Carol Boulware, Ph.D
Los Angeles - Santa Monica - Redondo Beach, California

Psychotherapist helps with anxiety, panic attacks, trauma, depression, anger, stress management, sexual problems, sex therapy, communication problems, marriage / relationship problems, co-dependency, and adults emotionally, physically or sexually abused as children, womens issues. 20 years counseling & psychology experience. EMDR Level II Trained.

Anxiety Disorders
Generalized Anxiety
Panic Attacks

Post-Traumatic Stress
Social Anxiety / Phobia
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Do I Have Anxiety

Needing Treatment?

--Do people say you worry too much?
- Are you overly sensitive to others people's feelings?
- Are you usually shy, self-conscious and embarrass easily?
- Are very nervous in social situations?
--Do you feel anxious at least one thing every day?
--Have you been through a crisis or trauma recently?
--Do you ever get a sudden rush of fearfulness without any apparent reason?

About five percent of Americans experience severe anxiety at one time or another in their lives. Only one out of four of them has sought treatment for their disorder. Whether or not you can answer "Yes" to any of the above questions at this point in time, it is a good idea to be aware of the symptoms and causes of anxiety disorders so that you can recognize any future symptoms that you may want to have professionally diagnosed.

We All Worry

From time to time we all worry about things that are important to us.
Students worry about their grades, some passengers are nervous when they are boarding an airplane, and even a first date can be nerve-wracking. What job applicant isn't anxious about whether he or she will get the job? Usually, when the anxiety-producing circumstance is over, we are no longer concerned and stop thinking about it. We may experience a sense of calm or satisfaction about the event.

But for some people, the resolution of a problem does not end their mental and emotional distress. They immediately start fretting about something else, and then something else. Their fear becomes the focal point of their daily experience. For these individuals, fear becomes a pervasive force that disrupts their lives or, in some cases, prevents them from functioning normally. Examples are people who take trains or buses to their business meetings across the country because they are afraid to fly. Or persons become so terrified of the "dangers" outside, they cannot leave their houses.

Being afraid is a healthy, normal response. It is a survival mechanism we share with the animal kingdom that keeps us out of threatening situations and preserves our lives. But when fear becomes so intense, so relentless and so overwhelming that it causes great distress and on-going disruption of normal functioning, it is a serious problem that needs to be remedied.

A Wide Range of Causes

Anxiety can be caused by substance abuse or even prescription medications. Sometimes genetics plays a hand. Increased stress is a common cause because most people don't know how to cope with stress effectively. Many anxiety problems are mood disorders can be easily brought under control. Other causes range from childhood trauma, physical illness, witnessing a crime or violence to brain chemical imbalances. Thankfully, today there is an abundance of research to help mental health professionals understand and treat the various manifestations of anxiety disorders.

Following in this article are general description, symptoms, possible causes, and treatment options for each of these five types of anxiety problems.

Five main categories of anxiety disorders

Generalized Anxiety
Panic Disorder (Panic Attacks)
Obsessive-Compulsive Disorder
Post-Traumatic Stress Disorder (PTSD
Social Anxiety Disorder (Social Phobia)


Generalized Anxiety Disorder, or GAD, is not "butterflies in the stomach" but
a serious disorder characterized by extreme worry -- and about more than one thing. A person with GAD would have persistent thoughts such as "What if my husband gets hit by a car on his way to the store?" or "What if I get sick and can't take care of my family?" These thoughts might cross anyone's mind, but a GAD sufferer is not able to "shake them off" as others can. They are fixated on the feelings of worry and dread. For these individuals normal anxiety has escalated into a serious problem that needs treatment.

Anxiety disorders affect every aspect of the sufferers' lives -- their activities, their decisions, their health, their businesses or jobs, the thoughts and their family life. When these people are in a stressful situation their anxieties become acute and erupt into symptoms.



Constant worrying, uneasiness, restlessness, a sense of dread, always "keyed-up", fret about health when there are no apparent problems. When faced with a stressful situation, irrational fear. Forgetful or confused. Negative interpretation of other peoples action, feel unsafe.

Physical Symptoms:

-- clenching teeth or jaw
-- tightened muscles
-- holding one's breath
-- sleeping problems
-- racing heart beat
-- breathing difficulties
-- chest pain
-- hyperventilation
-- irritability

Emotional Symptoms:

-- irritability
-- sadness
-- depression
-- low self-esteem
-- loneliness
-- "numb" emotions
-- explosive emotions
-- feeling guilty


An Anxiety Disorder can be brought on by a major life trauma, such as being a witness to or a victim of a crime, physical or sexual abuse, a major illness, or a life threatening experience. Sometimes financial difficulties, grief from a death
in one's family or a divorce can trigger anxiety symptoms. These type of "life stressors" are inevitable in life. But for many people, they are the root cause of their anxiety disorders.

Often it is a combination of these stressors that are just too much for some people to handle. Just think how overwhelming it would be to have more than one of these major stresses happen in a short period of time -- the death of a loved one, losing your job and finding out you have a serious illness.

In addition to external stressors, there are internal forces at work that sabotage our sense of peace and well-being. The number one culprit here is negative self image. When a person is highly self-critical and doesn't allow themselves to be simply "a human being being human" it can spell trouble in terms of emotional health. This is tantamount to holding yourself hostage -- without a ransom demand -- because you don't deserve to be rescued! Obviously, these types of destructive self-thoughts are a vicious cycle of misery that need to be treated
by a professional counselor.

Treatment Options

Fortunately, there are many avenues of successful treatment for the full spectrum of anxiety disorders. Behavior Therapy and Cognative Behavior Therapy are very helpful treatment methods.For some people sessions of psychotherapy can help a person understand the root causes of their disorder.Relaxation methods such as meditation, breathing techniques and visualization can help relieve symptoms.

Anti-anxiety drugs Xanax are non-addictive and can bring relief of anxiety symptoms.

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Most people feel panic over something at least once in their lives. But when it happens frequently and with extreme intensity it may indicate a serious problem that needs attention. Panic Disorder, or panic attacks, often begin in the teenage years or in early adulthood.

A key characteristic of Panic Disorder, is that it usually comes without warning and without any apparent cause. The unpredictable nature of panic attacks adds to the distress of having to deal with this disorder. After a period of time of having attacks, the sufferer so dreads a repeat of this very unpleasant experience, that they often develop a fear of having another attack in addition to the initial disorder.

If attacks persist, it can become so distressful to the person that he or she may not want to leave their house. This is a primary cause of Agoraphobia, the extreme fear of going outside of one's "safety zone," usually their home. For reasons not yet known, women are twice as likely as men to suffer from
panic attacks.


A Panic Attack, or Panic Disorder, is an unexpected experience of intense fear accompanied by physical symptoms of accelerated heart rate, rapid or difficult breathing, shaking, dizziness, sweating, hot or cold flashes, nausea , choking or smothering sensation. A person having a Panic Attack may think they are having a heart attack, since there is usually no apparent reason for the physical symptoms.

There is a mental or psychological aspect of panic attack which sufferers describe as a "sense of unreality," of feeling completely out of control or as though they are "going to die" or will "go insane."

"Fight or Flight" Response

Human beings have a built-in "fight or flight" response to a threatening situation. When perceived danger occurs, fear triggers a physical response where the pituitary glad excretes adrenaline into the bloodstream. The adrenaline enhances our ability to "fight" in our defense, or run ("flight") to save our lives. But when fear is triggered internally instead of by some actual physical danger, our bodies still experience the symptoms and physical readiness created by the adrenaline.

Panic Attacks are a serious disorder and can become disabling. The symptoms alone can be very frightening, especially when they come on without warning. People having Panic attacks often show up in Emergency Rooms thinking they have a serious or life-threatening medical condition.

Possible Causes

Scientists do not know exactly why the body's natural "warning system" gets triggered when there is no actual danger. First attacks can be triggered by physical illness or major stress in a person's life. The causes may involve an interaction of mental, or psychological and physical events. When stress is severe, as with the loss of one's job or a death in the family, it may stimulate
the part of the brain that controls fear response. Several very stressful events happening within a short period of time, can also set off panic attacks. In addition, panic attacks can accompany other types of anxiety disorders.

Stresses that may contribute to the onset of panic attacks are:

-- Serious relationship problems
-- Concerns about one's health
-- Physical illness
-- Tensions at the workplace
-- Poor self-esteem or self-hatred
-- Emotional problems
-- Worrying about finances
-- Legal problems
-- Physical or emotional abuse
-- A traumatic situation
-- Witnessing or being a victim of a crime

There is not yet a consensus among professionals about the exact nature of the causes. There are biological theories, behavioral theories and psychodynamic theories. There is also a brain-dysfunction theory and an inner-ear-dysfunction theory. But as yet, none of them has been proven to be the correct theory. Perhaps the true cause lies in a combination or synergy of factors. Researchers do know that panic attacks are connected to major life transitions that are inherently stressful, such as marriage, divorce, a first child, school graduation,
a new job, etc.

There may also be a heredity factor involved, since scientists have found that Panic Disorder can run in families.

Often Undiagnosed

Unfortunately, Panic Disorder frequently goes undiagnosed and, therefore, untreated. Some sufferers may rationalize their attacks for a long time as normal or "no big deal." Other people may call them nervous or "high strung." Sufferers may think that what's bothering them is not

important because it is from a long time ago and try to shake it off. They may try to hide their attacks from family, friends or co-workers. They may lose their jobs due to their attacks. However, if Panic Disorder goes untreated for months or years, it may worsen to the degree of seriously interfering with the normal daily life of the person affected.

Sometimes the sufferer actually helps bring on an attack by responding to the physical symptoms with more fear. They may be so anxious about the onset of an attack that they will actually cause an attack themselves. Or, they may mistakenly think that a symptom is from anxiety when it is really a flu symptom or simply from physical exertion.

Treatment Options

Cognitive Behavioral Therapy is often helpful to treat anxiety . This treatment helps the sufferer to be prepared for the situations that might trigger panic attacks.

How Cognitive Behavioral Therapy helps patients with panic disorders:

Explains anxiety and how to identify symptoms; designs a treatment plan.
The patient learns to monitor panic attacks and keeps a record of anxiety inducing situations.
Relaxation and breathing techniques are taught.
Teaches other skills to help block automatic reaction to fearful situations.
Shows how to recognize thoughts and beliefs that trigger anxiety and change their interpretation from catastrophic to realistic.
Develops gradual steps for exposing the patient to situations that cause anxiety.
Homework to help practice in everyday life what is being learned in therapy.

Often a combination of medication and Cognitive Behavioral Therapy is an effective method of treating panic disorder.

Medications that interact with brain chemicals can reduce or prevent attacks and lessen anxiety.

The main types for treating panic disorder are benzodiazepines and antidepressants. These must be taken on a regular basis, from six months to a year.

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It is estimated that five million Americans are affected by OCD. This disorder exists when a person's compulsions and obsessive thoughts overpower their life to the point that they are unable to function normally. Unwanted, disturbing or distracting thoughts, and out-of-control behaviors are typical of OCD. These thoughts may be accompanied by a personality disorder, an eating disorder, attention deficit disorder, anxiety or depression.

A compulsion, which is an irresistible impulse or urge, usually includes elaborate and repetitive rituals and often interferes with the person's normal functioning. An obsession is the preoccupation with, and repetition of, a persistent thought or behavior. The person with an obsession usually finds them disturbing and intrusive, but cannot stop doing whatever they are obsessive about.

The reason these conditions are components of the same disorder is because most people with this problem suffer from both obsessions and compulsions.
A smaller percentage has only one or the other. In most cases, OCD develops in early childhood, but may not be diagnosed until adulthood.

Some common compulsions are:

-- organizing and arranging things
-- checking the same thing over and over
-- counting and repeating
-- cleaning something over and over
-- shopping
-- gambling
-- lying

Some common obsessions are:

-- symmetry and order
-- talking, asking questions, confessing
-- germs and dirt
-- fear of making mistakes
-- working
-- sex
-- exercise

The Cause of OCD

Research indicates that OCD is a biology-based disorder involving the brain chemical, serotonin. Serotonin carries impulses to and from nerves for functions such as walking, eating and thinking. It is believed that very stressful events can cause an imbalance of this chemical in the brain of certain individuals and bring on OCD symptoms.

Treatment Options for OCD

If untreated, Obsessive-Compulsive Disorder is usually a lifelong illness.

OCD has usually been treated with a tricyclic antidepressant. Recently, though, additional drugs that selectively act on the neurotransmitter serotonin, called SSRIs, or selective serotonin reuptake inhibitors, are now available for treating OCD.

Behavior therapy has also helped OCD patients, as has a combination of therapy and drugs.

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A person with PTSD has experienced an event involving actual or threatened death or injury to themselves or others. They have experienced intense fear, a sense of helplessness and horror.

Trauma can be a one-time experience such as rape, assault, mugging, robbery, fire, accident or a natural disaster such as a flood or an earthquake, or it can be a prolonged trauma as in the case of physical or sexual abuse, living in a prison or concentration camp, or being a refugee.

Our brains and nervous systems are intended to handle stress and trauma - to a point. When our system is overwhelmed by traumatic stimuli, it goes into an overload situation. The result is that the anxiety of these traumatic events stays "locked" in our nervous system, waiting to be released.

Possible Causes

PTSD can develop after a major traumatic event, either emotional or physical. This disorder is characterized by flashbacks and nightmares, and is commonly found in returning military personnel and in people who have experienced natural disasters or been victims crimes. Other causes can be serious accidents, violent attacks such as rape or torture, or witnessing violence in which they or other people are seriously injured.

It is estimated that about ten percent of the U.S. population has or has had symptoms of PTSD. It affects people of all ages who have experienced a trauma. More females than males suffer from this anxiety disorder. Some people can recover from a traumatic event with brief therapy and the support of loved ones. But for others, it persists, often for years.



Symptoms can appear within a few months of a traumatic event or much later, after an event that triggers symptoms. Typical symptoms of PTSD are:

-- reliving the trauma event as if it were happening - flashbacks
-- intrusive thoughts, images, feelings and illusions
-- re-experiencing the traumatic even in dreams or nightmares
-- intense anxiety and physical distress when remembering the event
-- attempts to avoid the situation, feelings or activities related to the event
-- avoids conversations connected to the trauma
-- changes in appetite
-- feeling sadness, depression, hopelessness, and despair
-- difficulty falling asleep or staying asleep
-- anger, resentment, irritability or explosive outbursts
-- feeling "numb" emotionally
-- a sense of detachment; "spacing out"
-- overwhelmed by normal situations
-- love, sexuality or intimacy become restrictive
-- frequent and excessive crying; moodiness
-- trouble concentrating; poor memory
-- Hypervigilance and scanning; being on guard
-- easily startled, jumpiness
-- pessimism; a sense of doom and dread of the future
-- survivor guilt

It is important to diagnose and treat Post Traumatic Stress Disorder because if
it is not treated, it could lead to more serious psychological illnesses, such as clinical depression or drug dependency.


Treatment for PTSD

There are a number of treatments available to mental health professionals that have good track records with helping PTSD sufferers deal successfully with their traumatic experiences. Treatment usually focuses on anxiety reduction and stress-coping techniques.

Self-hypnosis can help, as can be relaxation exercises. In many cases, behavioral psychotherapy is effective. By bringing their experience into the therapy setting, the trauma survivor usually finds it easier to discuss their trauma, and learn new ways of reacting to their memories.

Another effective therapy for PTSD is a relatively new but powerful technique called Eye Movement Desensitization and Reprocessing, or EMDR. Drug therapy can be helpful if there is notable depression, panic attacks or debilitating stress symptoms. There are also peer-counseling and other groups which can help sufferers deal with their symptoms.

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Phobias are common in our society and are characterized by intense, irrational fears of things, situations, people or activities. Having high anxiety in social settings to the degree that it interferes with ordinary social interaction is called a Social Phobia.

Social Phobia is a major mental health disorder in the United States, affecting about eight percent of the population. However, it has only been taken seriously for about ten years. Fortunately, the body of research developed in that time has fostered numerous treatment modalities.



People with Social Anxiety Disorder or Social Phobia, or, are very fearful and anxious that other people will criticize them. In fact, they will go to any extreme to avoid a social gathering at which they might be stared at, and, in their mind, evaluated negatively. They are intimidated by every stranger they come across. They avoid eye contact with nearly everyone and feel that they will embarrass themselves if they do anything at all in public. Other typical symptoms are embarrassing easily, blushing, frequent swallowing and twitching.

"Trigger" Situations for Social Phobia

-- having to speak in front of other people
-- being the center of attention
-- dealing with people of authority
-- looking other people in the eye
-- being introduced to strangers
-- being teased or confronted
-- being in a public place
-- interviews and meetings

Social Phobia is very distressing emotionally because it adversely affects a very important aspect of life - social interaction. To make matters worse, other people often perceive those with Social Phobia as being unfriendly, aloof, withdrawn or inhibited.


Social Anxiety is very prevalent in our society probably partly because of social pressure to live up to idealized social expectations and partly due to the emotional and psychological insecurity of the individual with this disorder.
Add to this the tendency to analyze and evaluate everything. People with this disorder realize their negative thoughts and feeling are irrational, yet they cannot stop them. A cycle of negative thoughts and negative actions is set into play that can only be stopped with appropriate psychotherapy.

Cognitive-behavioral therapy is highly effective in treating social anxiety. Behavioral Therapy in a Group setting is also helpful because they allow opportunities for reestablishing healthy relating skills.

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Educate yourself about what you suspect is your disorder so that you can communicate more effectively with your medical doctor or your potential therapist.

Physical exercise is often an excellent temporary antidote for mild or moderate anxiety.

Be aware of what you eat and drink. Food additives such as Aspartame, the sugar substitute, or caffeine, can be toxic to some people and cause anxiety symptoms. Packaged meats contain preservatives and other chemicals.
A high intake of sugar can also trigger anxiety symptoms.

Eliminate alcohol and unprescribed drugs from your system.

It is a good idea to begin with a thorough physical exam by a physician. Many times symptoms are caused by a physical condition or illness, such as allergies.

Learn relaxation techniques. They are available everywhere - yoga classes, video tapes, meditation, etc.

Be confident that you will find relief for your symptoms. Many other people have suffered with the same unpleasant or uncomfortable conditions and have successfully gotten relief -- often permanently.

© Copyright 1999 by Carol Boulware, Ph.D.

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CALL (310) 395-3351

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Carol Boulware, Ph.D.
Licensed Marriage, Family Therapist- #MFCT11632
Board Certified Expert in Traumatic Stress
ABS Certified Sex Therapist
EMDR - Level 2 - 1994

626 Santa Monica Blvd., Suite 275
Los Angeles, California 90401
(310) 395-3351
Additional offices in Santa Monica & Redondo Beach

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