Approach Considerations

When the index of suspicion for anxiety being produced by a medical disorder is low (lack of physical findings, younger age, typical anxiety disorder presentation), initial laboratory studies might be limited to the following:

Complete blood cell count
Chemistry profile
Thyroid function tests
Urinalysis
Urine drug screen

Studies to Exclude Medical Disorders

For presentations with a higher index of suspicion for other medical causes of anxiety (ie, atypical anxiety disorder presentation, older age, specific physical examination abnormalities), more detailed evaluations may be indicated to identify or exclude underlying medical disorders.

Electroencephalography, lumbar puncture, and head/brain imaging

Rule out CNS disorder using electroencephalography (EEG), lumbar puncture, or brain computed tomography (CT) scan, as indicated by history and associated clinical findings. EEG may be used to exclude seizure disorder because these conditions may mimic anxiety.

Imaging studies are limited to presentations in which medical illness, such as a seizure disorder, is suspected. If headache is a prominent feature, an EEG or MRI could be considered along with neurologic consultation to rule out seizures or brain tumor. A head CT scan may be ordered for suspected intracranial abnormality, or an MRI scan for intracranial abnormality.

Functional MRI and PET scanning have shown increases in blood flow and metabolic activity in the orbitofrontal cortex, limbic structures, caudate, and thalamus, with a trend toward right-sided predominance, in patients with obsessive-compulsive disorder. In some studies, these areas of overactivity have been shown to normalize following successful treatment with either SSRIs or CBT.^[41]These imaging modalities, however, are of value for research, and not indicated for normal workups.

Electrocardiography

Rule out cardiac disorders (eg, myocardial infarction) using electrocardiography (ECG) or treadmill ECG. ECG may be used to check for mitral valve prolapse or to exclude arrhythmia.

Tests for infection

Rule out infectious causes using rapid plasma reagent test, lumbar puncture (CNS infections), or HIV testing.

Arterial blood gas analysis

Arterial blood gas analysis is useful in confirming hyperventilation (respiratory alkalosis) and excluding hypoxemia or metabolic acidosis. The presence of hypoxemia with hypocapnia or a widened alveolar-arterial (A-a) gradient should increase the suspicion of pulmonary embolus.

Electrolyte analysis

Electrolyte analysis is unnecessary, although several abnormalities may be present in the setting of hyperventilation. Serum phosphorus and ionized calcium may be diminished in patients with hyperventilation and carpopedal spasm, Chvostek sign, or Trousseau sign. The serum calcium level may be within the reference range.

Chest radiography

Chest radiography is useful in excluding other causes of dyspnea with chest pain (eg, pulmonary embolism).

Thyroid function

Hyperthyroidism is one of the most common medical causes for anxiety related to a medical condition. Serum thyroid-stimulating hormone and T4 levels should be considered for excluding a primary thyroid abnormality.

Treatment & Management

American Psychiatric Association. Available at https://www.psychiatry.org/patients-families/anxiety-disorders.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: APA Press; 2013.
Martinez RC, Ribeiro de Oliveira A, Brandão ML. Serotonergic mechanisms in the basolateral amygdala differentially regulate the conditioned and unconditioned fear organized in the periaqueductal gray. Eur Neuropsychopharmacol. 2007 Nov. 17(11):717-24. [QxMD MEDLINE Link]. [Full Text].
Keeton CP, Kolos AC, Walkup JT. Pediatric generalized anxiety disorder: epidemiology, diagnosis, and management. Paediatr Drugs. 2009. 11(3):171-83. [QxMD MEDLINE Link].
Freitas-Ferrari MC, Hallak JE, Trzesniak C, Filho AS, Machado-de-Sousa JP, Chagas MH. Neuroimaging in social anxiety disorder: a systematic review of the literature. Prog Neuropsychopharmacol Biol Psychiatry. 2010 May 30. 34(4):565-80. [QxMD MEDLINE Link].
Katerndahl DA, Talamantes M. A comparison of persons with early-versus late-onset panic attacks. J Clin Psychiatry. 2000 Jun. 61(6):422-7. [QxMD MEDLINE Link].
Vythilingam M, Anderson ER, Goddard A, Woods SW, Staib LH, Charney DS. Temporal lobe volume in panic disorder--a quantitative magnetic resonance imaging study. Psychiatry Res. 2000 Aug 28. 99(2):75-82. [QxMD MEDLINE Link].
Johnson PL, Truitt W, Fitz SD, Minick PE, Dietrich A, Sanghani S. A key role for orexin in panic anxiety. Nat Med. 2010 Jan. 16(1):111-5. [QxMD MEDLINE Link]. [Full Text].
Tambs K, Czajkowsky N, Røysamb E, Neale MC, Reichborn-Kjennerud T, Aggen SH. Structure of genetic and environmental risk factors for dimensional representations of DSM-IV anxiety disorders. Br J Psychiatry. 2009 Oct. 195(4):301-7. [QxMD MEDLINE Link].
Zwanzger P, Eser D, Nothdurfter C, Baghai TC, Möller HJ, Padberg F, et al. Effects of the GABA-reuptake inhibitor tiagabine on panic and anxiety in patients with panic disorder. Pharmacopsychiatry. 2009 Nov. 42(6):266-9. [QxMD MEDLINE Link].
Wedekind D, Bandelow B, Broocks A, Hajak G, Rüther E. Salivary, total plasma and plasma free cortisol in panic disorder. J Neural Transm. 2000. 107(7):831-7. [QxMD MEDLINE Link].
Neumeister A, Bain E, Nugent AC, Carson RE, Bonne O, Luckenbaugh DA. Reduced serotonin type 1A receptor binding in panic disorder. J Neurosci. 2004 Jan 21. 24(3):589-91. [QxMD MEDLINE Link].
Lonsdorf TB, Rück C, Bergström J, Andersson G, Ohman A, Schalling M, et al. The symptomatic profile of panic disorder is shaped by the 5-HTTLPR polymorphism. Prog Neuropsychopharmacol Biol Psychiatry. 2009 Nov 13. 33(8):1479-83. [QxMD MEDLINE Link].
Strug LJ, Suresh R, Fyer AJ, Talati A, Adams PB, Li W, et al. Panic disorder is associated with the serotonin transporter gene (SLC6A4) but not the promoter region (5-HTTLPR). Mol Psychiatry. 2010 Feb. 15(2):166-76. [QxMD MEDLINE Link]. [Full Text].
Johnson MR, Lydiard RB, Ballenger JC. Panic disorder. Pathophysiology and drug treatment. Drugs. 1995 Mar. 49(3):328-44. [QxMD MEDLINE Link].
Greist JH, Jefferson JW, Kobak KA, Katzelnick DJ, Serlin RC. Efficacy and tolerability of serotonin transport inhibitors in obsessive-compulsive disorder. A meta-analysis. Arch Gen Psychiatry. 1995 Jan. 52(1):53-60. [QxMD MEDLINE Link].
Maron E, Hettema JM, Shlik J. Advances in molecular genetics of panic disorder. Mol Psychiatry. 2010 Jul. 15(7):681-701. [QxMD MEDLINE Link].
Dannon PN, Lowengrub K, Amiaz R, Grunhaus L, Kotler M. Comorbid cannabis use and panic disorder: short term and long term follow-up study. Hum Psychopharmacol. 2004 Mar. 19(2):97-101. [QxMD MEDLINE Link].
Schifano F, Di Furia L, Forza G, et al. MDMA (‘‘ecstasy’’) consumption in the context of polydrug abuse: a report on 150 patients. Drug Alcohol Depend. Sep.
González-Berríos N. Sertraline-induced panic attack. Bol Asoc Med P R. 2009 Jan-Mar. 101(1):59-60. [QxMD MEDLINE Link].
Molosh AI, Johnson PL, Fitz SD, Dimicco JA, Herman JP, Shekhar A. Changes in central sodium and not osmolarity or lactate induce panic-like responses in a model of panic disorder. Neuropsychopharmacology. 2010 May. 35(6):1333-47. [QxMD MEDLINE Link].
Dratcu L. Panic, hyperventilation and perpetuation of anxiety. Prog Neuropsychopharmacol Biol Psychiatry. 2000 Oct. 24(7):1069-89. [QxMD MEDLINE Link].
Esquivel G, Fernández-Torre O, Schruers KR, Wijnhoven LL, Griez EJ. The effects of opioid receptor blockade on experimental panic provocation with CO2. J Psychopharmacol. 2009 Nov. 23(8):975-8. [QxMD MEDLINE Link].
Knuts IJ, Cosci F, Esquivel G, Goossens L, van Duinen M, Bareman M, et al. Cigarette smoking and 35% CO(2) induced panic in panic disorder patients. J Affect Disord. 2010 Jul. 124(1-2):215-8. [QxMD MEDLINE Link].
Kendler KS, Karkowski LM, Prescott CA. Fears and phobias: reliability and heritability. Psychol Med. 1999 May. 29(3):539-53. [QxMD MEDLINE Link].
Fyer AJ, Mannuzza S, Chapman TF, Liebowitz MR, Klein DF. A direct interview family study of social phobia. Arch Gen Psychiatry. 1993 Apr. 50(4):286-93. [QxMD MEDLINE Link]. [Full Text].
Kessler RC, McGonagle KA, Zhao S, Nelson CB, Hughes M, Eshleman S, et al. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Results from the National Comorbidity Survey. Arch Gen Psychiatry. 1994 Jan. 51(1):8-19. [QxMD MEDLINE Link].
Stein MB, Stein DJ. Social anxiety disorder. Lancet. 2008 Mar 29. 371(9618):1115-25. [QxMD MEDLINE Link].
Karno M, Golding JM, Sorenson SB, Burnam MA. The epidemiology of obsessive-compulsive disorder in five US communities. Arch Gen Psychiatry. 1988 Dec. 45(12):1094-9. [QxMD MEDLINE Link].
Magee WJ, Eaton WW, Wittchen HU, McGonagle KA, Kessler RC. Agoraphobia, simple phobia, and social phobia in the National Comorbidity Survey. Arch Gen Psychiatry. 1996 Feb. 53(2):159-68. [QxMD MEDLINE Link].
Wittchen HU, Fehm L. Epidemiology, patterns of comorbidity, and associated disabilities of social phobia. Psychiatr Clin North Am. 2001 Dec. 24(4):617-41. [QxMD MEDLINE Link].
Schneier FR, Heckelman LR, Garfinkel R, Campeas R, Fallon BA, Gitow A. Functional impairment in social phobia. J Clin Psychiatry. 1994 Aug. 55(8):322-31. [QxMD MEDLINE Link].
Lochner C, Mogotsi M, du Toit PL, Kaminer D, Niehaus DJ, Stein DJ. Quality of life in anxiety disorders: a comparison of obsessive-compulsive disorder, social anxiety disorder, and panic disorder. Psychopathology. 2003 Sep-Oct. 36(5):255-62. [QxMD MEDLINE Link].
Sareen J, Cox BJ, Afifi TO, de Graaf R, Asmundson GJ, ten Have M. Anxiety disorders and risk for suicidal ideation and suicide attempts: a population-based longitudinal study of adults. Arch Gen Psychiatry. 2005 Nov. 62(11):1249-57. [QxMD MEDLINE Link]. [Full Text].
Matza LS, Revicki DA, Davidson JR, Stewart JW. Depression with atypical features in the National Comorbidity Survey: classification, description, and consequences. Arch Gen Psychiatry. 2003 Aug. 60(8):817-26. [Full Text].
American Psychiatric Association. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition, Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Association Press; 2000.
Kluge M, Schüssler P, Steiger A. Persistent generalized anxiety after brief exposure to the dopamine antagonist metoclopramide. Psychiatry Clin Neurosci. 2007 Apr. 61(2):193-5. [QxMD MEDLINE Link].
Cha C, Nock M. Emotional intelligence is a protective factor for suicidal behavior. J Am Acad Child Adolesc Psychiatry. 2009 Apr. 48(4):422-30. [QxMD MEDLINE Link].
Nitschke JB, Sarinopoulos I, Oathes DJ, Johnstone T, Whalen PJ, Davidson RJ. Anticipatory activation in the amygdala and anterior cingulate in generalized anxiety disorder and prediction of treatment response. Am J Psychiatry. 2009 Mar. 166(3):302-10. [QxMD MEDLINE Link].
Siegmann E-M, Müller H, Luecke C, et al. Association of Depression and Anxiety Disorders With Autoimmune Thyroiditis: A Systematic Review and Meta-analysis. JAMA. May 2, 2018. [Full Text].
Baxter LR Jr, Schwartz JM, Bergman KS, Szuba MP, Guze BH, Mazziotta JC, et al. Caudate glucose metabolic rate changes with both drug and behavior therapy for obsessive-compulsive disorder. Arch Gen Psychiatry. 1992 Sep. 49(9):681-9. [QxMD MEDLINE Link].
de Beurs E, van Balkom AJ, Van Dyck R, Lange A. Long-term outcome of pharmacological and psychological treatment for panic disorder with agoraphobia: a 2-year naturalistic follow-up. Acta Psychiatr Scand. 1999 Jan. 99(1):59-67. [QxMD MEDLINE Link].
Shear MK, Beidel DC. Psychotherapy in the overall management strategy for social anxiety disorder. J Clin Psychiatry. 1998. 59 Suppl 17:39-46. [QxMD MEDLINE Link].
[Guideline] Mayor S. NICE advocates computerised CBT. BMJ. 2006 Mar 4. 332(7540):504. [QxMD MEDLINE Link].
Cuijpers P, Donker T, Weissman MM, Ravitz P, Cristea IA. Interpersonal Psychotherapy for Mental Health Problems: A Comprehensive Meta-Analysis. Am J Psychiatry. 2016 Apr 1. appiajp201515091141. [QxMD MEDLINE Link].
Barclay TH, Barclay RD. A clinical trial of cranial electrotherapy stimulation for anxiety and comorbid depression. J Affect Disord. 2014 Aug. 164:171-7. [QxMD MEDLINE Link].
Brooks M. FDA OKs Brain Stimulator for Insomnia, Anxiety, Depression. Medscape Medical News. Available at https://www.medscape.com/viewarticle/910999. March 27, 2019; Accessed: March 28, 2019.
Hunot V, Churchill R, Silva de Lima M, Teixeira V. Psychological therapies for generalised anxiety disorder. Cochrane Database Syst Rev. 2007. (1):CD001848. [QxMD MEDLINE Link].
Ipser JC, Carey P, Dhansay Y, Fakier N, Seedat S, Stein DJ. Pharmacotherapy augmentation strategies in treatment-resistant anxiety disorders. Cochrane Database Syst Rev. 2006 Oct 18. CD005473. [QxMD MEDLINE Link].
Walkup J, Labellarte M, Riddle MA, Pine DS, Greenhill L, Fairbanks J, et al. Treatment of pediatric anxiety disorders: an open-label extension of the research units on pediatric psychopharmacology anxiety study. J Child Adolesc Psychopharmacol. 2002 Fall. 12(3):175-88. [QxMD MEDLINE Link].
Toneatto T, Nguyen L. Does mindfulness meditation improve anxiety and mood symptoms? A review of the controlled research. Can J Psychiatry. 2007 Apr. 52(4):260-6. [QxMD MEDLINE Link].
[Guideline] American Psychiatric Association (APA). Practice guideline for the treatment of patients with panic disorder. 2nd ed. Washington (DC): American Psychiatric Association (APA); 2009 Jan. Available from the PsychiatryOnline website. Available at http://psychiatryonline.org/content.aspx?bookid=28&sectionid=1680635. Accessed: June 15, 2011.
Celexa (citalopram hydrobromide) [package insert]. St. Louis, Missouri: Forest Pharmaceuticals, Inc. August, 2011. Available at [Full Text].
US Food and Drug Administration. Celexa (citalopram hydrobromide): Drug safety communication – abnormal heart rhythms associated with high doses. [Full Text].
Croom KF, Perry CM, Plosker GL. Mirtazapine: a review of its use in major depression and other psychiatric disorders. CNS Drugs. 2009. 23(5):427-52. [QxMD MEDLINE Link].
Kim JE, Yoon SJ, Kim J, Jung JY, Jeong HS, Cho HB, et al. Efficacy and tolerability of mirtazapine in treating major depressive disorder with anxiety symptoms: an 8-week open-label randomised paroxetine-controlled trial. Int J Clin Pract. 2011 Mar. 65(3):323-9. [QxMD MEDLINE Link].
Sinclair LI, Christmas DM, Hood SD, Potokar JP, Robertson A, Isaac A. Antidepressant-induced jitteriness/anxiety syndrome: systematic review. Br J Psychiatry. 2009 Jun. 194(6):483-90. [QxMD MEDLINE Link].
Barlow JH, Ellard DR, Hainsworth JM, Jones FR, Fisher A. A review of self-management interventions for panic disorders, phobias and obsessive-compulsive disorders. Acta Psychiatr Scand. 2005 Apr. 111(4):272-85. [QxMD MEDLINE Link].
Lewis C, Pearce J, Bisson JI. Efficacy, cost-effectiveness and acceptability of self-help interventions for anxiety disorders: systematic review. Br J Psychiatry. 2012 Jan. 200:15-21. [QxMD MEDLINE Link].
Lydiard RB. The role of drug therapy in social phobia. J Affect Disord. 1998 Sep. 50 Suppl 1:S35-9. [QxMD MEDLINE Link].
Van Ameringen M, Allgulander C, Bandelow B, Greist JH, Hollander E, Montgomery SA, et al. WCA recommendations for the long-term treatment of social phobia. CNS Spectr. 2003 Aug. 8(8 Suppl 1):40-52. [QxMD MEDLINE Link].
Heimberg RG, Liebowitz MR, Hope DA, Schneier FR, Holt CS, Welkowitz LA, et al. Cognitive behavioral group therapy vs phenelzine therapy for social phobia: 12-week outcome. Arch Gen Psychiatry. 1998 Dec. 55(12):1133-41. [QxMD MEDLINE Link]. [Full Text].
Allgulander C. Paroxetine in social anxiety disorder: a randomized placebo-controlled study. Acta Psychiatr Scand. 1999 Sep. 100(3):193-8. [QxMD MEDLINE Link].
Stein MB, Fyer AJ, Davidson JR, Pollack MH, Wiita B. Fluvoxamine treatment of social phobia (social anxiety disorder): a double-blind, placebo-controlled study. Am J Psychiatry. 1999 May. 156(5):756-60. [QxMD MEDLINE Link].
Furukawa TA, Watanabe N, Churchill R. Psychotherapy plus antidepressant for panic disorder with or without agoraphobia: systematic review. Br J Psychiatry. 2006 Apr. 188:305-12. [QxMD MEDLINE Link].
Ayala ES, Meuret AE, Ritz T. Treatments for blood-injury-injection phobia: a critical review of current evidence. J Psychiatr Res. 2009 Oct. 43(15):1235-42. [QxMD MEDLINE Link].
Rothbaum BO, Anderson P, Zimand E, Hodges L, Lang D, Wilson J. Virtual reality exposure therapy and standard (in vivo) exposure therapy in the treatment of fear of flying. Behav Ther. 2006 Mar. 37(1):80-90. [QxMD MEDLINE Link]. [Full Text].
Practice guideline for the treatment of patients with panic disorder. Work Group on Panic Disorder. American Psychiatric Association. Am J Psychiatry. 1998 May. 155(5 Suppl):1-34. [QxMD MEDLINE Link].
Pohl RB, Wolkow RM, Clary CM. Sertraline in the treatment of panic disorder: a double-blind multicenter trial. Am J Psychiatry. 1998 Sep. 155(9):1189-95. [QxMD MEDLINE Link]. [Full Text].
Michelson D, Lydiard RB, Pollack MH, Tamura RN, Hoog SL, Tepner R, et al. Outcome assessment and clinical improvement in panic disorder: evidence from a randomized controlled trial of fluoxetine and placebo. The Fluoxetine Panic Disorder Study Group. Am J Psychiatry. 1998 Nov. 155(11):1570-7. [QxMD MEDLINE Link].
Uhlenhuth EH, Balter MB, Ban TA, Yang K. International study of expert judgment on therapeutic use of benzodiazepines and other psychotherapeutic medications: VI. Trends in recommendations for the pharmacotherapy of anxiety disorders, 1992-1997. Depress Anxiety. 1999. 9(3):107-16. [QxMD MEDLINE Link].
Herrera-Arellano A, Jiménez-Ferrer E, Zamilpa A, Morales-Valdéz M, García-Valencia CE, Tortoriello J. Efficacy and tolerability of a standardized herbal product from Galphimia glauca on generalized anxiety disorder. A randomized, double-blind clinical trial controlled with lorazepam. Planta Med. 2007 Jul. 73(8):713-7. [QxMD MEDLINE Link].
Komossa K, Depping AM, Meyer M, Kissling W, Leucht S. Second-generation antipsychotics for obsessive compulsive disorder. Cochrane Database Syst Rev. 2010 Dec 8. 12:CD008141. [QxMD MEDLINE Link].
Advisory Committee FDA. SEROQUEL XR for the Treatment of Patients with either Major Depressive Disorder or Generalized Anxiety Disorder. FDA. Available at http://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/Drugs/PsychopharmacologicDrugsAdvisoryCommittee/UCM161963.pdf.
Kobak KA, Greist JH, Jefferson JW, Katzelnick DJ, Henk HJ. Behavioral versus pharmacological treatments of obsessive compulsive disorder: a meta-analysis. Psychopharmacology (Berl). 1998 Apr. 136(3):205-16. [QxMD MEDLINE Link].
Bloch MH, Landeros-Weisenberger A, Kelmendi B, Coric V, Bracken MB, Leckman JF. A systematic review: antipsychotic augmentation with treatment refractory obsessive-compulsive disorder. Mol Psychiatry. 2006 Jul. 11(7):622-32. [QxMD MEDLINE Link].
Pittenger C, Krystal JH, Coric V. Glutamate-modulating drugs as novel pharmacotherapeutic agents in the treatment of obsessive-compulsive disorder. NeuroRx. 2006 Jan. 3(1):69-81. [QxMD MEDLINE Link].
van Grootheest DS, Cath DC, Beekman AT, Boomsma DI. Twin studies on obsessive-compulsive disorder: a review. Twin Res Hum Genet. 2005 Oct. 8(5):450-8. [QxMD MEDLINE Link].
Carey G, Gottesman I. Twin and family studies of anxiety, phobic, and obsessive disorders. In: Klein DF, Rabkin JG. Anxiety: New Research and Changing Concepts. New York: Raven Press; 2000.
Lochner C, Mogotsi M, du Toit PL, Kaminer D, Niehaus DJ, Stein DJ. Quality of life in anxiety disorders: a comparison of obsessive-compulsive disorder, social anxiety disorder, and panic disorder. Psychopathology. 2003 Sep-Oct. 36(5):255-62. [QxMD MEDLINE Link].
Arnold PD, Sicard T, Burroughs E, Richter MA, Kennedy JL. Glutamate transporter gene SLC1A1 associated with obsessive-compulsive disorder. Arch Gen Psychiatry. 2006 Jul. 63(7):769-76. [QxMD MEDLINE Link].
Denys D, Van Nieuwerburgh F, Deforce D, Westenberg H. Association between the dopamine D2 receptor TaqI A2 allele and low activity COMT allele with obsessive-compulsive disorder in males. Eur Neuropsychopharmacol. 2006 Aug. 16(6):446-50. [QxMD MEDLINE Link].
Dickel DE, Veenstra-VanderWeele J, Cox NJ, Wu X, Fischer DJ, Van Etten-Lee M. Association testing of the positional and functional candidate gene SLC1A1/EAAC1 in early-onset obsessive-compulsive disorder. Arch Gen Psychiatry. 2006 Jul. 63(7):778-85. [QxMD MEDLINE Link].
Lin PY. Meta-analysis of the association of serotonin transporter gene polymorphism with obsessive-compulsive disorder. Prog Neuropsychopharmacol Biol Psychiatry. 2007 Apr 13. 31(3):683-9. [QxMD MEDLINE Link].
Deykin EY. Posttraumatic Stress Disorder in Childhood and Adolescence: A Review. Medscape Mental Health [online]. 1999. [Full Text].
Marshall RD, Pierce D. Implications of recent findings in posttraumatic stress disorder and the role of pharmacotherapy. Harv Rev Psychiatry. 2000 Jan-Feb. 7(5):247-56. [QxMD MEDLINE Link].
Milad MR, Orr SP, Lasko NB, Chang Y, Rauch SL, Pitman RK. Presence and acquired origin of reduced recall for fear extinction in PTSD: results of a twin study. J Psychiatr Res. 2008 Jun. 42(7):515-20. [QxMD MEDLINE Link].
Goodman WK, Price LH, Rasmussen SA, Mazure C, Fleischmann RL, Hill CL, et al. The Yale-Brown Obsessive Compulsive Scale. I. Development, use, and reliability. Arch Gen Psychiatry. 1989 Nov. 46(11):1006-11. [QxMD MEDLINE Link].
First MB, Spitzer RL, Gibbon M, Williams JBW. Structured Clinical Interview for DSM-IV-TR Axis I Disorders. Patient Edition (SCID-I/P, 11/2002 revision). New York: Biometrics Research Department, New York State Psychiatric Institute; November 2002.
Helping Children and Adolescents Cope with Violence and Disasters. National Institute of Mental Health. NIH Publication No. 01-3518. Bethesda, Md: National Institute of Mental Health; 2001.
Dickie EW, Brunet A, Akerib V, Armony JL. An fMRI investigation of memory encoding in PTSD: influence of symptom severity. Neuropsychologia. 2008 Apr. 46(5):1522-31. [QxMD MEDLINE Link].
Germain A, Shear MK, Hall M, Buysse DJ. Effects of a brief behavioral treatment for PTSD-related sleep disturbances: a pilot study. Behav Res Ther. 2007 Mar. 45(3):627-32. [QxMD MEDLINE Link].
Raskind MA, Peskind ER, Hoff DJ, Hart KL, Holmes HA, Warren D. A parallel group placebo controlled study of prazosin for trauma nightmares and sleep disturbance in combat veterans with post-traumatic stress disorder. Biol Psychiatry. 2007 Apr 15. 61(8):928-34. [QxMD MEDLINE Link].
Rodriguez BF, Weisberg RB, Pagano ME, Machan JT, Culpepper L, Keller MB. Mental health treatment received by primary care patients with posttraumatic stress disorder. J Clin Psychiatry. 2003 Oct. 64(10):1230-6. [QxMD MEDLINE Link].
Högberg G, Pagani M, Sundin O, Soares J, Aberg-Wistedt A, Tärnell B. Treatment of post-traumatic stress disorder with eye movement desensitization and reprocessing: outcome is stable in 35-month follow-up. Psychiatry Res. 2008 May 30. 159(1-2):101-8. [QxMD MEDLINE Link].
Ponniah K, Hollon SD. Empirically supported psychological treatments for adult acute stress disorder and posttraumatic stress disorder: a review. Depress Anxiety. 2009. 26(12):1086-109. [QxMD MEDLINE Link].
Litz BT, Engel CC, Bryant RA, Papa A. A randomized, controlled proof-of-concept trial of an Internet-based, therapist-assisted self-management treatment for posttraumatic stress disorder. Am J Psychiatry. 2007 Nov. 164(11):1676-83. [QxMD MEDLINE Link].
Foa EB, Wilson R. Stop Obsessing!: How to Overcome Your Obsessions and Compulsions. Revis ed. New York: Bantam Dell; 2001.
Coric V, Taskiran S, Pittenger C, Wasylink S, Mathalon DH, Valentine G, et al. Riluzole augmentation in treatment-resistant obsessive-compulsive disorder: an open-label trial. Biol Psychiatry. 2005 Sep 1. 58(5):424-8. [QxMD MEDLINE Link].
Greenberg WM, Benedict MM, Doerfer J, Perrin M, Panek L, Cleveland WL. Adjunctive glycine in the treatment of obsessive-compulsive disorder in adults. J Psychiatr Res. 2009 Mar. 43(6):664-70. [QxMD MEDLINE Link].
Grayson J. Freedom From Obsessive Compulsive Disorder: A Personalized Recovery Program for Living With Uncertainty. New York: Berkley Publishing Group; 2004.
Koran LM, Hanna GL, Hollander E, Nestadt G, Simpson HB. Practice guideline for the treatment of patients with obsessive-compulsive disorder. Am J Psychiatry. 2007 Jul. 164(7 Suppl):5-53. [QxMD MEDLINE Link]. [Full Text].
Jung HH, Kim CH, Chang JH, Park YG, Chung SS, Chang JW. Bilateral anterior cingulotomy for refractory obsessive-compulsive disorder: Long-term follow-up results. Stereotact Funct Neurosurg. 2006. 84(4):184-9. [QxMD MEDLINE Link].
Greenberg BD, Malone DA, Friehs GM, Rezai AR, Kubu CS, Malloy PF. Three-year outcomes in deep brain stimulation for highly resistant obsessive-compulsive disorder. Neuropsychopharmacology. 2006 Nov. 31(11):2384-93. [QxMD MEDLINE Link].
Mallet L, Polosan M, Jaafari N, Baup N, Welter ML, Fontaine D, et al. Subthalamic nucleus stimulation in severe obsessive-compulsive disorder. N Engl J Med. 2008 Nov 13. 359(20):2121-34. [QxMD MEDLINE Link].

Media Gallery

Anxiety. Chart showing the female-to-male sex ratio for anxiety disorders. Adapted from Kessler et al, 1994.
Anxiety. Age of onset for anxiety disorders based on specific anxiety disorder type.
Brain structures involved in dealing with fear and stress.

of 3

Author

Nita V Bhatt, FAPA, MD, MPH Associate Professor, Associate Director of Medical Student Education (Psychiatry), Department of Psychiatry, Wright State University, Boonshoft School of Medicine; Staff Psychiatrist, Twin Valley Behavioral Healthcare; Clinical Assistant Professor, Ohio State University College of Medicine; Clinical Assistant Professor, Ohio University Heritage College of Osteopathic Medicine

Nita V Bhatt, FAPA, MD, MPH is a member of the following medical societies: American Medical Association, American Psychiatric Association, Ohio Psychiatric Physicians Association

Disclosure: Nothing to disclose.

Coauthor(s)

Matthew J Baker, DO Assistant Professor, Department of Psychiatry, Wright State University, Boonshoft School of Medicine

Matthew J Baker, DO is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, American Psychiatric Association, Ohio Psychiatric Physicians Association

Disclosure: Nothing to disclose.

Vina B Jain, MD Staff Psychiatrist, Department of Psychiatry and Behavioral Medicine, GHS University Medical Group, Greenville Health System

Vina B Jain, MD is a member of the following medical societies: American Association of Physicians of Indian Origin, American Psychiatric Association, Association of Women Psychiatrists, South Carolina Psychiatric Association

Disclosure: Nothing to disclose.

Chief Editor

David Bienenfeld, MD Professor, Departments of Psychiatry and Geriatric Medicine, Wright State University, Boonshoft School of Medicine

David Bienenfeld, MD is a member of the following medical societies: American Medical Association, American Psychiatric Association, Association for Academic Psychiatry

Disclosure: Nothing to disclose.

Additional Contributors

William R Yates, MD, MS Research Psychiatrist, Laureate Institute for Brain Research; Professor of Research, Department of Psychiatry, University of Oklahoma College of Medicine at Tulsa

William R Yates, MD, MS is a member of the following medical societies: American Academy of Family Physicians

Disclosure: Nothing to disclose.

Acknowledgements

Edward Bessman, MD Chairman, Department of Emergency Medicine, John Hopkins Bayview Medical Center; Assistant Professor, Department of Emergency Medicine, Johns Hopkins University School of Medicine

Edward Bessman, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine