The American Psychiatric Association Publishing Textbook of Anxiety, Trauma, and OCD-Related Disorders 3rd Edition Naomi Simon

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Textbook of
ANXIETY, TRAUMA, AND OCD-
RELATED DISORDERS
THIRD EDITION
Textbook of
ANXIETY, TRAUMA, AND OCD-
RELATED DISORDERS
THIRD EDITION
EDITED BY
Naomi M. Simon, M.D., M.Sc.
Eric Hollander, M.D.
Barbara O. Rothbaum, Ph.D., ABPP
Dan J. Stein, M.D., Ph.D.
Note: The authors have worked to ensure that all information in this book is
accurate at the time of publication and consistent with general psychiatric and
medical standards, and that information concerning drug dosages, schedules, and
routes of administration is accurate at the time of publication and consistent with
standards set by the U.S. Food and Drug Administration and the general medical
community. As medical research and practice continue to advance, however,
therapeutic standards may change. Moreover, specific situations may require a
specific therapeutic response not included in this book. For these reasons and
because human and mechanical errors sometimes occur, we recommend that
readers follow the advice of physicians directly involved in their care or the care of
a member of their family.
Books published by American Psychiatric Association Publishing represent the
findings, conclusions, and views of the individual authors and do not necessarily
represent the policies and opinions of American Psychiatric Association Publishing
or the American Psychiatric Association.
If you wish to buy 50 or more copies of the same title, please go to www.appi.org/
specialdiscounts for more information.
Copyright © 2020 American Psychiatric Association Publishing
ALL RIGHTS RESERVED
Third Edition
American Psychiatric Association Publishing
800 Maine Avenue SW
Suite 900
Washington, DC 20024-2812
www.appi.org
Library of Congress Cataloging-in-Publication Data
Names: Simon, Naomi M., editor. | Hollander, Eric, 1957- editor. | Rothbaum,
Barbara O., editor. | Stein, Dan J., editor. | American Psychiatric Association
Publishing, issuing body.
Title: The American Psychiatric Association Publishing textbook of anxiety, trauma,
and OCD-related disorders / edited by Naomi Simon, Eric Hollander, Barbara O.
Rothbaum, Dan J. Stein.
Other titles: Textbook of anxiety, trauma, and OCD-related disorders | Textbook of
anxiety disorders.
Description: Third edition. | Washington, DC : American Psychiatric Association
Publishing, [2020] | Preceded by: Textbook of anxiety disorders / edited by Dan
J. Stein, Eric Hollander, Barbara O. Rothbaum. 2nd ed. c2010. | Includes
bibliographical references and index. |
Identifiers: LCCN 2019057573 (print) | LCCN 2019057574 (ebook) | ISBN
9781615372324 (hardcover ; alk. paper) | ISBN 9781615372928 (ebook)
Subjects: MESH: Anxiety Disorders | Stress Disorders, Traumatic | Obsessive-
Compulsive Disorder
Classification: LCC RC531 (print) | LCC RC531 (ebook) | NLM WM 172 | DDC
616.85/22—dc23
LC record available at https://lccn.loc.gov/2019057573
LC ebook record available at https://lccn.loc.gov/2019057574
British Library Cataloguing in Publication Data
A CIP record is available from the British Library.
We dedicate this volume to the memory of Donald F.
Klein; his pioneering contributions to the field
inspired us, and he generously mentored several
generations of anxiety disorder researchers, including
many of our contributing authors.
Contents
Contributors
Foreword
Jerrold F. Rosenbaum, M.D.
Susan K. Gurley, J.D.
Preface
Naomi Simon, M.D., M.Sc.
Barbara O. Rothbaum, Ph.D., ABPP
Dan J. Stein, M.D., Ph.D.
Part I
Approaching Anxiety Disorders
1 Classification of Anxiety and

Related Disorders
Cary S. Kogan, Ph.D.
Andrea R. Ashbaugh, Ph.D.
2 Genetic Contributions to Anxiety
and Related Disorders
John M. Hettema, M.D., Ph.D.
Jürgen Deckert, M.D.
Thalia C. Eley, Ph.D.
Sandra Meier, Ph.D.
3 Neural Circuits in Fear and

Anxiety: Research Domain
Criteria: Preclinical to Clinical
J. Douglas Bremner, M.D.
4 Cultural and Social Aspects of

Anxiety Disorders
Denise April Chavira, Ph.D.
Carolyn Ponting, M.A.
Roberto Lewis-Fernández, M.D.
5 Economic and Social Burden of

Anxiety, Trauma-Related, and
Obsessive-Compulsive and
Related Disorders
David F. Tolin, Ph.D.
Part II
Core Principles for Treating
Anxiety Disorders
6 Cognitive-Behavioral Concepts
of Anxiety
Alexandra S. Tanner, M.A.
Michelle G. Craske, Ph.D.
7 Psychodynamic Concepts and

Treatment of Anxiety
Fredric N. Busch, M.D.
Barbara L. Milrod, M.D.
8 Unified Protocol: A
Transdiagnostic Cognitive-
Behavioral Therapy Approach
Todd J. Farchione, Ph.D.
Stephanie Jarvi Steele, Ph.D.
Brittany K. Woods, M.A.
Andrew J. Curreri, M.A.
Mengxing Wang, M.A.
David H. Barlow, Ph.D., ABPP
9 Combined Treatment of Anxiety
Disorders
Jessica L. Maples-Keller, Ph.D.
Mark Burton, Ph.D.
Emily Mellen, B.A.
Julia Merker, B.S.
Kerry J. Ressler, M.D., Ph.D.
Barbara O. Rothbaum, Ph.D.
10 Core Principles in
Pharmacotherapy of Anxiety
Disorders
Valerie Rosen, M.D.
Charles B. Nemeroff, M.D., Ph.D.
Part III
Generalized Anxiety Disorder
11 Phenomenology of Generalized
Anxiety Disorder
Katja Beesdo-Baum, Ph.D.
12 Pathogenesis of Generalized
Anxiety Disorder
Amina Sutherland-Stolting, M.D.
Betty Liao, Ph.D.
Karen Kraus, M.D.
Craig Campbell, M.D.
Andrew W. Goddard, M.D.
13 Pharmacotherapy for
Generalized Anxiety Disorder
Michael Van Ameringen, M.D.,
FRCPC
Beth Patterson, B.Sc.N., B.Ed.,
M.Sc.
Grishma Dabas, B.Sc.
Isobel Sharpe, B.Sc.
Daniel Marrello, B.Sc.
14 Psychotherapy for Generalized

Anxiety Disorder
Jonathan D. Huppert, Ph.D.
William C. Sanderson, Ph.D.
Part IV
Obsessive-Compulsive and
Related Disorders
15 Phenomenology of OCD
Christina L. Boisseau, Ph.D.
Brianna Prichett, B.S.
Steven A. Rasmussen, M.D.
Jane L. Eisen, M.D.
16 Pathophysiology of Obsessive-
Compulsive and Related
Disorders.
Darin D. Dougherty, M.D.
Scott L. Rauch, M.D.
Benjamin D. Greenberg, M.D.,
Ph.D.
17 Pharmacotherapy for OCD.

Benedetta Grancini, M.D.
Kevin J. Craig, M.B.B.Ch., M.Phil.,
MRCPsych
Eduardo Cinosi, M.B.B.S.,
MRCPsych
Ayotunde Shodunke, M.B.B.S.,
M.Sc., MRCPsych
Jemma Reid, M.B.B.S., MRCPsych
Zoya Marinova, M.D., Ph.D.
Naomi A. Fineberg, M.B.B.S., M.A.,
MRCPsych
18 Psychological Treatment for OCD

Jonathan S. Abramowitz, Ph.D.
Jennifer L. Buchholz, M.A.
19 The Obsessive-Compulsive
Spectrum of Disorders
Elisabetta Burchi, M.D.
Michael Diamond, M.D.
Erin Shanahan, B.S.
Dan J. Stein, M.D.
Part V
Panic Disorder and Agoraphobia
20 Phenomenology of Panic
Disorder.
Amanda Waters Baker, Ph.D.
Olivia Losiewicz, B.A.
Mark H. Pollack, M.D.
Jordan W. Smoller, M.D., Sc.D.
Michael W. Otto, Ph.D.
Elizabeth Hoge, M.D.
21 Pathogenesis of Panic Disorder.

Ryan D. Webler, B.A.
Jeremy D. Coplan, M.D.
22 Pharmacotherapy for Panic

Disorder
Borwin Bandelow, M.D., Ph.D.
David S. Baldwin, M.A., D.M.,
FRCPsych
23 Psychotherapy for Panic Disorder

Abigail L. Barthel, M.A.
Simona Stefan, Ph.D.
Stefan G. Hofmann, Ph.D.
Part VI
Social Anxiety Disorder (Social
Phobia)
24 Phenomenology of Social
Anxiety Disorder
Murray B. Stein, M.D., M.P.H.
Charles T. Taylor, Ph.D.
25 Pathogenesis of Social Anxiety

Disorder
Janna Marie Bas-Hoogendam,
M.Sc.
Eline F. Roelofs, M.D.
P. Michiel Westenberg, Ph.D.
Nic J.A. van der Wee, M.D., Ph.D.
26 Pharmacotherapy for Social

Anxiety Disorder
Franklin R. Schneier, M.D.
27 Psychotherapy for Social Anxiety
Disorder
Arielle Horenstein, M.A.
Michaela B. Swee, M.A.
Simona C. Kaplan, M.A.
Richard G. Heimberg, Ph.D.
Part VII
Specific Phobia
28 Specific Phobia.
Ella L. Oar, Ph.D.
Ronald M. Rapee, Ph.D.
Part VIII
Trauma- and Stressor-Related
Disorders
29 Phenomenology of PTSD.
Miranda Olff, Ph.D.
Alexander C. McFarlane, M.D.
30 Pathogenesis of PTSD.
Richard A. Bryant, Ph.D.
31 Pharmacotherapy for PTSD.

Boadie W. Dunlop, M.D.
Jonathan R.T. Davidson, M.D.
32 Psychotherapy for PTSD

Lily A. Brown, Ph.D.
Monnica T. Williams, Ph.D.
Edna B. Foa, Ph.D.
33 Phenomenology of Acute and

Persistent Grief
Sidney Zisook, M.D.
Charles Reynolds, M.D.
Ilanit R. Tal, Ph.D.
Barry Lebowitz, Ph.D.
Stephen J. Cozza, M.D.
M. Katherine Shear, M.D.
34 Treatment of Acute and
Persistent Grief
Natalia Skritskaya, Ph.D.
Colleen Gribbin Bloom, M.S.W.
Part IX
Anxiety Disorders and
Comorbidity
35 Mixed Anxiety-Depressive
Disorder
Jan Fawcett, M.D.
Rebecca P. Cameron, Ph.D.
Alan F. Schatzberg, M.D.
36 Anxiety in the Context of

Substance Use Disorders
Sudie E. Back, Ph.D.
Kathleen T. Brady, M.D., Ph.D.
37 Anxiety and Anxiety Disorders in
Medical Settings
Rushi H. Vyas, M.D.
Antolin Trinidad, M.D., Ph.D.
Thomas N. Wise, M.D.
38 Anxiety and Insomnia

Thomas W. Uhde, M.D.
Nicole A. Short, Ph.D.
Bernadette M. Cortese, Ph.D.
Part X
Anxiety Disorders in Special
Populations
39 Childhood Anxiety Disorders

Sandra S. Pimentel, Ph.D.
Carolyn Spiro-Levitt, Ph.D.
Anne Marie Albano, Ph.D., ABPP
40 Anxiety Disorders in Late Life.

Josien Schuurmans, Ph.D.
Gert-Jan Hendriks, Ph.D., M.D.
Claire Van Genugten, M.Sc.
Richard Oude Voshaar, Ph.D., M.D.
Index
Contributors
Jonathan S. Abramowitz, Ph.D.

Professor of Clinical Psychology, Department of Psychology and
Neuroscience, University of North Carolina–Chapel Hill, Chapel Hill,
North Carolina
Anne Marie Albano, Ph.D., ABPP

Professor of Medical Psychology in Psychiatry, Columbia University
Vagelos College of Physicians and Surgeons, New York, New York
Andrea R. Ashbaugh, Ph.D.

Associate Professor, School of Psychology, University of Ottawa,
Ontario, Canada
Sudie E. Back, Ph.D.

Associate Professor, Clinical Neuroscience Division, Department of
Psychiatry and Behavioral Sciences, The Medical University of South
Carolina, Charleston, South Carolina
Amanda Waters Baker, Ph.D.

Assistant Professor, Department of Psychiatry, Massachusetts
General Hospital/Harvard Medical School, Boston, Massachusetts
David S. Baldwin, M.A., D.M., FRCPsych

Professor of Psychiatry, Clinical and Experimental Sciences, Faculty
of Medicine, University of Southampton, Southampton, United
Kingdom
Borwin Bandelow, M.D., Ph.D.

Department of Psychiatry and Psychotherapy, University Medical
Center, Göttingen, Germany
David H. Barlow, Ph.D., ABPP

Professor Emeritus of Psychology and Psychiatry, Center for Anxiety
and Related Disorders, Boston University, Massachusetts
Abigail L. Barthel, M.A.

Graduate student, Department of Psychological and Brain Sciences,
Boston University, Boston, Massachusetts
Janna Marie Bas-Hoogendam, M.Sc.

Doctoral student, Department of Psychiatry, Leiden University
Medical Center; Developmental and Educational Psychology, Institute
of Psychology, Leiden University; Leiden Institute for Brain and
Cognition, Leiden, Netherlands
Katja Beesdo-Baum, Ph.D.

Professor, Technische Universität Dresden, Institute of Clinical
Psychology and Psychotherapy, Behavioral Epidemiology, Center for
Clinical Epidemiology and Longitudinal Studies, Dresden, Germany
Colleen Gribbin Bloom, M.S.W.

Program Manager, Field Instructor, Columbia School of Social Work,
Center for Complicated Grief, New York
Christina L. Boisseau, Ph.D.

Associate Professor, Department of Psychiatry and Behavioral
Sciences, Northwestern University Feinberg School of Medicine,
Chicago, Illinois
Kathleen T. Brady, M.D., Ph.D.

Professor and Director, Clinical Neuroscience Division, The Medical
University of South Carolina, Charleston, South Carolina
J. Douglas Bremner, M.D.

Professor of Psychiatry and Behavioral Sciences and Professor of
Radiology, Emory University School of Medicine, Atlanta; Staff
Physician, Atlanta Veterans Clinic General Mental Health (AVC GMH),
Atlanta VA Medical Center, Decatur, Georgia
Lily A. Brown, Ph.D.

Assistant Professor, Department of Psychiatry, University of
Pennsylvania, Philadelphia, Pennsylvania
Richard A. Bryant, Ph.D.

Professor, School of Psychology, University of New South Wales,
Sydney, Australia
Jennifer L. Buchholz, M.A.

Graduate student in Clinical Psychology, University of North Carolina–
Chapel Hill, Chapel Hill, North Carolina
Elisabetta Burchi, M.D.

Research Fellow, Autism and Obsessive Compulsive Spectrum
Program, Albert Einstein College of Medicine, Psychiatric Research
Institute at Montefiore-Einstein (PRIME), Bronx, New York
Mark Burton, Ph.D.

Postdoctoral Fellow, Emory University School of Medicine,
Department of Psychiatry and Behavioral Sciences, Atlanta, Georgia
Fredric N. Busch, M.D.

Professor of Psychiatry, Weill Cornell Medical College; Faculty,
Columbia University Center for Psychoanalytic Training and Research,
New York, New York
Rebecca P. Cameron, Ph.D.

Interim Department Chair and Professor, Department of Psychology,
Sacramento State University, Sacramento, California
Craig Campbell, M.D.

Health Sciences Clinical Professor of Psychiatry and Program
Director, UCSF Fresno, Fresno, California
Denise April Chavira, Ph.D.

Professor, Department of Psychology, UCLA, Los Angeles, California
Eduardo Cinosi, M.B.B.S., MRCPsych

Hertfordshire Partnership University NHS Foundation Trust, St.
Albans, United Kingdom
Jeremy D. Coplan, M.D.

Professor of Psychiatry, SUNY Downstate Medical Center, Brooklyn,
New York
Bernadette M. Cortese, Ph.D.

Postdoctoral Scholar and Assistant Professor, Department of
Psychiatry and Behavioral Sciences, Medical University of South
Carolina, Charleston, South Carolina
Stephen J. Cozza, M.D.

Associate Director, Center for the Study of Traumatic Stress,
Uniformed Services University for the Health Sciences, Bethesda,
Maryland
Kevin J. Craig, M.B.B.Ch., M.Phil., MRCPsych

Medical Director, P1vital Limited; University of Oxford Department of
Psychiatry, Warneford Hospital, Oxford, United Kingdom
Michelle G. Craske, Ph.D.

Distinguished Professor and Vice Chair, Department of Psychology,
University of California, Los Angeles, California
Andrew J. Curreri, M.A.

Doctoral student, Center for Anxiety and Related Disorders, Boston
University, Boston, Massachusetts
Grishma Dabas, B.Sc.

Ph.D. candidate, MacAnxiety Research Centre and Department of
Psychiatry and Behavioural Neurosciences, McMaster University,
Hamilton, Ontario, Canada
Jonathan R. T. Davidson, M.D.

Emeritus Professor, Department of Psychiatry and Behavioral
Sciences, Duke University School of Medicine, Durham, North
Carolina
Jürgen Deckert, M.D.

Professor of Psychiatry, Department of Psychiatry, Psychosomatics
and Psychotherapy, Center of Mental Health, University Hospital of
Würzburg, Würzburg, Germany
Michael Diamond, M.D.

Research Fellow, Autism and Obsessive Compulsive Spectrum
Program, Albert Einstein College of Medicine, Psychiatric Research
Institute at Montefiore-Einstein (PRIME), Bronx, New York
Darin D. Dougherty, M.D.

Associate Professor of Psychiatry, Harvard Medical School; Director
of Medical Education, Obsessive Compulsive Disorder Institute,
Department of Psychiatry, Massachusetts General Hospital, Boston,
Massachusetts
Boadie W. Dunlop, M.D.

Sciences, Emory University School of Medicine, Atlanta, Georgia
Jane L. Eisen, M.D.

Clinical Director, Division of Depression and Anxiety Disorders,
McLean Hospital, Belmont, Massachusetts
Thalia C. Eley, Ph.D.

Professor of Developmental Behavioural Genetics, and Lab Director,
Emotional Development Intervention and Treatment (EDIT), SGDP
Centre, Institute of Psychiatry, Psychology and Neuroscience, King’s
College, London, United Kingdom
Todd J. Farchione, Ph.D.

Research Associate Professor, Center for Anxiety and Related
Disorders, Boston University, Boston, Massachusetts
Jan Fawcett, M.D.

Professor of Psychiatry, University of New Mexico School of Medicine,
Albuquerque, New Mexico
Naomi A. Fineberg, M.B.B.S., M.A., MRCPsych

Professor of Psychiatry, University of Hertfordshire and Consultant
Psychiatrist, Highly Specialised Obsessive Compulsive Disorders
Service, Hertfordshire Partnership University NHS Foundation Trust,
Welwyn Garden City; Senior Clinical Research Fellow, Department of
Psychiatry, University of Cambridge School of Clinical Medicine,
Addenbrooke’s Hospital, Cambridge, United Kingdom
Edna B. Foa, Ph.D.

Professor, Department of Psychiatry, University of Pennsylvania,
Philadelphia, Pennsylvania
Andrew W. Goddard, M.D.

Professor, Department of Psychiatry, UCSF Fresno, Fresno, California
Benedetta Grancini, M.D.

Department of Biomedical and Clinical Sciences, University of Milan;
Psychiatry Unit, ASST Fatebenefratelli-Sacco, Milan, Italy
Benjamin D. Greenberg, M.D., Ph.D.

Associate Professor of Psychiatry and Human Behavior, Butler
Hospital, Warren Alpert Medical School of Brown University,
Providence, Rhode Island
Richard G. Heimberg, Ph.D.

Professor of Psychology, Department of Psychology, Temple
University, Philadelphia, Pennsylvania
Gert-Jan Hendriks, Ph.D., M.D.

Appointed Professor of the Treatment of Anxiety Disorders and
Depression in Older Adults, Overwaal Centre of Expertise for Anxiety
Disorders, OCD and PTSD, Institution for Integrated Mental Health
Care Pro Persona, Nijmegen, Netherlands
John M. Hettema, M.D., Ph.D.

Professor, Department of Psychiatry, Texas A&M Health Science
Center, Bryan, Texas; Associate Professor of Psychiatry, Virginia
Institute for Psychiatric and Behavioral Genetics, Virginia
Commonwealth University, Richmond, Virginia
Stefan G. Hofmann, Ph.D.

Professor, Department of Psychological and Brain Sciences, Boston
Elizabeth Hoge, M.D.

Director, Anxiety Disorders Research Program, and Associate
Professor of Psychiatry, Georgetown University School of Medicine,
Washington, DC

Director, Autism and Obsessive Compulsive Spectrum Program and
Anxiety and Depression Program, Montefiore Medical Center and
Albert Einstein College of Medicine; Professor of Psychiatry and
Behavioral Sciences, Albert Einstein College of Medicine, Bronx, New
York
Arielle Horenstein, M.A.

Doctoral student, Department of Psychology, Temple University,
Jonathan D. Huppert, Ph.D.

Professor and Sam and Helen Beber Chair of Clinical Psychology,
Department of Psychology, The Hebrew University of Jerusalem, Mt.
Scopus, Jerusalem, Israel
Simona C. Kaplan, M.A.

Cary S. Kogan, Ph.D.

Professor, School of Psychology, University of Ottawa, Ontario,
Canada
Karen Kraus, M.D.

Health Sciences Clinical Associate Professor of Psychiatry, Director of
Child Psychiatry, UCSF Fresno, Fresno, California
Barry Lebowitz, Ph.D.

Professor, Department of Psychiatry, University of California San
Diego, La Jolla, California
Roberto Lewis-Fernández, M.D.

Professor and Director, New York State Center of Excellence for
Cultural Competence, Hispanic Treatment Program, and Anxiety
Disorders Clinic, New York State Psychiatric Institute; Department of
Psychiatry, Columbia University Vagelos College of Physicians and
Surgeons, New York, New York
Betty Liao, Ph.D.

Clinical Psychologist, Director of Wellness and Mental Health Support
Services, UCSF Fresno, Fresno, California
Olivia Losiewicz, B.A.

Clinical Research Coordinator, Department of Psychiatry,
Massachusetts General Hospital, Boston, Massachusetts
Jessica L. Maples-Keller, Ph.D.

Assistant Professor, Department of Psychiatry and Behavioral
Sciences, Emory University School of Medicine, Atlanta, Georgia
Zoya Marinova, M.D., Ph.D.

Daniel Marrello, B.Sc.

M.Sc. candidate, MacAnxiety Research Centre and Department of
Psychiatry and Behavioural Neurosciences, McMaster University;
Neuroscience Graduate Program, McMaster University, Hamilton,
Ontario, Canada
Alexander C. McFarlane, M.D.

Professor, Centre for Traumatic Stress Studies, The University of
Adelaide, Adelaide, Australia
Sandra Meier, Ph.D.

Associate Professor of Psychiatry, Department of Psychiatry,
Dalhousie University, Halifax, Nova Scotia
Emily Mellen, B.A.

Research Assistant, McLean Hospital, Harvard Medical School,
Belmont, Massachusetts
Julia Merker, B.S.

Research Assistant, McLean Hospital, Harvard Medical School,
Belmont, Massachusetts
Barbara L. Milrod, M.D.

Professor of Psychiatry, Weill Cornell Medical College; Faculty, New
York Psychoanalytic Institute, New York, New York
Charles B. Nemeroff, M.D., Ph.D.

Professor and Acting Chair, Associate Chair for Research, Department
of Psychiatry; Director, Institute for Early Life Adversity Research,
Dell Medical School, University of Texas at Austin, Austin, Texas
Ella L. Oar, Ph.D.
Doctor, Centre for Emotional Health, Department of Psychology,
Macquarie University, Sydney, New South Wales, Australia
Miranda Olff, Ph.D.

Professor, Amsterdam UMC, Department of Psychiatry, Amsterdam
Neuroscience, Amsterdam; Arq Psychotrauma Expert Group,
Diemen, Netherlands
Michael W. Otto, Ph.D.

Director, Center for Anxiety and Related Disorders; Professor of
Psychology, Boston University, Boston, Massachusetts
Beth Patterson, B.Sc.N., B.Ed., M.Sc.

MacAnxiety Research Centre, McMaster University; Department of
Psychiatry and Behavioural Neurosciences, McMaster University,
Sandra S. Pimentel, Ph.D.

Sciences, Montefiore Medical Center/Albert Einstein College of
Medicine, Bronx, New York
Mark H. Pollack, M.D.

Chairperson and Professor, Rush University Medical Center, Chicago,
Illinois
Carolyn Ponting, M.A.

Doctoral student, Department of Psychology, UCLA, Los Angeles,
California
Brianna Prichett, B.S.

Research Assistant, Department of Psychiatry and Human Behavior,
Brown Medical School, Providence, Rhode Island
Ronald M. Rapee, Ph.D.

Distinguished Professor, Centre for Emotional Health, Department of
Psychology, Macquarie University, Sydney, New South Wales,
Australia
Steven A. Rasmussen, M.D.

Mary E. Zucker Professor and Chairman, Department of Psychiatry
and Human Behavior, Brown Medical School, Providence, Rhode
Island
Scott L. Rauch, M.D.

President and Psychiatrist in Chief, McLean Hospital, Belmont; Chair,
Partners Psychiatry and Mental Health; Professor of Psychiatry,
Harvard Medical School, Boston, Massachusetts
Jemma Reid, M.B.B.S., MRCPsych

Kerry J. Ressler, M.D., Ph.D.

Professor, McLean Hospital, Harvard Medical School, Belmont,
Massachusetts
Charles Reynolds, M.D.

Professor of Geriatric Psychiatry, Department of Psychiatry,
University of Pittsburgh, Pittsburgh, Pennsylvania
Eline F. Roelofs, M.D.

Doctoral student, Department of Child and Adolescent Psychiatry,
Curium, Leiden University Medical Center; Department of Psychiatry,
Leiden University Medical Center; Leiden Institute for Brain and
Cognition, Leiden, Netherlands
Valerie Rosen, M.D.

Associate Professor of Psychiatry, Department of Psychiatry, Dell
Medical School, University of Texas at Austin, Ascension Seton Family
of Hospitals, Austin, Texas
Barbara O. Rothbaum, Ph.D.
Professor, Department of Psychiatry and Behavioral Sciences, Emory
University School of Medicine, Atlanta, Georgia
William C. Sanderson, Ph.D.

Professor of Psychology; Director, Ph.D. Program in Clinical
Psychology; and Director, Anxiety and Depression Clinic, Hofstra
University, Hempstead, New York
Alan F. Schatzberg, M.D.

Professor, Department of Psychiatry and Behavioral Sciences,
Stanford University School of Medicine, Stanford, California
Franklin R. Schneier, M.D.

Co-Director, Anxiety Disorders Clinic, New York State Psychiatric
Institute; Special Lecturer, Department of Psychiatry, Columbia
University, New York, New York
Josien Schuurmans, Ph.D.

Senior Researcher, Amsterdam University Medical Center, Vrije
Universiteit, Psychiatry, Amsterdam Public Health Research Institute,
Amsterdam, Netherlands
Erin Shanahan, B.S.

Clinical Research Coordinator, Autism and Obsessive Compulsive
Spectrum Program, Albert Einstein College of Medicine, Psychiatric
Research Institute at Montefiore-Einstein (PRIME), Bronx, New York
Isobel Sharpe, B.Sc.

M.P.H. candidate, MacAnxiety Research Centre, McMaster University,

Marion E. Kenworthy Professor of Psychiatry, Columbia University
School of Social Work, Columbia University Vagelos College of
Physicians and Surgeons; Director, Center for Complicated Grief, New
York
Ayotunde Shodunke, M.B.B.S., M.Sc., MRCPsych
Nicole A. Short, Ph.D.

Assistant Professor, Department of Anesthesiology, University of
North Carolina at Chapel Hill, Chapel Hill, North Carolina
Naomi M. Simon, M.D., M.Sc.

Director, Anxiety and Complicated Grief Program, Department of
Psychiatry, New York University Langone Health; Professor of
Psychiatry, NYU School of Medicine, New York, New York
Natalia Skritskaya, Ph.D.

Adjunct Associate Research Scientist, Columbia School of Social
Work, Center for Complicated Grief, New York
Jordan W. Smoller, M.D., Sc.D.

Director, Center for Human Genetic Research, Massachusetts General
Hospital; Associate Professor of Psychiatry, Harvard Medical School,
Boston, Massachusetts
Carolyn Spiro-Levitt, Ph.D.

Clinical Assistant Professor, Department of Child and Adolescent
Psychiatry, Hassenfeld Children’s Hospital at New York University
Langone, New York
Stephanie Jarvi Steele, Ph.D.

Visiting Assistant Professor, Psychology Department, Williams
College, Williamstown, Massachusetts
Simona Stefan, Ph.D.

Visiting Scholar, Department of Psychological and Brain Sciences,
Boston University, Boston, Massachusetts; Assistant Professor,
Department of Clinical Psychology and Psychotherapy, Babes-Bolyai
University, Cluj-Napoca, Romania
Dan J. Stein, M.D.
Professor and Chair, Department of Psychiatry and Mental Health,
University of Cape Town, South Africa; Director, South African
Medical Research Council Unit on Anxiety and Stress Disorders;
Visiting Professor, Mt. Sinai Medical School, New York, New York
Murray B. Stein M.D., M.P.H.

Professor, Department of Psychiatry and Department of Family and
Preventive Medicine, and Director, Anxiety and Traumatic Stress
Disorders Program, University of California, San Diego, California
Amina Sutherland-Stolting, M.D.

Chief Resident in Psychiatry, UCSF Fresno, Fresno, California
Michaela B. Swee, M.A.

Ilanit R. Tal, Ph.D.

Department of Psychiatry, University of California San Diego, La
Jolla, California
Alexandra S. Tanner, M.A.

Doctoral student in Clinical Psychology, UCLA, Los Angeles, California
Charles T. Taylor, Ph.D.

Associate Professor, Department of Psychiatry, University of
California San Diego, La Jolla, California
David F. Tolin, Ph.D.

Director of the Anxiety Disorders Center and Adjunct Associate
Professor of Psychiatry, Institute of Living and Yale University School
of Medicine, Hartford, Connecticut
Antolin Trinidad, M.D., Ph.D.

Associate Clinical Professor of Psychiatry, Yale University School of
Medicine, New Haven, Connecticut
Thomas W. Uhde, M.D.
Professor and Chair, Department of Psychiatry and Behavioral
Sciences, Medical University of South Carolina, Charleston, South
Carolina
Michael Van Ameringen, M.D., FRCPC

Professor, MacAnxiety Research Centre, Department of Psychiatry
and Behavioural Neurosciences, and Neuroscience Graduate
Program, McMaster University, Hamilton, Ontario, Canada
Nic J.A. van der Wee, M.D., Ph.D.

Professor of Biological Psychiatry, Department of Psychiatry, Leiden
University Medical Center; Leiden Institute for Brain and Cognition,
Leiden, Netherlands
Claire Van Genugten, M.Sc.

Doctoral student, Amsterdam University Medical Center, Vrije
Universiteit, Psychiatry, Amsterdam Public Health Research Institute,
Amsterdam, Netherlands
Richard Oude Voshaar, Ph.D., M.D.

Professor of Geriatric Psychiatry, University Medical Center
Groningen, Department of Psychiatry, Groningen, Netherlands
Rushi H. Vyas, M.D.

Assistant Director of Consult Liaison Medicine, Department of
Psychiatry, Inova Fairfax Hospital, Fairfax, Virginia
Mengxing Wang, M.A.

Doctoral student, Department of Psychology, Stony Brook University,
Stony Brook, New York
Ryan D. Webler, B.A.

Doctoral student, Clinical Psychology, University of Minnesota,
Minneapolis
P. Michiel Westenberg, Ph.D.

Professor, Institute of Psychology, Leiden University; Leiden Institute
for Brain and Cognition, Leiden, Netherlands
Monnica T. Williams, Ph.D.

Associate Professor, Department of Psychological Sciences,
University of Connecticut, Storrs, Connecticut
Thomas N. Wise, M.D.

Professor of Psychiatry, Johns Hopkins University School of Medicine,
Baltimore, Maryland; Professor of Psychiatry, George Washington
University School of Medicine, Washington, DC; Psychiatrist, Inova
Fairfax Hospital, Fairfax, Virginia
Brittany K. Woods, M.A.

Doctoral student, Center for Anxiety and Related Disorders, Boston
Sidney Zisook, M.D.

Professor, Department of Psychiatry, University of California San
Diego, La Jolla, California
Disclosure of Interests
David S. Baldwin, M.A., D.M., FRCPsych: Attendee: Advisory
boards hosted by LivaNova and Mundipharma; Lecture Fees:
Janssen.
Borwin Bandelow, M.D., Ph.D.: Speakers Board: Hexal, Janssen,
Lilly, and Lundbeck; Advisory Board: Mundipharma and Lundbeck.
Kevin J. Craig, M.B.B.Ch., M.Phil., MRCPsych: Employee and
Stockholder: GW Pharmaceuticals Plc.
Jürgen Deckert, M.D.: Research/Grants: European Union, in
cooperation with P1Vital; Government of Bavaria, in cooperation with
BioVariance.
Naomi A. Fineberg, M.B.B.S., M.A., MRCPsych:
Research/Grants: European College of Neuropsychopharmacology,
National Institute for Health Research, Horizon 2020; Speaker:
Abbott, Sun Pharma; Travel and Expenses: British Association for
Psychopharmacology, European College of
Neuropsychopharmacology, Royal College of Psychiatrists, The
International College of Neuropsychopharmacology; Income: Taylor
& Francis; Leadership: National Health Service OCD treatment
service; Board Membership: various registered charities linked to
OCD.
Andrew W. Goddard, M.D.: Royalties: UptoDate;
Research/Grants: National Network of Depression, University of
California–San Francisco; Advisory Board: HWP, Almatica Pharma
Inc. (August 2018).
Richard G. Heimberg, Ph.D.: Royalties: Oxford University Press;
Advisor and Stockholder: Joyable, Inc.
Eric Hollander, M.D.: Research/Grant: Takeda.
Charles B. Nemeroff, M.D., Ph.D.: Research/Grants: National
Institutes of Health, Stanley Medical Research Institute; Consulting
(past 3 years): Xhale, Takeda, Taisho Pharmaceutical Inc., Bracket
(Clintara), Fortress Biotech, Sunovion Pharmaceuticals Inc.,
Sumitomo Dainippon Pharma, Janssen Research and Development
LLC, Magstim Inc., Navitor Pharmaceuticals Inc., TC MSO Inc., Intra-
Cellular Therapies Inc.; Stockholder: Xhale, Celgene, Seattle
Genetics, Abbvie, OPKO Health Inc., Antares, BI Gen Holdings Inc.,
Corcept Therapeutics Pharmaceuticals, TC MSO Inc.; Scientific
Advisory Boards: American Foundation for Suicide Prevention, Brain
and Behavior Research Foundation, Xhale, Anxiety Disorders
Association of America, Skyland Trail, Bracket (Clintara), Laureate
Institute for Brain Research Inc.; Board of Directors: American
Foundation for Suicide Prevention, Gratitude America, Anxiety
Disorders Association of America. Income Sources or Equity of
$10,000 or More: American Psychiatric Publishing, Xhale, Bracket
(Clintara), CME Outfitters, Takeda, Intra-Cellular Therapies Inc.,
Magstim; Patents: Method and devices for transdermal delivery of
lithium (US 6,375,990B1); method of assessing antidepressant drug
therapy via transport inhibition of monoamine neurotransmitters by
ex vivo assay (US 7,148,027B2); Compounds, Compositions,
Methods of Synthesis, and Methods of Treatment (CRF Receptor
Binding Ligand) (US 8,551, 996 B2).
Josien Schuurmans, Ph.D.: Speaker: Pfizer conferences, 2011.
Naomi Simon, M.D., M.Sc.: Spousal Equity: GI Therapeutics;
Research/Grants: National Institutes of Health, Department of
Defense, Highland Street Foundation.
Dan J. Stein, M.D., Ph.D.: Research/Honoraria: Biocodex,
Lundbeck, Servier, Sun.
David F. Tolin, Ph.D.: Research/Grants: Biohaven Pharmaceuticals,
Pfizer, Palo Alto Health Sciences.
Thomas W. Uhde, M.D.: Speaker’s Bureau: Jazz Pharmaceuticals.
Michael Van Ameringen, M.D., FRCPC: Advisory Board: Allergan,
Lundbeck, Purdue; Clinical Trials/Studies: Janssen Ortho Inc.;
Research/Grants: Hamilton Academic Health Sciences Organization
(HAHSO) Innovation Grant (AFP Innovation Grant); Speaker’s
Bureau: Allergan, Lundbeck, Pfizer, Purdue.
The following authors have no competing interests to report: Andrea
R. Ashbaugh, Ph.D.; Amanda Waters Baker, Ph.D.; Christina L.
Boisseau, Ph.D.; Frederic N. Busch, M.D.; Denise April Chavira,
Ph.D.; Eduardo Cinosi, M.B.B.S., MRCPsych; Michelle G. Craske,
Ph.D.; Thalia C. Eley, Ph.D.; Benedetta Grancini, M.D.; John M.
Hettema, M.D., Ph.D.; Arielle Horenstein, M.A.; Simona C. Kaplan,
M.A.; Cary S. Kogan, Ph.D.; Roberto Lewis-Fernández, M.D.; Jessica
Maples-Keller, Ph.D.; Zoya Marinova, M.D., Ph.D.; Sandra Meier,
Ph.D.; Barbara L. Milrod, M.D.; Ella L. Oar, Ph.D.; Sandra S.
Pimentel, Ph.D.; Carolyn Ponting, M.A.; Ronald M. Rapee, Ph.D.;
Jemma Reid, M.B.B.S., MRCPsych; Valerie Rosen, M.D.; Barbara O.
Rothbaum, Ph.D.; Franklin Schneier, M.D.; Ayotunde Shodunke,
M.B.B.S., M.Sc., MRCPsych; Carolyn Spiro-Levitt, Ph.D.; Michaela B.
Swee, M.A.; Alexandra S. Tanner, M.A.; Rushi H. Vyas, M.D.
Foreword
Consider anxiety and the biological systems through

which it operates to be analogous to the immune system. Hardwired
by evolution and varying genetic risk profiles but given greater
precision and specificity by exposure to threats in the environment,
it evolved to keep us safe and well. Like the immune system, even
when responding to relevant targets, appropriate activation can have
unwanted consequences (e.g., pain, swelling, fever). For some, the
consequences of even an appropriate or excessive immune response
can be harsher than the actual microbial threat or injury. More
unfortunately a common scenario, the immune system, rather than
reacting to an external threat, targets the self in autoimmune
disease. Adding insult to injury, each of these systems can activate
the other, because inflammation is both a risk factor and a response
in mood and anxiety disorders. As with the approaches available to
diminish inflammation, we clinicians can minimize anxiety with
avoidance of the threat, suppression with pharmacotherapy, or
better yet, retraining or desensitization so that benign challenges are
no longer triggers or the response is made more homeostatic. This
immune metaphor is not intended to be clever but rather to explain
by analogy to those who misunderstand or might trivialize the
neurobiological and experiential underpinnings of these often-
disabling disorders.
We’ve come a long way in our understanding, classification, and
treatment of anxiety and anxiety-related disorders. As a medical
student in 1971, I presented a case of “phobic anxiety
depersonalization syndrome,” a condition described by the eminent
British psychiatrist Sir Martin Roth. A few years later, as a newly
minted psychiatrist unashamed to manifest interest in the
medication treatment of psychiatric disorders, I was quite taken with
the early observational studies reported by Don Klein, employing
what he called “pharmacological dissection,” and with the
subsequent randomized antidepressant trials of “phobic anxiety” by
residents just ahead of me in the Massachusetts General Hospital
psychiatry residency program, Jim Ballenger and Dave Sheehan.
Those moments were pivotal in the emergence of the modern
conceptualization of panic disorder as distinct from other anxiety
syndromes.
As has been the neo-Kraepelinian tradition in psychiatry, efforts
to accomplish greater differentiation of phenotypes as represented
by evolving classification and diagnostic criteria led to increased
recognition and acceptance of anxiety syndromes by those who
experience them, to the evolution of greater understanding of risk
and vulnerability, and to the emergence of new and enhanced
therapies. These essential elements of the story are critically
reviewed and presented in the first part of this impressive volume,
“Approaching Anxiety Disorders,” which describes the foundational
elements of classification, inherited risk, neurobiology of fear
circuitry, other environmental contributors, and enormous societal
burden.
As with the immune analogy, many points of therapeutic
intervention are evidence based; we are moving closer to a time
when we will have precision in knowing to whom which approach or
combination of approaches should be offered. The current tools of
treatment are detailed in the section on “Core Principles for Treating
Anxiety Disorders.” The volume then turns its focus to specific
diagnostic categories and clinical issues, comprehensively presented
in state-of-the-art reviews that bring us to the brink of the future.
The textbook itself, now in its third edition, evolved from discussion
at the Scientific Council of the Anxiety Disorders Association of
America, now the Anxiety and Depression Association of America
(ADAA), and its publication by American Psychiatric Association
Publishing underscores the centrality of anxiety and its disorders to
the field.
A word about the ADAA, which was established nearly 40 years
ago as the Phobia Society of America: when the Phobia Society of
America was formed in 1979 by a small group of psychiatrists,
psychologists, social workers, patients, and family members, its
purpose was to convene those who wanted answers to these
questions: How can we better understand these disorders? What can
we do to help those who experience them? By 1990, several years
after DSM-III (American Psychiatric Association 1980) published
criteria for diagnosing distinct anxiety disorders, the organization
had changed its name to the Anxiety Disorders Association of
America to reflect the breadth of conditions the organization
represents. During the past few decades, research into the
phenomenology, pathophysiology, and neurobiology of anxiety
disorders has expanded, and the neurobiology of fear and anxiety
remains the best understood area of psychiatric neuroscience. Kudos
to Naomi Simon, Barbara Rothbaum, Eric Hollander, and Dan Stein
for, as editors, making a resource such as this extraordinary textbook
available to clinicians and students.
Jerrold F. Rosenbaum, M.D.

Chief of Psychiatry
Massachusetts General Hospital
Stanley Cobb Professor of Psychiatry
Harvard Medical School
Reference
American Psychiatric Association: Diagnostic and Statistical Manual of Mental
Disorders, 3rd Edition. Washington, DC, American Psychiatric Association, 1980
On behalf of the Anxiety and Depression Association of
America (ADAA), I am honored to comment on the 2020 updated
edition of the textbook, The American Psychiatric Association
Publishing Textbook of Anxiety, Trauma, and OCD-Related Disorders.
When the ADAA was established nearly 40 years ago (as the
Phobia Society of America), no “anxiety disorders field” existed.
Everything was labeled as a phobia. People who had anxiety felt
misunderstood and misdiagnosed. They often felt alone and
marginalized.
This resource will make a difference not only for the professionals
who will use the textbook during their course of studies but also for
the millions of people who are suffering and hoping for improved
treatment options. This textbook will inform the current professionals
in the field and, more importantly, will foster interest and
understanding in the field’s early career professionals. This new
edition will also promote evidence-based communications with other
critical stakeholders, such as legislators, patient-centered
organizations, and other health care professionals.
Although we have made tremendous strides in the field, more
needs to be done. Unfortunately, what Jerilyn Ross, one of the
founders of the Phobia Society of America, wrote in 2010 still stands
today: “We have a long way to go, especially with regard to
understanding the onset of the disorders and their impact on special
populations—women, children, adolescents, and the elderly.
Posttraumatic stress disorder, common to all populations, presents
an ongoing—and growing—global challenge.” I would now add that
we also need to do more to address the specific mental health issues
of a multicultural society.
The contributors to this edition are renowned experts in the field
who spend both their intellect and passion to help change patient
outcomes. Their research changes people’s lives. The authors and
those who have collaborated with them are the ones who help
support the ADAA’s promise to find new treatments and one day
prevent and cure these disorders.
Susan K. Gurley, J.D.

Executive Director
Anxiety and Depression Association of America
Preface
As long as humans have been humans, we have experienced

anxiety. Stress, fear, and anxiety are ubiquitous experiences. When is
anxiety a disorder? When is professional intervention indicated? Key
considerations include the intensity, severity, and clustering of
associated symptoms, their persistence, and, as with all psychiatric
disorders, their level of associated distress and impairment. Patients
with anxiety and related disorders often do not realize they have a
treatable condition and may not present with a chief complaint
aligned with DSM-5 gateway symptoms (American Psychiatric
Association 2013). Although great research advances have been
made in neuroscience, genetics, and understanding biological
responses to stress as well as the development of experimental
models of phenomena, such as fear conditioning and extinction, we
still do not have diagnostic biomarkers and depend on patient self-
awareness of symptoms and clinical assessment. These and other
factors, including structural barriers (e.g., lack of sufficient providers)
and attitudinal barriers (e.g., stigmatization of seeking psychiatric
care), continue to contribute to the underdiagnosis of patients with
anxiety, despite the very high prevalence of anxiety disorders
globally and their well-documented substantial global burden of
disability and associated socioeconomic costs. Educators and
advocacy groups have done a tremendous amount in the past
decades to increase awareness, and the explosion of the internet
has made information readily available to patients and clinicians
(when one can sort through it to find evidence-based information),
but more work needs to be done.
Another random document with
no related content on Scribd:
relating it as an amusing story to absolute strangers—turned out—how can I
say it, Ermengarde? for silly—for compromising intimacy—ugh!—with the
hotel-keeper's daughter's fiancé——"
"Really? Much obliged for your kind interest in my affairs. Slater's

detectives? Most ingenious. And, of course, you believed all you were told
by your Sherlock Holmes's and Paul Prys."
"And," he continued, ignoring these sarcasms, "to-day I come

personally to see for myself——"
"In the disguise of a Polish Anarchist——"
"And find you with that accursed young French idiot at your feet——"
"Young French idiots fall at people's feet on very small provocation."
"Making violent love to you—apparently."
"Ah! It's just as well you put in that 'apparently'," she commented quite
tranquilly, though all the time she was saying to herself, "Bluff,
Ermengarde, bluff! it's your only chance."
"You were crying——"
"Probably; I've had a good deal to cry about of late——" She looked
down as she spoke to arrange the set of her blouse, and gave her drapery a
few careful little pats.
"—Agitated. Perhaps you will offer some explanation of this?"
"Perhaps. In the meantime, perhaps you will offer some explanation of

your conduct." She looked up, quite satisfied now with the set of the blouse
belt.
"My dear child, this folly must end; this is a serious matter and not an
amateur farce. You have landed yourself in a most compromising situation,
made yourself the cause, the patent, acknowledged, loudly proclaimed
cause, of an engagement being broken off; and you simply laugh at the
whole thing."
"And if I have, as you say, brought myself into such a situation, pray,
whose fault was it?"
"Whose should it be but your own, your own folly and wilfulness and
insane disregard of common proprieties and decent conventions."
She had always understood that the Socratic method of conducting an

argument consisted in asking, and never answering, perpetual questions,
and being under the impression that Socrates was a person of quite
remarkable sagacity, resolved to employ it. As on this wise.
"Who refused to take me abroad for my health when I needed it, and
then followed me secretly in disguise to spy out and magnify every mistake
I might make? Who employed spies about me to report and distort every
incident of my life here? Who had grown so cold and cruel and faithless to
me at home that it was no home any more, and I felt I could endure it no
longer? Who was too busy and too poor to send his wife to the South after
illness, when he had just made a great success and was planning a tour of
his own to the very place he actually followed her to, disguised as a spy?
Who kept all his good fortune from his wife's knowledge?" A faint sob,
disguised as a cough, interrupted this interrogatory.
"Good Heavens! Ermengarde," cried Arthur, the expression of whose

face had undergone a variety of changes, mostly merging into one of
stupefaction, during this address, "what can you mean? What can you have
taken into your head? What on earth do you mean by faithless?"
"What," she cried, losing her head suddenly, and throwing prudence and
pride to the winds, though still adhering to the Socratic method—"what did
you mean by that scene in your study, the night I came home early with a
headache from my mother's, and looked in?"
"Scene in my study? There was never any scene in my study. What

night are you talking of? Look into my study whenever you like, and you'll
see nothing there but a man working or smoking, or both."
At this the Socratic method went by the board as well as pride and
prudence.
"The night—after—after—you had been so unkik-kik-kind about my

ha-ha-hats and gug-gug-gug-going abroad," she gasped, "the night the—the
woman was there—cry-crying—and being com-com-comforted?"
"Woman crying?" he muttered, puzzled. "Women don't come and cry in

my study. What on earth have you been imagining? Women don't come—
except, of course, the secretary—at all. You can't mean Miss Scott? By
George, now I come to think of it, she did come and cry there once, poor
girl. And of course, I tried to comfort her."
"Oh, of course!"
"Ermengarde! How can you?"
"How coo-coo-coo-could you?"
"Really one might almost suppose you had lowered yourself to some
vulgar suspicions——"
They had now arrived by slow degrees, and after various stops and turns
to emphasize rhetoric, at a place where the top of the ridge widened, and the
path ran between pine-woods clothing the side of the ravine, that here
sloped steeply instead of falling perpendicularly.
"You were, at any rate, landed in a most compromising situation," she

broke in, recovering her calm, "a nice predicament," she added, stepping
from the path into the wood among aromatic undergrowth and tall white
heath. "And when that predicament is satisfactorily explained, it will be
time——"
"You poor little fool!" he cried, suddenly turning, taking both her hands
and looking straight into her eyes, "you must have been off your head——"
"Arthur, how dare you!"
"Regularly off your head to stoop to such miserable suspicions——"

She wrenched her hands away. "I, at least, never spied on you. I had no
wish to verify any suspicions—I had seen more than enough," she said
scornfully.
"You could have falsified them at once with one question?"
"I—I couldn't—stoop—to that," she wept.
"My child, you must have had hysteria rather badly. I must have been
brutally impatient; I was so rushed just then. Poor Miss Scott brought some
typing that night and wrote shorthand notes until she was tired out. Then I
just happened to ask her a question about a family trouble I knew was
worrying her—you remember I engaged her on a family recommendation;
her people are old friends of mine—my question was an unlucky one, and
the poor girl broke down; she was so thoroughly tired out. You must have
chosen that exact moment to open the door——"
"I didn't at least go up on purpose, and come suddenly round a corner in

disguise," she protested.
"Most unfortunately you did not. But—Ermengarde——"
"And if I had stooped to ask explanations," she interrupted; "I ask none;
I wish none now; I merely suggest that before you demand explanations of
what you must know can have been nothing you could possibly complain
of, certain little eccentricities on your own part require to be cleared up.
What, for instance, took place under the olives yonder only yesterday
morning? Why all those secret meetings and communications in cipher with
a young woman of doubtful antecedents, of mysteries, of evasions, of
perpetual assignations and private interviews with notorious usurers and
pretended cousins? I don't wish to know—but—I resent the imputations you
cast upon my intercourse with a young man who is half secretary and half
waiter at this house, and at the beck and call of all here alike. I might," she
added, "go further, and ask why you chose to follow me about in a
ridiculous disguise, and worry and frighten me to death by spying on me
and posing as an Anarchist and conspirator?"
"Because I was an ass, probably. And when did I pose as anything but a
foreigner? Except at the Carnival, which is all masquerade"—"The
Carnival?" she murmured, puzzled—"We have both been infernal idiots,
Ermengarde. We quarrelled about nothing in particular to begin with——"
"If you call sarcasm, neglect, unkindness, coldness—nothing——"
"I certainly was a beast. Such a rush of work had come all at once, and I
hadn't time to consider that that infernal Flu had made you hysterical. And
you did cut into me about going abroad on your own finance. But look here,
Ermengarde, how could I have let you go alone, weak as you were? First I
got Miss Scott to go and look after you as your companion——"
"Miss Scott? Why, I never saw the woman in my life—except her back
in the study that night—if it was she—and as for a companion, I never had
such a thing in my life——"
"My dear child, Miss Somers is Miss Scott——"
"Oh-o-o-o-oh! The woman of mystery?—my companion?"
"She doesn't care to typewrite and do secretary under her own name,
but, coming here with you, and having relations she was bound to meet all
over the place——"
"Ah—a-a-a-ah! Aunts? Step-cousins? Ivor Paul?"
"Yes; her cousin, her uncle's stepson—she had to go back to her own
name. And then, that blessed book coming out and at once promising a
boom, unexpectedly put me in funds to come and look after you myself. I
was a good deal used-up, and ordered a rest-cure. As intelligence officer
and paper correspondent I've done disguises before—the only way to get
information—and incidentally I've picked up a lot of copy and been able to
help Agatha Somers in that family trouble, too. I didn't mean to keep up the
disguise more than to see you safe here at first. But it turned out to be so
useful. And, I say, look here, you little silly; don't let's quarrel any more."
It was pleasant on the wooded steep; myrtle-bushes gave out a delicious
aroma; innumerable bees made an organ-bourdon in grey masses of
rosemary-bloom; grasshoppers chirped in shrill pleasure; loveliest tints and
shadows were tangled in drooping olive-foliage; rugged peaks, soaring far
above gorge and ridge, ran up into a velvety blue sky; and, looking far
down the ravine's course, the connexions by marriage caught the deep warm
bloom of a peacock-blue sea, glowing in full sunshine and crossed by
silvery sails and long black hulls of steam vessels.
After all, a good hard shoulder is a pleasanter thing to lean one's head
upon than a cold, sharp rock or a rough and turpentiny tree-trunk; and any
more comfortable place to have a really good cry on has never yet been
imagined. Besides, however perverse and exasperating they may be,
husbands occasionally come in handy, when things suited to their obtuse
intellects have to be done—bills paid—insolent landladies tackled—hotel
accommodation provided.
So it was in a very light-hearted mood that Mrs. Allonby stepped out

into the olive-grove and walked along the mule-path, when the sun was
declining and western valleys were filling with purple shadow, and the light
pad-pad of a patient, soft-eyed mule warned them to step aside, on pain of
being jostled by his laden panniers, giving opportunity of answering a dark-
eyed peasant woman's "Buon sera," and admiring her pleasant smile and
white teeth, as she passed on, bearing her own burden behind her four-
legged slave's.
"I always wanted to show you this bit," Ermengarde said, when the
woods parted and sank at the top of the ridge and a sudden burst of broad
purple sea glowed to the east, where the gorge opened, and a smaller bay
disclosed itself on the west, all golden shimmer under a rose-gold sun. "And
you had been seeing it all the time. What a fraud you are!"
"I tell you what, Ermengarde; let's have the boy out when your mother
comes later on. She can bring him. Easter falls early; and, after all, the little
chap might as well miss the fag-end of the term. That'll set the old lady up,
eh? Italian lakes on the way home, or a look at Florence, or what?"
When they reached the hotel-gate, a woman with a tired, but serene and
sweet, face came down the twisted pine-root steps from the convent, with a
little start and flush of surprise at seeing them—the ex-anarchist now a
respectable, clean-shaven Briton, with a stable-cap in place of the broad felt
hat, and the cloak rolled in a neatly strapped bundle.
"Aha, my dear woman of mystery!" cried Ermengarde gaily, with open

hands. "Found out at last! All your machinations unmasked and exposed!
How are you? My best respects to you. I hear that you have been looking
after a certain Mrs. Allonby—connected with the Allonby, don't you know
—kind of dry-nursing the poor thing! If I'm not mistaken, you found her a
pretty good handful, didn't you?"
"Well, pretty fair at times," she admitted, observing that Mrs. Allonby
wore a diamond and pearl chain, closely resembling that flung to her by the
Spaniard at the Carnival, and afterwards exposed for sale in a Monte Carlo
window.
"Dear Miss Somers, I was a beast about the necklace. I am so sorry."
"Thought you'd sneaked the thing," Arthur blurted out with a grin, in
that exasperating way of his.
"I didn't," she stoutly contradicted; "I thought he had sneaked it and
made you the cat's paw to sell it. And, oh, my goodness, Miss Somers!" she
laughed out suddenly, "if I didn't think at one time that you were this man's
wife! And didn't I pity you, just! But we are not going to act charades any
longer. Nobody is to be anybody else any more; no, not even that wretched
young Isidore, the fraud! Ah! I wonder if Mr. Welbourne will turn out to be
some discontented duke in disguise," she cried, suddenly becoming aware
of the mystified countenance of the thin man, who had come by the mule-
path round the convent; "I'm not cracked, Mr. Welbourne, only a little crazy.
Let me introduce my husband—just arrived."
The thin man congratulated and opined that the arrival was singularly
opportune under the circumstances, while Arthur confessed that Mr.
Welbourne's virtues had long been familiar to him through correspondence.
And then, after proper comments on the weather, Arthur, with no
outward sign of terror, whatever he felt, sought the awful presence of
Madame Bontemps, while Ermengarde, with her heart in her mouth, and
cold chills running all over her, tried to be admitted to private conference
with Mlle. Geneviève, the woman of mystery acting as intermediary in this
difficult piece of diplomacy.
"The chain was from Spink's, after all," Mrs. Allonby admitted with a
blush, observing Agatha's glance upon it, "and people with glass houses
shouldn't throw stones. My husband saw the thing for sale at Poupart's, and
went in and redeemed it. He knew it by a flaw in a pearl. And you may
imagine I've had to sing pretty small, smaller than even the poor Boundrish
this afternoon—and with better reason, I'm afraid."
"You have sung very sweetly to me, dear Mrs. Allonby, and, after all, I
must have been a horrid nuisance——"
"You certainly were. But my husband, poor man, has to reckon with me
for that."
"Mine was not the easiest position; to act companion anonymously

——"
"And be taken for a spy, a conspirator——"
"And thief——"
"No, no; but that miserable man of mine pays the bill for all. And when
you marry, dear Miss Somers, take my advice; keep him well in hand, but
never let it come to a long sulk. Whatever it is, have it out with him at once
and have done with it."
In the meantime, Madame Bontemps, all unsuspicious of what was

coming, was sitting peacefully in the office, casting up the columns of the
weekly bills with one part of her sane and practical mind, and gloating in
memory over her powerful remarks of the morning in the garden with
another; while with a third she threw out staccato commands and
observations to M. Bontemps, who was placidly smoking a cigarette over
his Petit Niçois on the sofa, when a tall, clean-shaven, respectable Briton,
with a keen, unflinching eye, and the usual British air of holding a subject
universe in fee, walked in and bid her good evening in excellent French.
"This is without doubt Madame Bontemps," he said, introducing

himself as the husband of a lady staying in the house, a Mrs. Arthur
Allonby, and handing her his card, on reading which all Madame's bristles
rose, and she prepared herself for the battle she felt to be imminent and also
pregnant with victory to her side. Politely, but sadly, she desired her guest to
be seated in a chair handed him at a sign from her by M. Bontemps, who
smiled pleasantly to himself, expecting to be agreeably diverted by the
forthcoming combat.
But Mr. Allonby, declining the chair, much to Madame's regret, as she
found it easier to heckle opponents sitting than standing, began to address
her sternly but gently, more in sorrow than anger, and always with that air
of surprised dignity and unabated command. He had been led to suppose, he
said very politely, that Les Oliviers was an exceptionally well-managed and
high-class hotel, else, as Madame might easily surmise, he would never
have selected it for the temporary sojourn of his wife while waiting till he
would be able to join her. What, then, was his astonishment on learning that
Mrs. Allonby had actually been requested to leave the house? Such a thing
was outrageous, unheard-of, and must be apologized for without delay.
"Now for the fun!" reflected Monsieur, languidly adjusting a fresh

cigarette, while Madame promptly seized her chance of returning fire, and
turning about with expansive gestures and fluent delivery, poured in a
steady and powerful broadside calculated to silence the Englishman's guns
and shatter his forces beyond recovery.
What Monsieur had observed concerning Les Oliviers was absolutely

correct, she replied. The proceeding alluded to was undoubtedly unheard-
of, unparalleled, without precedent in the annals of that house—to which
only persons of absolutely irreproachable character and assured position
were admitted. Madame was filled with the profoundest compassion for
Monsieur; her bosom was torn for him; she regretted from the profoundest
depths of her being the necessity of inflicting upon him an immeasurable
pain. But she was woman; more than that, she asserted brokenly and with
deep sobs, she was mother. One's children were one's life. What mother
could view the silent, corroding anguish, could witness the perfidious
betrayal of a child, a guileless, a trusting, an adored child, unmoved? What
fiend in human shape could stand by in icy indifference and look upon the
gradual, irreparable blighting of a cherished daughter's life, the slow
destruction of her every hope, the corrosive agony perpetually gnawing at
her breaking heart, the withering, in short, of the pure and maidenly flower
of her youth, and raise no hand, utter no word, in her defence? Madame
Bontemps was the unfortunate possessor neither of a bosom of adamant nor
of a heart of granite; she possessed, on the contrary, those of a mother; with
a sacred fury and a noble indignation she chased from her hearth the serpent
whose envenomed tooth had poisoned the happiness of her child and ruined
the tranquillity of a cheerful and affectionate family circle. That the serpent
in question, whose wiles had been daily employed before her very eyes in
beguiling the youthful and pardonably sensitive affections of M. Isidore
from their lawful and pledged object, should be in effect the wife of
Monsieur, was for him, she admitted, a circumstance of supreme misfortune
and profoundly to be deplored, and upon which, from the depths of her
woman's breast, she offered him condolences of the deepest and most
sincere nature.
Here M. Bontemps, profoundly touched by his wife's eloquence, dashed

his cigarette despairingly to the floor, threw out his arms with gestures of
despair, and groaned aloud, while Madame sought relief in tears. "Ma fille,
ma Geneviève," she wailed, wildly smiting her breast, "mon enfant!"
But the stolid Englishman, surveying the afflicted parents with that
direct, undauntable soldier-look of his, appeared to be entirely unmoved and
awaiting further remarks from Madame Bontemps; and as these were not
after some seconds forthcoming, he ventured to represent to Madame with
infinite courtesy that she appeared to be the victim of an absurd
misapprehension, which, in a woman of her intellect and capacity,
paralyzed him with amazement. She had possibly taken some exaggerated
statements uttered in the course of a lover's quarrel literally. Madame's
words almost pointed to some vague suspicion that his wife—"my little
wife," he repeated, smiling—had perturbed the relations between those
young people, such a very droll supposition. If—as Madame here hastened
to assert—M. le Vicomte de Vieuxbois, whose father had been a friend of
his own, had been observed to converse in an agitated manner with Mrs.
Allonby, to whom, as to other pensionnaires, the Vicomte had obligingly
given Italian lessons, what more natural—Mrs. Allonby was herself a
mother, the wife of the Vicomte's father's friend; she was older than she
appeared, while M. de Vieuxbois was younger—what more natural than for
a young man, suffering from the apparent coldness and misunderstandings
of his betrothed, and far from his own mother, to seek counsel and comfort
of a lady by her age and experience eminently calculated to give them? As a
simple matter of fact, he was aware of all that had occurred; he had been
deeply interested in the course of the young man's love, which had met with
unusual, but not unnatural, obstacles, triumphantly and happily surmounted,
until this unfortunate, but truly absurd, little misunderstanding arose.
Madame probably knew that English wives had no secrets from their
husbands, so that for M. de Vieuxbois to confide in Mrs. Allonby the depth
of his passion and the misfortune of the various obstacles to its fulfilment,
was in effect to confide in himself. What a pity to let suspicions so absurd
divide two young and loving hearts! Mademoiselle's ear had doubtless been
abused by mischievous, misunderstood tittle-tattle. Girls were like that, he
knew from experience, and, having had the good fortune to win the best and
most charming of wives himself, it hurt him to think of M. de Vieuxbois
missing such a blessing—merely because of a little misconception of his
conduct—a misconception absolutely incredible in a person of Madame's
sagacity and knowledge of the world. In his anxiety for the young people's
happiness, he actually found himself forgetting the necessity for extracting
an apology for an unwarrantable act of incivility to his wife, the necessity
of which both Monsieur and Madame Bontemps would at once admit.
They did at once admit it, and with a celerity and sudden change of
front that not only took Mr. Allonby's breath away, but also that of M.
Isidore, who happened—no doubt by the merest chance—to be lounging
outside the ever open office door, intently studying the Figaro, and who
also happened to have dispatched Heinrich, the porter, on an errand, by the
latter deemed trivial and unnecessary to the last degree.
What M. Allonby had had the complaisance to observe, Madame

Bontemps blandly stated in reply, put an entirely different complexion on
the whole matter. She deeply regretted having, even in thought, wronged
Madame or M. Isidore, whom she embraced as a son—he made a grimace
over his Figaro outside at this remark—she deplored the inconvenience
suffered by Madame Allonby, and she should for the rest of her life cherish
the memory of M. Allonby as that of a valued, a beloved, an inestimable,
friend of the whole of her family.
M. Bontemps corroborated these assertions with tears of a noble and

profound emotion; Mlle. Geneviève (just then at the climax of an
explanatory and embarrassing interview with Mrs. Allonby) was promptly
summoned from the depths of the back premises at the very moment when
M. le Vicomte Isidore Augustin René Joseph Marie de Beauregard de
Vieuxbois was making a dramatic entrance from the front hall; and all was
joy, reconciliation, effusion, tears, transport, intoxication.
"It was all that little cat, Dorris," Ermengarde confided afterwards to
those fellow-conspirators, the ex-Anarchist and the woman of mystery; "so
that what she got this morning was perhaps not altogether wasted. Only I
wish she hadn't had it quite so hot."
"My conscience pricks me about de Vieuxbois' people," Arthur

confessed, when gratuitous champagne unexpectedly crowned the banquet
in the evening, and the visitors were asked by Madame Bontemps to drink
to the betrothal of M. Isidore and Mlle. Geneviève. "They won't thank me
for this afternoon's work. Just fancy a man in de Vieuxbois' position falling
in love with a girl like Mlle. Bontemps, and taking a post as general utility
person in a small hotel for her sake. Romantic young ass! The girl showed
her sense in refusing him. His mother is distracted. The whole family have
been at him about it! But the little chap would have her—Madame la
Vicomtesse!"
And when next day pack-mules waited by the place of Dorris's

execution, laden with Ermengarde's belongings, and she herself stood by
the lemon-laden trees and took a last view of the magnificent sweep of sea
below, and the splendid amphitheatre of encircling mountains above,
grasping a huge presentation bunch of roses, carnations, and heliotrope,
with a last lingering bough of mimosa bloom and one of lemon flower, and
receiving the farewells of the visitors, the salutations of the family and the
betrothed pair, and dazzling smiles from the well-tipped Heinrich, waiters
and chambermaids at windows, Ermengarde's heart rose in her throat; she
squeezed the thin man's hand to agony point; kissed Mrs. Dinwiddie, Lady
Seaton, and Miss Boundrish's mother; nodded to the young lady's father,
Major Norris and Bertie Trevor, turned and fled through the lemon-orchard
path so that Arthur could not overtake her till she came out upon the rock-
hewn road far below, where she was discovered gazing over the clean red
roofs and dark-leaved groves of Mentone out to sea, and unobtrusively
restoring a handkerchief to its pocket.
"It—it really was such a very lovely place—such a unique charm about
it," she said in apology.
"Tell you what, old lady, we'll come again next year if the boom keeps
up," Arthur replied, lighting his pipe in the shelter of a rocky scarp. "But I
bar squabbles first."
Before them the slender tower of St. Michel, just topping the mountain
spur that hides the Old Town, gleamed white on a clear blue sea; it had
rained during the night, and some cloud-wreaths still floated round the
craggy summits, leaving light veinings of snow on the amethystine peaks;
cheery voices and sounds rose from the saw-mill niched in the bottom of a
little gorge across the torrent; the plane avenue was alive with passing
wheels and steps and people of every sort and kind, but all gay as if they
had never known a care; the sea had richer and deeper hues, the sun a
warmer gold, the soaring mountains a more majestic outline, vegetation a
more varied luxuriance and colouring; and Ermengarde, listening to
Arthur's familiar, intermittent growl, and imparting pleasant secrets to him,
was lighter of heart than ever before. The full magic and splendour of the
azure shore was at last upon her, and the exhilaration and the pure joy of
living went to her head, sparkled in her eyes, glowed in her cheeks, and
thrilled her to the very finger-tips.
And yet she was at heart, if not a sadder, at least a wiser, and hoped to
be a better, woman than before those joyous adventures on the Côte d'Azur.
THE END
BILLING AND SONS, LTD., PRINTERS, GUILDFORD

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The American Psychiatric Association Publishing Textbook of Anxiety, Trauma, and OCD-Related Disorders 3rd Edition Naomi Simon

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The American Psychiatric Association

Publishing Textbook of Anxiety,

The American Psychiatric Association Publishing

The American Psychiatric Association Publishing

American Psychiatric Association Publishing Textbook of

The American Psychiatric Association Publishing

The American Psychiatric Association practice guideline

The Cambridge Handbook of Anxiety and Related Disorders

Cambridge IGCSE and O Level History Workbook 2C - Depth

Neurobiology of Brain Disorders: Biological Basis of

1 Classification of Anxiety and

3 Neural Circuits in Fear and

4 Cultural and Social Aspects of

5 Economic and Social Burden of

7 Psychodynamic Concepts and

14 Psychotherapy for Generalized

17 Pharmacotherapy for OCD.

18 Psychological Treatment for OCD

21 Pathogenesis of Panic Disorder.

22 Pharmacotherapy for Panic

23 Psychotherapy for Panic Disorder

25 Pathogenesis of Social Anxiety

26 Pharmacotherapy for Social

31 Pharmacotherapy for PTSD.

32 Psychotherapy for PTSD

33 Phenomenology of Acute and

36 Anxiety in the Context of

38 Anxiety and Insomnia

39 Childhood Anxiety Disorders

40 Anxiety Disorders in Late Life.

Jonathan S. Abramowitz, Ph.D.

Anne Marie Albano, Ph.D., ABPP

Andrea R. Ashbaugh, Ph.D.

Sudie E. Back, Ph.D.

Amanda Waters Baker, Ph.D.

David S. Baldwin, M.A., D.M., FRCPsych

Borwin Bandelow, M.D., Ph.D.

David H. Barlow, Ph.D., ABPP

Abigail L. Barthel, M.A.

Janna Marie Bas-Hoogendam, M.Sc.

Katja Beesdo-Baum, Ph.D.

Colleen Gribbin Bloom, M.S.W.

Christina L. Boisseau, Ph.D.

Kathleen T. Brady, M.D., Ph.D.

J. Douglas Bremner, M.D.

Lily A. Brown, Ph.D.

Richard A. Bryant, Ph.D.

Jennifer L. Buchholz, M.A.

Elisabetta Burchi, M.D.

Mark Burton, Ph.D.

Fredric N. Busch, M.D.

Rebecca P. Cameron, Ph.D.

Craig Campbell, M.D.

Denise April Chavira, Ph.D.

Eduardo Cinosi, M.B.B.S., MRCPsych

Jeremy D. Coplan, M.D.

Bernadette M. Cortese, Ph.D.

Stephen J. Cozza, M.D.

Kevin J. Craig, M.B.B.Ch., M.Phil., MRCPsych

Michelle G. Craske, Ph.D.

Andrew J. Curreri, M.A.

Grishma Dabas, B.Sc.

Jonathan R. T. Davidson, M.D.