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Specializing in Anxiety, Depression, Addictions, Children, Teenagers, Family & Couples Therapy

Anxiety & Panic

Anxiety is a mood often described as having excessive anxiety and worry over something in the future that may be related but not limited to work, school, or social life according to the DSM IV. You may find it difficult to control the anxiety and worry. 

The anxiety and worry have prevailed and persisted; and include any one or more of the following symptoms:

  1. Feeling keyed up or on edge

  2. Being easily fatigued 

  3. Difficulty concentrating or mind going blank

  4. Irritability

  5. Muscle tension

  6. Sleep disturbance-difficulty falling or staying asleep or unsatisfying sleep. The anxiety, worry or physical symptoms have negatively affected your performance at work, school or social life.

A variety of general medical conditions, according to the DSM IV may cause anxiety symptoms:

  1. Endocrine conditions, e.g., hyper- and hypothyroidism, pheochromocytoma (a form of hypertension), hypoglycemia, hyperadrenocorticism (high cortisol level)

  2. Cardiovascular conditions, e.g., congestive heart failure, pulmonary embolism, arrhythmia  

  3. Respiratory conditions, e.g., chronic obstructive pulmonary disease, pneumonia, hyperventilation

  4. Metabolic conditions, e.g., vitamin B-12 deficiency, porphyria

  5. Neurological conditions, e.g., neoplasms, vestibular dysfunction, encephalitis.

Panic Attack: The criteria for Panic Attack is stated in the DSM IV as a discrete period of intense fear or discomfort, in which four (or more) of the following symptoms developed abruptly and reached a peak within 10 minutes:

  1. Palpitations, pounding heart, or accelerated heart rate

  2. Sweating

  3. Trembling or shaking

  4. Sensations or shortness of breath or smothering

  5. Feeling of choking

  6. Chest pain or discomfort

  7. Nausea or abdominal distress

  8. Feeling dizzy, unsteady, lightheaded, or faint

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

  10. Fear of losing control or going crazy

  11. Fear of dying

  12. Paresthesias (numbness or tingling sensations)

  13. Chills or hot flushes.  


Panic Disorder is the presence of recurrent, unexpected panic attacks followed by at least 1 month of persistent concern about having another panic attack, worry about the possible implications or consequences of the Panic Attacks , or a significant behavioral change related to the attacks.


An unexpected (spontaneous, uncued) Panic Attack is defined as one that is not associated with a situational trigger, i.e., it occurs 'out of the blue'. At least two or more episodes of this unexpected panic attacks are required for the diagnosis, but most people have considerably more. Individuals with Panic Disorder frequently also have situationally predisposed Panic Attacks, i.e., those more likely to occur on, but not invariably associated with, exposure to a situational trigger. Situationally bound attacks, i.e., those that occur almost invariably and immediately on exposure to a situational trigger can occur but are less common. The frequency of episodes of Panic Attacks vary widely, however, the greater the frequency and intensity of the episodes the greater the sense of  morbidity for the individual.


Individuals with Panic Disorder display characteristic concerns or attributions about the implications or consequences of the Panic Attacks. Some fear that the attacks indicate the presence of an undiagnosed, like threatening illness, e.g., cardiac disease, seizure disorder. Despite repeated medical testing and reassurance, they may remain frightened and unconvinced that they do not have a life-threatening illness. Other fear that the Panic Attacks are an indication that they are 'going crazy' or losing control or are emotionally weak.


Some individuals with recurrent Panic Attacks significantly change their behavior, e.g., quit a job in response to the attacks, but deny rather fear of having another attack or concerns about the consequences of the Panic Attacks. Concerns about the next attack, to its implications, are often associated with development of avoidant behavior that may meet criteria for Agoraphobia, in which case Panic Disorder With Agoraphobia is diagnosed.


Depression is a mood often described, as stated in the DSM IV, as depressed, sad, hopeless, discouraged, or 'down in the dumps'. You may complain of feeling 'blah', having no feelings, or feeling anxious. You may emphasize experiencing bodily aches and pains rather than feelings of sadness. Many individuals report increased irritability where they are persistently angry or reactive to events with angry outbursts, or blaming others, or an exaggerated sense of frustration over minor matters. In children and adolescents, an irritable or cranky mood may be observed rather than a sad or dejected mood.


These warning signs have been identified with child and teen depression:

  1. Often feels anxious or worried

  2. Has very frequent tantrums or is intensely irritable much of the time

  3. Has frequent stomachaches or headaches with no physical explanation

  4. Is in constant motion, can't sit quietly for any length of time

  5. Has trouble sleeping, including frequent nightmares

  6. Loses interest in things he or she used to enjoy

  7. Avoids spending time with friends

  8. Has trouble doing well in school, or grades decline

  9. Fears gaining weight; exercises, diets obsessively

  10. Has low or no energy

  11. Has spells of intense, inexhaustible activity

  12. Harms himself/herself, such as cutting or burning her/his skin

  13. Engages in risky, destructive behavior

  14. Harm self or others

  15. Smokes, drinks or use drugs

  16. Has thoughts of suicide.


Anyone or a combination of these symptoms may cause significant distress in social, work, school and other important areas of your life. 


Major Depression is associated with high mortality. Up to 15% of individuals with severe major depression die by suicide. Epidemiological study also suggests that there is a fourfold increase or 4 times increase in death rates in individuals with Major Depression who are over age 55 years. Among individuals seen in general medical settings, those with Major Depression have more pain and physical illness and decreased physical physical, social and role functioning. 


Episodes of Major Depression often follow a severe psychosocial stressor, such as the death of a loved one or divorce. Chronic general medications and Substance Dependence, particularly Alcohol or Cocaine Dependence may contribute  to the onset or escalation of Major Depression.


Major Depression is 1.5-3 times more common among first-degree biological relatives or persons with this disorder than among the general population. 

Relationship Therapy

Dysfunctional Relationships or individuals in a dysfunctional relationship may show any one or combinations of these general symptoms:

  1. Anger: you may be the recipient of constant criticism, blaming, fault-finding or you feel used in the relationship and you're defensive and retaliating out of anger

  2. Depression: you may be responding to criticism, blaming, fault-finding or lack or absence of connection and you are shutting down, feeling depressed and hopeless

  3. Anxiety: you may be experiencing emotional, physical or sexual abuse and feel fearful, anxious or paralyzed to either stay, improve or leave the relationship 

  4. Resentment: you may be passively and privately despising the other individual and are disgusted with the other's unfairness, injustice, neediness or other weaknesses

  5. Guilt: you may be helping the other person to survive because he or she can't help him or herself. You will allow no one else to help because you feel guilty if you do not do it yourself. 


According to the National Domestic Violence Website,, some of the signs of an abusive relationship include a partner who:  

  1. Tells you that you can never do anything right

  2. Shows extreme jealousy of your friends and times spent away

  3. Keeps you or discourages you from seeing friends or family members

  4. Insults, demeans or shames you with put downs

  5. Controls every penny spent in the household

  6. Prevents you from making your own decisions

  7. Takes your money or refuses to give you money for necessary expenses

  8. Looks at you or acts in ways that scare you

  9. Controls who you see, where you go or what you do

  10. Tells you that you're bad parent or threaten to harm or take away your children

  11. Prevents you from working or attending school

  12. Destroys your property or threatens to hurt or kill your pets

  13. Intimidates you with guns, knives or other weapons

  14. Pressure you to have sex when you don't want to or do things sexually you/re not comfortable with

  15. Pressures you to use drugs or alcohol 

Couples Therapy
Couples or Marital Therapy

Marital or Couples Therapy is needed if any of the symptoms mentioned above in dysfunctional relationships appear. In addition, Dr. John Gottman through longitudinal research predicted divorce when these signs are present in a marriage:

  1. Harsh Startup: when a discussion starts off with criticism, sarcasm, or harsh tone of voice nothing can change or redirect the inevitable end, which is also harsh

  2. Criticism, Contempt, Defensiveness and Avoidance

  3. Flooding: you're done and checked-out from the marriage as a defense against criticism, contempt, defensiveness and avoidance

  4. Body Language: chronic high blood pressure, heart rate goes up, hormonal changes, cortisol goes up kicks in 'fight or flight' response which will make it impossible to communicate and problem solve effectively

  5. Failed Repair Attempts: the more criticism, contempt and defensiveness experienced in the marriage the greater the chances for flooding to happen and the harder it is to hear and respond to a repair. Each failed attempt to repair the marriage increases flooding

  6. Bad Memories: couples are historians in a way that when the marriage is drowned in negativity not only their present and future life are negatively impacted their past is at risk too. They rewrite the past negatively--the good times were short lived or did not happen.

Trauma & Stress Therapy

With Posttraumatic Stress Disorder (PTSD), the DSM IV states that you may be experiencing painful feelings of guilt about surviving when others did not survive or about the things you had to do to survive.


Phobic avoidance of situations or activities that resemble or symbolize the original trauma may interfere with interpersonal relationships and lead to marital conflict, divorce, or loss of job.


The following associated symptoms may occur and are more commonly seen in association with an interpersonal stressor, e.g,

childhood sexual or physical abuse, domestic battering, being taken hostage, incarceration as a prisoner of war or in a concentration camp, torture:


  1. Impaired affect modulation

  2. Self destructive and Impulsive behavior

  3. Dissociative symptoms

  4. Somatic complaints

  5. Feelings of ineffectiveness

  6. Shame

  7. Despair, or Hopelessness

  8. Feeling permanently damage

  9. A loss of previously sustained beliefs

  10. Hostility

  11. Social Withdrawal

  12. Feeling constantly threatened

  13. Impaired relationship with others; or a change from the individual's previous personality characteristics.


There may be increased risk of Panic Disorder, Agoraphobia, Obsessive Compulsive Disorder (OCD), social phobia, Major Depressive Disorder, Somatization Disorder and Substance-Related Disorders.

In younger children, distressing dreams of the event may, within several weeks, change into generalized nightmares of monsters, or rescuing others, or of threats to self or others.


Young children usually do not have the sense that they are reliving the past, rather, the reliving of the trauma may occur through repetitive play, e.g., a child was involved in a serious automobile accident repeatedly reenacts car crashes with toy cars.


Also, in children, the sense of a foreshortened future may be evidenced by the belief that life will be too short to include becoming an adult. There may also be 'omen formation'- that is, belief in an ability to foresee future untoward events. Children may also exhibit various physical symptoms, such as stomachaches and headaches.

Acute Stress Disorder (ACD) is mainly characterized in the DSM IV as the development of characteristic anxiety, dissociative, and other symptoms that occurs within 1 month after the exposure to an extreme traumatic stressor. Either while experiencing the traumatic event or after the event, the individual has at least 3 of the following dissociative symptoms:


  1. Subjective sense of numbing

  2. Detachment

  3. Absence of emotional responsiveness

  4. Reduction of awareness of his or her surroundings

  5. Derealization

  6. Depersonalization

  7. Dissociative amnesia.


Following the trauma, the traumatic event is persistently reexperienced (recurrent recollections, images, thoughts, dreams, illusions, flashback episodes, a sense of reliving the event, or distress on exposure to reminders of the event) and the individual displays marked avoidance of stimuli that may arouse recollections of the trauma.


Hyperarousal in response to stimuli reminiscent of the trauma is present, e.g., difficulty sleeping, irritability, poor concentration, hyper vigilance, an exaggerated startle response, and motor restlessness. 


Drug Addiction is generally defined as a symptom that is characterized by compulsive drug seeking and use, and is difficult to control despite harmful consequences. The initial decision to take drugs is voluntary for most people, but repeated drug use can lead to brain changes that challenge an addicted person's self control and interfere with their ability to resist intense urges to take drugs. Most drugs affect the brain's 'reward circuit', causing euphoria as well as flooding it with the chemical messenger dopamine. A properly functioning reward system motivates a person to repeat behaviors needed to thrive such as eating and spending time with loved ones. Surges of dopamine in the reward circuit cause the reinforcement of pleasurable but unhealthy behaviors like taking drugs leading people to repeat the behavior again and again.

Biological Signs and Symptoms for Adolescents drug use may include but limited to the following, according to NIH:

1. Behaving differently for no apparent reason, like acting withdrawn.

2. Frequently tired, depressed or hostile.

3. A change in peer group

4. Carelessness with grooming

5. Decline in academic performance

6. Missing classes or skipping school

7. Loss of interest in favorite activities.

8. Deteriorating relationships with family members and friends

Sexual Addiction is seeking fulfillment by substituting a maladaptive or sick relationship to a thing, event or process for a healthy relationship with others. Consequently, the person develops the following behaviors:

1. preoccupied or obsessed about seeking sexual stimulation.

2. has special routines that lead up to sexual behavior.

3. unable to control or stop this sexual behavior.

4. feeling hopeless and powerless to change behavior.

5. degree of unmanageability has increased and becomes worse.

6. isolation and disconnection become worse

Some activities that may include sexual addiction, according to Drs Sbraga and O'donahue, authors of "The sex addiction workbook":

1. Looking at pornography 

2. Engaging in internet and telephone sex

3. Having serial affairs

4. Frequenting prostitutes

5. Going to strip clubs obsessively

4. Frequenting massage parlors

5. Feeling driven to have sex many times a day

Adolescent Therapy
Child & Adolescent Therapy

Adolescence is the period following the onset of puberty during which a young person develops from a child into an adult. This period is filled with physiological, emotional and psychological growth. The child is trying to figure out how to meet the end of all of these growths -- to be independent.


The parent-child relationship can be the most challenging or most fulfilling depending on how they work to meet independence. The child and parent may need therapy if child is Oppositional and Defiant (ODD) and, as stated on the DSM IV, and shown by a pattern of negativistic, hostile, and defiant behavior lasting at least 6 months, during which 4 or more of the following symptoms are present:


  1. Often loses temper

  2. Often argues with adults

  3. Often actively defies or refuses to comply with adult's requests or rules

  4. Often deliberately annoys people

  5. Often blames others for his or her mistakes or misbehavior

  6. Often touchy or easily annoyed by others

  7. Often angry and resentful

  8. Often spiteful or vindictive.


The disturbance in behavior causes significant impairments in social, academic or work.


Manifestations of Oppositional Defiant Disorder (ODD) are almost invariably present in the home setting, but may not be evident at school or in the community.


Symptoms of ODD are typically more evident in interactions with adults or peers whom the individual knows well., and thus may not be apparent during clinical examination.


Usually individuals with this disorder do not regard themselves as oppositional or defiant but justify their behavior as a response to unreasonable demands or circumstances. In males, ODD has been shown to be more prevalent among those who, in the preschool years, have problematic temperaments, e.g., high reactivity, difficulty being soothed or high motor activity. During school years, there may be low self esteem, unstable moods, low frustration tolerance, swearing, and the precocious use of alcohol, or illicit drugs. They are often conflicts with parents, teachers, and peers. There may be a vicious cycle in which the parent and child bring out the worst in each other. ODD is more prevalent in families in which child care is disrupted by a succession of different caregivers or in a families in which harsh, inconsistent, or neglectful child rearing practices are common. AD/HD is common with ODD. Also, Learning Disorders and Communication Disorders also tend to be associated with ODD.

The child and parent may need therapy if the child shows symptoms of Conduct Disorder (CD). The child may have little empathy and little concern for the feelings, wishes and well-being of others. The child may frequently misperceive the intentions of others as more hostile and threatening than is the case and respond with aggression that they then feel is reasonable and justified. The child may be callous and lack appropriate feelings of guilt or remorse. It can be difficult to assess whether displayed remorse is genuine because these individuals learn that expressing guilt may reduce or prevent punishment. Individuals with conduct disorder may readily inform on their companions and try to blame others for their own misdeeds. Self-esteem is usually low, although the person may project an image of 'toughness'. Poor frustration tolerance, irritability, temper outbursts, and recklessness are frequent associated features. Accident rates appear to be higher in individuals with CD than in those without it.


Furthermore, CD is often associated with an early onset of sexual behavior, drinking, smoking, use of illegal substances, and reckless and risk-taking acts. Illegal drug use may increase the risk that CD will persist. CD behaviors may lead to school suspension or expulsion, problems in work adjustment, legal difficulties, sexually transmitted diseases, unplanned pregnancy, and physical injury from accidents or fights. These problems may preclude attendance in ordinary schools or living in parental or foster home. Suicide ideation, suicide attempts, and completed suicide occur at a higher than expected rate. Academic achievement, particularly in reading and other verbal skills, is often below the level expected on the basis of age and intelligence and may justify the additional diagnosis of a Learning or Communication Disorder. AD/HD is common in children with CD. CD may also be associated with one or more of the following mental disorders (DO): Learning DO, Anxiety DO, Mood DO, Substance-Related DO.


The following factors may predispose the individual to the development of CD:


  1. Parental rejection & neglect 

  2. Difficult infant temperament

  3. Inconsistent child-rearing practices with harsh discipline

  4. Physical or sexual abuse

  5. Lack of supervision

  6. Early institutional living

  7. Frequent changes of caregivers

  8. Large family size

  9. Association with delinquent peer group

  10. Certain kinds of familial psychopathology.


CD has both genetic and environmental components. The risk for CD is increased in children with a biological or adoptive parent with Antisocial Personality DO or a sibling with CD.


CD may also appear to be more common in children of biological parents with Alcohol Dependence, Mood Disorders, or Schizophrenia or biological parents who have a history of AD/HD or CD.

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