Appearance satisfaction mediates the relationship between recreational screen time and depressive symptoms in adolescents.

BACKGROUND: Research suggests there is an association between high levels of recreational screen time and depression among adolescents; however, mechanisms driving this association remain unknown. The present study examined appearance and weight satisfaction and disordered eating behaviors as mediators in the relationship between recreational screen time and depressive symptoms in adolescents. METHOD: Longitudinal data on screen time, depressive symptoms, disordered eating behaviors, and appearance and weight satisfaction from 304 adolescents (194 females, Mage = 13.40) were analyzed through a moment structure model. RESULTS: Results revealed appearance dissatisfaction mediated the direct effect of recreational screen time on depressive symptoms (Estimate = 0.48, SE = .18, 95% CI [0.12, 0.84]), and that recreational screen time was significantly related to lower appearance satisfaction (Estimate = -0.06, SE = .02, 95% CI [-0.10, -0.01]), which was significantly predictive of more severe depressive symptoms (Estimate = -1.49, SE = .62, 95% CI [-2.71, -0.28]). CONCLUSIONS: These findings suggest that modulating screen time may be an efficacious strategy to reduce appearance dissatisfaction and depressive symptoms during adolescence.

Coping in adolescents: A mediator between stress and disordered eating.

BACKGROUND: Adolescence is a developmental period that can place individuals at heightened risk of engaging in disordered eating patterns. Stress and coping have been included as etiological factors of eating pathology, yet the mechanism of this relationship in adolescent males and females remains understudied. AIMS: This study investigated the role of coping as a mediator in the stress-disordered eating relationship in a sample of adolescents. DEMOGRAPHICS/SETTINGS: Participants included 2262 grade 7-12 students from a larger cross-sectional study entitled, Research on Eating and Adolescent Lifestyles (REAL). METHODOLOGY/ANALYSES: Participants completed measures of perceived stress, life stressors, coping style, and disordered eating. Multiple mediator models of coping were analyzed to examine the extent to which coping mediated the stress-disordered eating relationship, for males and females separately. FINDINGS: Emotion-oriented coping was a significant partial mediator in the relationship between stress (perceived stress, life stressors) and disordered eating in male and female adolescents. Findings suggest adolescents experiencing high stress tend to engage in emotion-oriented coping, which may lead to greater levels of disordered eating. IMPLICATIONS: Interventions targeting effective coping strategies for dealing with different stress types may prevent youth from disordered eating, thus reducing their risk of eating disorders during a vulnerable period in development.

Examining Shared Pathways for Eating Disorders and Obesity in a Community Sample of Adolescents: The REAL Study.

Several psychosocial models have been proposed to explain the etiology of eating disorders (EDs) and obesity separately despite research suggesting they should be conceptualized within a shared theoretical framework. The objective of the current study was to test an integrated comprehensive model consisting of a host of common risk and protective factors (socio-environmental, psychological, and behavioral) expected to explain both eating and weight disorders simultaneously in a large school-based sample of adolescents. Data were collected from 3,043 youth (60% female, 14.00 ± 1.61) from 41 schools in the Ottawa region, Canada. Working with interested school staff, validated self-report scales in the form of a questionnaire booklet were administered to participating students to assess several understood risk and protective factors common to both eating disorders and obesity. Anthropometric measurements of weight and height were taken at the end of the questionnaire administration period by trained research staff. Structural equation modeling with cross-validation was used to test the hypothesized model. Findings demonstrated that dysregulated eating was associated with both eating disorder and weight status with diet culture and emotion dysregulation directly associated with some of these disordered eating patterns. It equally pointed to how lifestyle made up of high sedentary behaviors, low vigorous exercise and varied eating patterns contributed to both emotion dysregulation and poor body image which subsequently affected eating issues and weight status simultaneously, signaling the complex interplay of psychosocial factors that underlie these concerns. This study provides evidence for an integrated psychosocial model consisting of socio-environmental, psychological, and behavioral factors may best explain the complex interplay of risk and protective factors influencing eating disorders and obesity. It equally highlights understanding the direct and indirect effects of some of the most salient risk factors involved in eating and weight-related concerns, including the strong effects of diet culture and stressors such as weight-based teasing, providing interventionalists evidence of important risk factors to consider targeting in eating disorder and weight-based prevention efforts.

Examining the Bidirectional Association Between Body Esteem and Body Mass Index During Adolescence.

OBJECTIVE: Research on body esteem (weight and appearance esteem) and weight suggests that having a positive body esteem may be associated with more stable weight trajectories during adolescence, and adolescents with higher weight report lower levels of body esteem. However, bidirectional relationships between body esteem and weight have not yet been examined. This 3-year longitudinal study examined (1) bidirectional relationships between body esteem and body mass index (BMI) and (2) how BMI and body esteem changed together throughout adolescence. METHODS: Participants (N = 1163 adolescents, at time 1 [T1] baseline; 60.3% female) from a school-based community sample completed surveys approximately annually for 3 years. RESULTS: Latent growth modeling revealed that (a) among boys and girls, appearance and weight esteem scores decreased over time, (b) higher initial BMI scores were associated with slower decreases in appearance esteem over time. However, evidence for bidirectionality was not found, in which baseline appearance and weight esteem did not predict changes in BMI over time and vice versa. CONCLUSION: Results suggest that changes in BMI and body esteem are co-occurring (rather than predictive) throughout adolescence. The decreasing trajectory of body esteem over time suggests the need for prevention efforts to improve body esteem throughout adolescence.

Mediating role of disordered eating in the relationship between screen time and BMI in adolescents: longitudinal findings from the Research on Eating and Adolescent Lifestyles (REAL) study.

OBJECTIVE: This study investigated whether the duration and type of screen time (ST) (TV viewing, recreational computer use, video gaming) is longitudinally associated with z-BMI and if these relationships are mediated by disordered eating (emotional, restrained). DESIGN: At baseline, participants were n 1197 (T1; 60 % female) adolescents (mean age = 13·51 years) who completed surveys over 2 years. ST was assessed by a self-reported measure created by the investigative team, while emotional and restrained eating was measured by the Dutch Eating Behaviour Questionnaire (DEB-Q). Height and weight were objectively measured to quantify z-BMI. SETTING: Thirty-one public and two private schools from the region of Ottawa, Canada. PARTICIPANTS: Students in grades 7-12. RESULTS: Parallel multiple mediation analyses revealed that more time spent watching TV at baseline is associated with higher z-BMI at T3 (total effect; B = 0·19, se = 0·07, P = 0·01, 95 % CI 0·05, 0·34), but no relationships were observed for total ST exposure or other types of ST and z-BMI. Disordered eating did not mediate the positive association between baseline TV viewing and z-BMI at T3. CONCLUSIONS: TV viewing was longitudinally associated with higher z-BMI in a community-based sample of adolescents, but disordered eating behaviours did not mediate this relationship. However, other non-pathological eating behaviours may mediate the association between ST and obesity and warrant further investigation. Finding suggests that targeting reduction in youth's TV viewing may be an effective component in the prevention of childhood obesity.

Bingeing, Purging, and Suicidal Ideation in Clinical and Non-Clinical Samples of Youth.

Suicidal ideation is a serious mental health concern reported by adolescents. Despite understanding of increased suicidal ideation in patients with eating disorders (EDs) and obesity, few studies have compared how disordered eating (bingeing, vomiting and over exercising) is associated with suicidal ideation in clinical and non-clinical samples of youth across the ED and weight spectrum. The present study aimed to 1) comparatively examine rates of suicidal ideation and disordered eating behaviors in clinical samples of youth with EDs, complex obesity, or from the community, and 2) examine whether disordered eating was associated with suicidal ideation above and beyond age, body mass index, diagnosis, treatment-seeking status, and depressive symptoms in large samples of males vs. females in an attempt to understand whether these behaviors should lead to concern regarding suicidal ideation. Data from charts on treatment-seeking adolescents diagnosed with either an ED (N = 315), severe complex obesity (N = 212), and from the community (N = 3036) were pooled together for comparative purposes. Results showed that suicidal ideation was higher in youth seeking treatment for an ED (50.2%) and obesity (23.7%) as compared to youth from the community (13%). Binary logistic regression analyses revealed that vomiting (OR = 1.73 for females, 8.17 for males) and over-exercising (OR = 1.47 for females, 1.68 for males) was significantly associated with suicidal ideation in both males and females. Findings underscore the importance of screening for suicidal ideation in youth who report vomiting or over-exercising despite diagnostic presentation, age, weight, or treatment setting.

Eating disorder or oesophageal achalasia during adolescence: diagnostic difficulties.

Marine was a fourteen and a half-year-old adolescent female hospitalized for an eating disorder (ED) of the anorexic type with purging behaviors. She has had a complicated life course, made up of disruptions and discontinuities, both family and school. Since the age of five, Marine had been intermittently treated in psychiatry for a diagnosis of oppositional defiant disorder. The current illness started with spontaneous and induced vomiting associated with major weight loss (body mass index, 15.27 kg m-2). The diagnosis of anorexia nervosa was established after several opinions from professionals in five Parisian university pediatric departments, where additional investigations were carried out without any somatic cause being identified. In this context, Marine was transferred to a child psychiatry unit. There, she had acute dyspnea during the insertion of a nasogastric tube. As a result, a new specialized opinion was sought from a pediatric gastroenterologist and further explorations were performed (oeso-gastroduodenal transit and manometry), leading to the conclusion to an oesophageal achalasia requiring surgical treatment. This case report highlights that the exclusion of any organic disorder should be a priority in the diagnostic assessment of an ED. Oesophageal achalasia is a rare differential diagnosis and should be considered in case of swallowing difficulties or dysphagia. Health care professionals should take care to provide appropriate somatic follow-up for patients with psychiatric disorders.

Development of the Ottawa Disordered Eating Screen for Youth: The ODES-Y.

OBJECTIVE: To develop a concise screening tool that allows for early identification of disordered eating in youth. STUDY DESIGN: In this 2-step classification accuracy study, questions for the Ottawa Disordered Eating Screen-Youth, a 2-question screening tool (index test), were conceptualized by clinician-scientists from tertiary care pediatric eating disorder and weight-related clinics, and was validated using retrospective data (2004-2010) from a community-based study, the Research on Eating and Adolescent Lifestyles (REAL) study. RESULTS: Analyses of contrast between the index test and the reference standard using data from 2892 (1714 females) students between grade 7 and grade 12 revealed classification statistics of 67.1% for sensitivity, 85.9% for specificity, 4.7 for positive likelihood ratio, 0.38 for negative likelihood ratio, 50.6% for positive predictive value, and 92.4% for negative predictive value for females and 61.1% for sensitivity, 93.9% for specificity, and 9.9 for positive likelihood ratio, 0.41 for negative likelihood ratio, 32.3% for positive predictive value, and 98.0% for negative predictive value for males. CONCLUSIONS: Our findings suggest that the index test has utility as a short and accurate screening tool for earlier detection of disordered eating thoughts and behaviors in youth. Additional research is needed to best determine how the index test can be administered to youth across various health care, school, public health, and surveillance settings in clinically sensitive pragmatic ways.

Effects of weight teasing and gender on body esteem in youth: A longitudinal analysis from the REAL study.

Weight teasing is associated with body dissatisfaction, but no study has examined the differential impact of the teasing source's gender. This study examined whether the longitudinal relationship between weight teasing (by peers), weight-related comments (by parents) and body esteem differed by the teasing sources' gender, and whether these relationships were moderated by victims' weight status and demographic factors. A school-based sample (N = 1197 at Time 1; 60% female) of adolescents completed surveys over approximately 2 years (Time 1-Time 3). Multilevel modeling showed that teasing from a male peer had a stronger, negative association with appearance esteem for female victims than males. Although weight teasing was more prevalent among youth with overweight/obesity, teasing from female peers had a stronger negative association with weight esteem for adolescents of average weight. Results suggest the weight teasing sources' gender may differentially impact the victims' body esteem, and highlights the need to consider these factors in weight teasing prevention strategies.

Attachment Style and Obesity: Disordered Eating Behaviors as a Mediator in a Community Sample of Canadian Youth.

OBJECTIVE: Obesity and overweight are associated with many negative health outcomes. Attachment style has been implicated in the development of obesity in youth. The present study examined if disordered eating behaviors mediate the relationship between attachment style and body mass index (BMI) in a large community sample of Canadian youth. METHOD: A total of 3,043 participants (1,254 males and 1,789 females, Mage = 14.20 years) completed self-report questionnaires including the Relationship Questionnaire and the Dutch Eating Behavior Questionnaire, and BMI was objectively measured. Disordered eating behaviors (restrained, emotional, and external) were examined as possible mediating mechanisms in the relationship between attachment style and BMI z-score, using a multiple mediation model using bootstrapping while controlling for socio-demographic covariates. RESULTS: Insecure attachment was significantly associated with higher BMI, and disordered eating mediated this relationship. Restrained eating was the strongest mediator of this pathway. CONCLUSION: Results suggest that it may be important to take attachment history and restrained eating into account when designing treatment and prevention strategies for obesity in youth.

Benzodiazepine Misuse in the Elderly: Risk Factors, Consequences, and Management.

Benzodiazepine (BZD) inappropriate use (i.e., misuse and overuse) is a worldwide public health problem. Despite current knowledge about increased sensitivity to side effects in the elderly, that should lead to more caution, only a third of BZD prescriptions in this age group are considered appropriate. The most frequent inadequate situations are excessive duration and/or dosage of a medical prescription or self-medication, especially in a context where it would be contraindicated, e.g., long-acting BZD in the elderly. Polypharmacy and comorbidities are major risk factors. Consequences of BZD inappropriate use are falls, delirium and other cognitive dysfunction, acute respiratory failure, car accidents, dependence, and withdrawal symptoms. An emerging concern is a potentially increased risk of dementia. Contrary to most clinicians' belief, discontinuation of chronic BZD use in elderly patients is feasible, with adequate psychotherapeutic or pharmacological strategies, and can lead to long-term abstinence. Brief cognitive therapy mostly relies on psychoeducation and motivational enhancement and is particularly useful in this context. Further research is needed, notably in three areas: (1) assessing the impact of public health programs to prevent BZD inappropriate use in the elderly, (2) developing alternative strategies to treat anxiety and insomnia in elderly patients, and (3) exploring the association between chronic BZD use and dementia.

Examining the bidirectional relationship between physical activity, screen time, and symptoms of anxiety and depression over time during adolescence.

More physical activity (PA) and less screen time (ST) are positively associated with mental health in adolescents; however, research is limited by short-term designs and the exclusion of ST when examining PA. We examined: (a) changes in PA, ST, symptoms of depression, and symptoms of anxiety over four assessments spanning 11years, and (b) bidirectional relationships between initial PA, ST, and symptoms of depression and anxiety as predictors of change in each other during adolescence. Between 2006 and 2010, participants from Ottawa Canada (Time1; N=1160, Mean age=13.54years) completed questionnaires at four points covering the ages from 10 to 21years. Latent growth modeling was used. PA decreased over time whereas ST and symptoms of depression and anxiety increased over time. Controlling for sex, ethnicity, school location, zBMI, birth year, and parents' education, initially higher anxiety was associated with initially higher ST (covariance=.88, p<.05) and initially lower PA (covariance=-6.84, p=.07) independent of initial symptoms of depression. Higher initial depression was associated with higher initial ST (covariance=2.55, p<.05). Increases in anxiety were associated with increases in ST (covariance=.07, p=.06) and increases in depression (covariance=.41, p<.05). Examining bidirectional relationships, higher initial symptoms of depression predicted greater decreases in PA (b=-.28, p<.05). No other significant findings between initial PA, ST, anxiety, or depression were found as predictors of change in each other. Interventions targeting depression around age 13 may be useful to prevent further declines in PA. Similarly, interventions to reduce ST may be beneficial for concurrent reductions in symptoms of depression and anxiety, irrespective of PA.

Treatment of Maternal Depression in a Medication Clinical Trial and Its Effect on Children.

(Reprinted from the American Journal of Psychiatry 2015; 172:450-459, with permission from American Psychiatric Association Publishing).

Adapted Dialectical Behavior Therapy for Adolescents with Self-injurious Thoughts and Behaviors.

The purpose of this study was to explore clinical changes observed in suicidal adolescents treated with an adapted form of Dialectical Behavior Therapy for adolescents (A-DBT-A) in a tertiary care setting. We conducted an open-label naturalistic study including 61 adolescents with self-injurious thoughts and behaviors and associated features of borderline personality disorder, who underwent a 15-week course of A-DBT-A. Pre- and post-treatment measures were administered, the primary outcome being the total score on the Suicidal Ideas Questionnaire. Self-harm, symptoms of borderline personality disorder, resiliency measures, predictors of response, and predictors of attrition were also explored. Among participants who completed post-treatment measures, we found a significant reduction in suicidal ideation (n = 31, p < 0.001). Secondary outcomes also suggested improvement. Baseline substance use predicted attrition (HR 2.51; 95% CI 1.03-6.14; p < 0.05), as did baseline impulsivity score on the Life Problems Inventory (HR 1.03; 95% CI 1.004-1.06; p < 0.05). Overall, we observed clinical improvements in adolescents receiving A-DBT-A.

Weight Status and DSM-5 Diagnoses of Eating Disorders in Adolescents From the Community.

OBJECTIVE: To estimate jointly the point prevalence of weight and eating disorders in a community sample of adolescents; to investigate psychosocial correlates of thinness, overweight, and obesity, and of full- and subthreshold eating disorders (EDs); and to examine the relationships between weight status and prevalence of EDs. METHOD: A total of 3,043 Canadian adolescents (1,254 males and 1,789 females; mean age = 14.19 years, SD = 1.61 years) completed self-report questionnaires, including the Eating Disorder Diagnostic Scale, and measures of psychosocial functioning. Objective weight and height were collected, and weight status was defined according to the International Obesity Task Force body mass index growth curve centiles. RESULTS: In all, 29.5% (95% CI = 26.7, 32.5) of males and 22.8% (95% CI = 20.5, 25.2) of females were overweight or obese. A total of 2.2% (95% CI = 1.5, 3.2) of males and 4.5% (95% CI = 4.4, 4.5) of females met DSM-5 criteria for an ED; in addition, 1.1% (95% CI = 0.7, 1.9) of males and 5.1% (95% CI = 4.0, 6.5) of females were identified with a subthreshold ED. Both full- and subthreshold EDs were significantly associated with markedly impaired psychosocial functioning. There was a significant relationship between prevalence of EDs and weight status, with an increased risk for a bulimic disorder in obese relative to normal-weight males (odds ratio [OR] = 7.86) and females (OR = 3.27). CONCLUSION: This study provides estimates for the prevalence of DSM-5 EDs in adolescents, further support for their impact on mental health, and new evidence for an association between bulimic disorders and obesity. Results call for an integrated approach in research and prevention regarding the whole spectrum of eating- and weight-related disorders.

Use of Electroconvulsive Therapy in Adolescents With Treatment-Resistant Depressive Disorders: A Case Series.

OBJECTIVES: This study presents a comprehensive case series of adolescents who received electroconvulsive therapy (ECT) for treatment-resistant depression. METHODS: Conducting a chart review, we identified 13 adolescents who had ECT for treatment of depression over a 5-year interval (2008-2013) at a Canadian tertiary care psychiatric hospital. Details about participants' clinical profile, index course of ECT, outcome, side effects, and comorbidities were extracted and analyzed. RESULTS: Thirteen adolescents aged 15 to 18 years, received a mean of 14 (SD, 4.5) ECT sessions per patient. Based on the Beck Depression Inventory-II at baseline and after treatment with ECT, a reliable improvement was observed in 10 patients, with 3 achieving full recovery. Through mixed effects linear modeling, we found a decrease of 0.96 points (95% CI, -1.31 to -0.67, P < 0.001) on the Beck Depression Inventory-II total score for every ECT treatment received. The Montreal Cognitive Assessment was used for monitoring of cognitive function throughout the treatment. Adverse effects included transient subjective cognitive impairment (n = 11), headache (n = 10), muscular pain (n = 9), prolonged seizure (n = 3), and nausea and/or vomiting (n = 3). CONCLUSIONS: A clinically significant improvement was observed for 10 (77%) adolescents receiving ECT for treatment-resistant depression. These observations suggest that ECT is a potential treatment option for refractory depression in selected adolescents. More data are needed to draw conclusions about efficacy and possible predictors of treatment response.

Screen time is associated with depression and anxiety in Canadian youth.

OBJECTIVE: This study examined the relationships between screen time and symptoms of depression and anxiety in a large community sample of Canadian youth. METHOD: Participants were 2482 English-speaking grade 7 to 12 students. Cross-sectional data collected between 2006 and 2010 as part of the Research on Eating and Adolescent Lifestyles (REAL) study were used. Mental health status was assessed using the Children's Depression Inventory and the Multidimensional Anxiety Scale for Children-10. Screen time (hours/day of TV, video games, and computer) was assessed using the Leisure-Time Sedentary Activities questionnaire. RESULTS: Linear multiple regressions indicated that after controlling for age, sex, ethnicity, parental education, geographic area, physical activity, and BMI, duration of screen time was associated with severity of depression (ß=0.23, p<0.001) and anxiety (ß=0.07, p<0.01). Video game playing (ß=0.13, p<.001) and computer use (ß=0.17, p<0.001) but not TV viewing were associated with more severe depressive symptoms. Video game playing (ß=0.11, p<0.001) was associated with severity of anxiety. CONCLUSION: Screen time may represent a risk factor or marker of anxiety and depression in adolescents. Future research is needed to determine if reducing screen time aids the prevention and treatment of these psychiatric disorders in youth.

Treatment of maternal depression in a medication clinical trial and its effect on children.

OBJECTIVE: Observational studies show that when a depressed mother's symptoms remit, her children's psychiatric symptoms decrease. Using randomized treatment assignment, the authors sought to determine the differential effects of a depressed mother's treatment on her child. METHOD: The study was a randomized double-blind 12-week trial of escitalopram, bupropion, or the combination of the two in depressed mothers (N=76), with independent assessment of their children (N=135; ages 7-17 years). RESULTS: There were no significant treatment differences in mothers' depressive symptoms or remission. Children's depressive symptoms and functioning improved significantly among those whose mothers were in the escitalopram group (compared with those whose mothers were in the bupropion and combination treatment groups). Only in the escitalopram group was significant improvement of mother's depression associated with improvement in the child's symptoms. Exploratory analyses suggested that this may be due to changes in parental functioning: Mothers in the escitalopram group reported significantly greater improvement, compared with the other groups, in their ability to listen and talk to their children, who as a group reported that their mothers were more caring over the 12 weeks. Maternal baseline negative affectivity appeared to moderate the effect of maternal treatment on children, although the effect was not statistically significant. Children of mothers with low negative affectivity improved in all treatment groups. Children of mothers with high negative affectivity improved significantly only for those whose mothers were in the escitalopram group. CONCLUSIONS: The effects of the depressed mother's improvement on her children may depend on her type of treatment. Depressed mothers with high anxious distress and irritability may require medications that reduce these symptoms in order to show the effect of her remission on her children.

Comparative distribution and validity of DSM-IV and DSM-5 diagnoses of eating disorders in adolescents from the community.

OBJECTIVES: DSM-5 changes for eating disorders (EDs) aimed to reduce preponderance of non-specified cases and increase validity of specific diagnoses. The objectives were to estimate the combined effect of changes on prevalence of EDs in adolescents and examine validity of diagnostic groupings. METHOD: A total of 3043 adolescents (1254 boys and 1789 girls, Mage = 14.19 years, SD = 1.61) completed self-report questionnaires including the Eating Disorder Diagnostic Scale. RESULTS: Prevalence of full-threshold EDs increased from 1.8% (DSM-IV) to 3.7% (DSM-5), with a higher prevalence of bulimia nervosa (1.6%) and the addition of the diagnosis of purging disorder (1.4%); prevalence of binge eating disorder was unchanged (0.5%), and non-specified cases decreased from 5.1% (DSM-IV) to 3.4% (DSM-5). Validation analyses demonstrated that DSM-5 ED subgroups better captured variance in psychopathology than DSM-IV subgroups. DISCUSSION: Findings extend results from previous prevalence and validation studies into the adolescent age range. Improved diagnostic categories should facilitate identification of EDs and indicate targeted treatments.

Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders.

BACKGROUND: Anxiety and related disorders are among the most common mental disorders, with lifetime prevalence reportedly as high as 31%. Unfortunately, anxiety disorders are under-diagnosed and under-treated. METHODS: These guidelines were developed by Canadian experts in anxiety and related disorders through a consensus process. Data on the epidemiology, diagnosis, and treatment (psychological and pharmacological) were obtained through MEDLINE, PsycINFO, and manual searches (1980-2012). Treatment strategies were rated on strength of evidence, and a clinical recommendation for each intervention was made, based on global impression of efficacy, effectiveness, and side effects, using a modified version of the periodic health examination guidelines. RESULTS: These guidelines are presented in 10 sections, including an introduction, principles of diagnosis and management, six sections (Sections 3 through 8) on the specific anxiety-related disorders (panic disorder, agoraphobia, specific phobia, social anxiety disorder, generalized anxiety disorder, obsessive-compulsive disorder, and posttraumatic stress disorder), and two additional sections on special populations (children/adolescents, pregnant/lactating women, and the elderly) and clinical issues in patients with comorbid conditions. CONCLUSIONS: Anxiety and related disorders are very common in clinical practice, and frequently comorbid with other psychiatric and medical conditions. Optimal management requires a good understanding of the efficacy and side effect profiles of pharmacological and psychological treatments.