD, the etiology of panic disorder probably results from a combination of risk factors. There is a five-fold greater risk of developing panic disorder when the disorder is present in first-degree relatives. Shared genetic factors account for 30% to 40% of panic disorder heritability [12]. In addition, major adverse life events, especially those involving physical threat (e.g., physical abuse, sexual assault, military service in a combat zone), precede the onset of panic attacks in roughly 80% of patients. Trauma history is prevalent in patients with panic disorder, especially women [22].

Behavioral inhibition may contribute to panic risk in adulthood. Learned escape and avoidance behaviors can maintain the condition and worsen functional impairment over time. Anxiety sensitivity, or the tendency to catastrophically misinterpret physical symptoms as dangerous, is a risk factor for panic disorder. Personality pathology, particularly avoidant and dependent personality traits, are predictors of panic disorder or agoraphobia development [23,24].

Asthma severity is associated with an incremental risk for panic disorder, and respiratory variability may also increase risk for later onset panic disorder [25]. Baseline respiratory abnormalities are specific to panic disorder pathophysiology [6]. As noted, cigarette smoking and nicotine dependence is disproportionately high among patients with panic disorder and may be temporally related to elevated risk for developing panic disorder [26]. Additionally, panic attacks may be related to poorer cessation outcome during smoking treatment among patients with cancer [27]. Caffeine use is also positively correlated with increased anxiety symptoms and risk of inducing panic attacks in patients with panic disorder [28].

Clinical Course

Prospective studies of panic disorder show high rates of symptom chronicity, relapse after remission, and "switching" to other diagnoses [29,30]. Panic disorder symptoms remain persistent for 50% to 80% of cases even after treatment, increasing disability and impaired quality of life [31].

Agoraphobia

Epidemiology

Agoraphobia usually, but not always, occurs with panic disorder. In community populations, about 25% of those with panic disorder also have agoraphobia, but the proportion is substantially higher in clinical populations [20].

Agoraphobia was made an independent diagnostic entity in the DSM-5, and accordingly, epidemiologic and clinical data that consider agoraphobia in the absence of panic disorder are pending. In the DSM-IV-TR, panic disorder could be specified with or without agoraphobia. Lifetime and 12-month prevalence of panic disorder with agoraphobia were 1.0% and 0.5%, respectively [32].

Risk Factors

Much of the published agoraphobia research assumes panic disorder causation or comorbidity. As such, many of the known risk factors are the same. Comorbid panic disorder and agoraphobia aggregate in families, while agoraphobia without panic disorder is non-familial but may enhance familial transmission of panic disorder [33]. The risk of agoraphobia development in patients with panic disorder is elevated with female sex, more severe dizziness during panic attacks, cognitive factors, dependent personality traits, and SAD. Panic disorder with agoraphobia is associated with greater severity and worse prognosis [34].

Longitudinal studies show low remission rates (0% to 23%) over time in panic disorder or agoraphobia, and subjects with panic disorder with agoraphobia or agoraphobia with panic attacks at baseline were more likely to develop agoraphobia, panic attacks, and other anxiety disorders and experience greater severity (e.g., impairment, disability, treatment-seeking, comorbidity) than subjects with panic disorder without agoraphobia or agoraphobia without panic attacks at baseline [35].

A late-life subtype of agoraphobia (onset at or after 65 years of age) was identified through assessing elderly patients at baseline and four years later. Baseline agoraphobia prevalence was 10.4%, and 11.2% developed agoraphobia during the four-year follow-up. Agoraphobia in the elderly, unlike younger populations, was not more common in women and not associated with panic attacks. Risk factors for late-onset agoraphobia include severe depression, trait anxiety, and poor visuo-spatial memory [36]. Incident anxiety also appears to develop in response to subjective memory complaints independent of depressive symptoms [37].

Patients with panic disorder who experience their first panic attack while driving or using public transportation had higher rates of comorbid agoraphobia. Those with first panic attack at home had higher fear-of-dying rates than with first panic attack outside of the home and felt more severe distress from their first panic attack independent of whether agoraphobia developed. Treatment of patients with panic disorder whose first panic attack was at home should address secondary aspects of fear and distress elicited by the attack [38].

Clinical Course

In persons with panic disorder with or without agoraphobia, the strongest predictors of incidence and relapse were history of panic attacks, GAD/major depression, nicotine dependence, female sex, younger age, and major financial crises. Most predictor variables were similar between panic disorder and panic disorder with agoraphobia. Clinicians should bear in mind the characteristic relapsing-remitting nature of panic disorder/panic disorder with agoraphobia in order to avoid prematurely reducing or eliminating effective treatments. Close attention should be paid to concurrent factors linked to relapse that can be clinically addressed, such as comorbid major depression, GAD, and nicotine dependence [39].

One study followed 711 participants with anxiety disorder diagnoses over 15 years. At baseline, those with early-onset (≤20 years of age) panic disorder were more likely to have comorbid major depressive disorder, GAD, and SAD. Those with early-onset panic disorder with agoraphobia were less likely to be married and more likely to have comorbid GAD and SAD. During follow-up, persons with panic disorder with agoraphobia were significantly more likely to have illness recurrence after periods of recovery, while findings for the other disorders failed to reach significance. This was thought to reflect differences in typical age of onset among anxiety disorders. The onset of panic disorder with or without agoraphobia is usually early adulthood; earlier onsets are relatively uncommon and may signal a particularly pernicious form of illness. The results further support the particularly adverse effects of early-onset psychiatric illness [40].

Social Anxiety Disorder

Epidemiology

SAD can develop at any time during a lifespan, but the average age of onset is during late childhood and adolescence. The prevalence of SAD in pre-adolescence is 3.5%, with rates increasing to about 14% during adolescence [41]. The lifetime prevalence of SAD is 13%, and the prevalence in primary care settings (7%) is high compared with that of other anxiety disorders encountered in general practice [19,350]. Gender distribution is generally equal during pre-adolescence and becomes increasingly more common in girls/women through adolescence and adulthood. An estimated 70% to 80% of individuals with SAD have comorbid anxiety, mood, or substance use disorders. There are cultural variants in Asian and Eastern cultures that involve fears of offending others or making others uncomfortable [2].

Risk Factors

A combination of biologic, familial, environmental, and cultural risk factors drive the development of SAD. Life transitions, personal loss, poverty, and experiences of humiliation or embarrassment contribute to SAD risk [42]. Compared with data from the general population, first-degree relatives are as much as six times more likely to be at risk of SAD. Concordance rates are 24% in monozygotic twins and 15% in dizygotic twins [43].

Behavioral inhibition, shyness, introversion, and anxiety sensitivity are all common among patients with SAD. Emerging early in life, behavioral inhibition is a heritable trait, and 15% to 20% of young children with behavior inhibition exhibit extreme signs. Relative to children without behavioral inhibition, these patients are typically shy, fearful, and cautious and show elevated physiologic arousal signs at rest, such as higher heart rate, increased pupil dilation, and higher cortisol levels. Brain profiles of children with behavioral inhibition show distinct patterns, including electroencephalography asymmetry, functional differences in amygdala response to facial expression challenge, and structural differences in the ventral prefrontal cortex. Roughly 40% of children with behavioral inhibition eventually develop SAD, and childhood behavioral inhibition is a primary predictor of SAD. Other components of SAD probably appear later in development, including social-evaluative concerns and coping skills deficits that contribute to functional impairment [44,45].

A bi-directional relationship exists between parenting style and childhood anxiety. Parenting styles of criticism, over-protection, over-control, and lack of warmth can create insecure attachment and risk for SAD. Likewise, temperamentally introverted and anxious children may shape and change parenting styles, with parents becoming over-protective or over-controlling [42]. Studies suggest that challenging parenting behavior (especially in fathers) may play a protective role in anxiety development in the most vulnerable children [46,47].

Early childhood anxiety disorders, especially separation anxiety and other phobias, are associated with elevated SAD risk in adulthood. SAD is highly comorbid with other anxiety disorders, mood disorders, and substance use disorders; substance abuse is often used to regulate anxiety symptoms and social skills [48].

Multiple social cues can develop the capacity to elicit anxiety-related symptoms. Learned escape and avoidance behaviors maintain anxiety, interfere with skill development, and can lead to functional impairment and disability over time. Similarly, safety behaviors, such as only entering social situations with a trusted companion, averting eye contact, and staying on the periphery of social gatherings, may maintain anxiety-related impairments. Selective attention to social cues of negative evaluation and internal cues supporting danger perception may develop [49,50].

Primary Prevention

Childhood presence of fearfulness and behavioral inhibition can lead to chronic, disabling SAD. Early recognition of childhood impairments and evidence-based treatment intervention may offset the SAD trajectory of persisting into and through adulthood. Educational-behavioral interventions involving older children/adolescents, parents, school staff, and healthcare providers have been found to reduce the development of social anxiety [51,52,53].

Clinical Course

SAD tends to run a chronic course of long duration, associated with substantial impairment of work productivity, and has a reported recovery rate of only 38% [54].

Specific Phobia

Epidemiology

Women are two to three times more likely than men to develop phobias, with the exception of blood-injection-injury phobia, which is evenly distributed by sex. Roughly 70% of individuals with specific phobia report more than one clinically relevant fear. Animals and heights are the most common stimuli, followed by flying, enclosed spaces, and blood-injection-injury. The average period of onset is 7 to 10 years of age, with declining probabilities of onset into later adulthood. Most animal phobias develop before 8 years of age [2,41,56]. The average age of treatment engagement is 31 years, although only 8% of persons with specific phobia are reported to seek treatment [56].

The odds of developing phobias are significantly less in Hispanic and Asian individuals and greater in white individuals. Animal fears are prevalent in Japan and Hong Kong [56,57].

Risk Factors

For specific phobias, familial concordance rates among first-degree relatives are moderate. The greatest heritability indices are found in animal and blood-injection-injury phobias [58,59,60].

Intense anxiety or unexpected panic responses in the presence of specific objects or situations can mark phobia onset but are not the sole causal route. Disgust, either alone or combined with fear, may trigger the onset and maintenance of animal (particularly spiders, snakes, and worms) or blood-injection-injury phobias. Onset can occur indirectly by observing others reacting fearfully. Some stimuli are more likely to induce phobias than others (e.g., animals vs. electrical outlets) through evolutionary threat relevance.

Phobia onset can be precipitated by relationship problems, relocation, employment loss, or economic difficulties. In addition, anxiety, mood, or substance use disorders can co-occur with or predate phobia onset. Substance use disorder can maintain phobic symptoms. Phobia symptoms in adolescence predict adult symptoms but are not a risk factor for developing other anxiety, mood, or substance use disorders.

Adult Separation Anxiety Disorder

Epidemiology

The lifetime prevalence of adult SEPAD is 6.6% in the general population, 12% to 40% in psychiatric clinic settings, and more than 75% among those seeking treatment at anxiety disorder clinics [61]. In adults with lifetime SEPAD, 22.5% have childhood age of onset that persisted into adulthood, while 77.5% had adult onset. Girls/women show higher overall prevalence than boys/men and substantially higher rates of childhood-onset SEPAD persisting into adulthood [62]. SEPAD and panic disorder are highly comorbid in clinical settings. Among adult patients with panic disorder, 53.2% were diagnosed with SEPAD. Patients with panic disorder and SEPAD (versus no SEPAD) were more commonly female and younger and showed higher rates of childhood SEPAD and greater lifetime prevalence of mood disorder spectrum symptoms [63].

Risk Factors

Children of adults with anxiety disorders have higher rates of anxiety disorders. Early, traumatic separation from attachment figures and a positive family history of anxiety or depressive disorders may also elevate risk of SEPAD, school phobia, and depressive-spectrum disorders during adolescence or adulthood. Early, traumatic separation can include prolonged severance of contact with the primary caregiver during the neonatal period; later sudden hospitalization; early loss of attachments from death or divorce; or an interactive pattern with an over-protective, needy, or depressed parent [64].

Clinical Course

In one study, children with SEPAD were 3.5 times more likely to later develop panic disorder and more than twice as likely to develop any anxiety disorder but did not significantly differ in later development of depression or substance use disorder. These findings were considered supportive of a developmental psychopathology model of anxiety disorders [65].

4. ETIOLOGY AND PATHOPHYSIOLOGY

ANXIETY DISORDERS IN GENERAL

Anxiety disorders are characterized by diverse neuroendocrine, neurotransmitter, and neuroanatomical disruptions, the result of interactions between multiple genetic, environmental, and social factors. Although each disorder may have unique features, this group shares some underlying pathophysiology.

Pathologic Alterations in Brain Structure and Function

Fear and anxiety are thought to involve two major brain circuits: the limbic system and the prefrontal cortex. In the limbic system, which consists of the amygdala, hippocampus, central nucleus of the amygdala, insular cortex, and cingulate cortex, emotion-processing brain structures generate primitive innate responses to simple, overtly threatening stimuli. Functions of limbic structures include processing emotionally important external stimuli and initiating behavioral responses; mediating expressions of fear, aggression, and defensive behavior; and forming and retrieving emotional and fear-related memories [66,67]. The prefrontal cortex, comprised of the orbitofrontal cortex and the prefrontal, ventromedial, and dorsomedial prefrontal cortex, dampens emotional responses to anxiety-inducing stimuli. The prefrontal cortex functions to regulate impulses, emotions, and behavior via inhibitory "top-down" control of emotional-processing structures; this works to control impulses and regulate mood [66,67].

Altered limbic and prefrontal cortex functioning characterize anxiety disorders, with amygdala hyper-responsivity to threatening stimuli and impaired ventromedial prefrontal contex inhibitory control over limbic-generated, anxiety-inducing signals, associated with aberrant communication and functional connectivity between the amygdala and the prefrontal cortex [67].

Narrowing brain region contribution, amygdala and insula hyperactivation contribute to anxiety disorders triggered by specific stimuli (e.g., panic disorder, specific phobia). The insula integrates sensory, emotional, and cognitive information through extensive connections between the lateral prefrontal cortex, ventromedial prefrontal cortex, orbitofrontal cortex, cingulate, amygdala, bed nucleus of the stria terminalis, and ventral striatum. Changes in the level of insula activation influence anxiety level [66].

Amygdala-medial prefrontal cortex functional connectivity shows a developmental trajectory, and early temperamental risk for anxiety is associated with disruption of these circuits. Aberrant amygdala-prefrontal cortex connectivity is found in patients with adult-onset anxiety disorders who showed childhood temperament risk factors but did not develop early-onset anxiety. This suggests aberrant connectivity is a lingering biomarker of risk [68].

Familial and Environmental Contribution

Persons with anxiety and mood disorders show a shared genetic predisposition, with specific manifestation the product of genetic and environmental interactions. A developmental dynamic pattern of genetic influence on individual differences in anxiety and depression symptoms is apparent. Genetic influence on psychopathology changes over the lifespan, with different developmental stages associated with a unique pattern of risk factors [67].

Significant early-life stress (e.g., maternal deprivation) may degrade prefrontal cortex functional connectivity with subcortical panic-generating circuits, elevating risks of anxiety disorders and other psychopathology. Many significant early-life stress events (e.g., child abuse, neglect, parental loss from death or abandonment) are receiving heightened attention as contributing factors to anxiety disorders and trauma pathology, as in PTSD. Previous childhood or adult trauma is considered a predisposing/contributing factor to panic disorder and SEPAD as well as major depressive disorder and PTSD that may be primary or comorbid with other anxiety disorders [69]. Aversive experiences can lead to complex behavioral adaptations, including increased levels of anxiety and fear generalization.

Alterations in Brain Transmitter Chemicals

Neurotransmitters allow communication between brain regions. Alterations in neurotransmitter systems implicated in anxiety disorder pathogenesis include the monoamines serotonin (5-hydroxytryptamine or 5-HT), norepinephrine, and dopamine. Aberrant limbic signaling is associated with decreased inhibitory signaling by gamma-amino-butyric acid (GABA) or increased excitatory neurotransmission by glutamate. Many other neurotransmitter systems participate in the modulation of fear and anxiety, including the neuropeptide substances P, N, and Y; corticotropin-releasing factor (CRF); and endocannabinoids. Abnormalities in these systems are associated with structural and functional alterations in specific brain areas, such as the amygdala, prefrontal cortex, locus coeruleus, and hippocampus, and represent the therapeutic targets of drug therapy [70].

Gene products that regulate monoamine signaling may be critical in facilitating antidepressant effect. Monoaminergic regulators include transmitter receptors; vesicular monoamine transporter, which packages monoamines into vesicles; oxytocin and vasopressin; transmitter-specific reuptake transporters, such as the serotonin transporter, norepinephrine transporter, and dopamine transporter; monoamine oxidase, which degrades monoamines; and catecholamine-O-methyltransferase, which degrades norepinephrine and dopamine [67]. However, the cause of anxiety disorders is not simply a deficiency of one neurotransmitter or excess of another. The networks governed by these transmitters are extensively inter-related, with multiple feedback mechanisms and complex receptor structures. This complexity contributes to unpredictable and sometimes paradoxical medication responses [70].

GENERALIZED ANXIETY DISORDER

Neuronal circuits implicated in GAD are distinct from panic disorder, likely involving much greater frontal and prefrontal lobe than amygdala involvement. GAD is characterized by abnormalities in frontal and limbic structures and in the connectivity between these regions. The most frequently implicated frontal regions are the prefrontal cortex and the anterior cingulate cortex; in the limbic region, the amygdala and possibly the hippocampus are involved. Structural abnormalities and decreased structural and functional connectivity between frontal and limbic regions have repeatedly been documented in GAD [71,72]. Functional neuroimaging suggests that GAD is characterized by inefficient biologic mechanisms associated with emotion regulation. Worry induction increases prefrontal cortex activation and decreases amygdala activity in patients with GAD and non-anxious controls, but unlike non-anxious subjects, patients with GAD are unable to normalize this neural activity afterward. The results from studies using tasks that require conflict monitoring and emotion regulation support a model of GAD characterized by hypoactivation in the prefrontal cortex and anterior cingulate cortex indicative of deficient "top-down" emotional control [73].

PANIC DISORDER

Core Pathophysiology

Genetic, developmental, hormonal, and environmental factors interact to impair the ventromedial prefrontal cortex's ability to inhibit panic impulses generated by limbic regions. This underlies the pathogenesis of the initial onset of unexpected panic attacks. This pathology is further compounded by recurrent panic attacks with repeated activation of panic-generating subcortical sites, leading to recruitment and plasticity within extended amygdala fear-hippocampus-cortical circuits. This in turn facilitates the development of situational and anticipated panic attacks and agoraphobia. Imaging studies have demonstrated ventromedial prefrontal cortex structural abnormalities in patients with panic disorder, reflecting the loss of inhibitory control over panic-generating sites. CBT enhances medial prefrontal cortex activity in subjects with anxiety disorders, which may explain its efficacy in treating panic disorder [69].

Other Pathophysiologic Models

In addition to ventromedial prefrontal cortex inhibition, other alterations in brain function have been suggested in panic disorder. Involvement of the central nuclei of the amygdala and activation of other fear centers in the thalamus, hypothalamus, and hippocampus may dysregulate respiratory control in the brainstem [74,75]. Additionally, it has been proposed that genetic risk variants partly drive fear network activity [76]. Exaggerated hypothalamic-pituitary-adrenal axis reactivity to environmental stimuli may be involved in panic disorder etiology [77,78].

In patients with panic disorder, CBT significantly reduces left interior frontal gyrus region activation, and reduced activity is correlated with reduced agoraphobic symptoms [79]. This reduced activation appears to be a specific substrate of CBT effects in patients with panic disorder/agoraphobia without comorbid depressive disorders [80]. Functional magnetic resonance imaging (MRI) shows that pre-treatment activation of the bilateral insula and left dorsolateral prefrontal cortex during threat processing is associated with rapid response to CBT [81].

AGORAPHOBIA

Patients with panic disorder and agoraphobia who are anticipating agoraphobia-specific stimuli have shown stronger region-specific activations in the bilateral ventral striatum and left insula versus controls. Patients processed these stimuli more intensively based on individual salience, and this activation is stronger than found in patients with panic disorder alone. Ventral striatum and insula hyperactivation when anticipating agoraphobia-specific situations may be a key neurofunction modulator in agoraphobia [82].

In patients with panic disorder/agoraphobia, fear conditioning has shown enhanced activation of the bilateral dorsal inferior frontal gyrus. Simple conditioning, safety signal processing, and anxiety sensitivity correlate with the extent of midbrain activation. These findings suggest alterations in "top-down" and "bottom-up" processes during fear conditioning, interpreted within a neural framework of defensive reactions that mediate threat through distal (forebrain) versus proximal (midbrain) brain structures. This network may play a key role in panic disorder pathogenesis [83].

Genetic polymorphism (variation) may influence panic disorder with agoraphobia treatment response. Serotonin transporter gene promoter polymorphism (5-HTTLPR) is conclusively linked to emotion regulation and related patterns of brain connectivity. During functional MRI imaging, the patient subgroup that showed inhibitory anterior cingulate cortex-amygdala coupling during fear conditioning predominantly possessed the L/L genotype of 5-HTTLPR polymorphism. This activation of inhibitory function, the normal function in non-anxious persons, suggests an intermediate connectivity phenotype that modulates response to exposure-based CBT [84].

Expanding on these results, patients with panic disorder/agoraphobia and the low-expression allele of 5-HTTLPR showed more favorable exposure therapy response than patients with other 5-HTTLPR genotypes. This genetic contribution to exposure therapy outcome implicates the serotonergic system as a response mediator to exposure treatments [85].

Balance System Abnormalities

Patients with panic disorder/agoraphobia have shown subclinical abnormalities in balance system function that seemed to influence agoraphobia severity and contribute to dizziness and disorientation symptoms in complex sensory environments (e.g., shopping malls, traffic, crowds). These patients also display greater balance control reliance on non-vestibular, proprioceptive, visually dependent cues and greater balance system reactivity to peripheral visual stimulation. These possibly link to a more active visual alarm system involving visual, vestibular, and limbic areas. Patients with panic disorder/agoraphobia also show high sensitivity to light or brightness stimuli with photophobic behavior and abnormal retinal and pupillary reflex responses possibly linked to serotonergic and/or dopaminergic dysfunction. This overall amplified sensitivity to environmental stimuli suggests that agoraphobia involves activation of complex systems beyond panic attack fear and behavioral avoidance, including emotional responses to destabilizing/distressing environmental stimuli and operant-learning avoidance of experiences that provoke this distress [86].

SOCIAL ANXIETY DISORDER

Patients with SAD have shown hyper(re)active limbic, frontal, and parietal brain regions involved in emotional and attentional processes. Compared to healthy subjects, patients with SAD display increased cortical thickness in frontal, parietal, and other brain areas. CBT treatment success and symptom improvement have been associated with changes in prefrontal regions involved in emotion regulation [87].

Persons with SAD and GAD share core features of persistent, debilitating focus on negative or potentially threatening experience. This negative affective bias is characterized by increased threat processing at the neural, psychologic, and behavioral levels, with engagement of the dorsal medial prefrontal cortex-amygdala circuit during aversive processing. Anxiety disorder subtypes frequently co-occur, and while abnormal activation of this neural circuitry that mediates bias toward threats is diagnosis-independent, it also represents a cardinal feature of SAD and GAD [88].

SAD pathophysiology includes heightened autonomic arousal to social cues and novelty. Fear processing appears mediated by the amygdala, in which neuroimaging studies show exaggerated activations with exposure to novel facial stimuli. Amygdala activation to novelty is also found in persons with a behavioral inhibition temperament. Other pathophysiologic models suggest that exaggerated hypothalamic-pituitary-adrenal axis reactivity to environmental stimuli may be involved in SAD [89,90,91,92].

SPECIFIC PHOBIA

Amygdala, anterior cingulate cortex, and insula hyperactivity is believed to be the underlying pathophysiology of specific phobia. Neuroimaging studies have shown increased amygdala activation with exposure to phobic-relevant cues, and heightened activity in thalamic, insula, and dorsal anterior cingulate cortex regions [93,94,95]. Meta-analyses suggest the left amygdala/globus pallidus, left insula, right thalamus, and cerebellum regions are all more active among patients with a phobia compared with controls when exposed to phobic-relevant stimuli. Acute, exaggerated parasympathetic nervous system activity with exposure to stimuli is thought to underlie the vasovagal syncope experienced by up to 80% of people with blood-injection-injury phobia [96]. Exposure-based therapy leads to deactivation in the right frontal cortex, limbic cortex, basal ganglia, and cerebellum, and increased activity in the thalamus [97].

ADULT SEPARATION ANXIETY DISORDER

SEPAD etiology is thought to arise during childhood by disrupted caregiving environments that promote greater hypothalamic/pituitary stress responsivity. Neuroimaging research has focused on brain circuitry that shows abnormal activity at single time points during anxiety from close attachments. The underlying neural circuitry that mediates separation-hypersensitive attachment includes subcortical areas (amygdala, hippocampus, striatum) and cortical limbic areas (insula, cingulate). Predisposing endophenotypes may interact with circuitry involved in attention, learning, and executive control (medial prefrontal cortex, superior temporal sulcus, and temporoparietal junction). With social interaction central to separation anxiety, neural circuitry involved in separation-sensitive social representations that predict danger when separation occurs may include the anterior temporal cortex [98]. SEPAD is associated with hypersensitivity to inhaled carbon dioxide, with a similar pattern to patients with panic disorder, suggesting SEPAD and panic disorder may share a common pathophysiologic basis [99,100].

5. CLINICAL AND DIAGNOSTIC FEATURES

As with other psychiatric disorders, the treatment of anxiety disorders is guided by conceptualization of the disorder and theoretical basis for disorder/treatment relationships. The understanding of anxiety disorders has changed over time with input of new evidence. In the United States, the DSM, published by the American Psychiatric Association, is the authoritative reference in defining and diagnosing psychiatric disorders. In the modern era, revised DSM editions have been published in 1980, 1994, 2000, and most recently in 2013 with the DSM-5.

To better reflect current thinking on anxiety disorders, the DSM-5 made several important changes from the 1994 DSM-IV and its 2000 text revision [32,101]. As noted, the chapter on anxiety disorders no longer includes OCD, PTSD, and acute stress disorder. New sections were added for these conditions: obsessive-compulsive and related disorders and trauma- and stressor-related disorders. Duration criteria for several anxiety disorders were extended to six months or longer to minimize overdiagnosis of transient symptoms, applied to all ages.

With agoraphobia, specific phobia, and SAD, the requirement that patients recognize their anxiety as excessive or unreasonable has been eliminated. This change was based on evidence that individuals with such disorders often overestimated the danger in "phobic" situations and that older individuals often misattributed "phobic" fears to aging. Instead, the anxiety must be out of proportion to the actual situational danger or threat, with consideration of cultural contextual factors [102].

The DSM-5 (and previous DSM editions) has been criticized for emphasis on reliability at the expense of diagnostic validity and for use of symptom-based diagnosis when symptoms alone may not best inform treatment selection. In response, the National Institute of Mental Health is developing the Research Domain Criteria, a new taxonomy for mental disorders that draws from genetics, neuroscience, and behavioral science [103]. Additionally, the DSM-5-TR, which was released in March 2022, includes the addition of prolonged grief disorder; the inclusion of symptom codes for suicidal behavior and nonsuicidal self-injury; refinement of criteria; and comprehensive literature-based updates to the text [104].

GENERALIZED ANXIETY DISORDER

GAD is characterized by excessive and inappropriate worrying that is persistent and not restricted to circumstance or situation. Patients have physical anxiety symptoms and key psychologic symptoms. GAD is often comorbid with major depressive disorder, panic disorder, phobia, health anxiety, and OCD [3]. The DSM-5 diagnostic criteria for GAD remain unchanged from previous editions [2,102]:

- Excessive anxiety and worry (apprehensive expectation) over a number of everyday concerns (e.g., school/work performance)

- Individual finds it difficult to control the worry

- Excessive anxiety and worry are associated with three or more of the following six symptoms, with at least some occurring more days than not for at least six months:

- Restlessness, feeling "on edge"

- Easily fatigued

- Difficulty concentrating

- Irritability

- Muscle tension

- Sleep disturbance (difficulty falling or staying asleep, restless sleep)

- The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning

- Symptoms not better explained by another mental disorder

- The disturbance is not attributable to the physiologic effects of a substance or another medical condition

Patients with GAD in the absence of current or lifetime comorbidity are uncommon, and patients with GAD typically present to primary care with comorbid depression, anxiety disorders, or substance use disorders. The presence of comorbidity complicates diagnosis and treatment [2].

PANIC ATTACKS

Panic attacks are abrupt, unexpected periods of intense fear or discomfort with multiple physical or psychologic anxiety symptoms, often peaking by 10 minutes and lasting around 30 to 45 minutes. Panic disorder is characterized by recurrent unexpected surges of severe anxiety (panic attacks). As noted, most patients develop a fear of having further panic attacks. The extent of anticipatory anxiety between attacks varies, and patients may alter their behavior to reduce the recurrence risk [2,3].

The essential features of panic attacks are unchanged in the DSM-5, but the complicated DSM-IV terminology for describing different types of panic attacks (i.e., situational-bound/cued, situational-predisposed, and unexpected/uncued) is replaced with unexpected and expected panic attacks. Panic attacks function as a marker and prognostic factor for severity of diagnosis, course, and comorbidity across an array of disorders, including but not limited to anxiety disorders. Hence, panic attack can be listed as a specifier, applicable to almost all DSM-5 disorders [102]. The DSM-5 criteria for panic attacks specify an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes and includes four or more of the following symptoms [2]:

- Palpitations, pounding heart, or accelerated heart rate

- Sweating

- Trembling or shaking

- Sensations of shortness of breath or smothering

- Feelings of choking

- Chest pain or discomfort

- Nausea or abdominal distress

- Feeling dizzy, unsteady, light-headed, or faint

- Chills or heat sensations

- Paresthesias (numbness or tingling sensations)

- Derealization (feelings of unreality) or depersonalization (being detached from oneself)

- Fear of losing control or going crazy

- Fear of dying

Physical symptoms predominate.

Panic attack is not classified as a mental disorder and does not have a diagnostic code. Instead, an attack can occur with other mental disorders, such as depressive and anxiety disorders, and also be extant with physical disorders. While panic attack is a specifier for both mental and physical disorders, the elements of panic attack are contained within the criteria for panic disorder, making the specifier unnecessary for that diagnosis.

PANIC DISORDER

Panic disorder in the DSM-5 has an added criterion for unexpected panic attacks. This implies that expected panic attacks exist and that anticipated, situationally triggered panic attacks are somehow less pathologic than spontaneous panic attacks. This assumption is challenged on the basis that panic attacks are inherently pathologic, regardless of context or lack thereof, and individuals with panic disorder can have unexpected and expected panic attacks [18,105]. Regardless, the DSM-5 diagnostic criteria for panic disorder require [2]:

- Recurrent unexpected panic attacks

- One or more of the attacks followed by at least one month of one or both of the following:

- Persistent concern or worry about additional panic attacks or their consequences

- Significant maladaptive change in behavior related to the attacks

The symptoms must not be attributable to substance-related effects, other medical conditions, or other psychiatric disorders. Up to 70% of patients report a history of at least one nocturnal panic attack [106]. Patients may present with symptoms suggestive of heightened sympathetic nervous system activity such as palpitations, increased systolic blood pressure, hyperventilation, sweating, or flushing. Other common symptoms include chest pain and discomfort, dizziness, and paraesthesias, while gastrointestinal symptoms such as nausea and vomiting are more common among men [2,107].

The severity of distress during panic attacks by patients with panic disorder with or without agoraphobia is increasingly seen as traumatic. Panic attacks are frequently experienced as life threatening, and patients with panic disorder can experience PTSD symptoms in relation to their panic attacks. Patients with panic disorder/agoraphobia or PTSD were found to relive their trauma or panic attacks with equal frequency, report comparable bodily reactions and distress associated with trauma or panic attack memories, and avoid trauma or panic attack reminders (i.e., places and things associated with trauma or panic attacks). Trauma-like symptoms surrounding panic attacks are common, and panic attacks may be processed similarly to trauma in PTSD [108].

Intense, disorganized recollections, a core symptom of PTSD, are thought to result from inadequate processing of trauma information. A first panic attack resembles trauma; both are unexpected, frightening, and subjectively life-threatening events. Like PTSD, panic disorder with agoraphobia also involves fear conditioning after the first event. Therefore, panic attack and trauma processing may be similar, with panic attack and PTSD trauma memories sharing the characteristics of reliving and disorganization. A comparison of panic memories and PTSD trauma memories did not find differences between groups in reliving intensity and disorganization levels, suggesting that panic attacks may affect information processing similarly to a traumatic event [109,110].

Patients with panic disorder exhibit considerably worse overall mental well-being than individuals with cancer, diabetes, heart disease, arthritis, hypertension, and other chronic physical conditions [111]. Current panic disorder is also related to worse quality of life and physical function and an elevated risk of attempting suicide [112]. These effects are similar to or greater than those associated with major depression. A study found that nearly 33% of these patients in primary care had seen three or more healthcare professionals and almost 20% had visited emergency departments [113]. Another study found that although the majority of individuals with panic disorder first present to the primary care setting, only 38% of those with panic disorder with agoraphobia and 24% of those with panic disorder without agoraphobia were receiving appropriate treatment, and the use of empirically supported interventions was rare [114].

AGORAPHOBIA

Agoraphobia is defined as the fear of panic attacks occurring in places or situations from which escape might be difficult or embarrassing or where help may not be available. These situations can include crowds, going outside the home, or using public transportation and are either avoided or endured with significant personal distress [3]. Agoraphobia can become severely disabling, and more than 33% of patients diagnosed with agoraphobia cannot endure leaving their home environment. Roughly 66% of patients with panic disorder develop agoraphobia [2].

In the DSM-5, agoraphobia was de-aggregated from panic disorder and is now classed as a separate diagnostic entity. The former DSM-IV diagnoses of panic disorder with agoraphobia, panic disorder without agoraphobia, and agoraphobia without history of panic disorder are now replaced by two diagnoses with separate criteria: panic disorder and agoraphobia. Co-occurring panic disorder and agoraphobia are also coded as two diagnoses. This change recognizes that a substantial number of individuals with agoraphobia do not experience panic symptoms, although clinical prevalence is much lower than community prevalence. The diagnostic criteria for agoraphobia are derived from the DSM-IV descriptors, with endorsement of fears from two or more agoraphobia situations now required to more effectively distinguish agoraphobia from specific phobias. The criteria for agoraphobia are also extended to concord with criteria sets for other anxiety disorders [102]. Diagnosis is based on marked fear or anxiety about two or more of the following [2]:

- Public transportation (e.g., traveling in planes, automobiles, buses, trains, ships)

- Open spaces (e.g., parking lots, market places, bridges)

- Being in shops, theatres, or stadiums

- Standing in line or being in a crowd

- Being outside of the home alone in other situations

The individual with agoraphobia fears or avoids these situations due to thoughts that escape might be difficult or help might not be available in the event of panic-like symptoms. These situations almost always provoke fear or anxiety and are actively avoided, require presence of a companion, or are endured with marked fear or anxiety. The fear or anxiety is out of proportion to the actual threat posed by an agoraphobic situation. The fear, anxiety, or avoidance is persistent, typically lasting at least six months, and causes clinically significant distress or impaired functioning. Avoidance symptoms in PTSD differ in that the situations avoided are trauma-associated, such as a park or street where an assault occurred or riding in a car after a motor vehicle accident [2].

Major personality dimensions, such as introversion and neuroticism, have been studied for contribution to the risk of developing agoraphobia and other anxiety disorders. Genetic factors that influence individual variation in extraversion and neuroticism have been found to account entirely for genetic liability in SAD and agoraphobia but not animal phobia, emphasizing the importance of both introversion (low extraversion) and neuroticism as risk factors [115]. Situational avoidance is the most disabling aspect of agoraphobia. Temperament is shown to influence agoraphobia severity, with introverted temperament significantly associated with the presence and severity of agoraphobic situational avoidance [9].

The longitudinal relationship between personality disorder traits and panic disorder (with or without agoraphobia) is important for understanding agoraphobia etiology. A large-scale study that assessed community-dwelling adults at baseline and again 12 to 15 years later found that after excluding participants with baseline panic attacks, baseline timidity with avoidant, dependent, and related traits predicted the onset of panic disorder or panic disorder with agoraphobia during the follow-up period. These results suggest that avoidant and dependent personality traits are predisposing factors, or markers of risk, for panic disorder or panic disorder with agoraphobia, and not simply epiphenomena [24]. Additionally, personality and temperament traits may be potentially related to poor treatment response [116].

SOCIAL ANXIETY DISORDER

SAD is often misconstrued as mere shyness but can be considerably disabling and produce much greater distress and more severe symptoms. SAD is characterized by a marked, persistent, and unreasonable fear of being observed or evaluated negatively by other people in social or performance situations, which is associated with physical and psychologic anxiety symptoms. Feared situations, such as speaking to unfamiliar people or eating in public, are either avoided or are endured with significant distress [3]. Social phobia has been renamed SAD to reflect a new, broader understanding of the condition in a variety of social situations.

Previously, social phobia was primarily diagnosed in patients reporting extreme discomfort or fear when performing in front of others. Research indicates this definition is too narrow, and SAD in the DSM-5 can be diagnosed based on patient response to a variety of social situations. For example, the patient may be so uncomfortable engaging in conversation he or she is unable to talk to others, especially strangers. A patient with anxiety regarding being observed may be unable to go out to dinner over fears of being watched while eating and drinking [102].

The defining features of SAD diagnosis remain unchanged. However, some modifications in require features have been made, including deletion of the requirement that individuals older than 18 years of age must recognize their fear or anxiety is excessive or unreasonable, and addition of a duration criterion. A more significant change is that the "generalized" specifier has been deleted and replaced with a "performance only" specifier. The DSM-IV-TR generalized specifier was problematic in that "fears include most social situations" was difficult to operationalize. Individuals who fear only performance situations (i.e., speaking or performing in front of an audience) appear to represent a distinct subset of SAD in terms of etiology, age at onset, physiologic response, and treatment response. The DSM-5 establishes the following diagnostic criteria for SAD [2]:

- Marked fear or anxiety about social situations in which the person may be exposed to scrutiny by others

- Fear that actions or showing anxiety symptoms will cause negative evaluation (e.g., embarrassment, humiliation) or offend others

- The social situation:

- Almost always provokes fear or anxiety

- Is actively avoided or endured with marked fear or anxiety

- The fear, anxiety, or avoidance:

- Is disproportionate to actual threat posed by the social situation

- Is persistent, typically at least six months

- Causes significant distress or functional impairment

- If another medical condition is present (e.g., stuttering, obesity), the disturbance is unrelated or out of proportion to it

If the fear is restricted to speaking or performing in public, diagnosis should specify "performance only." Other diagnostic features of SAD include [2]:

- Post-event processing: Tendency to replay social encounters in a negative, self-critical manner

- Attentional bias: Heightened attention to negative evaluative threat cues and lack of attention to positive or benign cues

- Social skills deficits: Poor eye contact, closed stance, quiet tone of speech, and difficulties initiating conversations

Patients with SAD highly inflate perceived social costs from committing hypothetical blunders. Accounting for much of this social cost inflation are concerns about revealing self-flaws and, in particular, concerns over appearing socially incompetent [117].

SPECIFIC PHOBIA

Specific, simple, or isolated phobia describes excessive or unreasonable fear in the presence of phobic stimuli, typically involving specific animals, objects, or situations (e.g., dentists, spiders, elevators, flying, seeing blood). Phobic stimuli are either avoided or are endured with significant personal distress [3]. This fear or anxiety must be markedly stronger than the actual threat of the object or situation (e.g., likelihood of being stuck on a well-maintained elevator) [2]. The core features and different types of specific phobia remain unchanged from the DSM-IV, but the requirement was removed that individuals older than 18 years of age must recognize their fear and anxiety as excessive or unreasonable. The duration requirement of longer than six months now applies to all ages [102].

Specific phobias can develop after a traumatic event or from witnessing traumatic events. The fear or anxiety happens every time the person is exposed to the stimulus and may include panic attack symptoms.

The median age of onset with specific phobia is 13 years [2]. According to the DSM-5, specific phobia is diagnosed when the following criteria are met [2]:

- Marked fear or anxiety about a specific object or situation (e.g., flying, seeing blood)

- Phobic object or situation almost always provokes immediate fear or anxiety and is actively avoided or endured with marked fear or anxiety

- Fear or anxiety out of proportion to the actual danger posed by the specific object or situation

- The fear, anxiety, or avoidance is persistent, typically at least six months

- Marked distress or functional impairment

Specific phobia subtypes are organized by phobia categories:

- Animal: Dogs, snakes, insects

- Natural environment: Storms, heights, dark

- Blood-injection-injury: Injections, blood draws, medical procedures

- Situational: Driving, flying, enclosed spaces

- Other: Choking, vomiting, clowns

Specific Phobia Coding

Approximately 75% of individuals diagnosed with specific phobia fear more than one object. In the past, when this occurred, more than one ICD-10 code was given [2]. However, the ICD-11 eliminated this component. When individuals experience panic attacks in response to their phobia, clinicians should add "with panic attacks" to the diagnosis.

SEPARATION ANXIETY DISORDER

Separation anxiety is a basic human fear and readily observable in children. Close attachment to nurturing parental figures during infancy is necessary for survival, and close relationships throughout life are an important source of support in times of stress. Separation anxiety does not vanish with development and maturation, but persistant separation anxiety in adulthood should not become an issue of clinical importance. Manifestations of pathologic separation anxiety include uncontrollable apprehension over losing important attachment figures, intense fears of leaving home or going out unaccompanied, and nightmares around themes of separation. Persons with SEPAD have substantial impairments in many aspects of community life, although not all individuals show problems in attachment [118,119].

Pathologic early childhood attachments can have far-reaching consequences in adulthood. These patients often have a grossly impaired ability to experience and internalize positive relationships or to develop mental capacities for self-soothing, anxiety tolerance, affect modulation, and individuation. Adults with SEPAD feel unable to function in the absence of a mother surrogate. Separation anxiety has long been considered the distal antecedent to panic disorder. In adults, separation anxiety may reflect excessive activation of fear circuits in response to separation and over-activation of reward circuits with reunion, likely the result of abnormalities or deficits in underlying social representation and cognition systems [98].

SEPAD is characterized by fear or anxiety concerning separation from those to whom an individual is attached. Common features include excessive distress when experiencing or anticipating separation from home, and persistent and excessive worries about potential harms to attachment figures or untoward events that might result in separation [3].

The core features of SEPAD are mostly unchanged from DSM-IV, but the wording is modified to more adequately represent SEPAD expression in adulthood. For example, attachment figures may include the children of adults, and avoidance behaviors may occur in the workplace as well as at school. Diagnostic criteria no longer require childhood history of SEPAD or onset before 18 years of age, because a substantial number of adults report onset later in life. Adults with the condition include those with adult-onset and those with childhood onset and symptom persistence into adulthood. A duration criterion of six months or longer was added [64,102]. For a diagnosis of SEPAD, the persistent and excessive anxiety related to separation or impending separation from a major attachment figure (e.g., spouse, close family member) must be evidenced by at least three of the following criteria [2]:

- Recurrent excessive distress when anticipating or experiencing separation

- Persistent and excessive worry about losing a major attachment figure or about possible harm to him or her

- Persistent and excessive worry about experiencing an untoward event (e.g., getting lost, kidnapped, into an accident) that causes separation from a major attachment figure

- Persistent reluctance or refusal to go out, away from home, to school, to work, or elsewhere because of fear of separation

- Persistent and excessive fear of or reluctance about being alone or without a major attachment figure

- Persistent reluctance or refusal to sleep away from home or to go to sleep without major attachment figure near

- Repeated nightmares involving the theme of separation

- Repeated complaints of physical symptoms (e.g., headaches, stomachaches, nausea, vomiting) when separation occurs or is anticipated

To meet the criteria for this disorder, the symptoms must cause clinically significant distress or impairment in social, academic, occupational, or other important areas of functioning. Symptoms must not be better explained by another mental disorder (e.g., delusions or hallucinations concerning separation in psychotic disorders); refusal to go outside without a trusted companion (as in agoraphobia); worries about ill health or other harm befalling significant others (as with generalized anxiety disorder); or concerns about having an illness (as in illness anxiety disorder) [2]. Panic attacks commonly occur with youth and adult SEPAD.

Differential Diagnosis

In the past, adult SEPAD was often diagnosed as panic disorder, and it shares features with other psychiatric conditions. Excessive attachment toward others is a feature of a dependent personality, and avoidance behavior is a predominant feature of agoraphobia. With SEPAD, the focus involves key attachment figures, unlike dependent personality disorder, which is more indiscriminate. Panic and phobic-like behavior in SEPAD is specific to fears of separation from, or harm to, attachment figures and not spontaneous or triggered by other factors. Social and occupational function is frequently impaired, but individuals with SEPAD do not show impaired function in family life compared to controls and often function well in family environments. Borderline personality disorder differs by pervasive mood and relationship instability uncharacteristic of SEPAD [61].

A study exploring whether SEPAD in patients with panic disorder/agoraphobia was a manifestation of anxious attachment, a form of agoraphobia, or a specific condition with clinically significant consequences found that patients with SEPAD had greater panic symptom severity and quality of life impairment than those without separation anxiety. A greater rate of symptoms suggestive of anxious attachment was found among patients with panic disorder and SEPAD versus those without SEPAD. However, the relationship between SEPAD and attachment style was weak, and SEPAD occurred in some patients who reported secure attachment style. There was also little evidence SEPAD was a form of agoraphobia. SEPAD was found to be a distinct condition associated with impairment in quality of life and should be better recognized and treated in patients with comorbid panic disorder [119].

SELECTIVE MUTISM

Separation anxiety disorder and selective mutism were included in the DSM-IV section Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence, but were classed as anxiety disorders and moved to the anxiety disorder section in the DSM-5 [102]. The majority of children with selective mutism are anxious, and while selective mutism is now considered an anxiety disorder, it remains a disorder primarily of childhood and is beyond the scope of this course [102].

6. ASSESSMENT

Effective anxiety disorder treatment relies on accurate diagnosis. Diagnosis is made when diagnostic criteria for a specific disorder are established and symptoms cannot be better explained by the effects of the patient's other medical conditions, medications, substances, or pre-existing mental disorders [2].

Evidence Based Practice Recommendation

The American Psychiatric Association recommends that the initial psychiatric evaluation of a patient include assessment of anxiety and panic attacks.

https://psychiatryonline.org/doi/10.1176/appi.books.9780890426760.pe02

Last Accessed: April 27, 2025

Strength of Recommendation/Level of Evidence: 1C (Recommendation with low confidence that the evidence reflects the true effect)

The management of patients presenting with anxiety symptoms should initially follow the flow of these five components [120]:

1. Screen for anxiety and related symptoms.

2. Consider differential diagnosis and severity, impairment, and comorbidity.

3. Identify specific or multiple anxiety disorder(s), often in consultation with trained specialists using structured interview techniques.

4. Initiate psychologic and/or pharmacologic treatment.

5. Perform follow-up.

Evidence suggests that in primary care, patient tendency to ascribe pathologic anxiety symptoms to physical causes contributes to high rates of missed diagnoses and the misdiagnosis of GAD and panic disorder. To offset this requires a broad differential and caution to identify confounding variables and comorbid conditions [121].

SCREENING FOR ANXIETY DISORDERS IN THE PRIMARY CARE SETTING

Lifetime prevalence of anxiety in the general population is estimated 30%, and anxiety disorders are among the most common mental health syndromes encountered in general medical practice. In a study of 965 randomly selected patients across 15 primary care clinics, 19.5% had at least one anxiety disorder; of the four common disorders assessed in the study, 8.6% of patients had PTSD, 7.6% had GAD, 6.8% panic disorder, and 6.2% had SAD [55]. Each disorder was associated with functional impairment that became more substantial as the number of co-occurring anxiety disorders increased. The GAD-7 diagnostic scale was seen to perform well as screening tool for all four anxiety disorders studied [55]. Other studies in primary care settings have found that the prevalence of co-occurring GAD is 68% for patients with panic disorder and 38.6% for those with a diagnosis of major depression [34,122].

The American Academy of Family Physicians and other physician groups have noted that rates of failed diagnosis of anxiety disorder and misdiagnosis of GAD and panic disorder are high in primary care settings, in part because of time constraints, lack of a defining presentation, and the resemblance of symptoms to common somatic disorders [54,55,121]. Primary care clinicians have noted that patients with somatic complaints, sleep disturbance, or psychosocial distress are often unaware that anxiety disorder is the root cause of their symptoms. A study of older patients with GAD found that accurate referencing of symptoms to the onset of anxiety was low (34%), as was the rate of anxiety disorder diagnosis (9%), despite a high level of healthcare utilization [123]. In the current managed care environment, anxiety is usually treated in primary care settings, and given the increasing time constraints imposed on primary care providers, it is not surprising that anxiety disorders are under-recognized and undertreated [70].

Many patients with anxiety and depressive symptoms do not seek help, and in those who do, anxiety symptoms are often not the presenting complaint. Patients and providers often have difficulty initiating discussion of emotional problems and distress. Primary care providers with greater sensitivity to nonverbal communications have been found more likely to detect and diagnose anxiety, while those tending to "blame" patients make fewer psychologic inquiries and are less accurate in detecting distress [3,124].

SCREENING TOOLS

The American Academy of Family Physicians suggests using diagnostic screening and monitoring scales, such as the Generalized Anxiety Disorder 7-Item Scale (GAD-7) and the Severity Measure for Panic Disorder, to aide in diagnosis and monitor response to treatment [121]. The Primary Care Evaluation of Mental Disorders (PRIME-MD) was originally developed as a physician-administered screening tool for identifying mental disorders. It contained 12 different mental health disorder modules and required lengthy administration time, limiting its clinical usefulness [133]. Developers of the PRIME-MD subsequently crafted a self-administered version of the PRIME-MD, the Patient Health Questionnaire (PHQ). The PHQ includes mood, anxiety, alcohol, eating, and somatoform modules as covered in the original PRIME-MD [134]. In addition to its value in identifying anxiety and mood disorders, including depressive symptoms, panic disorder and other anxiety disorders, the PRIME-MD-PHQ is efficient for use in primary care settings; most clinicians can analyze the results in three minutes or less [134].

The GAD-7 scale is a brief, validated screening tool specifically designed to identify anxiety disorders. The patient with symptoms is asked to rate severity and frequency of occurrence over the previous two weeks. Each item is rated on a four-point scale (0 to 3), yielding a maximum score of 21. A score of 10 or greater is the cut-off point for diagnosis of anxiety disorder (sensitivity 87%; specificity 82%) [135]. The degree of distress/functional impairment varies directly with the total score. The GAD-7 scale is available online at https://adaa.org/sites/default/files/GAD-7_Anxiety-updated_0.pdf.

In theory, patients and providers should benefit from screening tools designed to detect anxiety disorders. However, regular use may require adjustments to practice structure, and it is uncertain to what extent routine screening (of all patients) and disclosure to "screened positive" patients improves clinical outcomes.

In 2022, the U.S. Preventive Services Task Force recommended screening all children older than 7 years of age for anxiety [349]. Primary care providers can improve anxiety detection skills by first acknowledging patients may be reluctant to discuss psychological and emotional distress early in the physician-patient relationship. This can be offset with greater sensitivity to nonverbal expression of distress and by allowing repeated patient encounters and deepening understanding to develop the rapport required for exploring the presence and depth of anxiety symptoms [3].

Healthcare providers can create a more comfortable environment for a patient of another culture by acknowledging the impact of culture and cultural differences on physical and mental health. The nature and expression of symptoms are influenced by cultural factors, and in some cultures anxiety is expressed through a heavy focus on somatic symptoms, such as musculoskeletal pain and fatigue. Providers may consider starting the clinical encounter by exploring such symptoms patiently and in greater depth. The concept of anxiety also varies across cultures, and patients may not seek medical treatment unless symptoms manifest as psychosis, conversion disorders, or significant physical ailments.

IDENTIFYING PATIENTS WHO REQUIRE TREATMENT

The potential chronicity and disability of anxiety disorders indicates that most patients meeting diagnostic criteria should receive psychologic and/or pharmacologic treatment. Treatment selection is guided by severity, duration, patient distress and impairment, the presence of depression and other comorbid disorders, previous treatment response or contraindication, patient preference, provider experience, and treatment availability [3,126]. However, many patients with anxiety disorder who could benefit do not receive treatment; fewer than one in five receive appropriate medication, improving to one in three for patients with comorbid depression [127].

Treatment quality is improved with accurate diagnosis and regular monitoring. Inadequate dosage and treatment duration were found common in the primary care treatment of patients with panic disorder, but improved outcomes were more likely with enhanced patient education and follow-up contact than with physician education [3,128]. Worth noting is the contrast between concerning media reports of medicalization and inappropriate psychotropic prescribing for "normal" anxiety, shyness, or situational stress, and the repeated findings in primary care studies of inadequate or no prescribing and a high level of unmet patient need [3].

General Use Screening Questions

Clinical care providers may consider incorporating a simple question format into the routine clinical encounter, asking patients if they have recently felt excessively nervous, anxious, or on edge, and if worrying is ever uncontrollable or otherwise distressing. The DSM-5-TR suggests the following questions for identifying anxiety-related symptoms [2]:

During the past two weeks, how much have you been bothered by the following problems:

- Feeling nervous, anxious, frightened, worried, or on edge

- Feeling panic or being frightened

- Avoiding situations that make you anxious

A positive history of anxiety symptoms should be explored with screening questions for specific anxiety disorders.

Screening for Specific Anxiety Disorders

In addition to the general questions suggested for all patients with complaints of anxiety, it is important to inquire regarding disorder-specific symptoms. This will allow for more specialized assessment and diagnosis.

Generalized Anxiety Disorder

- During the past four weeks, have you been bothered by feeling worried, tense, or anxious most of the time?

- Are you frequently tense or irritable, or do you have trouble sleeping?

If the patient acknowledges in the positive, then follow with the GAD-7 screening tool.

Panic Disorder

- Do you have sudden, unexpected episodes/spells/attacks of intense fear or discomfort? If yes, then continue.

- Have you had more than one of these attacks?

- Does the worst part of these attacks usually peak within several minutes?

- Have you ever had one of these attacks and spent the next month or more living in fear of having another attack or worrying about the consequences of the attack?

Agoraphobia

- Do you avoid certain situations or places where panic attacks have occurred or may occur?

Social Anxiety Disorder

- Does fear of embarrassment cause you to avoid doing things or speaking to people?

- Do you avoid activities where you are, or may be, the center of attention?

- Is being embarrassed or looking stupid among your worst fears?

Specific Phobia

- Do you feel intense anxiety or fear when confronted by certain animals, objects, or situations?

- Are you avoiding these animals, objects, or situations because of your fear?

- In what ways has this anxiety or fear interfered with your life?

- How would you react if you were exposed to the animal, object, or situation right now?

- Have you ever fainted or almost fainted around blood, injuries, or needles?

Separation Anxiety Disorder

- Do you feel anxious, fearful, or upset thinking about separation, or being away from, your (spouse, partner, primary support person)?

Evidence Based Practice Recommendation

If an adult with possible social anxiety disorder finds it difficult or distressing to attend an initial appointment in person, the National Collaborating Centre for Mental Health recommends making the first contact by phone or Internet, but aiming to see the person face to face for subsequent assessments and treatment.

https://www.nice.org.uk/guidance/cg159/resources/social-anxiety-disorder-recognition-assessment-and-treatment-pdf-35109639699397

Last Accessed: April 27, 2025

Level of Evidence: Expert Opinion/Consensus Statement

Positive responses to screening questions is followed by a formal assessment.

PATIENT HISTORY

A patient history is performed to assess patient and family history for clinically relevant information. Patients should be assessed for onset of anxiety symptoms, duration (remission or persistent), association with life events or trauma, level of distress, and effect on current functioning (academic, occupational, relationships, leisure activities, role functioning). Also inquire about a personal history of physical or emotional trauma, anxiety or mood disorders, medications or therapies, and patient response. Family history should be assessed for anxiety, mood, and substance use disorders [2]. Screening for depression is very important, given its high comorbidity rate and associated risk of suicidal behavior [129].

A thorough list of prescribed, over-the-counter, and herbal medications should be obtained [2]. Furthermore, substance use should be assessed, including:

- Current and past tobacco use

- Current and past alcohol use

- Current and past use of illicit drugs (e.g., cannabis, cocaine, heroin, methamphetamine)

- Current and past use of pharmaceutical drugs (e.g., opioids, stimulants, benzodiazepines)

- Current and past use of "legal high" or novel drugs (e.g., club drugs, "bath salts," "synthetic cannabis")

- Having been told their substance use is a problem

- Having received counseling or treatment for a substance use problem

PHYSICAL EXAMINATION

The physical examination of most patients evaluated for anxiety is usually unrevealing but necessary in order to assess the possibility of primary disorders and conditions associated with anxiety. Careful measurement and recording of resting pulse rate and blood pressure (including postural effect) are important. Patients may be uncomfortable discussing their anxiety, but physical signs of heightened sympathetic nervous system activity (e.g., tachycardia, hyperventilation, sweating, flushing) are absent in the context of a reassuring clinical encounter (excepting acute examination of a patient following panic attack). Routine examination of adolescents and young adults with recent-onset anxiety should prompt careful assessment for signs of hyperthyroidism (e.g., the stare of early proptosis; fine tremor of outstretched hands; tachycardia; brisk deep tendon reflexes). Patients with observed (or history of) vasovagal fainting, especially those suspected of specific phobia disorder, should be assessed for other medical conditions associated with fainting risk (including blood glucose levels and orthostatic hypotension) [2].

Diagnosis is made through self-report, clinical interview, and behavioral observation of impairments in personal, social, or occupational domains; no laboratory testing is necessary. Several empirically validated self-report questionnaires are available to assess baseline functioning and track treatment response. Assessment of anxiety symptoms and associated impairments optimally includes key informant interviews with family members or close friends [2].

DIFFERENTIAL DIAGNOSIS

Differential diagnosis is performed to eliminate potential underlying causes that, if present, would better account for patient anxiety complaints. As noted, screening for other anxiety, mood, and substance-related disorders should be routinely conducted due to high comorbidity rates.

Other Mental Disorders

Evidence Based Practice Recommendation

When assessing an adult with possible social anxiety disorder, the National Collaborating Centre for Mental Health recommends that clinicians be aware of comorbid disorders, including avoidant personality disorder, alcohol and substance misuse, mood disorders, other anxiety disorders, psychosis, and autism.

https://www.nice.org.uk/guidance/cg159/resources/social-anxiety-disorder-recognition-assessment-and-treatment-pdf-35109639699397

Last Accessed: April 27, 2025

Level of Evidence: Expert Opinion/Consensus Statement

To confirm or rule out the presence of comorbid anxiety or related disorders, determine the nature and focus of patient apprehension/anxiety. It may be [2]:

- Diffuse, non-specific (GAD)

- Discrete, intense anxiety episodes (panic disorder)

- Fear of one's panic attacks and avoidance of places or situations where they may occur (agoraphobia)

- Embarrassment in public (SAD)

- Fear of specific objects or situations (specific phobia)

- Attachment figure separation (separation anxiety)

- Contamination (OCD)

- Weight gain (anorexia nervosa)

- Multiple physical complaints (somatization disorder)

- Serious illness (hypochondriasis)

- Strictly trauma-related (PTSD)

A diagnosis of SAD should rule out avoidant personality disorder. Some symptoms of avoidant personality disorder resemble SAD, such as a pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation. However, avoidant personality disorder is distinguished by non-social avoidance that extends to novel situations and positive affect. Roughly 36% of patients with SAD are comorbid for avoidant personality disorder, and some believe avoidant personality disorder is a more severe variant of SAD [130,131].

Medication or Substance Use

It is important to rule out medication side effects as the underlying cause of anxiety by obtaining a complete list of currently used prescribed, over-the-counter, and herbal medications. Examples of common medications with anxiety side effects are asthma medications (e.g., albuterol, theophylline), herbal medicines (St. John's wort, ginseng, ma huang), corticosteroids, and antidepressants [2].

Patients should also be assessed for current use of alcohol, nicotine, stimulants, benzodiazepines, and opioids, because the direct, adverse, or withdrawal effects can mimic anxiety or panic symptoms [132]. Illicit or illicitly used drugs with acute effects most commonly associated with anxiety include cocaine, methamphetamine, prescription amphetamines (e.g., lisdexamfetamine), methylphenidate, and MDMA ("Ecstasy") [2]. Caffeine may also provoke anxiety in sensitive patients, including those with anxiety disorders [28]. Alcohol use disorder is highly prevalent among persons with anxiety disorders. Acute anxiety relief may powerfully reinforce alcohol use, but frequent or heavy drinking commonly exacerbates the anxiety disorder symptoms. When these two disorders co-occur, treatment can be complicated.

Medical Conditions

Careful history taking and physical examination are warranted for all patients to rule out medical causes of anxiety symptoms. Conditions that can mimic or cause anxiety complaints include hyperthyroidism and hypothyroidism, asthma, cardiac arrhythmias, pheochromocytoma, and temporal lobe epilepsy. As noted, screening for depression is very important, given its high comorbidity rate and associated risk of suicidal behavior [129].

Laboratory Tests and Imaging

Although usually negative in the absence of other suggestive evidence, laboratory testing or imaging studies may be indicated to help rule out medical cause. For example, a routine blood panel with thyroid-stimulating hormone and blood glucose levels may help to identify or rule out conditions such as hyperthyroidism or hypoglycemia that may be responsible for intense, persistent anxiety and panic. Toxicology screening may also be indicated to determine whether illicit substances are contributing to the clinical presentation. An electrocardiogram is required in all patients presenting with chest pain (to exclude cardiac causes), and pulmonary function tests are used to rule out pulmonary disease in patients with shortness of breath. It is important to note that cardiopulmonary disorders can co-occur with anxiety disorders [2].

7. GENERAL TREATMENT CONSIDERATIONS

Information in this section is derived from published research, meta-analyses, and clinical practice guidelines. The most recent anxiety disorder guideline (on panic disorder) by the American Psychiatric Association was published in 2009. The 2014 Anxiety Disorders Association of Canada (ADAC) guidelines are the most recent and comprehensive North American publication and are emphasized accordingly [120]. Successful treatment requires tailoring options to individuals and may often include a combination of modalities [121]. When selecting a treatment regimen, clinicians should consider current and prior treatments, comorbid conditions, age, cost of and access to care, and patient preference [350].

The two recommended first-line modes of therapy for anxiety disorder are psychotherapy (principally CBT) and pharmacotherapy. CBT, which includes an exposure therapy component when there are triggered episodes (e.g., SAD, specific phobia), is designed to work through maladaptive beliefs and avoidance behaviors that reinforce pathology surrounding fear-eliciting stimuli. CBT with some variant of exposure is the first-line psychotherapy approach for most adult patients and all childhood cases of anxiety disorder. Selecting CBT as treatment option has two limitations: it requires patient willingness to engage in therapy and the availability of well-trained therapists. Pharmacotherapy is also considered a first-line treatment option for anxiety disorders. While many medications have received FDA approval to treat anxiety, antidepressants have proven to be the most effective. Either a selective serotonin reuptake inhibitor (SSRI) or serotonin-norepinephrine reuptake inhibitor (SNRI) is recommended initial treatment of GAD, SAD, and panic disorder [350]. Benzodiazepines, which once served as a first-line option, are now best reserved for short-term use or as a supplement to the primary treatment regimen.

Advances in anxiety disorder neuroscience have increasingly pointed to the necessary role of fear extinction learning (through exposure therapy) in addressing underlying pathophysiology. While efficacy is shown with CBT and exposure, patients can have difficulty with the demanding and exhausting therapy process, and many who do manage to complete therapy respond partially and relapse with time. Efforts to improve CBT/exposure outcomes have led to the investigation of augmenting agents. In contrast to standard anti-anxiety drugs, these agents are not anxiolytic but are used to promote and accelerate long-term adaptive changes in brain function initiated by successful exposures [137].

Any review of treatment efficacy for anxiety disorders, and pharmacotherapy in particular, requires a disclaimer. Most treatment outcomes were based on studies using methodologies that excluded those with additional anxiety disorders and comorbid psychiatric or medical disorders. Patients seeking care for anxiety problems in primary care and other real-world settings often differ from carefully screened study participants. The extent that efficacy, response, and remission rates reported in the published research generalize to typically more complex clinic patients has been questioned [138].

Treatment refusal and attrition are significant problems. Patients with anxiety disorders show treatment refusal rates of 25% to 30% and treatment dropout rates of 10% to 82% [139]. Treatment dropout is very high in exposure therapy, as patients repeatedly confront (with graded intensity) the situations or objects that trigger their greatest fear or panic response. The intensity of distress during exposure can overwhelm patients, and with avoidance the hallmark feature of most anxiety disorders, attrition is significant [2,139]. Attrition can interfere with evaluating treatment efficacy (or the lack thereof), and unless explicit in study reporting, can be misleading. Attrition is also a clear concern in the clinical care of patients with anxiety.

PREDICTORS OF WORSE TREATMENT RESPONSE AND OUTCOMES

SEPAD

Severe forms of SEPAD are associated with a pervasive negative influence on treatment response. Comorbid SEPAD is highly correlated with poor treatment response and patient outcomes across a range of anxiety and mood disorders. SEPAD negatively impacts response to major depression treatment and is linked to worse symptom chronicity and quality of life. SEPAD decreases CBT response and predicts worse outcomes in patients treated for panic disorder, GAD, or SAD. SEPAD also predicts nonresponse to selective serotonin re-uptake inhibitors (SSRIs) or tricyclic antidepressants (TCAs) in patients with panic disorder with agoraphobia [98,140].

Chronic Pain

Uncontrolled pain is also increasingly recognized to negatively impact anxiety disorder treatment outcomes. In primary care patients with a GAD or panic disorder diagnosis treated for severe anxiety and followed for one year, patients with moderate or greater pain levels were found to show significantly lower rates of clinical improvement [141]. A cohort of 1,122 individuals with remitted anxiety or depressive disorders were followed up to four years, and pain (but not chronic disease) was associated with recurrence during follow-up [142].

Social Drinking

Problematic, excessive drinking clearly disrupts treatment response, but social drinking can also aggravate panic disorder and probably other anxiety syndromes. The short-acting effects of alcohol wear off rapidly, followed by rebound to a state of hyper-excitability that may be more problematic for patients with anxiety. This can occur with one to two drinks in some patients, who often do not even consider this a contributing factor to their anxiety complaint. Explaining the simple physiology of rebound excitation after profound neuronal inhibition will often convince patients that alcohol may be sensitizing the neural circuits subserving their anxiety and that a trial period of abstinence is indicated [28].

Other Anxiety Disorders

Highly symptomatic panic inhibits benefit from interpersonal psychotherapy, either alone or combined with SSRIs. The presence of any anxiety disorder impairs response to treatment of comorbid major depression [98]. Patients with major depressive disorder and a comorbid anxiety disorder demonstrate longer time to recovery and greater risk of early treatment termination. Patients with comorbid anxiety and depressive disorders generally have worse outcomes than patients with either disorder alone. Patients with comorbid GAD and major depression are significantly more likely to remain symptomatic than those with depression or GAD alone [143]. When anxiety symptoms are present within a dominant depressive disorder, antidepressant drugs are often effective in reducing anxiety [144]. However, depression that follows or is comorbid with an anxiety disorder usually indicates greater severity and worse prognosis [145].

Among treatment-seeking patients with panic disorder, SAD, or GAD followed over two years, symptom changes in GAD were most specifically related to changes in impairment, suggesting that treatment of patients with multiple anxiety disorders should initially focus on GAD symptoms or employ trans-diagnostic modalities [146].

Patients with panic disorder/agoraphobia who display the low-expression allele of the serotonin transporter gene promoter show more favorable exposure therapy response than patients with other 5-HTTLPR genotypes. This genetic contribution to exposure therapy outcome implicates the serotonergic system as a response mediator to exposure treatments [85].

OVERLAPPING PSYCHOLOGIC AND DRUG THERAPY MECHANISMS

Emerging evidence is challenging conventional wisdom by showing that antidepressant therapeutic action may begin with the first dose and that psychologic and drug therapy approaches share common mechanisms. In one study, a single dose of norepinephrine reuptake inhibitor reboxetine reduced negative affective bias in depression by increasing recognition of positive facial expressions and enhancing memory for positive vs. negative information [147]. These early changes in emotional processing reflect changes in frontolimbic circuitry involved in detection and response to biologically salient information. These findings were replicated following seven days of escitalopram treatment [148]. Changes in neurocognitive processing that precede clinical improvement predict later antidepressant response [149]. A 2013 study found that the initial session of CBT administered for panic disorder/agoraphobia led to reduced threat processing the following day, with the magnitude of early effect predictive of the therapeutic response after four weeks [150]. These findings challenge assumptions that psychologic therapies address conscious thought processes before automatic information processing and suggest a greater similarity between early effects of pharmacologic and psychologic treatments for anxiety than previously thought [149].

PSYCHOTHERAPIES: OVERVIEW

Psychologic treatments play an integral role in the management of anxiety disorders, and efficacy is established for several modalities. Most broadly effective are exposure-based and other CBT approaches. When choosing psychologic treatments for individual patients, the forms of therapy developed for the specific anxiety disorder should be used first.

Cognitive and Behavioral Approaches

Psychotherapy can be as effective as medication for GAD and panic disorder, and CBT has the best level of evidence [121]. CBT is the most extensively evaluated psychologic therapy in anxiety disorders and contains elements of cognitive and behavioral therapy approaches.

Behavior therapy consists of using exposure to modify dysfunctional behaviors that may contribute to the development and persistence of psychologic symptoms [151]. Cognitive therapy involves cognitive restructuring, a psychotherapeutic process of learning to identify and modify irrational or maladaptive thoughts using strategies such as Socratic questioning, thought recording, and guided imagery [34].

CBT is not a single treatment approach but a process that addresses factors that caused and maintain patient anxiety symptoms. The classic CBT approach involves disorder-specific treatment protocols that target the symptoms and the cognitive, behavioral, and emotional vulnerabilities that underlie development and maintenance of each disorder. This approach reflects the assumption that each form of psychopathology has a distinct cognitive profile, to which CBT is tailored accordingly. Disorder-specific CBT is the standard of care for anxiety and depressive disorders [152]. However, there are common components of CBT used in anxiety disorders (Table 2) [120].

Table 2: COMMON COMPONENTS OF CBT USED IN THE TREATMENT OF ANXIETY DISORDERS

Cognitive Strategies

Cognitive restructuring, behavioral experiments, and related strategies target exaggerated perception of danger (e.g., fear of negative evaluation in SAD).

Therapy provides corrective information regarding the level of threat and can also target self-efficacy beliefs.

Arousal Management

Relaxation and breathing control skills help control increased anxiety levels.

Exposure

Encourage patients to face fears.

Patients learn corrective information through experience.

Extinction of fear occurs through repeated exposure.

Successful coping enhances self-efficacy.

Safety Response Inhibition and Surrender of Safety Signals

Patients wean from and relinquish use of their usual anxiety-reducing safety signals and behaviors (e.g., presence of a companion, need for reassurance, knowing the location of nearest exit or toilet), which decreases negative reinforcement.

Coping with anxiety without using anxiety-reducing behavior enhances self-efficacy, allowing patients to learn adaptive self-efficacy beliefs.

Source: [120]

There is some debate regarding whether the efficacy of CBT that targets common underlying factors would be comparable to standard diagnosis-tailored CBT. Support for CBT that addresses common underlying factors includes frequent comorbidities in anxious patients, such as major depressive disorder, which some studies found present in close to 50% of patients with anxiety [153]. The frequent co-presence of mood and anxiety disorders, substantial overlap in dimensional symptom ratings, and extensive evidence of shared vulnerability factors enabled identification of common underlying factors that represent targets for CBT. These include [152]:

- Motivational enhancement

- Psychoeducation and understanding emotions

- Emotional awareness training

- Cognitive reappraisal

- Attenuation of emotional and behavioral avoidance

- Awareness and tolerance of physical sensations

- Interoceptive and situational exposure

- Relapse prevention

Psychotherapy and drug therapy show similar efficacy in most anxiety disorders. There is variability and conflicting data on outcome measures from studies of psychotherapy in combination with drug therapy; current evidence does not support routine combination therapy as initial treatment. However, patients lacking response to either CBT or drug therapy may benefit from adding the other modality [120].

Delivery of effective CBT is versatile. Individual or group delivery is effective in most anxiety disorders. A variety of self-directed or minimal intervention formats (e.g., bibliotherapy/self-help books, Internet/computer-based CBT with or without minimal therapist contact) have shown significant improvements in anxiety symptoms, and exposure therapy can be effective using a virtual reality format. These strategies can be very useful when real-life exposure is made difficult by inconvenience or patient reluctance [120].

Third-Wave Therapies

Mindfulness-based cognitive therapy, acceptance and commitment therapy, compassionate mind training, extended behavioral activation, metacognitive therapy, and schema therapy are diverse approaches originating from CBT. These modalities place greater importance on the form rather than content of patient cognitions. These third-wave therapies help patients develop more adaptive emotional responses to situations by focusing on the function of cognition. Mindfulness and acceptance are used in anxiety disorders to help patients observe symptomatic processes without overly identifying with or reacting to them in ways that perpetuate distress [154].

Mindfulness

Mindfulness involves attending to relevant aspects of experience in a non-judgmental manner. The goal of mindfulness is to maintain moment-by-moment awareness; disengage oneself from strong attachment to beliefs, thoughts, or emotions; and develop a greater sense of emotional balance and well-being. An aim of mindfulness practice is to take greater responsibility for one's life choices. Some evidence supports the efficacy of this approach in GAD and panic disorder [155,156,157].

Mindfulness versus active control was compared in ability to reduce negative thought intrusions activated by a worry-induction procedure. Negative thought intrusions significantly increased with progressive muscle relaxation and focused attention but not with brief mindfulness meditation, suggesting mindfulness might target anxiety by reducing negative elaborative processes that maintain worry [158].

Acceptance and Commitment Therapy

Acceptance and commitment therapy views psychologic events as a set of ongoing interactions between whole organisms and contexts defined historically and situationally. Acceptance and commitment therapy states that analyzing problematic behaviors but excluding the contexts that participate in the event misses the nature of the problem and pathways for its solution. This approach promotes a conscious posture of openness and acceptance of all psychologic events, including those deemed "negative" or "irrational." In acceptance and commitment therapy, when patients feel frustrated, afraid, angry, or anxious, this represents an opportunity to examine how powerful events in the present can become barriers to growth [159]. Some evidence suggests acceptance and commitment therapy may be as effective as CBT in anxiety disorder treatment, including panic disorder [151,160,161].

Acceptance-based skill training differs from traditional coping skills training by de-emphasizing control (over physiology or thoughts) to focus on acceptance of panic-related sensations and cognitions as they occur from moment to moment. Patients learn to pay nonjudgmental attention to thoughts, feelings, images, and bodily sensations. Thoughts are viewed as an ongoing process distinct from self, rather than events with literal meaning (cognitive defusion). Efficacy of acceptance approaches has been shown in patients with panic disorder/agoraphobia [162].

Education and Support

Psychoeducation states that providing information to patients with anxiety about their anxiety symptoms and theories of psychologic therapy may help reduce these symptoms. By increasing the patient's sense of control, psychoeducation may reduce catastrophic thoughts and emotions. This is especially relevant to patients with panic disorder, whose cognitive coping mechanisms are disrupted and whose anticipatory anxiety may cause additional attacks [151].

Supportive psychotherapy uses encouragement, rationalizing/reframing, and anticipatory guidance to reduce symptoms and maintain, restore, or improve self-esteem, ego function, and adaptive skills. This approach views the therapeutic alliance as the most important element. The archetype of supportive psychotherapy is the Rogerian client-centered approach; a warm, empathic, and non-directive therapeutic relationship helps clients become aware of their true feelings and achieve full self-acceptance. This approach may benefit patients with agoraphobia, but efficacy in panic disorder is unclear [151].

Physiologic Therapy

Physiologic therapies involve physical training (e.g., breathing retraining, relaxation techniques, biofeedback) to help patients control physiologic anxiety symptoms. Hyperventilation and hypocapnia are identified factors in panic disorder development and maintenance; panic attacks can be caused by acute hypocapnia states in a positive feedback loop between hyperventilation and anxiety. Breathing training is used to ameliorate panic symptoms, but it shows mixed efficacy in panic disorder [162]. Progressive muscle relaxation teaches patients with panic to reduce general tension and achieve a body state that lowers the risk for panic-inducing stressors. Applied relaxation teaches patients to observe the first signs of a panic attack and apply a rapid and effective relaxation technique to cope with and abort panic symptoms before escalation into a panic attack. Applied relaxation is comparable to progressive muscle relaxation in reducing panic attacks [151].

Psychodynamic Approaches

Psychodynamic therapies differ in length and depth, influenced by Freudian psychoanalysis and later refinements. Psychodynamic psychotherapy views mental symptoms as manifestations of intrapsychic and unconscious conflicts; treatment involves uncovering, interpreting, and resolving such conflicts using analysis of unconscious contents, dreams, past experiences, parental relationships, transference, and/or resistances [151]. A brief panic-focused psychodynamic psychotherapy, derived from psychodynamic theories, utilizes emotion-focused therapy, whereby the therapist is viewed as an "emotion coach" who works to enhance emotion-focused coping by helping patients become aware of, accept, and make sense of their emotional experience [163].

One psychodynamic psychotherapy approach is derived from the proposition that fearful parental dependency in childhood may lead to anger toward the parent. A vicious cycle is created; anger threatens the needed tie to the parent and increases fearful dependency, which promotes further frustration and rage at the parent. This cycle may recur in adulthood when threats to attachment trigger intense feelings of abandonment, anger, and anxiety, promoting the development of pathologic anxiety. The goal is to address such underlying psychologic factors to decrease panic symptoms. Some evidence suggests this approach is a valid therapeutic option, especially when SEPAD is present [98,151].

Exposure Therapies

Exposure therapy is defined as any treatment that encourages patients to systematically confront feared stimuli, which can be external (e.g., feared objects, activities, situations) or internal (e.g., feared thoughts, physical sensations) [136]. Exposure therapy is an effective, empirically supported treatment modality for anxiety disorders and a core component of CBT. Variants of exposure therapy include:

- In vivo exposure: Exposure that involves real-world confrontation of feared stimuli

- Imaginal exposure: Vividly imagining and describing the feared stimulus, including details about external (sights, sounds) and internal (thoughts, emotions) cues

- Virtual reality exposure: Patient immersion into a software-generated virtual world that allows them to confront their fears

The success of exposure therapy occurs by targeting maladaptive learning and fear conditioning, core mechanisms implicated in anxiety disorder etiology and maintenance. Standard exposure therapy involves exposure to feared objects or situations and gradual elimination of safety behaviors—the subtle avoidance behaviors that temporarily diminish distress in feared situations but interfere with long-term anxiety reduction. Patients are encouraged to continue confronting the feared situations through exposure until substantive reductions in fear occur. Exposure therapies facilitate extinction learning by diminishing the association between the avoided situation and fear and promoting new learning of the true nonthreatening nature of the situation [164,165].

Exposures are graded in intensity, with the same process used for weaning safety signals. For instance, a patient with panic disorder and agoraphobia can initially practice walking through a congested shopping mall with a family member; on the next exposure, he or she may practice walking separately through the shopping mall and eventually walk through the congested mall alone. Patients are taught that treatment setbacks are common and to distinguish between expected treatment lapses and relapses. Symptom flare-ups do not mean treatment failure, but instead are opportunities to revisit psychoeducation, cognitive restructuring, or exposure, and work toward regaining progress [166].

A substantial number of patients fail to achieve substantive symptom relief from exposure-based therapies or experience fear relapse following exposure therapy. This results from deficits in the mechanisms considered central to extinction learning (e.g., poor medial prefrontal cortex inhibition of amygdala-generated fear impulses) that contributed to the development of pathologic anxiety and avoidance in the first place. Because of this, effort is underway to optimize exposure therapies to improve significant and durable patient response [167]. This effort includes the therapeutic alliance as a potential prognostic indicator [168].

PHARMACOTHERAPY: OVERVIEW

The first-generation antidepressants monoamine oxidase inhibitors (MAOIs) and TCAs were introduced in the late 1950s and early 1960s, and the first report of antidepressant use in anxiety treatment was published in 1962. In this account, patients with agoraphobia who were given the TCA imipramine showed reductions in panic attacks and improved exposure to feared situations [169]. The benzodiazepine chlordiazepoxide (Librium) was introduced to the U.S. market in 1960. This was followed by diazepam (Valium) in 1963, which became the most prescribed drug in the United States from 1969 to 1982; in 1978, more than 2.3 billion diazepam doses were sold in the United States [170]. Panic disorder was first formalized as a psychiatric disorder in the 1980 DSM-III, and alprazolam (Xanax) became the first U.S. Food and Drug Administration (FDA)-approved drug for panic disorder treatment in 1981, remaining the most-prescribed benzodiazepine to date [171].

In the past two decades, antidepressant drugs, specifically SSRIs, have displaced benzodiazepines as the most widely prescribed and recommended anxiety disorder pharmacotherapy. Efforts to improve safety, efficacy, and tolerability led to introduction of the second-generation antidepressants, with trazodone (Oleptro) in 1982, bupropion (Wellbutrin) in 1985, and fluoxetine (Prozac)—the first domestically marketed SSRI—in 1987.

Antidepressants are generally recommended as first-line therapy for panic disorder because, unlike benzodiazepines, antidepressants treat comorbid depression and lack abuse risk and potential side effects of excessive sedation, cognitive impairment, and ataxia. All major antidepressant classes are comparably effective, but SSRIs and, increasingly, SNRIs are recommended over TCAs and MAOIs due to better safety and tolerability [172].

Tricyclic Antidepressants

Norepinephrine, serotonin (5-HT), and dopamine are termed monoamines. Monoamine reuptake transporters retrieve monoamines released into the synaptic cleft to terminate their activation of post-synaptic monoamine receptors. TCAs act by inhibiting norepinephrine and 5-HT reuptake transporters. This increases synaptic levels of norepinephrine and 5-HT by preventing their clearance, which increases post-synaptic receptor activation and signaling. TCAs generally have greater norepinephrine than 5-HT reuptake transporter potency. TCAs also act as histamine H1/H2, muscarinic acetylcholine, and alpha-adrenergic receptor antagonists, resulting in a range of undesirable side effects associated with patient intolerance and discontinuation, including [173]:

- Anticholinergic: Dry mouth, blurred vision, constipation, urinary hesitancy and retention, confusion, precipitation of glaucoma, delayed ejaculation, sweating

- Alpha-1-adrenoceptor antagonism: Postural hypotension, increased heart rate, dizziness

- Antihistaminergic: Sedation, psychomotor slowness, weight gain

- Cardiac sodium channel blockade: QTc prolongation, decreased cardiac conduction, fatal cardiac arrest in overdose

TCAs have comparable efficacy to SSRIs in panic disorder and GAD [174,175]. TCAs are lethal in overdose and, compared to SSRIs, have a markedly broader, more problematic, and less tolerable side effect profile [172]. Nonetheless, TCAs may work when first-line agents do not [136]. Also, some patients with panic disorder are sensitive to both beneficial and adverse effects of TCAs, so they cannot tolerate imipramine doses >10 mg/day but may still experience panic blockade [172].

Monoamine Oxidase Inhibitors

MAOIs inhibit MAO, an enzyme that degrades and inactivates 5-HT, norepinephrine, and dopamine, thereby increasing monoamine levels and activity. The earlier MAOIs—phenelzine (Nardil) and tranylcypromine (Parnate)—are characterized by irreversibility and nonselectivity. Irreversibility refers to tenacious drug binding to the MAO enzyme for the 14- to 28-day lifespan of the drug molecule. Nonselectivity refers to phenelzine and tranylcypromine binding to both A and B isoenzymes of MAO. While tyramine and dopamine are metabolized by both MAO-A and MAO-B, MAO-A inhibition is established as the precursor to hypertensive crises [176].

During phenelzine or tranylcypromine therapy, dangerous and potentially fatal hypertensive reactions can result from co-ingestion of drugs with monoamine activity or foods high in tyramine content (e.g., cheese, beer, wine). Concurrent use of serotonergic agents or supplements such as St. John's wort can cause potentially lethal serotonin syndrome. Common side effects include orthostatic hypotension, weight gain, sexual dysfunction, sedation, headache, and insomnia. To avoid drug interactions, washout periods are required before an MAOI is started (≥5 days) or stopped before switch to another medication (≥14 days) [136].

Moclobemide is a reversible inhibitor of monoamine oxidase type A (RIMA). With reversibility, MAO enzyme detachment and/or displacement readily occur, greatly improving safety. Compared to tranylcypromine, it takes eight times the tyramine level (8 mg vs. 63 mg) with moclobemide to induce a 30 mm Hg rise in diastolic blood pressure; dietary and co-medication concerns are greatly reduced. No washout period is required for switching anti-depressants. Moclobemide is safe in overdose, and 20,000 mg has been ingested without fatality. Common side effects include nausea, insomnia, tremor, and lightheadedness. Orthostatic hypotension is uncommon, even in the elderly [176]. Moclobemide lacks the cholinergic and histaminergic side effects of TCAs and the sexual side effects of SSRI/SNRIs. Depressive patients more commonly reported improved libido, erection/ejaculation, and orgasm with moclobemide. Weight gain or lowered seizure threshold are not side effects [177]. Moclobemide was slated for introduction in the United States in 1992. It was withdrawn from the application process because SSRI popularity cast doubts on its profit potential. This drug is available in Canada and throughout Europe and Asia [176,178].

MAOIs and RIMAs are effective for panic disorder and SAD and are thought by some to be superior options for severe, treatment-resistant anxiety disorders. As noted, MAOIs have a substantial side effect profile and impose the greatest safety burden of all antidepressants. Therefore, they are usually reserved as the last treatment option after other drug therapies have failed to achieve remission [179]. Clinicians do not routinely prescribe MAOIs for anxiety disorders, although they are probably not considered often enough in treatment-resistant patients [136].

SSRIs

SSRIs are considered first-line therapy for GAD and panic disorder [121,172]. SSRI mechanism is thought to involve serotonin transporter (SERT) inhibition at the presynaptic axon terminal of 5-HT neurons. SERT inhibition also occurs at the somatodendritic end of the neuron, where the increase in 5-HT causes 5-HT1A autoreceptors to downregulate, desensitize, and over time lose the ability to inhibit 5-HT release. The resultant increase in synaptic 5-HT level mediates the therapeutic action. SSRIs were termed "selective" because, unlike TCAs, they were believed to have little-to-no interaction with non-serotonin receptors and transporters [136,180].

It is now recognized that SSRIs differ in pharmacologic effect, including activity beyond SERT inhibition [179,180]:

- Fluoxetine: Antagonist at 5-HT2C receptors, which enhances norepinephrine and dopamine release. Therapeutic effects may emerge more slowly than other SSRIs.

- Sertraline (Zoloft): A weak dopamine transporter inhibitor, sigma-1 receptor activity. Along with fluoxetine, increases cortex monoamine levels to possibly explain patient reports of improved energy, motivation, and concentration.

- Paroxetine (Paxil): A weak norepinephrine transporter inhibitor, which contributes to antidepressant effects. Muscarinic cholinergic receptor activity may underlie some sedative and anxiolytic effects.

- Fluvoxamine (Luvox): Along with sertraline, has sigma-1 receptor activity that possibly contributes to the anxiolytic effects of both agents.

- Citalopram (Celexa): Mild antihistamine properties not observed with escitalopram.

- Escitalopram (Lexapro): Is considered the only SSRI without pharmacologic activity beyond SERT inhibition.

The atypical SSRIs vilazodone (Viibryd) and vortioxetine (Brintellix) display expanded serotonergic and other monoaminergic activity beyond those of standard SSRIs. Vilazodone and vortioxetine are likely to be treatment options for patients who do not respond to or cannot tolerate typical SSRIs/SNRIs.

Side effects associated with SSRI treatment include gastrointestinal upset (nausea, vomiting, diarrhea), activation/insomnia (restlessness, agitation, anxiety, akathisia, sleep disturbances), sexual dysfunction (loss of erectile or ejaculatory function in men, loss of libido and anorgasmia in both sexes), headache, fatigue, and weight gain. Many side effects dissipate over time. Sertraline is particularly associated with diarrhea, and paroxetine with weight gain. Discontinuation syndrome from paroxetine is more severe and protracted than other SSRIs [181]. To avoid relapse, medication should be continued for at least 12 months after symptom improvement before tapering [121].

Vilazodone

Approved by the FDA in 2011, vilazodone primarily acts as a serotonin reuptake inhibitor and 5-HT1A receptor partial agonist, with modest action as a dopamine and norepinephrine reuptake inhibitor, with 5-HT4 receptor activity [173]. This profile resembles the combination of SSRI and buspirone, and GAD efficacy of both agents suggests a potential role for vilazodone in anxiety disorder treatment. Two eight-week randomized controlled trials of vilazodone treatment of GAD have been published. One using a flexible-dose design found nominal clinical improvement with vilazodone compared with placebo, while the other study using a fixed-dose design found statistically significant reduction in anxiety scores (vs. placebo) with vilazodone 40 mg but not 20 mg [182,183]. Vilazodone does not appear to improve efficacy over drugs already in use, but it does have advantages of earlier onset of clinical response (beginning by two weeks) and little evidence of sexual dysfunction or weight gain. Vilazodone should be taken with food, which increases its absorption and bioavailability by 72% [184].

Vortioxetine

Approved by the FDA in 2013, vortioxetine is a multimodal antidepressant and potential anxiolytic with activity as an antagonist in 5-HT1D/3A/7 receptors, a 5-HT1A receptor agonist, 5-HT1B partial agonist, serotonin transporter inhibitor, and weak norepinephrine transporter inhibitor. This multiple receptor activity modulates serotonergic, noradrenergic, dopaminergic, and histaminic systems to produce clinical effect [185]. Results from four randomized controlled trials suggest vortioxetine may have potential efficacy in the treatment of severe GAD, but effects in patients with more moderate GAD were minimally improved compared with placebo. Nausea, the most common side effect, was dose dependent [186]. Sexual dysfunction rates were similar to placebo across the 5–20 mg/day dose range, and vortioxetine can be taken without regard for meals [187].

SNRIs

Venlafaxine, the first SNRI approved in the United States, was introduced as immediate release (IR) in 1993 and extended release (XR) in 1997. This was followed by the introduction of duloxetine in 2004, desvenlafaxine in 2008, milnacipran in 2009, and levomilnacipran in 2013. SNRIs increase synaptic concentrations of 5-HT and norepinephrine by blocking reuptake of these neurotransmitters by their respective transporters. SNRIs lack significant affinity for adrenergic, cholinergic, histaminergic, opioid, glutamate, or GABA receptors and transporters [136,188].

SNRIs differ in proportion of 5-HT/norepinephrine reuptake inhibition. Venlafaxine is the most serotonergic SNRI, followed by duloxetine and desvenlafaxine. Milnacipran shows relatively equal influence on 5-HT and norepinephrine reuptake inhibition, and levomilnacipran is a greater norepinephrine than 5-HT reuptake inhibitor. Such differences suggest that SNRIs are dissimilar from one another. Venlafaxine and duloxetine exhibit dose-related sequential effects on reuptake inhibition, while desvenlafaxine, milnacipran, and levomilnacipran act simultaneously on 5-HT and norepinephrine reuptake inhibition with proportionality intact with dose escalation [189].

Side effects from SNRIs overlap with SSRIs but can also include adrenergic effects of increased pulse rate and blood pressure, dilated pupils, dry mouth, and excessive sweating. Venlafaxine has a greater incidence of nausea and vomiting than SSRIs and may be associated with an increased risk for cardiovascular events [181]. Sexual side effects associated with SNRIs include decreased response to sexual stimuli, loss of interest in sex, anorgasmia, and much less frequently, genital anesthesia. Discontinuation syndrome from venlafaxine is markedly worse than other SNRIs and SSRIs [188].

Relative to SSRIs and TCAs, the SNRIs have relatively short half-lives, and few or no active metabolites for simpler overall pharmacology. In contrast to venlafaxine and duloxetine, desvenlafaxine, milnacipran, and levomilnacipran largely bypass the hepatic cytochrome P450 isoenzyme system, making drug interactions less likely. Of the five available SNRIs, only venlafaxine has an active metabolite (desvenlafaxine). Dosing with venlafaxine IR and milnacipran is twice daily; the remaining SNRIs are dosed once daily [184].

The impairing effects from synaptic plasticity induced by conditioned psychologic stress were found reversed by SNRI treatment. Long-term venlafaxine and milnacipran use suppressed long-term potentiation in hippocampal CA1 via 5-HT1A receptor and a1-adrenoceptor activity, contributing to reversal in synaptic plasticity-related impairment induced by conditioned fear stress. Increased responsiveness of a1-adrenergic and dopaminergic D3 systems, decreased responsiveness of 5-HT2 systems, and development of adaptive changes occurred despite lack of SNRI affinity for these neurotransmitter receptors [188,190,191].

Venlafaxine

Venlafaxine IR was introduced in 1993 but from the outset was plagued with side effects, leading to the 1997 introduction of venlafaxine XR. The XR formulation has become a widely prescribed agent with established efficacy in several anxiety disorders. In addition to the dose-related reuptake inhibition of 5-HT and norepinephrine mentioned, weak dopamine reuptake inhibition may appear at dosages greater than 300 mg/day. This sequential activity is mirrored by the initial predominant serotonergic side effects (headache, nausea, fatigue, sexual dysfunction), with noradrenergic effects at higher doses (activation effects, dry mouth, night sweats) [184].

Desvenlafaxine

Desvenlafaxine (Pristiq) shows a 10-fold higher selectivity for serotonin over norepinephrine reuptake inhibition at 50 mg/day, with selectivity unchanged by dose increase to 100 mg/day [184]. A primary advantage of desvenlafaxine over venlafaxine involves metabolic pathways and drug interactions. Venlafaxine is extensively metabolized by the hepatic CYP2D6 isoenzyme to desvenlafaxine, while desvenlafaxine is metabolized primarily via glucuronidation and minimally through CYP3A4 [178]. Venlafaxine, but not desvenlafaxine, clearance in patients with polymorphic 2D6 can be accelerated or delayed, resulting in non-efficacy or greater side effects/toxicity. This makes desvenlafaxine preferable to venlafaxine for these patients. The desvenlafaxine metabolic pathway also eliminates adverse drug interactions with 2D6 substrates that require consideration with venlafaxine prescribing [188,192]. However, few trials have evaluated desvenlafaxine in anxiety disorder treatment [184]. A comparison of the efficacy and safety of desvenlafaxine and escitalopram for treatment of depression with anxiety found that both drugs reported similar efficacy, but escitalopram was better tolerated with fewer adverse effects [193].

Duloxetine

Duloxetine (Cymbalta) has greater potency in 5-HT reuptake inhibition than fluoxetine. It has an elimination half-life of roughly 12.5 hours, steady-state is usually achieved after three days, and metabolism occurs mainly through hepatic CYP 2D6 and 1A2 [178,194]. Common adverse effects of duloxetine include nausea, headache, and weight loss. Certain adverse effects, including xerostomia, drowsiness, and fatigue, are dose related [178].

Milnacipran

Milnacipran (Savella) has been marketed in France since 1997 for the treatment of major depression, but it is indicated for use by the FDA solely for fibromyalgia [178]. Milnacipran is not available in a generic formulation, and the expiration of the patent is not imminent. Anxiolytic effects of milnacipran are at least partially mediated by 5-HT2A receptor agonism [188,195]. Results of a systematic review were inconclusive regarding the comparative efficacy, acceptability, and tolerability of milnacipran versus other antidepressive agents; however, milnacipran reportedly was more favorable than TCAs in terms of acceptability and tolerability [196].

Levomilnacipran

Levomilnacipran (Fetzima) differs from other SNRIs in that it is a more potent and selective inhibitor of norepinephrine than serotonin, especially at low doses. Alcohol may disrupt the extended-release mechanism to release large amounts of drug over a brief period, and co-ingestion should be avoided. With reports of milnacipran increasing hepatic transaminases to cause fulminant hepatitis, levomilnacipran should be avoided in patients with a history of alcoholism or chronic liver disease. Levomilnacipran is not associated with weight gain [173,178]. Levomilnacipran ER 40–120 mg daily was found to be effective in preventing relapse in patients with major depressive disorder [197].

Other Antidepressants

Bupropion

Bupropion (Wellbutrin) lacks effect on serotonin neurotransmission either presynaptically (through serotonin release or reuptake inhibition) or postsynaptically (acting on serotonin receptors). Instead, bupropion inhibits the reuptake of norepinephrine and dopamine without affecting release or transport of other neurotransmitters and without binding to other neurotransmitter receptors. This unique pharmacologic profile makes bupropion the only approved antidepressant that increases dopamine neurotransmission in the nucleus accumbens and prefrontal cortex. The side effect profile, distinct from other antidepressants, lacks sexual dysfunction, weight gain, and sedation. The activating effects of bupropion can increase insomnia and anxiety, leading to its infrequent use in anxiety disorders [179,198].

Trazodone and Nefazodone

The anxiolytic effects of trazodone are mediated by activity as a highly potent 5-HT2A receptor antagonist and moderately potent 5-HT1A partial agonist, with additional activity in SERT and 5-HT2C receptor inhibition. The combined actions of 5HT2A/5HT2C antagonism and SERT inhibition only occur at moderate-to-high doses, with doses lower than effective for antidepressant action frequently used for the effective treatment of insomnia [178,179,199]. Nefazodone (Serzone) is highly similar in pharmacologic activity to trazodone, but it is rarely prescribed due to liver toxicity concerns [179].

Mirtazapine

Mirtazapine (Remeron) is a tetracyclic compound with a unique mechanism of action, leading to description as a noradrenergic antagonist-specific serotonin antagonist antidepressant. Pharmacologically, mirtazapine is a 5-HT1 receptor agonist, and antagonism of 5-HT2A/C receptors increases cortical serotonin, dopamine, and norepinephrine modulation. Inhibition of norepinephrine alpha-2 autoreceptors allows greater norepinephrine release from neuron terminals. Also antagonized are receptors of 5-HT3, 5-HT5, and H1 histamine. This unique profile helps account for earlier onset of action than SSRI/SNRIs. Mirtazapine tends to promote sleep or drowsiness, and the most frequent side effect of daytime sedation can be a beneficial effect in highly anxious patients [178,179,188].

Mirtazapine is found beneficial in patients with GAD, SAD, OCD, panic disorder, and PTSD [200]. It is relatively safe in overdose. Mirtazapine is particularly useful in patients with sexual dysfunction from other antidepressants and is a good choice in patients with significant insomnia. Weight gain is a side effect, and if the risks for elevated lipid levels and rare agranulocytosis are a concern, mirtazapine may be reserved as a third-line choice [200,201].

Agomelatine

Agomelatine is approved for clinical use in Europe, Australia, and a total of 40 countries overall, but not by the FDA. It is discussed in light of its novel mechanism and particular benefit in GAD [202].

Agomelatine is a synthetic melatonin analog with activity as a melatonin MT1/MT2 receptor agonist and 5-HT2C receptor antagonist. Unique to agomelatine, and one of its most important properties, is a sleep-promoting and pro-chronobiologic effect. Its 5-HT2C antagonism promotes dopaminergic firing in the ventral tegmental area, frontal cortex, hypothalamus, hippocampus, medulla, pons, and retina by enhancing norepinephrinergic activity in the locus coeruleus [185,203].

With a unique non-monoaminergic mechanism of action, clinical trials have shown a low risk of sexual dysfunction, lack of weight gain or withdrawal symptoms, and overall side effect profile similar to placebo. However, reports of liver injury require patients to receive liver enzyme monitoring [204].

Anti-Epileptic Drugs

Gabapentinoids

Pregabalin (Lyrica) and gabapentin (Neurontin) are structurally analogous GABA analogs, with pregabalin more extensively evaluated in anxiety disorders. The anxiolytic, antinociceptive, and antiseizure properties of pregabalin are mediated through binding to presynaptic α2δ subunits of central nervous system (CNS) voltage-gated calcium channels, which decreases calcium influx at presynaptic channels and inhibits neurotransmission of excitatory glutamate, norepinephrine, and substance P [185,205].

The relative efficacy and early onset of effect of pregabalin versus benzodiazepines may represent a new therapeutic intervention for GAD as mono- and augmentation therapy. Pregabalin has a low risk of drug interactions, lacks withdrawal or physical dependence risk, is associated with minimal adverse effects (e.g., dizziness, weight gain, insomnia), and is safe and well tolerated. A potential role for pregabalin in patients with GAD tapering off long-term benzodiazepine therapy has been suggested [185].

Benzodiazepines have been the only anxiolytic agents that rapidly reduce anxiety, but trials conducted in the last decade have also found this effect with pregabalin. In 89 patients with moderate-to-severe dental anxiety (without anxiety disorder diagnosis) given single-dose pregabalin 150 mg, alprazolam 0.5 mg, or placebo four hours before a dental procedure, the onset of anxiolytic effects began within three to four hours after pregabalin and within two hours after alprazolam. The magnitude of anxiety reduction and tolerability were equivalent between pregabalin and alprazolam [206].

Common GAD comorbidities of insomnia, gastrointestinal symptoms, and depression do not impair efficacy and are specifically improved by pregabalin. Pregabalin is generally well tolerated; the adverse event profile includes dizziness, somnolence, incoordination, dry mouth, headache, and weight gain. Risk of withdrawal symptoms is low when tapered over one week [205].

Levetiracetam (Keppra) is an analog of the nootropic drug piracetam and structurally unrelated to other anti-epileptic drugs. It has a novel mechanism of action that involves binding to synaptic vesicle protein SV2A, a protein that modulates neurotransmitter release including GABA. Metabolism has no effect on the cytochrome P450 enzyme system. The most common side effects include somnolence, dizziness, and weakness [207]. In one study, adjunctive levetiracetam (mean: 1,969 mg/day for 9.3 weeks) in highly symptomatic patients with treatment-refractory anxiety disorders led to clinically and statistically significant improvement in illness severity [208]. Further research involving patients with panic disorder with or without agoraphobia given levetiracetam for 12 weeks showed significant improvement in panic attack frequency, anxiety, and global severity ratings. Clinical benefits were apparent by one to two weeks for most patients, and side effects were minimal [209]. Patients with SAD initially administered levetiracetam 250 mg/day and flexibly titrated up to 3,000 mg/day over eight weeks showed significant improvements on measures of social anxiety, overall anxiety, and illness severity [210]. In contrast to the anti-epileptic agents zonisamide and topiramate, levetiracetam has not shown decrements in neuropsychologic performance on tests of cognitive impairment in patients with seizure disorder [211].

Atypical Antipsychotics

Olanzapine, risperidone, aripiprazole, and quetiapine are dopamine D2 receptor antagonists, as with all antipsychotic drugs, but differ from typical (first-generation) antipsychotics by also acting as 5-HT2A receptor antagonists (minimizing development of extrapyramidal effects), 5-HT1A receptor partial agonists (producing anxiolytic effects), and histamine receptor antagonists (further augmenting sedative and anxiolytic effects) [185].

Quetiapine

Quetiapine (Seroquel) is the most-studied atypical in anxiety disorder treatment and has greatest efficacy in GAD. A review of quetiapine in GAD found efficacy and tolerability in all acute and long-term monotherapy trials and statistically significant changes in anxiety and symptom severity in three of five adjunct therapy studies. Quetiapine is a treatment option for patients unresponsive to first-line therapy, and potential benefits may outweigh risks with appropriate monitoring and side effect management [212]. While the unique efficacy of quetiapine monotherapy in GAD is supported by a Cochrane review, quetiapine was denied FDA approval for GAD, likely due to its tendency for inducing lipid abnormalities, weight gain, and glucose intolerance, and concerns over widespread use in primary care without careful consideration of alternatives or monitoring adverse metabolic effects during follow-up [136,213].

Buspirone

Introduced in 1986, buspirone (BuSpar) was the first anxiety-specific medication unrelated to benzodiazepines or barbiturates in pharmacology, effect, and abuse potential. The 5-HT1A receptor partial agonism mediates the anxiolytic effects. Buspirone acts as a weak presynaptic dopamine D2, D3, and D4 receptor antagonist and alpha-1 agonist [214]. Buspirone is primarily used in the treatment of GAD and to augment antidepressants for improved response.

Hydroxyzine

Hydroxyzine (Vistaril) acts mechanistically as a potent H1 receptor inverse agonist, and as a 5-HT2A, D2, and alpha-1-adrenergic receptor antagonist. The serotonergic activity of hydroxyzine is more potent than its dopaminergic and adrenergic activity and likely accounts for its anxiolytic efficacy, as other antihistamines lacking this property have not been effective in the treatment of anxiety [178,216]. Hydroxyzine efficacy in anxiety disorders is limited to GAD, for which anxiety-reducing efficacy is demonstrated [217,218,219].

Benzodiazepines

Since their introduction in the early 1960s, benzodiazepines have been the most prescribed drugs for anxiety over the majority of the past half-century. Although SSRI/SNRI agents have replaced benzodiazepines as the top-prescribed anxiolytics, benzodiazepine prescribing remains common. In 2020, alprazolam, clonazepam, and lorazepam were among the top 25 most frequently prescribed psychotropic medications in the United States; alprazolam ranked ninth, clonazepam ranked 12th, and lorazepam ranked 16th [220,221].

Pharmacology and Short-Term Effects

Numerous benzodiazepines are available and have similar pharmacodynamic properties and clinical actions; they mainly differ in pharmacokinetic properties (absorption, distribution, metabolism, elimination). Benzodiazepines bind to a specific receptor site in the GABA-A receptor complex. GABA is the primary inhibitory neurotransmitter in the CNS, and benzodiazepines cause non-selective GABA-A inhibitory effects throughout the brain that include drowsiness, cognitive impairment, dampening of fear and anxiety, memory impairment, anticonvulsant actions, and impairment of balance, motor control, muscle tone, and coordination. Adverse reactions to alprazolam also include amnesia, aggression, mood changes, and hostility. The newer Z drugs (e.g., zolpidem, zopiclone) have similar actions to benzodiazepines but are marketed for insomnia due to their pharmacokinetic profile, with high doses required for anxiolytic effects. There is evidence the Z drugs share similar risks to benzodiazepines [222,223].

Meta-analyses suggest alprazolam, lorazepam, and diazepam are effective but comparable in GAD efficacy, while clonazepam shows much greater efficacy in the treatment of panic disorder than alprazolam, lorazepam, and diazepam, which all have modest efficacy [224].

Appropriate Prescribing

Benzodiazepine treatment of anxiety disorders is controversial. While effective in rapid anxiety reduction, the potential drawbacks with long-term use are substantial. These agents are indicated when potent, short-term anxiolytic effects are necessary to permit infrequent exposure to feared stimuli and potentially severe anxiety, such as airplane travel [121,129,136]. Clonazepam, lorazepam, and alprazolam are effective for short-term use in panic disorder, GAD, and SAD, but ineffective for, and potentially worsening, comorbid depression [28]. The rapid anxiolytic effects make benzodiazepines highly appealing to patients with anxiety, but aside from this specific context, benzodiazepine prescribing for as-needed use is discouraged [136,225,226]. Benzodiazepines can reinforce pill taking, serve as a safety signal that undermines self-efficacy, and become incorporated into conditioned fear responses; these concerns are heightened with as-needed use. On-demand dosing links pill taking to rapid anxiety reduction, powerfully reinforcing avoidance in anxiety-provoking situations and encouraging longer-term reliance on the drug. This iatrogenic effect also contributes to poor CBT response.

The current recommended prescribing is for time-dependent use, instead of panic response-dependent use, to minimize the risks [121]. This would also seem to maximize risk of withdrawal syndrome from uninterrupted versus intermittent drug exposure.

Benzodiazepines are also useful in the initial weeks of SSRI/SNRI initiation, to rapidly reduce anxiety and possible early anxiogenic medication side effects before the onset of SSRI/SNRI anxiolytic effects [121,129,136]. However, patients may discontinue the antidepressant when co-prescribed a rapidly effective benzodiazepine, believing the benzodiazepine's symptom relief makes the SSRI/SNRI unneeded. Supportive therapy with regular visits or phone contacts may also help patients remain adherent until the delayed onset of antidepressant benefits appears or early antidepressant side effects lessen [227].

Another indication for benzodiazepine use is for the short-term relief (two to four weeks only) of anxiety that is severe, disabling, or subjecting the individual to unacceptable distress. Perhaps the greatest prescribing challenge with benzodiazepines is preventing short-term use from insidiously developing into long-term use. Patients with the most severe anxiety may obtain the greatest relief and become most hesitant to discontinue use [228]. In many cases, clinicians ignore the recommended two- to four-week prescribing limit, mainly because alternative options with superior anxiolytic effects are not available [229]. Clinicians intending to prescribe alprazolam should carefully consider the likelihood that its use will remain restricted to the very short term—a few days to a couple weeks—to see the patient through a crisis [228].

Benzodiazepines may be prescribed to augment SSRI/SNRI therapy for improved response in select patients with significant residual anxiety or non-response. In one study, patients with SAD and sertraline nonresponse after 10 weeks were given sertraline plus clonazepam (≤3 mg/day), venlafaxine (≤225 mg/day), or sertraline plus placebo for 12 weeks. Those with sertraline augmented by clonazepam showed greatest reduction in SAD symptoms and a better overall response rate than comparator groups, although remission rates did not differ significantly [230]. These agents are third- or fourth-line treatment in patients unresponsive or intolerant to other anxiolytic drugs who remain highly symptomatic [121,129,136]. Generally, patients with a history of substance abuse, personality disorder, or chronic pain should not be treated with benzodiazepines because of the high risk for overuse of these medications [129]. While benzodiazepines should usually be reserved for patients lacking response to at least two treatments (i.e., non-response to an SSRI/SNRI and a psychologic treatment), concerns about potential problems in long-term use should not prevent their use in patients with persistent, severe, distressing, and impairing anxiety symptoms [231].

It seems the most appropriate guidance for benzodiazepine prescribing involves occasional, context-specific use or cautious use during SSRI/SNRI initiation [3,231]. Otherwise, benzodiazepines should be reserved for patients lacking response to three or more treatments, such as an SSRI, an SNRI, and a psychologic intervention, who remain highly symptomatic.

Risks/Drawbacks

While alprazolam remains the most-prescribed benzodiazepine for anxiety disorders, evidence suggests that relative to other benzodiazepines, alprazolam is no more effective and may have specific drawbacks [171]. Alprazolam may have greater potential for dependence than other benzodiazepines due to its rapid onset of anxiolysis and short half-life. With the short half-life, persons prescribed fixed-interval alprazolam (e.g., every six to eight hours) can experience morning withdrawal symptoms following the last nighttime dose. This is frequently mistaken as relapse in anxiety for which the drug was originally prescribed, confirming the continuing need for the drug [228]. The alprazolam product monograph states that such emergence of interdose symptoms reflect insufficient plasma levels, best managed by adding the same dose for four times daily administration (but breakthrough anxiety and alprazolam withdrawal are not differentiated). The document also states that alprazolam treatment of panic disorder differs from sub-syndromal anxiety, in that recommended dosing is as close to around-the-clock as possible, or three or four times per day [232].

Long-term benzodiazepine use can result in added symptoms during stable-dose maintenance, including increasing anxiety and withdrawal-associated symptoms such as perceptual disturbances and paresthesia. This emerging withdrawal syndrome despite ongoing benzodiazepine use is much more likely with highly potent and rapidly eliminated alprazolam or lorazepam and is temporarily alleviated by dose escalation. As craving, dysphoria, and other withdrawal symptoms develop over time between doses, the motivation to continue benzodiazepine use for anxiolysis gradually merges with the need to avoid withdrawal symptoms [233].

Benzodiazepine prescriptions are associated with nonmedical use and the development of benzodiazepine use disorder unrelated to co-occurring drug use or anxiety disorder diagnosis/severity [221]. Acute cognitive-impairing side effects are drowsiness, increased reaction time, ataxia, motor incoordination, and anterograde amnesia. In one study, long-term use of an average 17 mg/day diazepam equivalent led to substantial cognitive decline that did not resolve three months after cessation [234]. Motor vehicle accident risks during benzodiazepine therapy are comparable to driving with a blood alcohol concentration of 0.050% to 0.079% [235]. Hip fracture risk is increased by ≥50% in older persons who take benzodiazepines; with zolpidem, the risk is increased 200% in persons older than 65 years of age [236]. The risk of overdose is particularly great when benzodiazepines are combined with sedative drugs such as opioids or alcohol.

Personality traits associated with long-term use, emotional dependence, and more severe/protracted benzodiazepine withdrawal have been described. Long-term benzodiazepine users often have poor stress coping abilities. Benzodiazepines compensate for these deficits, but their use interferes with learning stress coping strategies, including behavioral therapy for agoraphobia. Passive-dependent personality traits and lack of internal and external stress coping resources increases vulnerability to withdrawal symptoms and motivation for continued use. In these patients, benzodiazepine deprivation renders them unprotected from stress and re-exposes their coping deficits. Chronically anxious people have been found innately hypersensitive to punishing stimuli and punishment; benzodiazepines can be described as "depunishing" drugs [233].

Withdrawal

Withdrawal symptoms following benzodiazepine cessation are appropriately concerning and a liability of this drug class that all prescribers should understand. In patients with panic disorder discontinuing alprazolam following 1.5 to 22 months of treatment, 33% to 100% were unable to completely taper [181]. These data did not include the 50% of long-term benzodiazepine users who do not consent to withdrawal studies or who later quit the study. The experience of benzodiazepine withdrawal is known to deter patients from future attempts [237]. An estimated 25% to 76% of patients prescribed benzodiazepines are long-term users. Defining high-dose benzodiazepine varies, but users of high-dose benzodiazepines commonly have comorbid disorders and are unlikely to benefit from current discontinuation and withdrawal strategies that expose them to greater risk of impairment and injury [237].

Despite comparable dosing, patients with panic disorder often show greater difficulty tapering than patients with GAD. Problems during alprazolam tapering are most severe during the last half of the taper. Patients with panic disorder receiving diazepam or alprazolam had fewer problems during taper of the top 50% of daily dose. However, with abrupt discontinuation of the remaining dose, alprazolam caused significantly more anxiety, relapse, and rebound. This may reflect greater problems withdrawing from short half-life, high-potency benzodiazepines like alprazolam [181].

The patient experience of benzodiazepine withdrawal was studied in 41 high-dose benzodiazepine-using inpatients deciding to withdraw (median dosage: 70 mg/day diazepam equivalent; median duration: six years) [237]. Driving this decision were health concerns of cognitive and physical impairments; feeling addicted; belief benzodiazepine use was a moral burden that limited autonomy; and pressure or coercion by relatives or institutional or governmental bodies to change benzodiazepine consumption patterns. The patients had long histories of repeated unsuccessful attempts to stop taking benzodiazepines and disappointment and frustration by the outcomes. However, many wanted to withdraw completely, with abstinence the goal. Most subjects described benzodiazepine withdrawal symptoms as severe, unpredictable, diverse in manifestation, and of duration difficult to anticipate. Common symptoms included chills, weakness, headache, muscle pains, abdominal pain, nausea, vomiting, diarrhea, tachycardia, dizziness, vision disorders, irritability, nervousness, restlessness, difficulties sleeping, depression, anxiety, tickling sensations, dissociation, complete loss of appetite, and epileptic seizures. Most experienced prolonged post-withdrawal symptoms. Many initially tried withdrawing by abruptly stopping benzodiazepine usage at home; most stated this resulted in perceived epileptic seizures. All favored gradual, long-term tapering over abrupt withdrawal [237].

Normally used to reverse benzodiazepine overdose and post-surgery sedation, flumazenil has shown effects that diminish benzodiazepine withdrawal severity and duration and improve abstinence rates. Dosage and infusion rates vastly differ between these two indications [238]. Flumazenil requires IV or subcutaneous infusion, because its brief half-life and extensive gastric metabolism prohibit oral use [239].

In a study of flumazenil IV infusion, 29 patients stopped benzodiazepines and began flumazenil 1.6 mg/day and oral clonazepam 2–6 mg/day. Antidepressants were started three weeks before the trial or were maintained. Clonazepam was tapered during outpatient follow-up. No patient dropped out, withdrawal severity showed significant linear reduction through the seven-day infusion, and 53% remained free of clonazepam and other benzodiazepines at six-month follow-up [240]. In patients with protracted withdrawal at 47 weeks, IV flumazenil significantly reduced aggression and hostility compared with placebo [241].

In research focused on subcutaneous infusion of flumazenil, patients were switched to oxazepam, began a 48-hour taper, and started flumazenil 16 mg over 96 hours. Subcutaneous infusion significantly reduced psychologic distress and benzodiazepine withdrawal symptoms during treatment. Patients with the highest initial withdrawal severity showed greatest improvement. Patients reported high treatment comfort, willingness to receive the treatment again, and likelihood to recommend it to a friend [239].

Flumazenil attenuates chronic benzodiazepine withdrawal symptoms by up-regulating benzodiazepine receptor binding sites to reverse uncoupling between benzodiazepine and GABA binding sites on the GABA-A complex. This reversal of GABA-A functional alteration helps explain its effect on benzodiazepine withdrawal and reports of positive effects on mood, memory, cognition, and motor performance [229].

CLINICAL ISSUES

Poor Treatment Response or Nonresponse

An estimated 30% to 60% of patients with anxiety disorders do not achieve meaningful symptom reduction or remission with initial therapy [242]. Decades of psychopharmacologic research have yielded safer, more tolerable side-effect profiles, but without improved efficacy in anxiety disorders. With poor or non-response, clinicians and patients then must decide how treatment should proceed, but research that best informs this clinical dilemma is only beginning to emerge. Given the limitations of SSRIs and benzodiazepines, investigators are pursuing novel treatment approaches and molecular targets [136].

With apparent patient nonresponse to treatment, clinicians should explore other factors before deciding the next therapy approach. The two broad causes of treatment resistance are pseudo-resistance and true treatment resistance [28].

Treatment Pseudo-Resistance

Pseudo-resistant patients have not actually received sufficient treatment, because of ineffective treatment matching for the anxiety diagnosis, insufficient medication dose or psychotherapy delivery, or patient non-adherence. Treatment pseudo-resistance may be the result of ineffective drug therapies, such a bupropion, beta-blockers (except in performance anxiety), buspirone and trazodone (except in GAD), and TCAs in SAD. Insufficient dosages and waiting an inadequate period for onset are also factors. The time for treatment onset is often longer for anxiety than depression. Patients may not fully respond until 8 to 12 weeks, and response may further increase in the second 6 months. Waiting an adequate time for response may be difficult for patients and healthcare providers, who may feel a need to change prescriptions or the regimen if a patient is distressed over his or her continued anxiety symptoms [28].

Poor patient adherence may also present as apparent treatment resistance. Only half of patients refill their first prescription, and many patients discontinue their drug in the first six months of treatment [136,185]. Nonadherence may result from medication intolerance or side effects. Even if patients with troubling side effects do not stop the drug, the inherent distress avoidance and anticipatory anxiety with anxiety disorders can delay achieving adequate dose or taking medication long enough for response. Therapeutic skills can help to gain patient trust and overcome their anxiety of medication; adherence improves with medication counseling [136,185]. Medication beliefs or attitudes that contribute to poor adherence include [28]:

- Unrealistic expectations

- Negative beliefs of perceived harmful effects

- Stigma

- Not "buying in" to treatment rationale or difficulty believing that treatment will work

- Psychologic conflicts over dependence and fear of becoming "addicted" to the medication

- Preference for psychotherapy over medication (as patients are less likely to adhere to a treatment modality they prefer less)

Following adherence and remission or large improvement, some patients will become non-adherent, and relapse follows. This may be addressed by explaining that the disorder requires ongoing treatment, like diabetes or any other chronic disease.

Overlooked Diagnosis, Comorbid Conditions, or Psychosocial Contributors

When established that adequate treatment was delivered and received, factors contributing to treatment resistance can include misdiagnosis or overlooked comorbidities or psychosocial factors. The following should be revisited [28]:

- Primary diagnosis accuracy

- Presence and contribution of unrecognized substance use disorder, psychiatric comorbidity, and/or complicating medical condition

- Psychosocial or lifestyle factors (e.g., caffeine overuse, sleep deprivation, interpersonal or family conflict)

Necessary Treatment Duration for Evidence of Response or Dose Escalation

Compared with treatment of simple depression, SSRI/SNRI treatment of anxiety disorder typically requires somewhat higher dosage and longer initial treatment duration before realizing a therapeutic effect. With duloxetine and escitalopram, a satisfactory response is unlikely without some degree of clinical benefit within four weeks of initiating therapy. With pregabalin, onset of clinical effect within two weeks is associated with a 5.3-fold increased likelihood of treatment response; 25% of patients not showing clinical effect at two weeks will ultimately respond to treatment. A pregabalin dosage of 150 mg/day is suboptimal; a dose-response effect usually requires 300–600 mg/day [243].

In clinical trials of venlafaxine XR, therapeutic benefits usually diverged from placebo at four to six weeks. However, the percentage remitted from panic disorder in one trial increased from 18% at 6 weeks to 50% at 12 weeks [244].

SSRIs/SNRIs usually take two to six weeks to show an initial "partial" response, often defined as ≥25% improvement (i.e., beyond random noise or natural symptom fluctuations). Full benefit may not appear for another four to six weeks or longer. Data from patients with depression, and some uncontrolled data with anxiety, suggest that about 20% of patients may need 10 to 12 weeks or longer before responding. Thus, dose escalation to highest level tolerated is recommended for patients with incomplete response before adequate time has passed [245]. In contrast to depression, antidepressant efficacy in anxiety disorders appears to be lost soon after stopping, with anxiety recurrence being the rule rather than the exception [228].

Patient Education

Successful medication treatment often involves dosage adjustments and/or trials of a different medication at some point in order to maximize response and minimize side effects. Because patient adherence is the essential pre-condition for maximum clinical benefit, the following messages should be communicated to the patient to encourage and support ongoing medication adherence [246]:

- Side effects often precede therapeutic benefit and typically recede over time.

- It is important to expect some discomfort prior to the benefit.

- Successful treatment may involve dose adjustments and/or trials of different medications to maximize response and minimize side effects.

- Most people must be on medication at least 6 to 12 months after adequate response, and patients may show improvement at two weeks but need a longer length of time to really see response and remission.

- It is important to take the medication as prescribed, even after feeling better, because early discontinuation is associated with high rates of relapse/recurrence.

- Do not stop taking the medication without calling the provider.

- Side effects can often be managed by changing the dose or dosage schedule.

A novel approach to improve patient understanding of their anxiety disorder and treatment rationale incorporates anxiety neuroscience. A core concept is that anxiety disorders/symptoms with amygdala origin (e.g., panic disorder, phobias) require different approaches than anxiety of cortical origin (e.g., SAD, GAD). Educating patients of the brain-based source of their anxiety can improve treatment adherence and empower patients to modify these areas of brain function. For example, patients with cortex-related symptoms such as obsessions, perfectionism, and chronic worry benefit from an approach termed "Question Your Cortex." They can be encouraged to identify anxiety-generating thoughts in the cortex and use cognitive restructuring methods to exploit cortical neuroplasticity by modifying their thoughts. However, cortex-based interventions are not effective at reducing or managing anxiety with amygdala-mediated symptoms; for these patients, exposure to feared situations is stressed. Most patients benefit from a combination of cortex- and amygdala-focused interventions, with the rationale and order of interventions differing by disorder and individual patient [247].

Antidepressant Withdrawal

Evidence Based Practice Recommendation

The National Collaborating Centre for Mental Health asserts that all patients prescribed antidepressants should be informed that, although the drugs are not associated with tolerance and craving, discontinuation/withdrawal symptoms may occur on stopping or missing doses or, occasionally, on reducing the dose of the drug.

https://www.nice.org.uk/guidance/cg113

Last Accessed: April 27, 2025

Level of Evidence: Expert Opinion/Consensus Statement

In reference to withdrawal of SSRI therapy, "withdrawal syndrome" has been largely replaced by the term "discontinuation syndrome" with industry support to convey the message that SSRIs do not cause addiction, dependence, or withdrawal syndrome as one might experience following cessation of benzodiazepines. This has been challenged, given the potential seriousness of SSRI post-cessation symptoms, as a false dichotomy that minimizes the vulnerabilities induced by SSRIs. For the purposes of this course, the term "withdrawal syndrome" will be used [248]. Clinicians should be aware of these withdrawal syndromes, as misdiagnosis may result in inappropriate diagnostic tests and treatment and unnecessary patient distress and morbidity [248].

A 2015 meta-analysis found SSRI withdrawal symptoms can occur with any SSRI but are exceedingly more frequent with paroxetine [248]. Common symptoms include dizziness, nausea, headache, confusion, low energy, weakness, sleep disturbance, flu-like symptoms, restlessness, agitation, anxiety, panic, anger, and irritability. Less common and more severe symptoms include electric-shock sensations, vertigo, paresthesias, intensified suicidal ideation, aggression, derealization, depersonalization, and visual/auditory hallucinations. Symptoms do not greatly differ between patients with anxiety versus mood disorders. The authors concluded that the typical SSRI withdrawal syndrome begins within a few days of cessation and lasts two to three weeks [248]. Variations include late onset and protracted duration up to one-year follow-up. Several cases of persistent postwithdrawal disorders induced by paroxetine have been described.

Gradual tapering is a reasonable strategy but does not prevent the onset of SSRI withdrawal [248]. Patient characteristics that predict increased vulnerability are not known. Recognition of withdrawal symptoms requires careful exploration, as they can be misidentified as signs of impending relapse. Even when withdrawal symptoms are recognized, clinical management is hindered by the lack of research.

SSRI cessation may trigger complex phenomena related or unrelated to the onset of withdrawal, such as hypomania, mania, and persistent postwithdrawal disorders. Iatrogenic comorbidity describes the lasting effects from treatment well beyond their time of administration, such as mood instability and high reactivity to environmental stimuli in persistent postwithdrawal disorders [248].

Among 20 patients with remitted panic disorder with agoraphobia followed over one year after SSRI cessation, nine experienced SSRI withdrawal syndrome that subsided within one month [249]. Exceptions were three patients taking paroxetine, who experienced worsened mood, fatigue, and emotional lability with trouble sleeping, irritability, and hyperactivity. One patient prescribed clonazepam after three months of symptom persistence improved considerably but was later unable to discontinue clonazepam. A second patient did not improve with clonazepam or fluvoxamine, and symptoms subsided only with paroxetine reinstatement. In a third patient, clonazepam had little benefit, paroxetine reinstatement was refused, and symptoms persisted unchanged over one year [249].

Following SSRI/SNRI cessation, the rates of withdrawal syndrome range from 17.2% to as high as 78% (with venlafaxine). Among SSRI/SNRIs, venlafaxine XR may have the worst withdrawal syndrome. In addition to serotonergic withdrawal symptoms, palinopsia (persistent visual images) and sensory disturbances are frequently reported. These symptoms are described as sensations affecting the brain and head that feel like electrical shocks or the sensation of the brain shivering. This sensory disturbance, often accompanied by dizziness, headache, and disorientation, is distressing to patients and has been reported to persist for months after venlafaxine XR cessation [244,250]. Other unexpected withdrawal symptoms that may emerge include gait difficulties, delirium, suicidal ideation, and hypomania or mania. The onset of withdrawal is usually one to four days post-venlafaxine XR cessation; dose reduction can also trigger withdrawal [251].

The etiology and treatment of these highly distressing sensory symptoms are unknown. However, contribution from noradrenergic dysregulation is suggested theoretically and by reports of positive treatment response to noradrenergic agents. Abrupt cessation of venlafaxine XR 37.5 mg led to a sensation that "felt like the brain was shaking inside the skull," with anhedonia, anxiety, tinnitus, headache, nausea, and increased noise sensitivity. A trial of the norepinephrine transporter inhibitor atomoxetine 40 mg/day led to immediate improvement in "brain shivers" two to three hours from the first dose [250]. Post-venlafaxine XR electric shock-like sensations and dizziness were greatly reduced by low-dose clonidine (0.05 mg twice/day), a central α-2 adrenergic agonist. The positive response suggests an underlying noradrenergic rebound mechanism [244].

Interdose withdrawal symptoms have been reported with venlafaxine XR, probably resulting from the "ultrarapid metabolizer" genetic variant of 2D6, the hepatic cytochrome P450 isoenzyme that metabolizes venlafaxine. Occurring in 3% to 5% of white individuals, this polymorphism accelerates venlafaxine elimination, causing interdose withdrawal [251].

Antidepressant Lethality in Overdose

In some patients with anxiety disorder, and especially those with depressive comorbidity, consideration of overdose fatality is necessary when deciding on therapy options. Lethality rates from intentional overdose involving single medication ingestions of agents commonly prescribed for depression and anxiety were calculated from data obtained during the period 2000–2014 [252]. TCAs remain the most lethal antidepressants, with fatality rates from 31–142 per 10,000 ingestions. Amitriptyline is associated with the greatest lethality in overdose and alone accounted for 37% of all deaths from antidepressants [252]. Lithium, bupropion, venlafaxine, quetiapine, and valproic acid had rates of 6.9–12.0 per 10,000 ingestions, while citalopram and fluvoxamine had rates of 3.9–4.1 per 10,000. Fluoxetine, sertraline, paroxetine, and escitalopram had the lowest overdose lethality rates at 0.79–1.34 per 10,000 ingestions [252].

Substance Use Disorder

Anxious patients often use alcohol or anxiolytics to regulate general anxiety, distressing panic symptoms, or social anxiety and social skills deficits. Substance use disorder is highly prevalent in patients with anxiety disorders and interferes with treatment response and leads to poor outcomes [28]. More than 33% of patients with GAD have an alcohol use disorder, and patients with SAD have a lifetime substance use disorder prevalence of roughly 40%. Nicotine dependence is also disproportionately high among patients with panic disorder [253,254,255].

Self-medication of anxiety disorder symptoms has been conclusively identified as a significant predictor for later development of alcohol or drug dependence. This is consistent with the self-medication hypothesis, which posits that the specific substance used for anxiety relief/control tends to be the substance to which the person develops a substance use disorder [256]. Ongoing substance use problems are abundantly linked to worse outcomes in comorbid anxiety disorders. Long-term effects of substance use negatively interact with anxiety symptoms, and quitting substances may improve anxiety in some patients. A trial of abstinence will usually answer this question. The duration must be several months to evaluate the link between anxiety and substance use, and there should be ongoing treatment, preferably in a 12-step program. Twelve-step programs have been shown to have anxiolytic effects themselves due to the support and empowerment they offer. Residual anxiety then should be treated with either medication or CBT [28].

If substance use is suspected, patients should be screened during diagnosis. A motivational interviewing approach is recommended to frame the rationale for substance abuse in a non-judgmental manner and explore patient desire and readiness for change. For patients initiating efforts to decrease substance use, concurrent treatment with an SSRI or venlafaxine is reasonable; benzodiazepines should be avoided due to the abuse liability [257]. Detoxification from alcohol or benzodiazepines is indicated if signs of substance withdrawal appear, and referral to a formal substance abuse treatment is recommended. Recognition and treatment of underlying substance abuse is an essential component in the overall treatment plan [13,28].

Anxiety Disorder Treatment Effect Sizes

A 2015 meta-analysis of panic disorder, GAD, and SAD assessed treatment efficacy [224]. Studies published through 2012 were used to calculate medication, psychologic, or combination treatment efficacy. Effect sizes were calculated from pre- versus post-treatment and treatment versus control comparisons (Table 3) [224]. A significantly higher average pre-post effect size was found for medication outcomes than psychotherapy outcomes. Side effects, contraindications, drug interactions, and efficacy should all guide drug selection. Benzodiazepine abuse, dependence, and withdrawal potential; TCA side effects; and quetiapine metabolic risks make these agents second- to fourth-line options and not first-line options, as suggested by effect sizes alone [224].

Table 3: EFFECT SIZES OF TREATMENTS FOR PANIC DISORDER, GENERALIZED ANXIETY DISORDER, AND SOCIAL ANXIETY DISORDER

Treatment Modality

Effect Sizea

Medications

SNRIs

2.25

Benzodiazepines

2.15

SSRIs

2.09

Tricyclic antidepressants

1.83

Psychotherapy

Mindfulness therapies

1.56

Relaxation

1.36

Individual CBT/exposure therapy

1.30

Group CBT

1.22

Psychodynamic therapy

1.17

Internet and self-directed therapies

1.11

Eye movement desensitization and reprocessing

1.03

Interpersonal therapy

0.78

Other approaches

CBT/drug combination therapy

2.12

Exercise

1.23

aAn effect size greater than 0.80 is considered large, indicating that the treatment is effective.

CBT = cognitive-behavioral therapy, SNRI = serotonin-norepinephrine reuptake inhibitor, SSRI = selective serotonin re-uptake inhibitor.

Source: [224]

8. TREATMENT OF GENERALIZED ANXIETY DISORDER

The goals of GAD treatment are reduction in severity of ambient symptoms followed by prevention of symptoms and relief of disability. Pharmacotherapy (SSRIs and SNRIs) is considered the mainstay of therapy; psychotherapy (CBT or cognitive therapy) is also highly effective and may be preferred during pregnancy and by patients who cannot tolerate or wish to avoid medication [54,258]. GAD is associated with specific biases for mood-congruent information. Patients with GAD are vigilant for threatening stimuli and tend to misinterpret ambiguous information as threat. These cognitive biases diminish with successful psychologic or drug treatment [243].

PSYCHOTHERAPY

First-Line Options

CBT

Evidence Based Practice Recommendation

According to the National Collaborating Centre for Mental Health, the recommended high-intensity psychological intervention for persons with generalized anxiety disorder is cognitive-behavioral therapy (CBT) or applied relaxation.

https://www.nice.org.uk/guidance/cg113

Last Accessed: April 27, 2025

Level of Evidence: Expert Opinion/Consensus Statement

CBT for GAD uses some combination of psychoeducation (understanding safety behaviors), worry exposure, applied relaxation, and re-structuring common automatic thoughts (e.g., catastrophizing). Meta-analyses clearly demonstrate that CBT significantly reduces GAD symptoms and is markedly more effective than placebo or wait-list control conditions [120]. Sessions should occur at least weekly over 6 to 12 weeks and involve 12 to 20 sessions. While fewer than eight sessions is as effective as eight or more sessions for anxiety symptoms, more intense regimens are more effective in improving worry and depression symptoms [258,259,260]. Individual and group CBT seem equally effective in anxiety symptom reduction, but individual therapy may lead to earlier improvement in worry and depression symptoms [120].

Cognitive Therapy

Cognitive therapy teaches patients to evaluate their anxious thoughts objectively. Variants include pure cognitive therapy, cognitive restructuring, meta-cognitive therapy, and uncertainty intolerance therapy. Cognitive therapy typically involves 15 to 20 individual sessions [261].

As discussed, effective cognitive therapy/CBT treatment helps patients develop new, alternative strategies to manage worries and habits and cope with life stressors, which reduces the symptoms of anxiety. Cognitive therapy/CBT helps patients to understand [261]:

- They cannot control their fears but can control their worrying behavior as a fear response.

- Worrying has no protective value, reinforces negative thinking, and increases the risk of escalating anxiety levels in the future.

- Worrying does not assist in managing negative future scenarios, and patients are equipped to handle whatever future challenges appear.

Cognitive therapy/CBT techniques may be especially helpful for generalized anxiety in later life [120].

Internet-Based CBT

Internet-based CBT is delivered by patient-administered media interventions. Components include cognitive restructuring, exposure, problem solving, and applied relaxation, usually over six to eight sessions [261,262]. Efficacy is demonstrated, with benefits maintained at long-term follow-up. A peer-to-peer cognitive self-therapy program has been found as effective as treatment-as-usual, with a decreased need for therapist contact [120].

Applied Relaxation

Applied relaxation teaches the patient a coping skill that will enable him or her to relax rapidly in order to counteract and eventually abort the anxiety reactions. This therapy is different from simple relaxation alone, which is not helpful. Applied relaxation entails having patients relax in actual anxiety-provoking situations. Achieving effective applied relaxation technique requires around 15 individual sessions [261].

Second-Line Options

Acceptance and commitment therapy and mindfulness are CBT variants with promising initial results. They teach patients to focus on the present moment and follow actions guided by their values rather than by emotions and anxiety. Effective acceptance and commitment therapy usually involves 10 to 15 individual sessions [261].

Short- and long-term psychodynamic psychotherapy has a degree of efficacy and may be useful when CBT/cognitive therapy is unavailable. Specific psychotherapy targets in GAD include intolerance of uncertainty, poor problem-solving confidence, and positive and negative metacognitive beliefs concerning the value or utility of worry [263].

Adjunctive Approaches

Additional modalities can be added to psychotherapy and/or drug therapy. Exercise is not widely studied in GAD, but available data have shown reduction in anxiety symptoms [264]. Meditation training is an option for patients unable or unwilling to receive psychotherapy [265]. Applied relaxation is effective as adjunctive therapy and uses relaxation techniques that are self-monitoring without the use of in-depth psychotherapy [266]. In addition, physical activity has been noted as a cost-effective treatment for GAD [121].

Sleep disturbances are highly prevalent in patients with GAD. Sleep hygiene education can be a useful tool in primary care, used with CBT in GAD to ensure the best possible sleep efficiency and quality. Patients can be counseled to improve sleep hygiene by going to bed and waking up at the same time each day, eliminating alcohol after 6 p.m., avoiding caffeine after 3 p.m., and getting out of bed if unable to fall asleep to avoid development of negative associations with the bed environment [267,268]. Long-term follow-up data from a meta-analysis and randomized controlled trials suggest that benefits of psychologic treatments are maintained one to three years following treatment [120].

PHARMACOTHERAPY

In addition to demonstrated efficacy, the selection of initial drug therapy for GAD is based on illness severity (degree of distress and disability), medical and psychiatric comorbidities, substance abuse profile, patient preference, and side effect profile. In general, an SSRI or SNRI is preferred for initial pharmacological treatment. These agents have been shown to be moderately effective in multiple controlled clinical trials, and no single agent has proved more effective than others. The choice of an SNRI or SNRI over an older antidepressant (e.g., TCA) is due more to increased tolerability (side effects and toxicity) than to difference in efficacy [54].

First-Line Options

The ADAC and the Anxiety and Depression Association of America (ADAA) have created guidelines for the selection of appropriate pharmacotherapy in the treatment of GAD with differing recommendations regarding first- and second-line medications [120,261]. The ADAC recommends agomelatine, pregabalin, venlafaxine XR, duloxetine, escitalopram, paroxetine, or sertraline as first-line options, while the ADAA suggests venlafaxine XR, duloxetine, paroxetine, escitalopram, sertraline, or fluoxetine [120,261].

Pregabalin

Two randomized, placebo- and active comparator-controlled, double-blind studies evaluated the efficacy of pregabalin versus lorazepam for the treatment of GAD. The pregabalin and lorazepam groups experienced greater reductions in Hamilton Anxiety Rating Scale (HAM-A) score by week 4 compared with placebo, with no observed statistically significant differences among the active-treatment groups. Relative to placebo, pregabalin 600 mg significantly reduced psychic and somatic anxiety, while lorazepam significantly reduced somatic anxiety symptoms only. Anxiety reduction with pregabalin and lorazepam was evident within one week [185].

A four-week trial randomized 451 patients with GAD to alprazolam 1.5 mg/day; pregabalin 300, 450, or 600 mg/day; or placebo. As measured by HAM-A scores, psychic anxiety symptoms were significantly reduced (vs. placebo) with all pregabalin doses and alprazolam by weeks 1 and 4. Somatic anxiety symptoms were significantly reduced by 300 and 600 mg pregabalin, but not by 450 mg pregabalin or 1.5 mg alprazolam (vs. placebo). Pregabalin produced an early onset (≤1 week) of clinically relevant anxiety reduction comparable to alprazolam and anxiety reduction over a broader range of GAD symptoms than alprazolam by four weeks [269].

Data was combined from six placebo-controlled trials of patients with GAD randomized to pregabalin 150 mg, 300–450 mg, or 600 mg; lorazepam 6 mg/day; alprazolam 1.5 mg/day; or placebo. Pregabalin 300–600 mg significantly improved HAM-A psychic and somatic anxiety factor scores, but pregabalin 150 mg showed significance in psychic anxiety only. Of the 14 HAM-A items, significant improvement was shown on 13 with pregabalin 300–450 mg, 10 with pregabalin 600 mg, and 5 with benzodiazepines. A dose-response effect was evident for pregabalin [270].

Along with SSRIs/SNRIs, pregabalin is considered a first-line agent for long-term GAD treatment by the World Federation of Societies of Biological Psychiatry. Head-to-head studies with SSRIs/SNRIs are lacking, but pregabalin augmentation of SSRI/SNRI therapy has been found more effective than SSRI/SNRI alone [205].

Sleep dynamics were evaluated in healthy volunteers randomized to pregabalin (150 mg three times per day), alprazolam (1 mg three times per day), or placebo for three days. Pregabalin and alprazolam modestly but significantly reduced sleep-onset latency (compared with placebo). Pregabalin significantly increased the proportion of slow-wave sleep to total sleep period, and the slow-wave sleep duration of stage 4 sleep. Alprazolam significantly reduced slow-wave sleep. Rapid eye movement (REM) sleep latency with pregabalin did not differ from placebo and was significantly shorter than with alprazolam. Pregabalin and alprazolam similarly reduced the REM sleep proportion to total sleep (vs. placebo), while pregabalin significantly reduced the number of awakenings longer than one minute. Ease in getting to sleep and sleep quality were subjectively rated as improved with both active treatments. Pregabalin effects on sleep and sleep architecture were distinct from benzodiazepines. Enhancement of slow-wave sleep was relevant to frequent reports of reductions in slow-wave sleep in patients with fibromyalgia or GAD [271].

Clinical trials have reported euphoria, which emphasizes the need for careful and continuing evaluation of any potential for abuse. Reports of pregabalin abuse have appeared, usually involving individuals with a history of psychotropic medication abuse [243]. Discontinuation symptoms were reported after abruptly stopping pregabalin and were more prominent with higher daily doses. However, significantly fewer withdrawal symptoms were found after stopping pregabalin compared with lorazepam, and when tapered over one week, pregabalin withdrawal symptoms are minimal. Tentative evidence suggests pregabalin may be beneficial in withdrawal from benzodiazepines and related compounds [243].

Agomelatine

Agomelatine studies have mostly investigated its efficacy in GAD. Three randomized controlled trials have been performed. One trial with an escitalopram arm found that agomelatine led to comparable efficacy in GAD and significantly improved sleep restoration with fewer side effects and no discontinuation symptoms compared with escitalopram [202]. The low discontinuation rate reflected good tolerability, and laboratory results showed a low incidence of transient elevations in liver enzymes. Another trial that measured therapeutic response as 50% or greater reduction in HAM-A score found response rates of 66.7% with agomelatine, compared with 46.6% with placebo. Agomelatine was noted to improve sleep quality, with a lack of sexual side effects or discontinuation syndrome. Dizziness (8%) and nausea (5%) were more frequent than placebo [202,272]. Agomelatine was superior to placebo in symptom reduction beginning at six weeks and in relapse prevention at six-month follow-up [203].

Second-Line Options

When treatment with SSRIs/SNRIs proves to be ineffective or intolerable, alternative choices with demonstrable efficacy include TCAs (e.g., imipramine) or a second-generation antipsychotic agent (quetiapine or pregabalin). Pregabalin is also effective for augmenting other first- and second-line agents in patients showing partial response. Internationally, pregabalin is regarded as a first-line option for GAD, but U.S. guidelines have not yet integrated this agent into the first-line tier [185].

Several options as second-line agents have efficacy in GAD comparable to first-line agents but possess potential side effects or other risks that preclude first-line use [120]. Benzodiazepines would be considered first in most cases, except where there is a risk of substance abuse, while bupropion XL would likely be reserved for later. Quetiapine XR remains a good choice in terms of efficacy, but given the metabolic concerns associated with this atypical antipsychotic, it should be reserved for patients who lack response or cannot tolerate antidepressants or benzodiazepines [120]. It is important to note that drugs such as beta-blockers (e.g., propranolol) prescribed to address the physical symptoms of anxiety are ineffective in the treatment of GAD [243].

Quetiapine

In three 10-week randomized controlled trials of patients with GAD, quetiapine monotherapy showed clinically and statistically significant improvements in anxiety reduction and remission rates versus placebo [185]. Meaningful separation from placebo in anxiety reduction began as early as four to seven days after initiation of treatment. Somnolence, dizziness, and fatigue were more frequent with quetiapine, and sexual function improved slightly in quetiapine groups. Quetiapine has shown decreased symptom recurrence and improved sleep quality during maintenance treatment. However, quetiapine is not recommended for patients with nonresponding GAD because efficacy is inconsistent [185]. One literature review included three studies that evaluated the use of quetiapine extended-release (XR) as monotherapy for acute GAD treatment, one study that evaluated quetiapine XR monotherapy for maintenance treatment of GAD, and five studies that evaluated quetiapine (2 XR, 3 immediate release) as adjunct therapy for acute GAD treatment [273]. Quetiapine displayed both efficacy and tolerability in all monotherapy trials evaluating its use for acute and long-term treatment of GAD. Despite limitations to and heterogeneity among the five adjunct therapy studies, three studies showed that quetiapine resulted in statistically significant changes in the HAM-A scores [273].

Imipramine

While TCA use has become disfavored because of tolerability and safety issues, compelling support of imipramine efficacy for GAD came from a landmark study comparing the anxiolytic effects of imipramine, trazodone, diazepam, and placebo in non-depressed patients with GAD. Imipramine resulted in moderate-to-marked improvement between weeks 2 and 8 of therapy in 73% of patients, compared with 69% for trazodone, 66% for diazepam, and 44% for placebo [274].

Vortioxetine

Multiple randomized controlled trials involving patients with GAD found clinical improvement and symptom reduction with vortioxetine marginally greater or similar to placebo. With vortioxetine, discontinuation from side effects was modestly greater than placebo, with incidence of sexual dysfunction comparable. Patients with severe baseline GAD did show significantly greater benefit from vortioxetine [186,275,276].

Comorbid Major Depression

With a few caveats, treatment of GAD is generally the same whether comorbid major depression is present or absent. Use of buspirone and pregabalin is not recommended, while duloxetine has shown efficacy in comorbid anxiety disorder and major depressive disorder [277]. Patients with comorbid major depression and GAD prescribed benzodiazepines, sedating medications, or TCAs should be monitored for suicide risk; those with severe depression and suicidal ideation may require hospitalization while therapy is initiated [278].

Relapse Prevention

Relapse-prevention studies randomized patients showing response to acute treatment to placebo or the same medication/dose. Results in GAD showed significant advantages with continuing the active medications agomelatine, duloxetine, escitalopram, paroxetine, quetiapine, venlafaxine, or vortioxetine versus switching to placebo for periods of 6 to 18 months [243].

9. TREATMENT OF PANIC DISORDER

Evidence Based Practice Recommendation

The National Collaborating Centre for Mental Health asserts that people who have panic disorder and their families and carers need comprehensive information, presented in clear and understandable language, about the nature of their condition and the treatment options available.

https://www.nice.org.uk/guidance/cg113

Last Accessed: April 27, 2025

Level of Evidence: Expert Opinion/Consensus Statement

Treatment of panic disorder is directed at prevention of panic attacks and reducing preoccupation and anxiety around possibility of impending attacks. SSRIs and SNRIs are effective in preventing panic attacks and relieving anxiety but have no impact on acute symptoms associated with an attack. A treatment duration of four to eight weeks is generally required to see a significant reduction in symptoms. A meta-analysis of 54 psychotherapy studies found that eight standard interventions, including supportive psychotherapy, behavioral therapy, cognitive therapy, and CBT, were equally efficacious for managing panic disorder, independent of accompanying agoraphobia [125]. Another meta-analysis found that combined psycho- and pharmacotherapy was superior to single-mode therapy, with efficacy verses placebo twice as large as pharmacotherapy alone [279]. The results also suggest that the effects of pharmacotherapy and psychotherapy are largely independent from each other and roughly equal in contribution to the effects of combined treatment. The effects remain strong and significant up to two years post-treatment.

PSYCHOTHERAPY

Behavior Therapy

Behavior therapy for panic disorder consists of graded exposure to body sensations that accompany panic (interoceptive exposure), to situations perceived as threatening (in vivo exposure, imagery exposure, virtual reality exposure), or both, in order to progressively reduce apprehensive reaction toward them by the patient. Although exposure strategies alone can be effective in the treatment of panic disorder, they do not appear to be a valid alternative to CBT as a first-line treatment [151].

Cognitive Therapy

In cognitive therapy for panic disorder, panic attacks are thought to result from the catastrophic misinterpretation of certain bodily sensations. The patient perceives the sensations of normal anxiety response as much more dangerous than they are, such as palpitations viewed as evidence of impending heart attack. Cognitive therapy identifies these negative interpretations of the bodily sensations experienced in panic attacks, suggests alternative non-catastrophic interpretations, and helps the patient test the validity of these alternative interpretations. While cognitive therapy is often combined with behavioral techniques, there is some evidence that training in cognitive procedures in isolation from exposure and behavioral procedures is efficacious in reducing some aspects of panic [151,280,281,282,283].

CBT

CBT assumes that cognitions, behaviors, and emotions are interrelated and combines behavior therapy and cognitive therapy to reduce emotional distress and psychologic symptoms. CBT for panic disorder consists of psychoeducation, breathing retraining, progressive muscle relaxation, cognitive restructuring, behavioral experiments, interoceptive exposure, and in vivo exposure. A consistent body of evidence supports the efficacy of CBT for panic disorder in individual or group sessions. There is also growing evidence that supports CBT efficacy when therapist-supported and self-administered via the Internet [151,284,285]. A network meta-analysis found that the most effective combination of CBT components for treatment of panic disorder was face-to-face administration and graded interoceptive exposure to physiological aspects of the panic response, while muscle relaxation and virtual-reality exposure were the least effective components [286].

Patient Education

An essential step after diagnosis of panic disorder is to review with patients their fears of medical illness and expectations of medical testing and treatment. More than 80% of patients with panic disorder present with a medical symptom, and most are fearful of having a serious condition, such as a stroke. Clinical experience suggests that patients benefit from education about panic disorder as the cause of their symptoms and the mechanism by which a mental disorder may provoke physical symptoms. Educational materials for patients may be obtained from the ADAA (https://adaa.org) and the National Institute of Mental Health (https://www.nimh.nih.gov) [129].

PHARMACOTHERAPY

The first-line drugs recommended for the treatment of panic disorder are SSRIs or venlafaxine XR [120]. Research suggests that the largest effect size is found with clonazepam, followed by venlafaxine and fluoxetine [224]. Despite a sizeable number of pharmacologic options, less than 50% of patients with panic disorder experience full and sustained remission to first-line medication therapy [287].

SSRI/SNRI

The SSRI safety/side effect profile relative to TCAs, MAOIs, and benzodiazepines led to their recommendation as first-line drug options for patients with panic disorder. SSRI side effects occur early in treatment before the therapeutic effects. Many patients with panic disorder are highly sensitive to side effects, and SSRIs should be started at low doses, with dose titration every five to seven days, as tolerated [129].

Following 10 weeks of venlafaxine treatment for panic disorder, patients with few dissociative symptoms during panic attacks showed significantly greater treatment response than patients with greater presence of panic attack-associated dissociative symptoms. These findings suggest that dissociative symptoms accompanying panic disorder negatively impact pharmacologic treatment response. Re-evaluation of dissociative symptoms at the beginning and end of treatment would help in personalizing therapy [288].

Benzodiazepines

A meta-analysis was performed of randomized controlled trials comparing alprazolam to other benzodiazepines in the treatment of panic disorder with or without agoraphobia [289]. In the pooled results, there were no significant differences in efficacy between alprazolam and comparator benzodiazepines on improvements in panic attack frequency, anxiety rating scores, or proportion of patients panic attack-free at final evaluation. To date, the evidence fails to demonstrate alprazolam superiority to other benzodiazepines for panic disorder treatment [289]. Additionally, while alprazolam is one of the most widely prescribed benzodiazepines for the treatment of panic disorder, its clinical use is contentious due to its potential for misuse [290].

10. TREATMENT OF AGORAPHOBIA

Almost all agoraphobia studies reported treatment outcomes of patients with co-occurring panic disorder, as they were not separated into distinct diagnostic entities until the DSM-5 was published in 2013.

PSYCHOTHERAPY

CBT is the most empirically supported psychosocial treatment for panic disorder with agoraphobia, with a central focus of repeated exposure to feared situations and sensations and application of skills learned in therapy. These include cognitive skills to control negative thoughts and somatic skills to control dysregulated physiology during exposure. While CBT has clearly been established as an effective treatment for panic disorder with agoraphobia, the effect sizes are smallest among the anxiety disorders and a large percentage of treatment completers are not panic free or do not reach responder status after treatment. The largest randomized controlled trial to date for panic disorder with agoraphobia found only 32% of those assigned to CBT alone demonstrated strong treatment response at 12 months post-treatment [162]. A small 20-year follow-up of patients with panic disorder with agoraphobia found that completion of medication-free, integrated exposure and psychodynamic treatment resulted in excellent very long-term outcomes for these patients [291].

The relevance of process variables in patient response and outcomes with CBT have been studied. Among 301 patients with panic disorder/agoraphobia, changes in panic symptoms were preceded by changes in catastrophic appraisal and agoraphobic avoidance in all treatment phases, anxiety sensitivity during generalization and follow-up, and psychologic flexibility during exposure therapy. Changes in functioning were preceded by changes in agoraphobic avoidance and psychologic flexibility in all treatment phases, fear of bodily symptoms during generalization/follow-up, and anxiety sensitivity during exposure. The effects of process variables on outcomes differed across treatment phases and outcomes. Agoraphobic avoidance and psychologic flexibility should be therapeutically targeted in addition to cognitive variables [292].

Low remission rates in patients with panic disorder/agoraphobia following CBT-based therapies has led to the development and evaluation of novel psychotherapies, adjunctive drug therapies, and cognitive enhancer drugs to improve exposure therapy response and remission rates.

Novel Psychotherapies

The intervention for patients with panic disorder/agoraphobia who are nonresponsive to CBT has generally been pharmacotherapy, with few studies evaluating a switch to psychotherapy. In one study, patients with previous unsuccessful state-of-the-art treatment were randomized to immediate acceptance and commitment therapy or four-week waiting list with delayed acceptance and commitment therapy; they were then followed for up to six months. Significantly greater changes in functioning and symptomatology were found in patients who received immediate acceptance and commitment therapy versus those on the waiting list, and medium-to-large effect sizes were maintained for six or more months. Acceptance and commitment therapy may be a viable treatment option for treatment-resistant panic disorder with agoraphobia [293].

A long-term study of patients with panic disorder and agoraphobia found catastrophic beliefs to be an important mediator of change. Of 46 patients with panic disorder/agoraphobia randomized to cognitive or guided mastery therapy, 31 (67.4%) medication-free patients who completed treatment were followed up to 18 years post-treatment. Both groups showed a large effect size for avoidance of situations when alone, and 56.5% no longer met diagnostic criteria for panic disorder or panic disorder with agoraphobia. Patient outcomes between the two treatments were comparable, although guided mastery was associated with greater beneficial changes in catastrophic beliefs and self-efficacy. Greater reduction in panic-related beliefs about physical and mental catastrophes predicted lower anxiety level at follow-up [294].

Combination Therapy

Following paroxetine plus CBT (once weekly for 12 weeks), paroxetine plus CBT and virtual reality exposure (four sessions), or paroxetine only, the six-month follow-up of 99 patients with panic disorder/agoraphobia showed reduced anxiety levels in all three groups and greatest reduction in both CBT groups. The virtual reality exposure group showed greater improvement in confronting agoraphobic stimuli, although medication cessation and dropout were high [295].

The one-year follow-up of patients with panic disorder with and without agoraphobia treated with CBT, SSRI, or CBT and SSRI found that panic attack frequency significantly declined in all groups and both SSRI groups improved significantly faster than CBT [296]. The SSRI gains were maintained after tapering. Panic frequency in patients with moderate-to-severe agoraphobia decreased more rapidly with CBT plus SSRI than either sole treatment. With CBT alone, improvement was slower than with SSRI or CBT plus SSRI. SSRI monotherapy was concluded sufficient for patients with panic disorder with no or mild agoraphobia, while patients with panic disorder and moderate-to-severe agoraphobia should receive CBT plus SSRI [296].

PHARMACOTHERAPY

An efficacy analysis of drug therapy trials in the treatment of panic disorder with agoraphobia was published in 2011 [86]. It concluded that panic attack recurrence worsens agoraphobic behaviors in panic disorder with agoraphobia and disrupts agoraphobia remission. This suggests that using panic attack-blocking medication in patients with panic disorder/agoraphobia at risk of panic attack recurrence is more appropriate than CBT alone.

The meta-analysis also found that paroxetine displayed high efficacy in panic and phobic symptoms and agoraphobia severity reduction. This efficacy was similar to CBT in reducing agoraphobic behaviors and superior to CBT in reducing panic attacks during acute treatment phase [86]. Adding paroxetine to CBT in patients with poor CBT response is significantly more effective in improving agoraphobic behaviors than adding placebo, so it is strongly suggested to add paroxetine for patients lacking adequate response or panic attack reduction with CBT [86]. Sertraline, citalopram, and escitalopram are also effective in the treatment of panic disorder/agoraphobia.

A randomized controlled trial compared treatment with an SSRI (paroxetine or citalopram) to continued treatment with CBT in a sample of 68 individuals with panic disorder (with or without agoraphobia) who had not responded to an initial course of CBT [297]. Participants were randomized to three months of treatment and then followed for an additional nine months. Those who responded to treatment after 3 months were maintained on the treatment until 12-month follow-up. Participants receiving an SSRI showed significantly lower panic disorder symptoms compared with continued CBT at three months, suggesting a greater improvement in panic disorder symptoms when patients are switched to an SSRI after failure to respond to an initial course of CBT [297].

The TCA clomipramine has similar panic/phobic efficacy to paroxetine and sertraline. Imipramine is more effective than placebo in long-term maintenance, but less effective than sertraline in short-term outcomes. Venlafaxine is effective in reducing panic and phobic symptoms [86]. Reboxetine is more effective in the treatment of panic/phobia than placebo. It has similar efficacy to paroxetine in phobic avoidance and anticipatory anxiety, but lower efficacy in reducing panic attacks.

Fluvoxamine has only inconsistent efficacy in the treatment of panic disorder/agoraphobia, and while fluoxetine may be used to address panic attacks, it has limited efficacy for panic disorder/agoraphobia [86].

These results suggest noradrenergic system involvement in modulating panic disorder with agoraphobia avoidance behaviors, but serotonergic system targeting is important to decrease panic attacks. Re-analysis of prior pharmacologic randomized controlled trial data found higher efficacy with sertraline and clomipramine in reducing agoraphobic symptoms than paroxetine, fluvoxamine, or citalopram. This may reflect the added dopaminergic modulation of these agents beyond their primary serotonergic activity [86].

A novel treatment approach is based on multiple findings of balance system dysfunction in patients with panic disorder/agoraphobia. An open study found citalopram influenced the balance system in these patients by improving postural stability, as measured by static posturography. Compared with baseline scores, most patients whose balance system function improved were no longer agoraphobic, while those whose posturography scores remained abnormal continued to be agoraphobic. These findings suggest the involvement of balance system dysfunction in panic disorder with agoraphobia and serotonergic system relevance in mediating the connection between balance and agoraphobia [298]. The authors suggest that real abnormal body functioning (primarily involving cardiorespiratory and balance systems), which leads to reduced overall physical fitness, may be a primary cause of panic disorder and that the anxiety and fear it induces is sustained by repeated signals of impaired body functioning [299].

In one study, patients with panic disorder/agoraphobia received alprazolam plus exposure, alprazolam plus progressive muscle relaxation, placebo plus exposure, or placebo plus progressive muscle relaxation. The highest rate of improvement at follow-up was observed in the placebo/exposure (71%) and alprazolam/exposure (71%) groups; alprazolam/progressive muscle relaxation (51%) and progressive muscle relaxation/placebo (25%) groups were less improved [300]. Alprazolam showed no benefit over placebo when added to exposure therapy as treatment for panic disorder/agoraphobia [300].

CONTRIBUTING FACTORS TO PANIC DISORDER WITH AGORAPHOBIA TREATMENT RESPONSE

Pronounced safety behaviors during exposure therapy, but not at baseline, have been associated with poor treatment response in patients with panic disorder/agoraphobia. This underscores the importance of rigorous safety behavior assessment during therapy [301].

During 13 to 21 years post-treatment follow-up, major depression at baseline predicted worse improvement in agoraphobic avoidance in the first year. Employment and marriage/cohabitation at baseline predicted greater improvement at 1-year, 2-year, and 13- to 21-year follow-up [302].

A substantial number of patients with panic disorder/agoraphobia fail to improve following CBT. Agoraphobic avoidance is the most consistent predictor of decreased improvement, followed by low expectancy for change, high levels of functional impairment, and Cluster C personality pathology [303].

11. TREATMENT OF SOCIAL ANXIETY DISORDER

PSYCHOTHERAPY

CBT is the criterion-standard psychologic treatment for SAD. Cognitive restructuring techniques are used to challenge assumptions and maladaptive thoughts (i.e., "I will embarrass myself"), while the behavioral component centers on patient exposure to anxiety-provoking situations. Over time and with repeated exposure sessions, the goal is to reduce anxiety symptoms and to demonstrate that the situational anxiety is tolerable and without substantial risk. The efficacy of CBT is supported by many randomized controlled trials, with outcomes that vary but are typically similar to pharmacotherapy. Some reports suggest that, after treatment discontinuation, gains achieved with CBT may persist longer than those achieved with pharmacotherapy. CBT for SAD can be administered in group or individual formats. Although some studies have reported that individual CBT is superior to group CBT, meta-analyses have failed to find significant differences in efficacy between the two modalities. There is evidence to support the effectiveness of exposure therapy alone, but efficacy compared with CBT is equivocal [120].

Several CBT variants have been examined. Videotaped feedback was not shown to enhance the effects of exposure-based treatment. However, CBT with virtual reality exposure was found more effective than wait-list control and as effective as CBT with imaginal or in vivo exposure according to two meta-analyses [120].

A form of CBT focused on interpersonal behavior found similar improvements in social anxiety compared to standard CBT and also increased relationship satisfaction and social approach behaviors. Evidence to support interpersonal therapy in SAD is conflicting; while some results are negative, interpersonal therapy is probably more effective than wait-list control, but less effective than traditional CBT [120].

With Internet CBT for SAD, patients with an avoidance and depression profile showed lower remission after treatment, higher levels of social anxiety at follow-up assessments, and typically remained highly symptomatic. In patients with SAD, high levels of social avoidance and depressive symptoms constitute a risk profile for poor treatment response [304].

PHARMACOTHERAPY

Pharmacotherapy of SAD is effective but varies considerably, with room for further improvement [305]. Placebo-controlled clinical trials have shown that SSRIs and SNRIs are the most effective class of pharmacologic treatment. The ADAC recommends escitalopram, fluvoxamine (immediate- or controlled-release), paroxetine (immediate- or controlled-release), pregabalin, sertraline, or venlafaxine XR for first-line treatment of SAD [120]. Citalopram has less evidence but is likely as effective as other SSRIs. Phenelzine efficacy is established in multiple randomized controlled trials but is recommended as a second-line option due to concerns over dietary and medication restrictions that, if not strictly adhered to, can lead to hypertensive crisis [120].

Abnormalities in brain GABA and glutamate systems have been studied in patients with SAD, including whether these changed following eight weeks of levetiracetam. Compared to healthy controls, patients with SAD at baseline showed significantly higher whole brain levels of glutamate and glutamine (but not GABA) and significantly higher thalamic glutamine and lower GABA levels. Following treatment, these patients showed significant reduction in thalamic glutamine. These findings support the role of impaired GABAergic and overactive glutamatergic function in SAD and may explain the anxiolytic effects of levetiracetam [306].

12. TREATMENT OF SPECIFIC PHOBIA

Patients with specific phobias generally do not consult medical professionals when able to avoid the specific feared situations or objects. Exposure therapy is effective in treating specific phobia and is the favored approach.

PSYCHOTHERAPY

Exposure-based therapies are the treatments of choice and show a high degree of successful remission for all phobias. In vivo exposure and virtual reality exposure to phobic stimuli or situations are both effective, with in vivo exposure superior to imaginal and virtual reality exposure at post-treatment but not at follow-up [307]. The effectiveness of exposure-based therapy is enhanced when exposure sessions are grouped closely together; when exposure is prolonged, real (not imagined), and provided in different settings; and when there is some degree of therapist involvement instead of being entirely self-directed. A greater number of sessions have been shown to predict more favorable outcomes. There is no evidence that flooding is more effective, and patients usually find graded, progressive exposures more tolerable [307].

A variety of psychotherapeutic options have been found effective for the treatment of specific phobias, with some approaches recommended for particular phobias (Table 4) [120]. For blood-injection-injury phobias, an effective approach is combining exposure therapy with muscle tension exercises (applied tension) designed to prevent fainting. Using stress-reducing medical devices, such as decorated butterfly needles and syringes, has significantly reduced needle phobia and stress in pediatric and adult patients. With dental phobias, use of CBT can reduce avoidance of oral injections and decrease patient anxiety [120,307].

Table 4: PSYCHOLOGIC TREATMENTS EFFECTIVE IN SPECIFIC PHOBIA

Treatment Approach

Phobia(s)

Exposure-based treatments

All specific phobias

Virtual reality exposure

Heights, flying, spiders, claustrophobia

Computer-based self-help programs

Spiders, flying, small animals

Applied muscle tension (i.e., exposure with muscle tension exercises)

Blood-injection-injury type

Cognitive therapy and exposure

Dental, flying

Source: [120]

Evidence Based Practice Recommendation

The National Collaborating Centre for Mental Health recommends against routinely offering computerized CBT to treat specific phobias in adults.

https://www.nice.org.uk/guidance/cg159/resources/social-anxietydisorder-recognition-assessment-and-treatmentpdf-35109639699397

Last Accessed: April 27, 2025

Level of Evidence: Expert Opinion/Consensus Statement

Long-term treatment of specific phobia is rare. CBT and exposure therapies show sustained benefits at long-term follow-up assessments following a time-limited course of treatment [120].

PHARMACOTHERAPY

Pharmacotherapy has a minimal role in specific phobia treatment, largely from the lack of drug therapy research and the success of exposure therapies. Alprazolam benefit was studied in 28 women with flying phobia during two air travel exposures, one week apart. Compared with subjects given pre-flight placebo for both flights, those receiving alprazolam before the first flight had less anxiety and symptoms but greater heart and respiratory rates. Those given alprazolam had a substantial increase in panic attacks during the second flight compared with the first flight (71% vs. 7%), greater overall anxiety, and further elevation in heart rate. Alprazolam increased physiologic activation under acute stress conditions and hindered the therapeutic effects of exposure therapy for flying phobia [120,308]. These findings require replication to determine clinical utility.

Some benefit is suggested by small trials of paroxetine or escitalopram. However, there is too little evidence to recommend any drug treatment of specific phobias [224].

A NOVEL APPROACH COMBINING MEDICATION AND EXPOSURE THERAPY

In 2015, a potential landmark study of 45 subjects with spider phobia was published. A pre-treatment two-minute tarantula exposure was followed four days later by randomization to propranolol without exposure or to exposure and then propranolol 40 mg or placebo (within 10 minutes). All three groups went through tarantula exposure 9 days, 16 days, 90 days, and one year later [309].

After nine days, all exposure/propranolol subjects touched the tarantula, while the other two groups barely touched its container. By 16 days, all exposure/propranolol subjects further progressed in approach, while the two other groups did not progress. Approach behavior remained stable for all three groups throughout one year. Most interestingly, significant reduction in self-reported spider fear lagged several months behind the instant behavioral transformation in the exposure/propranolol group [309].

This study is the first to identify optimal drug and timing for durable remission of phobic anxiety and avoidance. The results challenge the fundamental tenet of CBT that changes in cognition are necessary for behavioral change. Such a novel approach is clearly needed, and similar trials enrolling subjects with agoraphobia and social phobia are expected in the future [309].

13. TREATMENT OF SEPARATION ANXIETY DISORDER

PSYCHOTHERAPY

As mentioned, the presence of pathologic separation anxiety has a pervasive negative influence on treatment response in patients with diverse anxiety and mood disorders receiving standard therapies. Patients with SEPAD show poor response to standard CBT and exposure-based therapies. This poorer treatment response may reflect the difficulties these patients experience forming and maintaining attachments, including therapeutic relationships. Growing evidence points to the incompatibility in applying the prevailing fear extinction model of anxiety to patients with SEPAD. This pathophysiologic model emphasizes desensitization to threatening stimuli. While theoretically and empirically supported in other anxiety disorders, this model does not consider the role of earlier childhood SEPAD in adult panic disorder and other anxiety disorders [98].

The unmet need for SEPAD-specific treatment has led to psychotherapies that focus on relationships and separation anxiety. These approaches use the therapist-patient relationship to recapture and better understand important elements of earlier pathologic parent-child relationships. Panic-focused psychodynamic psychotherapy is an affect-focused therapy that specifically targets separation anxiety as a core component of panic disorder. Preliminary efficacy is shown in patients with prominent separation anxiety symptoms across different anxiety and mood disorders. High separation anxiety levels constitute a central organizing element in patient self-perception as incompetent and unable to manage developmentally normative tasks without the presence of their central attachment figures. Panic-focused psychodynamic psychotherapy emphasizes free association, centrality of transference, unconscious thoughts that underlie physical sensations of panic, and difficulty with separation and autonomy. The therapist focuses on these processes as they relate to panic symptoms. Common themes of difficulty with separations and unconscious rage inform interpretive interventions. The pre-determined 24-session, 12-week time limit enhances the opportunity to work with separation anxiety and permits the re-experiencing and better understanding [98].

PHARMACOTHERAPY

With adult SEPAD becoming formalized in 2013 as a distinct diagnostic entity and anxiety disorder, little pharmacotherapy research has been performed specifically addressing this condition.

14. EMERGING THERAPIES AND NOVEL TREATMENT APPROACHES

NEUROENHANCING AGENTS TO AUGMENT EXPOSURE THERAPY

Some neuroenhancers, especially D-cycloserine (DCS), are promising for treating anxiety disorders because these agents improve extinction learning efficacy, integral in exposure therapy. They facilitate learning new memories through habituation and extinction, and these safe memories will over-ride the previous fear memories. Use of neuroenhancers to augment CBT represents a promising translational effort—taking neuroscience discovery into clinical practice. In contrast, use of anxiolytics and CBT in anxiety disorders did not originate from a theoretical basis for the mechanism of action, and overall effectiveness leaves substantial room for improvement [164].

D-Cycloserine

The most extensively studied exposure augmentation agent is DCS, an N-methyl-D-aspartate (NMDA) receptor partial agonist. Findings that extinction learning is modulated, in part, by the glutamatergic NMDA receptor complex prompted interest in the role of glutamatergic transmission in anxiety disorders. Clinical trials began to study the potential efficacy of low-dose DCS for enhancing memory consolidation and thereby improving the effectiveness of exposure therapies for anxiety disorders [165]. DCS studies of patients with specific phobia (e.g., heights, snakes), OCD, panic disorder with agoraphobia, PTSD, or SAD have been published, showing a marginal benefit when combined with exposure therapy. Following promising early findings, more recent studies have reported inconsistent results, including findings that DCS resulted in faster rates of improvement but not higher response or remission rates in SAD and even more symptoms at post-treatment in PTSD. These inconsistent trials have informed the understanding of limitations and indications of DCS augmentation of exposure therapy [310,311,312,313].

Dosing and dose timing of DCS is essential. Most trials reporting positive results used low-dose DCS (50–250 mg) one to two hours before three to five exposure sessions. Studies with negative results often used higher doses (≥250 mg), chronically (before 12 exposures), and more than one to two hours before an exposure. Higher-dose DCS shows weaker NMDA partial agonist or antagonist effects. Key extinction learning processes occur hours following exposure, and DCS blood concentration peaking at four to six hours makes it more effective taken within one to two hours before exposure for peak activity to coincide with key extinction processes. Repeated DCS use can desensitize the NMDA receptor complex, leading DCS to effectively work as an NMDA antagonist. Long-term antidepressants can induce neurochemical changes at the glycine binding site of the NMDA receptor complex, which alters the action of DCS. Therefore, use of DCS should consider the narrow therapeutic window and the need to be administered without concomitant medication, acutely, and at low doses one to two hours pre-exposure [310].

DCS is associated with serious risks. DCS not only enhances cognitive processes during fear extinction learning but also during fear memory reconsolidation, thus improving good exposures and worsening bad exposures. If fear-inducing stimulus re-exposure during fear memory reactivation is too brief relative to the strength of fear conditioning or if fear decrease during exposure is inadequate, little extinction is induced and DCS can augment the process of fear memory reconsolidation to worsen symptoms [310].

These findings led to DCS administered post-exposure, contingent on the level of fear reduced (i.e., extinction learning achieved) by the end of the exposure session. Preliminary evidence shows that this approach may be effective in capitalizing on the benefits while minimizing the risks of DCS use to augment exposure therapy [310].

Yohimbine Hydrochloride

Yohimbine hydrochloride (YOH) is a selective competitive alpha2-adrenergic receptor antagonist currently only approved for veterinary use. This compound increases extracellular norepinephrine in humans by blocking autoreceptor inhibition of norepinephrine release. This mechanism potentially facilitates extinction learning in exposure therapies. Placebo-controlled trials have been performed in specific phobia and SAD. Subjects with claustrophobia given YOH 10.8 mg before two 60-minute exposures of sitting in a closed, dark chamber showed more robust reductions in claustrophobia symptoms. Patients with SAD given YOH 10.8 mg before four exposure sessions showed accelerated treatment improvement and lower levels of social anxiety symptoms. More research is needed, but these results suggest YOH may have a role in augmenting exposure therapy [164].

Glucocorticoids

Glucocorticoids have shown enhancement of virtual reality-based exposure therapy for fear of heights and were investigated for possible outcome enhancement in exposure-based group therapy for spider phobia. In one randomized controlled trial, cortisol 20 mg or placebo was orally administered one hour before each therapy session and patients were assessed at one-month post-therapy follow-up. Compared to placebo, cortisol led to significantly greater reduction in fear of spiders at follow-up but not immediately post-treatment, as measured psychometrically and by exposure to live spiders. Groups did not differ in phobia-unrelated state-anxiety before and after exposure sessions and at follow-up [314].

Another randomized controlled trial investigated the role of hydrocortisone as an adjunct to brief CBT for specific (spider) fear [315]. Spider-fearful participants were randomized to receive either 20 mg hydrocortisone or placebo one hour prior to single-session, predominantly computerized, exposure-based CBT. Participants' fear of spiders was assessed using self-report and approach behaviors measured at baseline and at one-day and one-month follow-up. Threat processing was assessed at baseline and at one-day follow-up. Cortisol and cortisone levels from hair and saliva samples were analyzed at baseline. All measures improved following CBT. Augmentation with hydrocortisone resulted in greater improvement in self-reported fear and approach behavior but not threat bias. Neither threat bias nor endogenous glucocorticoids predicted symptom change. Evidence indicates that higher hair cortisone predicts a stronger threat bias reduction [315].

Methylene Blue

Methylene blue is a nitric oxide synthase inhibitor, central MAO inhibitor, and cerebral metabolic enhancer. A placebo-controlled trial of subjects with severe claustrophobic fear found that participants displaying low fear at the end of extinction training showed significantly less fear at follow-up if they received methylene blue post-training relative to placebo. In contrast, participants displaying moderate-to-high levels of post-training fear tended to fare worse at follow-up with methylene blue compared with placebo. Similar to the profile of DCS, methylene blue enhanced memory and retention of fear extinction when administered after a successful exposure session, but it may have deleterious effects on extinction when administered after an unsuccessful session [316].

CAPNOMETRY-ASSISTED RESPIRATORY TRAINING

Panic disorder and sensitivity to increased carbon dioxide (CO_2) levels common in patients with panic disorder may represent pathologically amplified survival mechanisms. Panic disorder reflects a "fight-or-flight" response, and CO_2 hypersensitivity is an evolutionary carry-over from when alarm response to dwindling oxygen helped ensure survival. Panic attacks that awaken people at night only occur during non-REM sleep, when deep relaxation and slowed breathing lead to rising CO_2 levels that trigger a false suffocation alarm [317].

Capnometry-assisted respiratory training (CART) is an intervention that addresses CO_2 fluctuation and its role in panic attacks for some people. CART targets respiratory dysregulation and hypocapnia through a four-week training using immediate feedback of end-tidal CO_2 pressure (PCO_2). Patients are taught how to raise subnormal PCO_2 levels (caused by hyperventilation) to control dysfunctional respiratory patterns and related panic symptoms of shortness of breath and dizziness. CART uses novel technologies that allow precise assessment and monitoring of core respiratory variables. A portable capnometer offers breath-by-breath feedback of expired CO_2 and breathing rate, as measured via nasal cannula.

In one study, four weeks of CART led to reductions in panic symptom severity and frequency comparable to standard CBT, maintained at 12-month follow-up. Patients with panic disorder/agoraphobia randomized to four weeks of CART or cognitive therapy showed significant and comparable reductions in panic symptom severity and panic-related cognitions [281]. Across studies in patients with panic disorder with agoraphobia and asthma, compliance with the 17-minute, twice-daily exercises was high, and compliance correlated with the extent of panic symptom reduction [281,318]. Changes in PCO_2 mediated and preceded changes in fear of panic sensations, cognitive reappraisal of symptoms, and perceived control. Reductions in respiration rate were unrelated to outcome [281,319]. These findings strengthen the idea that panic symptom reduction can be achieved through different mechanisms [162].

NEUROMODULATION THERAPIES

Brain stimulation (also referred to as neuromodulation, neurostimulation, or somatic therapy) for the treatment of neuropsychiatric disorders was developed as an option for patients with severe disorders refractory to multiple treatments. Electroconvulsive therapy, introduced more than 75 years ago, has been historically the only widely used somatic treatment of psychiatric disorders. This was changed by the development and FDA approval of several minimally or non-invasive brain stimulation modalities with much greater specificity than electroconvulsive therapy. Other modalities are undergoing evaluation and possible market entry [320]. This approach shifts the treatment focus from altering synaptic neurotransmission to altering or modulating the function of entire neural circuits, the dysfunction of which underlies anxiety disorders [120].

Repetitive Transcranial Magnetic Stimulation

The most studied neurostimulation approach in the United States is repetitive transcranial magnetic stimulation (rTMS). As discussed, patients with panic disorder often lack response or only partially respond to drug or psychologic treatments, which increases the risk of the disorder becoming chronic and disabling. Transcranial magnetic stimulation delivers non-invasive stimulation to the cerebral cortex, with currents induced by powerful, extremely brief magnetic fields. Administration in a rhythmic, repetitive form is rTMS. Modulation of cortical excitability uses high-frequency rTMS to increase cortical excitability or low-frequency rTMS to inhibit cortical excitability of targeted areas. rTMS can also affect remote brain areas connected to the stimulated site [321].

Early studies of rTMS in anxiety disorders often found no difference between active vs. sham rTMS, reflecting the inability to stimulate brain regions deeper than superficial cortical layers and inadequate treatment duration or post-treatment follow-up [322]. Subsequent technical refinements show treatment efficacy.

A randomized controlled trial treated 28 patients with panic disorder and major depression with active or sham rTMS to the right dorsolateral prefrontal cortex. Response was defined as reduction by ≥40% in panic disorder severity and ≥50% in depression ratings. After four weeks, panic disorder response rate was 50% with active and 8% with sham rTMS, with no difference in depression. After eight weeks of active rTMS, response rates were 67% for panic and 50% for depressive symptoms. Significant improvements occurred in panic disorder, major depression, clinical global impression, and social adjustment. Clinical improvements were maintained at six months post-treatment. While four weeks of rTMS was sufficient to significantly reduce panic symptoms, a longer course led to better outcomes for both panic disorder and major depression. These data suggest that inhibitory rTMS to the right dorsolateral prefrontal cortex affects symptom expression in comorbid anxiety and depressive disorder [323]. Another study found that inhibitory rTMS to the left dorsolateral prefrontal cortex showed therapeutic effects in patients with major depressive disorder [324].

NEW OR NOVEL ANXIOLYTIC AGENTS

Cannabidiol

Cannabidiol is the second most abundant cannabinoid in Cannabis plants and lacks the consciousness-altering effects of delta-9-tetrahydrocannabinol (THC), the primary psychoactive compound in Cannabis. Cannabidiol is a pharmacologically broad-spectrum drug that has drawn increasing interest as a treatment for a range of neuropsychiatric conditions, including anxiety disorders. Preclinical evidence supports cannabidiol as a treatment for GAD, panic disorder, SAD, OCD, and PTSD when administered acutely, but few studies have investigated chronic cannabidiol dosing. Randomized controlled trials showed that, relative to placebo, cannabidiol significantly reduced anxiety in patients with SAD and GAD [136,325].

In a series of randomized controlled trials using fear-conditioning paradigms, subjects who received cannabidiol (vs. placebo) all showed successful conditioning, extinction, and recall. When given after resolution of symptoms, cannabidiol enhanced consolidation of extinction learning. Cannabidiol administered pre- or post-extinction reduced the reinstatement of autonomic contextual responding. No acute effects of cannabidiol were found on extinction. These results are the first evidence that cannabidiol may enhance consolidation of extinction learning in humans, suggesting cannabidiol may have potential as an adjunct to extinction therapies for anxiety disorders [326].

Brain imaging cannabidiol trials in patients with GAD or SAD consistently showed changes in functional activity in limbic and paralimbic cortical areas implicated in anxiety pathophysiology, with effects in the left para-hippocampal gyrus, the hippocampus, and the right posterior cingulate gyrus. Cannabidiol was found safe and tolerable, with few side effects and without major side effects during acute treatment. Cannabidiol administered chronically in oral doses of 10–1,280 mg/day to healthy volunteers and patients with schizophrenia, bipolar affective disorder, Parkinson disease, or Huntington disease did not find significant side effects or induction of any new neurologic, psychiatric, or general clinical conditions [136,327]. Overall, evidence indicates cannabidiol has considerable potential as a treatment for several anxiety disorders, with further study of chronic and therapeutic effects in relevant clinical populations needed [325,328].

Etifoxine

Etifoxine (also known as etafenoxine) is a non-benzodiazepine anxiolytic and anticonvulsant not yet approved in the United States. Clinical effects are mediated by GABA-Aα2 receptors, similar to benzodiazepines, and etifoxine appears to produce anxiolytic effects directly by binding to β2 or β3 subunits of the GABA-A receptor complex. The effects of etifoxine are not completely reversed by the benzodiazepine antagonist flumazenil. Etifoxine also stimulates neurosteroid production, which contributes to anxiolytic and neuroprotective effects. Several randomized controlled trials comparing etifoxine to lorazepam found vigilance, psychomotor performance, and free recall significantly impaired by lorazepam but not etifoxine. Superior anxiolytic effect and memory recall were noted with etifoxine, with fewer withdrawal symptoms than with lorazepam. Etifoxine appears promising as a non-benzodiazepine anxiolytic agent that lacks many shortcomings with benzodiazepines and SSRIs, although acute liver toxicity has been reported [329,330].

Asenapine

Asenapine is a newer atypical antipsychotic drug. Its dominant mechanism of action is mediated through 5HT2A and D2 receptor antagonism and also by antagonism of 5HT2B, 5HT2C, 5HT6, and 5HT7 serotoninergic; α1A, α2A, α2B and α2C adrenergic; and D3/D4 dopaminergic receptors [178]. Clinical efficacy in anxiety and mood disorders is predicted by its serotoninergic profile. This agent lacks affinity for muscarinic receptors and induces fewer anticholinergic side effects than other second-generation antipsychotics [331]. Asenapine is FDA-approved for schizophrenia and bipolar disorder; its use for anxiety disorders is off-label [178].

Tandospirone

Closely related to buspirone, tandospirone (also known as metanopirone) is a 5-HT1A receptor partial agonist used in China and Japan. Its efficacy was compared to sertraline in an eight-week randomized controlled trial in adolescents with SAD. Both drugs significantly improved anxiety scores from baseline, showed similar overall response and anxiety symptom-specific response rates (≥50% reduction), and resulted in significant and comparable improvements in social phobia symptoms. Tandospirone appeared non-inferior to sertraline treatment of SAD in adolescents. The drug is not FDA-approved [332].

15. COMPLEMENTARY/ALTERNATIVE THERAPIES

HERBAL PRODUCTS AND SUPPLEMENTS

Myo-Inositol

Myo-inositol is a glucose isomer and essential component of the phosphatidylinositol second messenger system critically linked to several CNS receptor-signaling systems [333]. Myo-inositol anxiolytic and antidepressant activity is mediated by a serotoninergic 5-HT2A/5-HT2C receptor-signaling pathway [334].

Several randomized controlled trials have been conducted using placebo or active controls. In 21 patients with panic disorder with or without agoraphobia given inositol 12 g/day or placebo for four weeks, significant decreases were found in the frequency and severity of panic attacks and agoraphobia severity with inositol relative to placebo [335]. Another randomized controlled trial compared myo-inositol 18 g/day with fluvoxamine 150 mg/day in patients with panic disorder with or without agoraphobia. Both drugs led to significant but comparable improvements in anxiety symptoms/severity, agoraphobia symptoms/severity, and global impression. In the first month, reduction in the number of panic attacks per week was significantly greater with inositol than fluvoxamine (4.0 vs. 2.4). Nausea and fatigue were significantly more common with fluvoxamine [336].

Other randomized controlled trials found that myo-inositol 12 g/day in 28 patients with major depression significantly reduced Hamilton Depression Rating Scale scores (vs. placebo) after four weeks; and 18 g/day given to patients with OCD for six weeks led to significant reductions in OCD symptom scores (vs. placebo) [335]. A review of supplements and herbal therapies with purported anxiolytic efficacy concluded myo-inositol was one of very few with demonstrated effectiveness [337]. The published research needs larger trials but is intriguing in light of a study in which patients with severe depression receiving treatment with rTMS showed significantly elevated prefrontal cortex myo-inositol levels, and this elevation correlated with extent of clinical improvement [338]. A meta-analysis of inositol for depression and anxiety disorders found that the agent may be particularly beneficial for treatment of depression [339].

The effective dose is 12–18 g per day, and inositol is free of side effects other than loose stools and drowsiness [335]. A drawback is the large amount required for therapeutic benefit, necessary to compensate for poor blood-brain barrier penetration. An Italian pharmaceutical company has developed a more concentrated myo-inositol formulation, with dose comparability to standard myo-inositol at 25% the dose level [338].

Overall, inositol is a natural compound with few side effects and may be an attractive option for patients with panic disorder who are ambivalent about taking psychiatric medication [336]. Myo-inositol is one of nine inositol isomers, but unless another inositol isomer is specified, inositol sold at retail is almost always myo-inositol.

Kava

Kava (Piper methysticum) extract has been used for anxiolytic effects, mediated through GABA channel modulation and weak GABA binding, β-adrenergic downregulation, and MAO-B inhibition. Efficacy studies in GAD showed superiority to placebo and comparability to buspirone. However, distribution and use of kava dropped off when reports of liver toxicity surfaced in the early 2000s [340,341,342].

Lavender Oil

A six-week randomized controlled trial compared silexan, a lavender oil capsule preparation, with lorazepam in GAD treatment efficacy. Both treatment groups showed similar reductions on the primary anxiety measure (HAM-A) and similar and comparable reductions on measures of somatic anxiety, psychic anxiety, anxiety self-rating, impression of illness severity, sleep quality, and other scales. Silexan appears to be an effective and well-tolerated alternative to benzodiazepines for GAD treatment [343]. A 10-week randomized controlled trial compared silexan with paroxetine and placebo in GAD treatment efficacy. Participants received 80 mg or 160 mg silexan, 20 mg paroxetine, or placebo once daily for 10 weeks [344]. The primary outcome measured was HAM-A total score reduction between baseline and treatment end. A total of 60.3% of participants in the silexan 160 mg group showed a HAM-A total score reduction greater than 50% of the baseline value compared with 51.9% in the silexan 80 mg group, 34.1% in the paroxetine group and 37.8% in the placebo group. Silexan additionally showed a pronounced antidepressant effect and improved general mental health and health-related quality of life. Rates of adverse effects were comparable among the silexan and placebo groups and lower for the paroxetine group [344].

EXERCISE THERAPY

Resistance exercise (i.e., strength training) includes a broad group of activities that evoke repeated muscle action against resistances above those encountered in daily life. A growing body of literature has identified anxiolytic effects of resistance exercise after both single sessions and long-term training. This research has shown that resistance training at a low-to-moderate intensity produces the most reliable and robust decreases in anxiety. Higher intensity has shown either no change or increased anxiety from baseline. One caveat is most of this research involved participants with state (not trait) anxiety [345].

YOGA

Yoga is an ancient mind/body practice that involves different techniques in physical postures, controlled breathing, deep relaxation, and meditation that have positive and specific influences. Research on yoga has demonstrated significant improvements in emotional self-regulation with consequent reductions in depression, stress, and anxiety levels and improvements in mood, quality of life, and well-being [346]. Several studies have found significant anxiolytic effects with yoga in patients with GAD or panic disorder, and it is considered the complementary therapy with strongest evidence of safety and efficacy in anxiety disorders.

One randomized controlled trial compared patients with panic disorder who received yoga or CBT plus yoga weekly over two months. Both treatment groups showed significant decreases from baseline in anxiety levels associated with panic disorder, panic-related beliefs, and panic-related body sensations, although the CBT/yoga combination group led to greater reductions over yoga alone [346].

A group of patients with GAD lacking response to pharmacotherapy received a five-day, 22-hour yoga course. Compared with baseline, follow-up at four weeks found a 73% response rate and 41% remission rate and significant reductions in HAM-A total score and psychic subscale score. Attrition was 25% [347].

Combining yoga with CBT integrates yoga and meditation with traditional and alternative CBT methods to enhance restructuring of the destructive cognitive and emotional patterns associated with physical and psychologic anxiety symptoms. Given in 90-minute sessions once per week for six weeks, CBT/yoga consisted of yoga/meditation, instruction and experiential cognitive restructuring using traditional and alternative CBT interventions, and group discussion with processing. In a group of patients with GAD receiving CBT/yoga, post-treatment scores were compared to baseline. The patients showed significant improvements on measures of state and trait anxiety, depression, panic, suicidality, sleep disturbance, sexual function, and quality of life [348].

16. CONCLUSION

Anxiety disorders are among the most prevalent mental health disorders encountered in primary care settings, yet these disorders often go under-recognized and undertreated for a variety of reasons, including reluctance to discuss emotional and psychological distress; clinic and practitioner time constraints; and attribution of symptoms to somatic conditions. Chronicity and episodic exacerbations often lead to ongoing personal distress and functional disability, resulting in excessive healthcare utilization and societal costs. Screening tools are available for diagnostic purposes, and effective pharmacotherapy and psychotherapy regimens specific to each anxiety disorder have been developed. The prevalence, distress/disability, potential for comorbidity, and management complexities associated with anxiety disorders emphasize the need for understanding (and paying attention to) the clinical presentation, differential diagnosis, and appropriate treatment selection in these patients.

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Evidence-Based Practice Recommendations Citations

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