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Anxiety Disorders Back to Basics 2012

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Title: Anxiety Disorders Back to Basics 2012


1
Anxiety DisordersBack to Basics 2012
  • Dr. Holly Dornan
  • PGY-4 Psychiatry Resident
  • University of Ottawa

2
Anxiety
3
LMCC Objectives
  • Key Objectives
  • In patients with many other medical complaints
    and/or excessive utilisation of medical health
    care, determine whether anxiety co-exists.
  • Differentiate situational stress from true
    anxiety disorder and from drug and physical
    causes of anxiety.
  • Objectives
  • Through efficient, focused, data gathering
  • Review various physical symptoms briefly elicit
    history of other non-psychiatric illness, intake
    of alcohol and caffeine, and a brief history of
    any major life stresses.
  • Elicit a history of excessive worry about events
    which is out of proportion to the impact of the
    event history present for at least six months
    (anxiety).
  •     

4
LMCC Objectives
  • Determine whether there is restlessness, fatigue,
    inability to concentrate, irritability, muscle
    tension, sleep disturbance.
  • Determine whether social, occupational, or
    function in general has been affected.
  • Determine whether co-morbid psychiatric disorders
    exist, stress, substance abuse, past sexual,
    physical and emotional abuse, or neglect.
  • Determine whether there is a discrete period of
    intense fear, recurrent panic attacks,gt1 month of
    concern about more attacks, change in behavior in
    relation to attacks, along with cardiopulmonary,
    neurologic, psychiatric or other medical symptoms
    agoraphobia.

5
LMCC Objectives
  • List and interpret critical clinical and
    laboratory findings which were key in the
    processes of exclusion, differentiation, and
    diagnosis.
  • Conduct an effective initial plan of management
    for a patient with anxiety or panic
  • Outline supportive therapy (e.g., psychosocial
    interventions) and counseling and list
    indications for drug therapy (e.g., selective
    serotonin re-uptake inhibitors).
  • Select patients in need of specialized care.

6
LMCC Objectives
  • Applied Scientific Concepts
  • 1. Explain that although the pathophysiology of
    panic disorder/attacks is incompletely
    understood, the amygdala, locus ceruleus, and
    hippocampus along with several neurotransmitters
    have been the focus of attention.

7
LMCC Objectives
  • Causal Conditions
  • 1.     Panic attack
  • a.     Cardiopulmonary symptoms -
    40
  • b.     Neurologic symptoms - 40
  • c.     Gastrointestinal symptoms -
    30
  • d.     Psychiatric symptoms
  • e.     Autonomic symptoms
  • 2.     Panic disorder
  • a.    With agoraphobia/Without
    agoraphobia
  • b.    With social/Specific phobia
  • c.    Trauma/Stress related/Post
    traumatic stress disorder
  • 3.     Associated with other conditions
  • a.    Depression
  • b.    Obsessive compulsive disorder
  • c.    Substance abuse
  • 4.     Generalized anxiety disorder

8
What is anxiety?
  • A feeling state consisting of physical, emotional
    and behavioural responses to perceived threats1
  • Diffuse, unpleasant sense of apprehension
    accompanied by physical symptoms such as
    headache, sweating, palpitations, chest
    tightness, stomach upset, restlessness
  • Normal and necessary part of everyday life

1 Can J Psychiatry Clinical Practice Guidelines
for the Management of Anxiety Disorders July 2006
9
Anxiety vs. Fear
Anxiety
Fear
Threat
Threat
Response to a threat that is unknown, internal,
vague or conflictual
Response to a known, external, definite threat
10
Anxiety as a Disorder
  • When does anxiety become a disorder?
  • 1) Greater intensity and/or duration than
    expected given the circumstances
  • 2) Leads to impairment or disability
  • 3) Daily activities are disrupted by
    avoidance of certain situations or objects to
    decrease anxiety
  • 4) Includes clinically significant
    unexplained physical symptoms, obsessions,
    compulsions, or intrusive recollections of trauma

Can J Psychiatry Clinical Practice Guidelines for
the Management of Anxiety Disorders July 2006
11
Anxiety
Overestimated
Likelihood x Harm
Anxiety
Ability to cope
Underestimated
Beck et al. 1985
12
Pathophysiology of Anxiety
  • Caudate nucleus has been implicated in OCD
  • fMRI studies have found increased activity in the
    amygdala in PTSD
  • Abnormalities in parahippocampal gyrus in Panic
    Disorder
  • 3 major neurotransmitters involved are
    norepinephrine, serotonin, and GABA

Kaplan and Sadocks Synopsis of Psychiatry 10th
edition
13
Neurobiology of anxiety
Slide courtesy of Dr. Elliott Lee
Limbic cortex
Nucleus accumbens
Periaqueductal Gray matter
Orbitofrontal cortex
Amygdala
Locus coeruleus
Brain Stem
Ventral Tegmental Area
Hippocampus
14
Anxiety
  • Patients try to alleviate the unpleasant feeling
    of anxiety by
  • Avoiding the trigger
  • Developing a safety behaviour (i.e. having
    someone else accompany them)
  • Using a substance or medication

15
Anxiety Disorders in DSM-IV TR
  • Panic Disorder with and without agoraphobia
  • Agoraphobia without history of Panic Disorder
  • Social Phobia
  • Specific Phobia
  • Obsessive Compulsive Disorder
  • Generalized Anxiety Disorder
  • Post Traumatic Stress Disorder
  • Acute Stress Disorder
  • Anxiety Disorder due to a General Medical
    Condition
  • Substance-Induced Anxiety Disorder
  • Anxiety Disorder NOS

16
Epidemiology
  • Lifetime prevalence for any anxiety disorder
    ranges from 10 to 29
  • 12 month prevalence 18
  • Common presentation in primary care
  • 15 to 112 patients presenting to primary care
    will have an anxiety disorder
  • Suicide rate 10 x higher than general population

Can J Psychiatry Clinical Practice Guidelines for
the Management of Anxiety Disorders July 2006
17
Initial Assessment of Patients with Anxiety
  • Four scenarios
  • 1) Anxiety disorder is primary and there is
    no physical disorder present (any physical
    symptoms present are due to the anxiety)
  • 2) The anxiety is secondary to a physical
    illness (e.g. hyperthyroidism)
  • 3) The anxiety is secondary to a medication
    or substance
  • 4) Both an anxiety and physical disorder are
    present by not causally related

Can J Psychiatry Clinical Practice Guidelines for
the Management of Anxiety Disorders July 2006
18
Medical conditions that mimic or worsen anxiety
symptoms
Endocrine conditions Hyperthyroidism Hypothyroidism Pheochromocytoma Cushings disease Addisons disease Menopause
Cardiovascular Acute Coronary Syndrome Arrhythmia CHF Hypertension Hypertension Mitral Valve Prolapse
19
Medical conditions that mimic or worsen anxiety
symptoms (cont)
Neurological Epilepsy Cerebrovascular disease Menieres disease Multiple Sclerosis Migraine Encephalitis Early dementia
Metabolic Porphyria Diabetes
Pulmonary Asthma COPD Pulmonary Embolism Pneumonia
20
Medical conditions that mimic or worsen anxiety
symptoms (cont)
Other Anemia UTI (in elderly) Irritable Bowel Syndrome Heavy metal poisoning B12 deficiency Electrolyte disturbances
Medications Anti-cholinergics Steroids Stimulants (methylphenidate and amphetamine based) Theophylline Ventolin Nasal decongestants SSRIs
21
Substance Abuse and Anxiety
  • Substance abuse is often co-morbid with anxiety
    disorders as patients often try to self-medicate
    to cope with anxiety
  • 37 of patients with GAD and 20-40 of patients
    with Panic Disorder have alcohol abuse/dependence
  • Drug intoxication can mimic anxiety
  • - Amphetamines - Marijuana
  • - Caffeine -
    Hallucinogens
  • - Nicotine - Ecstasy
  • - Cocaine -
    Excessive alcohol consumption
  • - Phencyclidine

22
Substance Abuse and Anxiety (cont)
  • Drug withdrawal also associated with anxiety
  • Alcohol
  • Benzodiazepines
  • Opiate
  • Barbiturate
  • Anti-hypertensives

23
Key features
Panic Disorder Fear of losing control, dying or going crazy Avoid situations in which attacks may occur
Agoraphobia Fear of situations from which escape may be difficult or help unavailable (crowds, bus, bridge etc.)
OCD Intrusive, unwanted thoughts or urges (obsessions) and/or repetitive behaviours or mental acts (compulsions) Fear of harm, uncertainty, uncontrollable actions
24
Key features
Generalized Anxiety Anxiety regarding a number of everyday events Future and uncertainty difficult to accept
Social Anxiety Fear of humiliation, embarrassment or scrutiny by others
PTSD Re-experiencing of trauma through flashbacks, dreams, recollections
Specific phobia Fear of a specific object, animal or situation
25
Generalized Anxiety Disorder DSM IV TR
  • Excessive anxiety and worry about a number of
    events or activities, occurring more days than
    not for at least 6 months
  • Difficult to control the worry
  • Associated with three of the following
  • Restlessness, difficulty concentrating, muscle
    tension, fatigue, sleep disturbances,
    irritability
  • Not due to a substance, medical condition or
    other mental disorder
  • Causes clinically significant distress or
    impairment in functioning

26
Generalized Anxiety Disorder
  • Lifetime prevalence 61
  • 68 comorbidity with other psychiatric illness
    (depression, substance abuse, other anxiety
    disorder)
  • Female to male ratio 211
  • 25 of 1st degree relatives also have GAD2
  • Twin studies show concordance rate of 502

1Can J Psychiatry Clinical Practice Guidelines
for the Management of Anxiety Disorders July 2006
2Kaplan and Sadocks Synopsis of Psychiatry 10th
edition
27
Generalized Anxiety Disorder
  • Chronic condition, usually lifelong
  • Screening questions
  • Do others call you a worry-wort?
  • What kinds of things do you worry about?
  • Usually seek treatment for somatic symptoms
    rather than anxiety
  • Only 1/3 seek psychiatric treatment
  • Often see specialists (GI, cardiology,
    internists)

Can J Psychiatry Clinical Practice Guidelines for
the Management of Anxiety Disorders July 2006
28
GAD - treatment
  • Pharmacotherapy
  • 1st line SSRI or SNRI
  • 2nd line Benzodiazepine
  • Only recommended for short term use due to side
    effects (cognitive impairment, ataxia, sedation)
    and dependence and withdrawal)
  • Avoid in substance abuse and the elderly
  • 3rd line Adjunctive olanzapine or risperidone
  • Mirtazapine

Can J Psychiatry Clinical Practice Guidelines for
the Management of Anxiety Disorders July 2006
29
GAD - treatment
  • An optimal trial involves 8-12 weeks
  • If there is not an adequate response, switch to
    another 1st line agent
  • Reasonable to try another 1st line agent with a
    different mechanism of action
  • Treatment resistant patients should be assessed
    for comorbid medical and psychiatric conditions

Can J Psychiatry Clinical Practice Guidelines for
the Management of Anxiety Disorders July 2006
30
GAD - treatment
  • Psychological treatment
  • CBT as effective as medication (also 1st line)
  • CBT involves
  • Psychoeducation
  • Cognitive interventions (addressing cognitive
    distortions, unrealistic beliefs)
  • Exposure
  • Relaxation strategies
  • Problem Solving
  • Assertiveness training
  • Relapse Prevention

31
Panic Attack DSM-IV criteria
  • A discrete period of intense fear or discomfort,
    in which 4 or more develop abruptly and reach a
    peak within ten minutes
  • Palpitations, increased heart rate
  • Sweating
  • Tremor or shaking
  • Shortness of breath or smothering sensation
  • Feeling of choking
  • Chest pain
  • Nausea or abdominal distress
  • Feeling dizzy, lightheaded, or faint
  • Derealization
  • Depersonalization
  • Parasthesias
  • Chills or hot flushes
  • Fear of losing control or going crazy
  • Fear of dying

32
Panic Disorder with or without agoraphobia
DSM-IV criteria
  • The person has experienced both
  • Recurrent, unexpected panic attacks
  • One or more of the attacks has been followed by
    either
  • 1) Persistent concern about having another
    attack
  • 2) Worry about the implications of the
    attack
  • 3) Significant change in behaviour
  • The presence (or absence of agoraphobia)
  • Not due to a substance, medication or medical
    condition
  • Not better accounted for by another mental
    disorder

33
Panic Disorder
  • Lifetime prevalence of Panic Disorder is 4.7
  • Lifetime prevalence of having a panic attack is
    15
  • 1/3 to 1/2 of patients also have agoraphobia
  • More common in women than in men
  • Generally begins in late adolescence or early
    adulthood

Can J Psychiatry Clinical Practice Guidelines for
the Management of Anxiety Disorders July 2006
34
Panic Disorder
  • 20 X the risk of suicidal ideation and suicide
    attempts as the general population
  • Felt to be related to dysregulation of brain
    noradrenergic systems
  • Abnormalities have been found in the autonomic
    nervous system of some patients (increased
    sympathetic tone, less adaptive to repeated
    stimulit)

Kaplan and Sadocks Synopsis of Psychiatry 10th
edition
35
Panic Disorder
  • Initially, panic attacks are unexpected
  • Can occur any time (even night)
  • Can also develop panic attacks that have triggers
    (situationally-predisposed panic attacks)
  • Patients begin to have anticipatory anxiety about
    having another panic attack
  • This can lead to avoidance of situations where
    escape or help may not be readily available
    (agoraphobia)

36
Panic Disorder - Treatment
  • Pharmacotherapy
  • 1st line SSRI or SNRI
  • 2nd line Benzodiazepines
  • Only recommended for short term use due to side
    effects (cognitive impairment, ataxia, sedation)
    and dependence and withdrawal
  • Avoid in substance abuse and the elderly
  • Often clinically, a small dose of long acting
    benzodiazepine is started along with SSRI/SNRI to
    provide more immediate relief from distressing
    symptoms
  • i.e. 0.5 mg clonazepam BID for 2-3 weeks, then
    tapered until it is stopped

Can J Psychiatry Clinical Practice Guidelines for
the Management of Anxiety Disorders July 2006
37
Panic Disorder - Treatment
  • Psychological treatment
  • CBT most consistently efficacious psychotherapy
    for Panic Disorder, according to the literature
  • Individual or group therapy, bibliotherapy
  • CBT for Panic Disorder includes same CBT concepts
    of psychoeducation, cognitive approaches,
    relaxation, problem solving
  • Also incorporates interoceptive exposure
    (exposure to feared symptoms ? therapist may ask
    patient to hyperventilate or spin to make
    themselves dizzy)
  • Exposure to avoided situations is important

38
Obsessive Compulsive Disorder DSM IV criteria
  • Either obsessions or compulsions
  • Obsessions are defined as
  • Recurrent and persistent thoughts, images or
    impulses that are experienced as intrusive and
    inappropriate and cause marked anxiety/distress
  • Not simply excessive worries about real-life
    problems
  • Person attempts to ignore or suppress the
    obsessions, or neutralize them with other
    thoughts or actions
  • Recognized as a product of the patients own mind
  • Compulsions are defined as
  • Repetitive behaviours or mental acts that the
    person feels driven to perform in response to an
    obsession, or according to rigid rules
  • Compulsions are aimed at reducing distress or
    preventing some dreaded event, however they are
    not connected in a realistic way to what they are
    meant to neutralize, or are clearly excessive

39
Obsessive Compulsive Disorder DSM IV criteria
(cont)
  • At some point during the course of the disorder,
    the person recognizes that the obsessions and/or
    compulsions are excessive or unreasonable
  • The obsessions and/or compulsions cause marked
    distress, are time consuming (gt 1 h/day), or
    significantly interfere with functioning
  • Not due to substance, or another medical or
    mental disorder

40
Obsessive-Compulsive Disorder
  • Estimated lifetime prevalence of 1.6
  • Median age of onset 19 years (range 14 30
    years)
  • 60 are female
  • High psychiatric co-morbidity rate (56 -83)
  • Common co-morbidities include substance abuse,
    depression, social phobia, generalized anxiety
    disorder, panic disorder

Can J Psychiatry Clinical Practice Guidelines for
the Management of Anxiety Disorders July 2006
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Obsessive-Compulsive Disorder
  • In 50-70 of patients, onset of symptoms is
    following a stressful event (i.e. pregnancy,
    death)
  • Course is usually long, can be constant or
    fluctuating
  • 20-30 have significant improvement
  • 40-50 have moderate improvement
  • 20-30 have no improvement or worsening

Kaplan and Sadocks Synopsis of Psychiatry 10th
edition
42
Obsessive-Compulsive Disorder
  • 20-30 have tics, 6-7 Tourettes
  • Possible link between a subset of OCD and tics
  • PET studies have shown increased activity in the
    frontal lobes, basal ganglia (caudate), and
    cingulum in patients with OCD
  • PANDAS Pediatric Autoimmune Neuropsychiatric
    Disorders associated with Streptococcal
    infections
  • Streptococcus infection may trigger an autoimmune
    response which causes acute onset OCD symptoms
    and tics in children

Kaplan and Sadocks Synopsis of Psychiatry 10th
edition
43
Obsessive-Compulsive Disorder
  • Most common obsessions include
  • Contamination (1)
  • Doubt/safety (idea that stove was left on, door
    unlocked etc.) (2)
  • Sexual and aggressive impulses (3)
  • Symmetry and exactness (4)
  • Somatic and religious preoccupations
  • Most common compulsions include
  • Checking
  • Washing
  • Repeating
  • Ordering
  • Counting
  • Hoarding

44
OCD - treatment
  • Pharmacotherapy
  • 1st line SSRI (serotonergic response needed)
  • 2nd line Clomipramine (2nd line due to side
    effects cardiotoxicity, anticholinergic, drug
    interactions and lethality in overdose)
  • Effexor XR, Mirtazapine
  • Adjunctive Risperidone
  • Dosages of meds e.g. SSRIs may need to be higher
    than in mood disorders
  • Response may take 6 wks or longer (Guidelines
    state adequate trial 6-8 weeks)

Can J Psychiatry Clinical Practice Guidelines for
the Management of Anxiety Disorders July 2006
45
OCD - treatment
  • Psychological








  • 1) Exposure with Response Prevention
    (ERP) form of behavioural therapy
  • 2) CBT which combines Exposure and Response
    Prevention with cognitive interventions

46
Posttraumatic Stress Disorder DSM-IV criteria
  • The person has been exposed to a traumatic event
    which included both
  • 1) The person experienced or witnessed an event
    involving actual or threatened death or serious
    injury, or a threat to personal integrity of self
    or others
  • 2) Response was fear, horror, or helplessness
  • The traumatic event is re-experienced including
    at least one of
  • Distressing memories, dreams, acting or feeling
    as if event is recurring (illusions, dissociative
    flashbacks, hallucinations), intense
    psychological or physiological distress when
    exposed to cues that symbolize the trauma

47
Posttraumatic Stress Disorder DSM-IV criteria
  • Persistent avoiding of stimuli associated with
    the trauma and numbing of responsiveness
    including at least 3 of
  • Efforts to avoid thoughts, feelings,
    conversations associated with the trauma
  • Efforts to avoid people, places and activities
    associated with the trauma
  • Inability to recall an important aspect of the
    trauma
  • Feeling of detachment or estrangement from others
  • Restricted range of affect
  • Sense of foreshortened future

48
Posttraumatic Stress Disorder DSM-IV criteria
  • Persistent symptoms of increased arousal
    including at least two of
  • Difficulty falling or staying asleep
  • Irritability or outbursts of anger
  • Difficulty concentrating
  • Hypervigilance
  • Exaggerated startle reflex
  • Duration is more than 1 month
  • Causes clinically significant distress or
    impairment in functioning

49
Posttraumatic Stress Disorder
  • Key features include exposure to trauma,
    re-experiencing of the trauma, avoidance and
    emotional numbing, and hyperarousal
  • Examples of traumas include exposure to war,
    terrorist attacks, natural disasters, accidents
    involving serious injury or death, rape, torture
  • If symptoms are present for less than one month,
    then the diagnosis may be Acute Stress Disorder

50
Posttraumatic Stress Disorder
  • Prevalence in Canada 2.4 (1 month prevalence)
    and 9.2 (lifetime prevalence)
  • Higher among women than men
  • Lifetime prevalence estimates 16-37 in areas of
    the world where conflict has occurred
  • Frequent co-morbidity with depression, substance
    abuse, other anxiety disorders

Can J Psychiatry Clinical Practice Guidelines for
the Management of Anxiety Disorders July 2006
51
Posttraumatic Stress Disorder
  • 6X increased risk of suicide attempts
  • Predisposing factors include
  • Childhood trauma
  • Inadequate support system
  • Female
  • Genetic vulnerability to psychiatric illness
  • Excessive alcohol use (recent)

52
Posttraumatic Stress Disorder - Treatment
  • Guidelines recommend SSRI/SNRI as first line
    treatment1
  • Recommended that patients with PTSD should
    continue medication for at least 1 year1
  • In practice, agents to help with insomnia are
    often added (i.e. Trazadone)

1Can J Psychiatry Clinical Practice Guidelines
for the Management of Anxiety Disorders July 2006
53
Posttraumatic Stress Disorder - Treatment
  • Other meds sometimes used include
  • Clonidine (antiadrenergic agent)
  • Prazosin for nightmares (alpha-1 adrenergic
    antagonist)
  • Psychological treatment
  • CBT recommended

54
Social Anxiety Disorder (Social phobia) DSM IV
criteria
  • Marked and persistent fear of social or
    performance situations in which the person is
    exposed to unfamiliar people or possible scrutiny
    by others
  • Fear that they will embarrass or humiliate
    themselves
  • Exposure to the feared situation invariable
    produces anxiety which may be in the form of a
    panic attack
  • The person recognizes that the fear is excessive
    or unreasonable

55
Social Anxiety Disorder (Social phobia) DSM IV
criteria (cont)
  • The feared situations are avoided or endured with
    intense anxiety and distress
  • The avoidance, anxious anticipation or distress
    interferes with functioning or causes marked
    distress
  • In individuals under 18, duration is at least 6
    months
  • Not due to substance, medical condition or other
    mental disorder
  • If a medical condition is present, the fear is
    not related to it (i.e. trembling in Parkinsons)

56
Social Phobia
  • Most people in the general population experience
    a degree of discomfort with certain social
    situations
  • Generalized type vs. non-generalized (a
    restricted number of situations i.e. public
    speaking)
  • Differentiate from panic disorder (panic attacks
    in social phobia always occur in feared
    situations)
  • Differentiate from normal shyness (shyness should
    not cause functional impairment or marked
    distress)

57
Social Phobia
  • Has significant impact on quality of life
  • Lifetime prevalence of 8-12 1 (one of the most
    common anxiety disorders)
  • Early onset, usually in childhood
  • Chronic course, usually 20 years or longer

r
Can J Psychiatry Clinical Practice Guidelines for
the Management of Anxiety Disorders July 2006
58
Social Phobia
  • Interferes with career, relationship, goals
  • illness of missed opportunities
  • Comorbid conditions include substance abuse,
    depression, or another anxiety disorder
  • Key symptoms include blushing, sweating,
    palpitations, tremor and lightheadedness, panic
    attacks
  • Situations are often avoided as an effort to
    alleviate distress

59
Social Phobia - treatment
  • Pharmacotherapy
  • 1st line SSRI or SNRI
  • 2nd line Benzodiazepine
  • Only recommended for short term use due to side
    effects (cognitive impairment, ataxia, sedation)
    and dependence and withdrawal
  • Avoid in people with substance abuse and the
    elderly
  • 3rd line Adjunctive Abilify or Risperidone
  • Mirtazapine, wellbutrin
  • Although not in guidelines, in practice, beta
    blockers have been used with effect for
    non-generalized type performance anxiety

Can J Psychiatry Clinical Practice Guidelines for
the Management of Anxiety Disorders July 2006
60
Social Phobia - treatment
  • Psychological treatment
  • CBT (group or individual)
  • CBT for social phobia includes exposure to feared
    situations and social skills training
  • Similar efficacy to pharmacotherapy
  • In practice, CBT and medications are often
    combined
  • After discontinuation of CBT or medications,
    gains with CBT last longer

61
Specific Phobia DSM IV criteria
  • Excessive or unreasonable fear cued by the
    presence or anticipation of a specific object or
    situation (insects, flying, heights, blood)
  • Exposure provokes an immediate anxiety response
  • Fear is recognized as excessive or unreasonable
  • Situation is avoided or endured with intense
    distress
  • Marked distress or interferes with functioning
  • Not due to a substance, medical condition or
    other mental disorder

62
Specific Phobia
  • Lifetime prevalence of 12
  • Most common mental disorder
  • Begins at young age, 5-12 years old
  • Treatment is exposure based therapy
  • Graded exposure helpful
  • Virtual reality or computer programs sometimes
    used for fear of heights, flying, dentist

Can J Psychiatry Clinical Practice Guidelines for
the Management of Anxiety Disorders July 2006
63
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