Psychiatric Services Treatment Plan Form For Provider Type 36: Fill & Download for Free

before you read the article as i have stated below, let me give you a briefing of mine in the yeaes , that i have refered patients to psy chiatrics and psy chologists. in two different states- goa and maharashtra and their results.i have had experience of one of my client who had an attack and had to be carried to hospital -govt in mental hospital ward in emergenc.he had to be given sedatives as he had become violent by the time he was diagonised ,govt has setagenda in hospitals to treat such patients which is electrical shocks and long and tedious.results were uncertain and long.the patient came out of this process and could retain his job due to long such process and its effects on his health and miseries for his family during the process,he had to take medicines perreniaaly.another was the case of patient that was surrounding based.here the patient recovered in short time because he was identified for deppression and timely treatment and lead a normal life within few weeks.frankely speaking. in india, the psychiatric treatment is a taboo and the patient in such treatment is frowned upon and needs high level of secrecy during prolongued period of such treatments.yougsters can turn into mental wrecks if the symptoms are not identified in time and reach a stage of no return.deliberately, i have not discussed the financial gains by practicioners as cinics - because my approach here is of correctional therapy for patients where they exist in large volume of population - manly because society pressures and tension built in at young age on minors because of competition and excelling reuired to survive.if my article helps in improving mental well being of the ones who assist those affected or are near affections, the whole purpose , i believe is served.Psychiatry is the medical specialty devoted to the diagnosis, prevention and treatment of mental disorders .These include various maladaptations related to mood, behaviour, cognition, and perceptions.Initial psychiatric assessment of a person typically begins with a case history and mental status examination. Physical examinations and psychological tests may be conducted. On occasion, neuroimaging or other neurophysiological techniques are used.Mental disorders are often diagnosed in accordance with clinical concepts listed in diagnostic manuals .The combined treatment of psychiatric medication and psychotherapy has become the most common mode of psychiatric treatment in current practice .The combined treatment of psychiatric medication and psychotherapy has become the most common mode of psychiatric treatment .The field of psychiatry has many subspecialties that require additional training and certification . Such subspecialties include :Addiction psychiatryBrain Injury Medicine[35][36]Child and Adolescent PsychiatryClinical neurophysiologyEpilepsy[37][38]Forensic psychiatryGeriatric psychiatryHospice and palliative medicinePain medicine[39]Psychosomatic medicine[40] (also known as consultation-liaison psychiatry)Sleep medicineother aditions are :Cross-cultural psychiatryEmergency psychiatryLearning disabilityNeurodevelopmental disorderCognition diseases as in various forms of dementiaBiological psychiatryCommunity psychiatryGlobal Mental HealthMilitary psychiatrySocial psychiatryNeuropsychiatryA psychiatrist is a physician who specializes in psychiatry, the branch of medicine devoted to the diagnosis, prevention, study, and treatment of mental disorders. Psychiatrists are medical doctors, unlike psychologists, and must evaluate patients to determine whether their symptoms are the result of a physical illness, a combination of physical and mental ailments, or strictly psychiatric.As part of the clinical assessment process, psychiatrists may employ a mental status examination; a physical examination; brain imaging such as a computerized tomography (CT), magnetic resonance imaging (MRI), or positron emission tomography (PET) scan; and blood testing. Psychiatrists prescribe medicine, and may also use psychotherapy, although the vast majority do medical management and refer to a psychologist or other specialized therapist for weekly to bi-monthly psychotherapy.In India MBBS degree is the basic qualification needed to do Psychiatry. After completing MBBS (including internship) one can attend various PG Medical Entrance Exams and take MD in psychiatry which is a 3-year course. Diploma Course in Psychiatry or DNB Psychiatry can also be taken to become a Psychiatristsetting up a private practice in mumbai or india“To be or not to be” will always be the question. But when it comes to setting up a psychiatric practice in Mumbai, this question takes on ominous proportions. For the psychiatrist in a teaching institution, protected as he is by the institution in whatever he does, or who feels comfortable and secure with the salary he receives, it is often a gamble, which he feels unsure about, and which causes much anxiety. For the psychiatrist who feels the pinch, especially when he confronts his affluent colleagues who have a lucrative private practice, it is often a source of restlessness, unhappiness, and discontent, which causes him to decide to take the plunge into private practice come what may. To the psychiatrist who has just graduated and must start private practice sooner or later, it can be the cause for insecurity, uncertainty and anxiety. To the psychiatrist who is working abroad and must return to India because of family ties, setting up practice can be a headache, a nuisance and a constant source of worry. This Address is dedicated to all such psychiatrists, and to all those who have known and suffered tension and disillusionment, since we have known and fought these circumstances ourselves.Taking the Decision to Enter Private PracticeToying and playing with a decision to set up private practice is indeed foolhardy. These decisions have to be taken, and lesser the delay, the better. He who hesitates is lost, and it is never truer than when you have to setup a psychiatric practice. The longer you delay, the more are the chances that you never will; and the longer you delay, the lesser will be the drive that you bring to your effort. Most of it will be lost in useless activity, which is considered under the category of planning and more planning, leaving very little for the real effort that is essential later on. Having taken your decision then, let it be a firm one. “Burn your boats behind you”, and do not look back. Summon your total strength and make a constant all-out effort while setting up practice. Be ready to take chances but give yourself the best chance. Remember, “Never Venture, Never Gain” and forge ahead. “Nothing Succeeds like Success”, but success only comes to those who want it and mount a true concentrated attack. Move like a bulldozer on your target, and do not let anything come in your way once your target is in sight. In all your efforts, learn to be an early bird. It is the early bird that catches the worm, and you will succeed if you are determined; so have no anxiety. A successful practice only needs an individual with drive, an individual who can deliver the goods, an individual who realises early what his patients want, and an individual who tailor-makes his therapy to suit the individual needs of the patient. It cannot be stressed enough that to set up a successful practice, you need to bring all you have in you in one solid effort. Once the decision is taken this effort has to come.Where Should One Start Practice?In large cities as well as in the smaller towns, it is common to decide to practice in the heart of a business area, especially where other medical practitioners are concentrated. It is also possible to join an established clinic, where contact with other practitioners of modern medicine may be easy, and the location known to the patient population. In deciding the area of practice, the following should be the prime considerations viz., the initial cost and recurring expenditure, the location of a proposed clinic from point of view of convenience both to the psychiatrist and the patients, the familiarity of the area, the patient drainage of the area, other conveniences like suitability of time schedules, assistants, transport and nursing home facilities close by.It has always been a matter of discussion as to whether setting up practice separately is better than working in a polyclinic. Psychiatric patients, being what they are, may prefer the anonymity of a separate practice but having to enter a clinic of this type could identify them as well. On the other hand, in a polyclinic, they may be able to ‘mask’ their presence as visiting other medical consultants. Being familiar with an area helps the psychiatrist to know what to expect, and assures him of a certain amount of patient contact, but it may also prevent known patients from visiting him because of the stigma attached to psychiatry. All said and done, often the initial cost is generally the deciding factor with regard to the decision as to where to practice, and determines in some way the setup of the clinic and the type of practice expected and catered to. Here, again, too much of hesitation is bad and considerations that take plenty of time and are uselessly centred around calculations, only inhibit a decision and cause a final situation where no decision is taken; or, if a decision is indeed taken, causes a situation soaked with anxiety, worry and depression, which again prevents useful goal-directed activityDeveloping Contacts to Increase One's PracticeHaving decided the area in which to practice, it is befitting the psychiatrist to survey the “hinterland” and come to understand the drainage of practice to this particular area. His next job is establishing contacts and the following individuals and institutions must be kept in mind viz., relatives, friends and others known to the psychiatrist, hospitals in the area, especially those that do not have psychiatric facilities, polyclinics in the area and their medical consultants, general medical practitioners in the area, social workers and social welfare agencies in the area, schools/colleges in the area and their principals and teachers and any and every individual with whom there is even a fleeting contact. The psychiatrist should take every opportunity to disseminate the information that he is a psychiatrist and is practicing in the area. Most psychiatrists prefer to have an official opening of their clinics with much fanfare that often results in unnecessary expenses and fails to have the desired effect. It is much better to have in your service an ample supply of visiting cards, which can be given freely to all demanding one, or even slightly interested in getting one. This minute reminder, in addition to providing reading material, serves as a good reference guide as most contacts prefer to preserve visiting cards.The psychiatrist should take every opportunity to deliver lectures, to attend meetings and must make himself available in every manner possible whenever some opportunity is offered. The psychiatrist must make it his routine to write articles in journals as well as in the popular press, appear in the social media and television, as often and in whatever manner possible, whenever some opportunity is offered. It is foolhardy for psychiatrist to waste time waiting in the consulting-room of medical consultants with the hope that this contact may render an abundance of referral work. Most consultants and private practitioners, once they know the psychiatrist, refer the patient if they choose to do so; and if they don’t (with offence to none) it must be said that they should be forgotten.The psychiatrist would do well to give lectures to parents of school-going children, who are not only prospective patients themselves, but could also serve the cause of preventive psychiatry in their children. The contacts must be built up from time to time, and the psychiatrist will do well to give the right image while establishing these contacts, with the aim of correcting misconceptions about psychiatry, and at the same time drawing patients by making them realise that they need to see the psychiatrist. If this process of building up contacts is undertaken on a war footing, the psychiatrist can firmly hope to have the waiting room of his consulting room filled to capacity in a short time. Remember patients are often waiting to leave one psychiatrist and move to the next. Only they must feel they are likely to get a better deal. The call from the psychiatrist must go out to them, and this call will be answered! Only ensure while doing so that you do not indulge in mudslinging of a psychiatric colleague, much as the patient, and your own flattered sense of importance, may tempt you toAttachment to HospitalsGetting attachment to the local hospital has always been the first interest of any psychiatrist while setting up a practice. It is indeed true that getting attachments to good public hospitals assist the psychiatrist in getting known to prospective patients and getting an attachment to a teaching hospital helps him to keep abreast with advancements in the field, and prevents his knowledge from getting stale. While all these attachments are useful and assist the psychiatrist in setting up practice and giving the fillip he needs in the early days of his practice, getting ‘neurotic’ about getting an attachment should be condemned. In the present state of affairs, it is going to be more and more difficult for a psychiatrist to get attachments to a hospital, irrespective of his academic qualifications, teaching experience, specialty experience or for that matter social influence, especially in a large city like Mumbai. It is indeed possible to set up a lucrative practice without a hospital attachment if social contacts are established sufficiently, and the psychiatrist can bring about sufficient progress and social recovery in the illness of the patient. Remember, each individual patient treated well is your best advertisement, and work sufficiently with each patient to achieve this end. Building up a good reputation assures the psychiatrist of continuing practice, whether he has a hospital attachment or not. It is always possible for the psychiatrist to assist poor patients by making concessions in fees and at times treating some free, thus devoting some of the time for free work that in any case would have been done in the public hospital. Again these so-called poor patients do their best to bring in patients who can pay, in gratitude for favours received. The psychiatrist who does not have a hospital attachment, has that commodity that is impossible to buy, namely “time”; and he can devote this time for treating the patients with utmost consideration and care, and spending greater time with them for establishing a sufficient degree of rapport to bring about changes, which are possible in the patient's personality and environment; and also giving the patient strength to accept whatever cannot be changed. Once again having sufficient time, the psychiatrist is free and available to his patients at different times. Thus, it could be possible for him to garner a lot more practice than his colleagues who devote hours to a hospital attachment.Setting Up PracticeIn the present state of practice in India, it is not possible for a psychiatrist to have a total team in the form of a clinical psychologist, social worker, occupational therapist etc., while setting up practice. Most patients in India cannot afford the luxury of attention from an expert team of this type, although it is desirable this happens as soon as possible. Accordingly, the psychiatrist will have to be all in one and do counselling on his own. Likewise he may have to give social advice, even occasionally visit the patient's home and see for himself the situation that prevails. He will have to take various decisions on his own without the assistance of para-psychiatric professionals. This is especially applicable for a psychiatrist who sets up private practice after a stint either at an institution in India or abroad; he should be aware and prepared for practice along these lines.Private practice is very different from institutional practice as not only the responsibility falls heavily on the shoulders of the psychiatrist but also it offers many new arenas and challenges that the psychiatrist has to be ready to accept. Even the question of what fee to charge can be not only a vexing point but also causes much uncertainty. The psychiatrist can do well to study the prevailing pattern of practice in his particular area, and it would be proper, at least in the initial stages, for him to rate his professional fees below those that are prevailing. This stand, in addition to showing conformity with whatever prevails, serves to get the psychiatrist the confidence of the new patients who are always looking for a cheaper deal; and if he takes care to deliver the goods just as well, he could continue to have their confidence in the years to come. The psychiatrist who returns from abroad must be prepared to understand the pattern of practice in India. The authors have known many psychiatrists who had practiced abroad for sometime and came to India and become totally disillusioned in next to no time, causing them to pack their bags and go back.With regard to therapies, each psychiatrist generally follows a particular regimen to which he is accustomed. Thus, it is common for a particular psychiatrist to rely heavily on drugs and psychotherapy while another relies on drugs and electroconvulsive therapy (ECT). To the psychiatrist returning from abroad it would be better to remember that ECT is well appreciated in India, and suits the needs of Indian patients who have to return to work without much delay, and accordingly cannot afford the loss of disability hours that often occurs with prolonged psychotherapy. It goes without saying that the treatment has to be tailor made to suit the patient, and it would be well to remember as to what exactly the patient wants. And thus at times, it is wise to withhold ECT on a patient who is reluctant, particularly if the relatives feel the same way; and at other times, it would be a good working plan to hasten the start of ECT without which the patient would be lost because of the feeling that the psychiatrist is ineffective. On deciding to give ECT, it is the best to be very firm in the decision because hesitancy puts doubts in the patients’ mind. Never tell a patient, ‘We will give you ECT, if you like’. It is always the psychiatrist's decision and only consent is given by the patient and relatives. At times, the patients’ consent will have to be overlooked as he is not likely to give it, and in these situations, the psychiatrist will have to be content with the relatives’ consent.With regard to medication, patients always ask how long they should continue the medication, and the reply is always difficult. Behind the patient's mind, there is always a lingering doubt that psychiatrists are anxious that they should continue the medication indefinitely to keep their practice going, especially when follow-up consultation fees are charged. It is good to remind such patients that psychiatric illness is very different from physical illnesses like infectious diseases, wherein for example, if an organism is rooted out by an antibiotic, there is no need to continue medication any further. In psychiatric illness, medication needs to be continued because it takes a long time to change the psyche of the individual, if at all it does change. It is more like the long-term treatment of diabetes or hypertension. This would also explain why psychiatric illness seems to be so chronic to them, and also why some psychiatric patients do not get well. They should be made to realise that medication of any type helps to control the illness, changing moods, perception thinking and activity, but the real change in the individual will only come if this ‘status quo’ continues for an indefinitely long time.It has always been said that there is a stigma attached to visiting the consulting rooms of a psychiatrist, and as a result patients tend to shy away. Nothing is further from the truth that stigma is unwillingly created by the psychiatrist who gives in to the whims and fancies of the patients, encourages them to follow certain rituals and thus increases the tendency to be very secretive and exclusive about therapy. Every psychiatrist must endeavour to explain to the patients and relatives that there is no need for secrecy because this tendency increases the suspicions of those around. It is better to visit the consulting rooms of the psychiatrist like the visiting the rooms of other consultants. Often in the case of an unmarried girl or a person of high popularity and position, it may be necessary to maintain strict secrecy, but even here the relatives can often take the onus on themselves, saying that they are consulting the psychiatrist.The psychiatrist would do well to spread education about the causation of illness not only at public meetings but also to the individual patients and their relatives. A successful psychiatrist, in addition to casting a proper image being a good clinician and maintaining a good rapport with the patient and relatives, should be a good liaison officer in keeping the contact going with referring sources, be it general medical practitioners, social workers, relatives of patients, or patients themselves. This manoeuvre does not entail discussing intimacies of the patients with these individuals but informing them that their patient is making good progress. This is particularly important when the improvement is hardly visible to the relatives and serves to make the referring authority feel reassured that he has done the right thing. Later on, when confidence is achieved, it may not be necessary.The psychiatrist must not get hassled or disturbed by the attitudes of certain individuals either in his consulting room, at public meetings, or in society, who either tend to laugh at him or bring him down; and this attitude applies equally to the psychiatrist's ability and his treatment programme. The psychiatrist who has faith and confidence in his own ability needs no compliments from his patients; and compliments should not affect him because they are likely to change and end just as quickly as they started. The same applies to insults and comments. It is a good working plan to let compliments, comments and insults from patients and relatives pass like water down the duck's back, because these are everyday happenings in a psychiatrist's life and should not affect the psychiatrist one bit, considering the population of disturbed individuals he deals with. The psychiatrist who knows he is doing his best has no need for any anxiety or alarm, should remain unscathed in all such situations, considering the fact that if he is doing his best, he cannot do better. The psychiatrist in his early practice may also face adverse criticism or remarks from senior colleagues who lack courtesy toward their fellow psychiatrists. This position sometimes arises out of seniors wanting to impress their patient, but a young budding psychiatrist should not let any of these affronts get him down. He should remember he will soon have his day; and he is inferior to none.It is common for patients to move from one psychiatrist to another, and it is common for relatives to get disillusioned with therapy early due to lack of improvement, and thus terminate treatment and seek another psychiatrist. With this knowledge in mind, the psychiatrist should realise that this shifting tendency is rampant in a particular section of the patient population. Mental illness being what it is and results being a slow process, the tendency to get fed up easily should be accepted. The psychiatrist should take pains to establish rapport with his patient right at the beginning and make the patient as well as relative realise that they have come to the right person and that he is capable of efficiently treating the patient. If pains are taken to reach this state of affairs, the chances are that the patient is less likely to shift. Even then, should a patient choose to move away, the psychiatrist should not get affected by this drift but rather understand that it is at times bound to be so. After all, understanding the psychology of human beings is part of the psychiatrist's training and considering the fact that all humans have a tendency to have multiple alliances and transferences, probably the transference in this case was not sufficient with this particular psychiatrist to keep the patient with him; and in such a situation there should be no regrets. If this is a recurring pattern, however, the psychiatrist would need to ask himself where he is failing. Could it be that he is lacking in knowledge or experience, or is his handling of the patient defective? In that case, it would be essential to undo and correct what is really going wrong. All said and done, the psychiatrist must be prepared to understand that this state of affairs is rampant in psychiatric practice and must be accepted.The psychiatrist who returns from abroad and starts practice in India often finds that his working situation is very different from that which existed abroad. He further finds that the manner of conducting practice is different, and the requirement in his mode of handling the patient is totally different. The authors send out a word of caution to these psychiatrists to acquaint themselves sufficiently with the local conditions, the mode of practice, the requirements of Indian patients, and their expectations, before rushing into practice. It is good to remember also that there is a long waiting period during which frustrations may creep in, particularly if the psychiatrist has held a lucrative post abroad. It is also important to realise that India is India. The response is different and patient fail to keep appointments for the flimsiest of excuses. With the emphasis on ‘keeping the wolf from the door’, economic considerations are always foremost in the minds of Indian patients. Moreover, there are those who consider what return they can achieve, and these and other calculations determine in large measure their frequency in attending the psychiatrist's clinic. By and large, the psychiatrist who decides to return from abroad and plunge into private psychiatric practice here must be ready to face the challenge that his colleagues in India face day after day before they can say they are well settled.Alternative PsychiatryPsychiatry has reached that stage where it has caused plenty of re-thinking and fresh thinking all over the world; and particularly in India, we have come to realise that our methods of therapy offer little to cure and that all they do is to arrest the illness for a while to set the ball rolling once again. In these circumstances, it is customary to ask the age-old question, ‘Quo Vadis’. The role of spiritual healing and religious forms of therapy has been well documented throughout the world from ages immemorial. Where better can we apply such forms of therapy than in psychiatry, particularly where a psychogenic cause has been postulated? In India, a land soaked with religiosity and superstitious beliefs, religion seems to be, and has been, the answer for many psychiatric illnesses, though it has failed in certain patients. The reason for such a predicament is that this form of treatment is not for everyone. It is indeed not possible for an individual who does not have sufficient faith in religion to benefit from religious therapy as such cures can only be achieved by a rather child-like faith. The psychiatrists of tomorrow need to consider the utilisation of all forms of therapy in their practice. They have to arm themselves with a thorough knowledge of different religions and religious practices. They can then choose those patients who can benefit from religious therapy and start them on meditative processes that give such patients a liaison with a deity or a saint, wherein the psychiatrist acts as a guru or a minister. Having established a connection, the psychiatrist teaches his patients how to enrich their egos with this particular religious bonding, which they can invoke in all times of stress to feel refreshed and reassured. Even in patients with depression and neurosis, this form of treatment can be of immense help, provided the right patient is selected and the right mode of therapy offered by the psychiatrist. This could at times work much more than any form of psychotherapy, as it is a liaison with the Creator Himself and the ‘all powerful allay’. The psychiatrist of tomorrow needs to consider this paradigm of therapy.The above modes of therapy could do well in specially selected group of patients who have a strong faith in religion, a faith backed by that of the relatives. On the other hand, in the disbelievers and atheists who choose to believe in natural causes and have a materialistic outlook of life, it would be necessary to use other modes of therapy. With this aim in view, yoga has been used successfully to treat minor psychiatric illnesses. Many explanations have been given to understand the theory behind these therapies, but the authors feel that it is a form of learning by which the person concentrates his energy in a particular organ, part of the body or bodily function, in addition to preventing this concentration from moving here and there. In short, yoga therapy serves as an ego-strengthening device as well as causes the ego to exercise certain controls, which stand the patient in good stead in times of stress. Psychiatrists of tomorrow will need to have a thorough knowledge of these forms of treatments and utilise them in their practice, if they want to offer cost effective forms of therapies that are better appreciated by their patients.The psychiatrist who wishes to practice in India will have to be very versatile. He will have to thoroughly understand the ethnic, religious, cultural and social background of his patient and offer therapy that his patients appreciate. He will have to realise that following therapies based on western thinking may not be appreciated for long, and their results may not help his image an iota. On the other hand, offering cheaper modes of therapy that can be carried out by the patient and relatives will be more effective with patients. Also, the psychiatrist will have to understand the making of a delusion in his patient, especially when his background contributes to that delusion. The psychiatrist will need to comprehend the content of the delusions and lead the patient to a successful termination of his delusions; and the patient will automatically respond positively when the psychiatrist accepts the patient's delusions and assists the patient in getting rid of them without casting any aspersions on their stupidity and ridiculousness. Time and again the relatives are found to be happy when a psychiatrist follows this technique, as they know the psychiatrist respects their patient and will also respect their beliefs.It must be realised that most mental illnesses are a result of the abnormal perception by the patient that is basic to the patient and relatives, and gets coloured by the background of the patient. Accordingly, it will not be good to shake this belief prematurely but rather to accept it as well as the traditional practices that are performed without a word of ridicule. After all, these practices only help strengthen the patient's ego and are useful in no small measure. Mental illness being what it is, the successful psychiatrist will have to follow a different approach, especially when practicing in India where every demand comes heavily on him. Practicing here is a real challenge and the moment the challenge is taken, the challenge has to be met!

Hi sweetie: This should really answer not only your question but about a million other questions that you didn’t ask. haha. This is from Wikipedia. It came out with a weird layout, but just keep scrolling down and reading, and you will be an expert by the end of this thing (Pleeeeeze an upvote? THANK you!!!):Anxiety disorderFrom Wikipedia, the free encyclopediaJump to navigation Jump to searchAnxiety disorderThe Scream (Norwegian: Skrik) a painting by Norwegian artist Edvard Munch[1]SpecialtyPsychiatrySymptomsWorrying, fast heart rate, shakiness[2]Usual onset15–35 years old[3]Duration> 6 months[2][3]CausesGenetic and environmental factors[4]Risk factorsChild abuse, family history, poverty[3]Differential diagnosisHyperthyroidism; heart disease; caffeine, alcohol, cannabis use; withdrawal from certain drugs[3][5]TreatmentLifestyle changes, counselling, medications[3]MedicationAntidepressants, anxiolytics, beta blockers[4]Frequency12% per year[3][6]Anxiety disorders are a group of mental disorders characterized by significant feelings of anxiety and fear.[2]Anxiety is a worry about future events, and fear is a reaction to current events.[2]These feelings may cause physical symptoms, such as a fast heart rate and shakiness.[2]There are a number of anxiety disorders including generalized anxiety disorder, specific phobia, social anxiety disorder, separation anxiety disorder, agoraphobia, panic disorder, and selective mutism.[2]The disorder differs by what results in the symptoms.[2]People often have more than one anxiety disorder.[2]The cause of anxiety disorders is a combination of genetic and environmental factors.[4]Risk factors include a history of child abuse, family history of mental disorders, and poverty.[3]Anxiety disorders often occur with other mental disorders, particularly major depressive disorder, personality disorder, and substance use disorder.[3]To be diagnosed symptoms typically need to be present for at least 6 months, be more than what would be expected for the situation, and decrease functioning.[2][3]Other problems that may result in similar symptoms include hyperthyroidism; heart disease; caffeine, alcohol, or cannabis use; and withdrawal from certain drugs, among others.[3][5]Without treatment, anxiety disorders tend to remain.[2][4]Treatment may include lifestyle changes, counselling, and medications.[3]Counselling is typically with a type of cognitive behavioral therapy.[3]Medications, such as antidepressants, benzodiazepines, or beta blockers, may improve symptoms.[4]About 12% of people are affected by an anxiety disorder in a given year, and between 5% and 30% are affected at some point in their life.[3][6]They occur about twice as often in females as males and generally begin before the age of 25.[2][3]The most common are specific phobia which affects nearly 12% and social anxiety disorder which affects 10% at some point in their life.[3]They affect those between the ages 15 and 35 the most and become less common after the age of 55.[3]Rates appear to be higher in the United States and Europe.[3]Contents1 Classification 1.1 Generalized anxiety disorder 1.2 Specific phobias 1.3 Panic disorder 1.4 Agoraphobia 1.5 Social anxiety disorder 1.6 Post-traumatic stress disorder 1.7 Separation anxiety disorder 1.8 Situational anxiety 1.9 Obsessive–compulsive disorder 1.10 Selective mutism2 Causes 2.1 Drugs 2.2 Medical conditions 2.3 Stress 2.4 Genetics3 Mechanisms 3.1 Biological4 Diagnosis 4.1 Differential diagnosis5 Prevention6 Treatment 6.1 Lifestyle changes 6.2 Therapy 6.3 Medications 6.4 Alternative medicine 6.5 Children7 Prognosis8 Epidemiology9 Children10 References11 External linksClassificationFacial expression of someone with chronic anxietyGeneralized anxiety disorderMain article: Generalized anxiety disorderGeneralized anxiety disorder (GAD) is a common disorder, characterized by long-lasting anxiety that is not focused on any one object or situation. Those suffering from generalized anxiety disorder experience non-specific persistent fear and worry, and become overly concerned with everyday matters. Generalized anxiety disorder is "characterized by chronic excessive worry accompanied by three or more of the following symptoms: restlessness, fatigue, concentration problems, irritability, muscle tension, and sleep disturbance".[7]Generalized anxiety disorder is the most common anxiety disorder to affect older adults.[8]Anxiety can be a symptom of a medical or substance abuse problem, and medical professionals must be aware of this. A diagnosis of GAD is made when a person has been excessively worried about an everyday problem for six months or more.[9]A person may find that they have problems making daily decisions and remembering commitments as a result of lack of concentration/preoccupation with worry.[10]Appearance looks strained, with increased sweating from the hands, feet, and axillae,[11]and they may be tearful, which can suggest depression.[12]Before a diagnosis of anxiety disorder is made, physicians must rule out drug-induced anxiety and other medical causes.[13]In children GAD may be associated with headaches, restlessness, abdominal pain, and heart palpitations.[14]Typically it begins around 8 to 9 years of age.[14]Specific phobiasMain article: Specific phobiaThe single largest category of anxiety disorders is that of specific phobias which includes all cases in which fear and anxiety are triggered by a specific stimulus or situation. Between 5% and 12% of the population worldwide suffer from specific phobias.[9]Sufferers typically anticipate terrifying consequences from encountering the object of their fear, which can be anything from an animal to a location to a bodily fluid to a particular situation. Common phobias are flying, blood, water, highway driving, and tunnels. When people are exposed to their phobia, they may experience trembling, shortness of breath, or rapid heartbeat.[15]People understand that their fear is not proportional to the actual potential danger but still are overwhelmed by it.[16]Panic disorderMain article: Panic disorderWith panic disorder, a person has brief attacks of intense terror and apprehension, often marked by trembling, shaking, confusion, dizziness, nausea, and/or difficulty breathing. These panic attacks, defined by the APA as fear or discomfort that abruptly arises and peaks in less than ten minutes, can last for several hours.[17]Attacks can be triggered by stress, irrational thoughts, general fear or fear of the unknown, or even exercise. However sometimes the trigger is unclear and the attacks can arise without warning. To help prevent an attack one can avoid the trigger. This being said not all attacks can be prevented.In addition to recurrent unexpected panic attacks, a diagnosis of panic disorder requires that said attacks have chronic consequences: either worry over the attacks' potential implications, persistent fear of future attacks, or significant changes in behavior related to the attacks. As such, those suffering from panic disorder experience symptoms even outside specific panic episodes. Often, normal changes in heartbeat are noticed by a panic sufferer, leading them to think something is wrong with their heart or they are about to have another panic attack. In some cases, a heightened awareness (hypervigilance) of body functioning occurs during panic attacks, wherein any perceived physiological change is interpreted as a possible life-threatening illness (i.e., extreme hypochondriasis).AgoraphobiaMain article: AgoraphobiaAgoraphobia is the specific anxiety about being in a place or situation where escape is difficult or embarrassing or where help may be unavailable.[18]Agoraphobia is strongly linked with panic disorder and is often precipitated by the fear of having a panic attack. A common manifestation involves needing to be in constant view of a door or other escape route. In addition to the fears themselves, the term agoraphobia is often used to refer to avoidance behaviors that sufferers often develop.[19]For example, following a panic attack while driving, someone suffering from agoraphobia may develop anxiety over driving and will therefore avoid driving. These avoidance behaviors can often have serious consequences and often reinforce the fear they are caused by.Social anxiety disorderMain article: Social anxiety disorderSocial anxiety disorder (SAD; also known as social phobia) describes an intense fear and avoidance of negative public scrutiny, public embarrassment, humiliation, or social interaction. This fear can be specific to particular social situations (such as public speaking) or, more typically, is experienced in most (or all) social interactions. Social anxiety often manifests specific physical symptoms, including blushing, sweating, and difficulty speaking. As with all phobic disorders, those suffering from social anxiety often will attempt to avoid the source of their anxiety; in the case of social anxiety this is particularly problematic, and in severe cases can lead to complete social isolation.Social physique anxiety (SPA) is a subtype of social anxiety. It is concern over the evaluation of one's body by others.[20]SPA is common among adolescents, especially females.Post-traumatic stress disorderMain article: Post-traumatic stress disorderPost-traumatic stress disorder (PTSD) was once an anxiety disorder (now moved to trauma- and stressor-related disorders in DSM-V) that results from a traumatic experience. Post-traumatic stress can result from an extreme situation, such as combat, natural disaster, rape, hostage situations, child abuse, bullying, or even a serious accident. It can also result from long-term (chronic) exposure to a severe stressor--[21]for example, soldiers who endure individual battles but cannot cope with continuous combat. Common symptoms include hypervigilance, flashbacks, avoidant behaviors, anxiety, anger and depression.[22]In addition, individuals may experience sleep disturbances.[23]There are a number of treatments that form the basis of the care plan for those suffering with PTSD. Such treatments include cognitive behavioral therapy (CBT), psychotherapy and support from family and friends.[9]Posttraumatic stress disorder (PTSD) research began with Vietnam veterans, as well as natural and non natural disaster victims. Studies have found the degree of exposure to a disaster has been found to be the best predictor of PTSD.[24]Separation anxiety disorderMain article: Separation anxiety disorderSeparation anxiety disorder (SepAD) is the feeling of excessive and inappropriate levels of anxiety over being separated from a person or place. Separation anxiety is a normal part of development in babies or children, and it is only when this feeling is excessive or inappropriate that it can be considered a disorder.[25]Separation anxiety disorder affects roughly 7% of adults and 4% of children, but the childhood cases tend to be more severe; in some instances, even a brief separation can produce panic.[26][27]Treating a child earlier may prevent problems. This may include training the parents and family on how to deal with it. Often, the parents will reinforce the anxiety because they do not know how to properly work through it with the child. In addition to parent training and family therapy, medication, such as SSRIs, can be used to treat separation anxiety.[28]Situational anxietySituational anxiety is caused by new situations or changing events. It can also be caused by various events that make that particular individual uncomfortable. Its occurrence is very common. Often, an individual will experience panic attacks or extreme anxiety in specific situations. A situation that causes one individual to experience anxiety may not affect another individual at all. For example, some people become uneasy in crowds or tight spaces, so standing in a tightly packed line, say at the bank or a store register, may cause them to experience extreme anxiety, possibly a panic attack.[29]Others, however, may experience anxiety when major changes in life occur, such as entering college, getting married, having children, etc.Obsessive–compulsive disorderMain article: Obsessive–compulsive disorderObsessive–compulsive disorder (OCD) is not classified as an anxiety disorder by the DSM-5 but is by the ICD-10. It was previously classified as an anxiety disorder in the DSM-IV. It is a condition where the person has obsessions (distressing, persistent, and intrusive thoughts or images) and compulsions (urges to repeatedly perform specific acts or rituals), that are not caused by drugs or physical order, and which cause distress or social dysfunction.[30][31]The compulsive rituals are personal rules followed to relieve the anxiety.[31]OCD affects roughly 1-2% of adults (somewhat more women than men), and under 3% of children and adolescents.[30][31]A person with OCD knows that the symptoms are unreasonable and struggles against both the thoughts and the behavior.[30][32]Their symptoms could be related to external events they fear (such as their home burning down because they forget to turn off the stove) or worry that they will behave inappropriately.[32]It is not certain why some people have OCD, but behavioral, cognitive, genetic, and neurobiological factors may be involved.[31]Risk factors include family history, being single (although that may result from the disorder), and higher socioeconomic class or not being in paid employment.[31]Of those with OCD about 20% of people will overcome it, and symptoms will at least reduce over time for most people (a further 50%).[30]Selective mutismMain article: Selective mutismSelective mutism (SM) is a disorder in which a person who is normally capable of speech does not speak in specific situations or to specific people. Selective mutism usually co-exists with shyness or social anxiety.[33]People with selective mutism stay silent even when the consequences of their silence include shame, social ostracism or even punishment.[34]Selective mutism affects about 0.8% of people at some point in their life.[3]CausesDrugsAnxiety and depression can be caused by alcohol abuse, which in most cases improves with prolonged abstinence. Even moderate, sustained alcohol use may increase anxiety levels in some individuals.[35]Caffeine, alcohol, and benzodiazepine dependence can worsen or cause anxiety and panic attacks.[36]Anxiety commonly occurs during the acute withdrawal phase of alcohol and can persist for up to 2 years as part of a post-acute withdrawal syndrome, in about a quarter of people recovering from alcoholism.[37]In one study in 1988–1990, illness in approximately half of patients attending mental health services at one British hospital psychiatric clinic, for conditions including anxiety disorders such as panic disorder or social phobia, was determined to be the result of alcohol or benzodiazepine dependence. In these patients, an initial increase in anxiety occurred during the withdrawal period followed by a cessation of their anxiety symptoms.[38]There is evidence that chronic exposure to organic solvents in the work environment can be associated with anxiety disorders. Painting, varnishing and carpet-laying are some of the jobs in which significant exposure to organic solvents may occur.[39]Taking caffeine may cause or worsen anxiety disorders,[40][41]including panic disorder.[42][43][44]Those with anxiety disorders can have high caffeine sensitivity.[45][46]Caffeine-induced anxiety disorder is a subclass of the DSM-5 diagnosis of substance/medication-induced anxiety disorder. Substance/medication-induced anxiety disorder falls under the category of anxiety disorders, and not the category of substance-related and addictive disorders, even though the symptoms are due to the effects of a substance.[47]Cannabis use is associated with anxiety disorders. However, the precise relationship between cannabis use and anxiety still needs to be established.[48][49]Medical conditionsOccasionally, an anxiety disorder may be a side-effect of an underlying endocrine disease that causes nervous system hyperactivity, such as pheochromocytoma[50][51]or hyperthyroidism.[52]StressAnxiety disorders can arise in response to life stresses such as financial worries or chronic physical illness. Anxiety among adolescents and young adults is common due to the stresses of social interaction, evaluation, and body image. Anxiety is also common among older people who have dementia. On the other hand, anxiety disorder is sometimes misdiagnosed among older adults when doctors misinterpret symptoms of a physical ailment (for instance, racing heartbeat due to cardiac arrhythmia) as signs of anxiety.[8]GeneticsGAD runs in families and is six times more common in the children of someone with the condition.[53]While anxiety arose as an adaptation, in modern times it is almost always thought of negatively in the context of anxiety disorders. People with these disorders have highly sensitive systems; hence, their systems tend to overreact to seemingly harmless stimuli. Sometimes anxiety disorders occur in those who have had traumatic youths, demonstrating an increased prevalence of anxiety when it appears a child will have a difficult future.[54]In these cases, the disorder arises as a way to predict that the individual’s environment will continue to pose threats.Persistence of anxietyAt a low level, anxiety is not a bad thing. In fact, the hormonal response to anxiety has evolved as a benefit, as it helps humans react to dangers. Researchers in evolutionary medicine believe this adaptation allows humans to realize there is a potential threat and to act accordingly in order to ensure greatest possibility of protection. It has actually been shown that those with low levels of anxiety have a greater risk of death than those with average levels. This is because the absence of fear can lead to injury or death.[54]Additionally, patients with both anxiety and depression were found to have lower morbidity than those with depression alone.[55]The functional significance of the symptoms associated with anxiety includes: greater alertness, quicker preparation for action, and reduced probability of missing threats.[55]In the wild, vulnerable individuals, for example those who are hurt or pregnant, have a lower threshold for anxiety response, making them more alert.[55]This demonstrates a lengthy evolutionary history of the anxiety response.Evolutionary mismatchIt has been theorized that high rates of anxiety are a reaction to how the social environment has changed from the Paleolithic era. For example, in the Stone Age there was greater skin-to-skin contact and more handling of babies by their mothers, both of which are strategies that reduce anxiety.[54]Additionally, there is greater interaction with strangers in present times as opposed to interactions solely between close-knit tribes. Researchers posit that the lack of constant social interaction, especially in the formative years, is a driving cause of high rates of anxiety.Many current cases are likely to have resulted from an evolutionary mismatch, which has been specifically termed a "psychopathogical mismatch". In evolutionary terms, a mismatch occurs when an individual possesses traits that were adapted for an environment that differs from the individual’s current environment. For example, even though an anxiety reaction may have been evolved to help with life-threatening situations, for highly sensitized individuals in Westernized cultures simply hearing bad news can elicit a strong reaction.[56]An evolutionary perspective may provide insight into alternatives to current clinical treatment methods for anxiety disorders. Simply knowing some anxiety is beneficial may alleviate some of the panic associated with mild conditions. Some researchers believe that, in theory, anxiety can be mediated by reducing a patient’s feeling of vulnerability and then changing their appraisal of the situation.[56]MechanismsBiologicalLow levels of GABA, a neurotransmitter that reduces activity in the central nervous system, contribute to anxiety. A number of anxiolytics achieve their effect by modulating the GABA receptors.[57][58][59]Selective serotonin reuptake inhibitors, the drugs most commonly used to treat depression, are frequently considered as a first line treatment for anxiety disorders.[60]AmygdalaThe amygdala is central to the processing of fear and anxiety, and its function may be disrupted in anxiety disorders.[61]Sensory information enters the amygdala through the nuclei of the basolateral complex (consisting of lateral, basal, and accessory basal nuclei). The basolateral complex processes sensory-related fear memories and communicates their threat importance to memory and sensory processing elsewhere in the brain, such as the medial prefrontal cortex and sensory cortices.Another important area is the adjacent central nucleus of the amygdala, which controls species-specific fear responses, via connections to the brainstem, hypothalamus, and cerebellum areas. In those with general anxiety disorder, these connections functionally seem to be less distinct, with greater gray matter in the central nucleus. Another difference is that the amygdala areas have decreased connectivity with the insula and cingulate areas that control general stimulus salience, while having greater connectivity with the parietal cortex and prefrontal cortex circuits that underlie executive functions.[61]The latter suggests a compensation strategy for dysfunctional amygdala processing of anxiety. Researchers have noted "Amygdalofrontoparietal coupling in generalized anxiety disorder patients may ... reflect the habitual engagement of a cognitive control system to regulate excessive anxiety."[61]This is consistent with cognitive theories that suggest the use in this disorder of attempts to reduce the involvement of emotions with compensatory cognitive strategies.Clinical and animal studies suggest a correlation between anxiety disorders and difficulty in maintaining balance.[62][63][64][65]A possible mechanism is malfunction in the parabrachial area, a brain structure that, among other functions, coordinates signals from the amygdala with input concerning balance.[66]Anxiety processing in the basolateral amygdala has been implicated with dendritic arborization of the amygdaloid neurons. SK2 potassium channels mediate inhibitory influence on action potentials and reduce arborization. By overexpressing SK2 in the basolateral amygdala, anxiety in experimental animals can be reduced together with general levels of stress-induced corticosterone secretion.[67]DiagnosisAnxiety disorders are often severe chronic conditions, which can be present from an early age or begin suddenly after a triggering event. They are prone to flare up at times of high stress and are frequently accompanied by physiological symptoms such as headache, sweating, muscle spasms, tachycardia, palpitations, and hypertension, which in some cases lead to fatigue.In casual discourse the words "anxiety" and "fear" are often used interchangeably; in clinical usage, they have distinct meanings: "anxiety" is defined as an unpleasant emotional state for which the cause is either not readily identified or perceived to be uncontrollable or unavoidable, whereas "fear" is an emotional and physiological response to a recognized external threat.[68]The term "anxiety disorder" includes fears (phobias) as well as anxieties.[medical citation needed]The diagnosis of anxiety disorders is difficult because there are no objective biomarkers, it is based on symptoms,[69]which typically need to be present at least six months, be more than would be expected for the situation, and decrease functioning.[2][3]Several generic anxiety questionnaires can be used to detect anxiety symptoms, such as the State-Trait Anxiety Inventory (STAI), the Generalized Anxiety Disorder 7 (GAD-7), the Beck Anxiety Inventory (BAI), the Zung Self-Rating Anxiety Scale, and the Taylor Manifest Anxiety Scale.[70]Other questionnaires combine anxiety and depression measurement, such as the Hamilton Anxiety Rating Scale, the Hospital Anxiety and Depression Scale (HADS), the Patient Health Questionnaire (PHQ), and the Patient-Reported Outcomes Measurement Information System (PROMIS).[70]Examples of specific anxiety questionnaires include the Liebowitz Social Anxiety Scale (LSAS), the Social Interaction Anxiety Scale (SIAS), the Social Phobia Inventory (SPIN), the Social Phobia Scale (SPS), and the Social Anxiety Questionnaire (SAQ-A30).[71]Anxiety disorders often occur along with other mental disorders, in particular depression, which may occur in as many as 60% of people with anxiety disorders. The fact that there is considerable overlap between symptoms of anxiety and depression, and that the same environmental triggers can provoke symptoms in either condition, may help to explain this high rate of comorbidity.[72]Studies have also indicated that anxiety disorders are more likely among those with family history of anxiety disorders, especially certain types.[73]Sexual dysfunction often accompanies anxiety disorders, although it is difficult to determine whether anxiety causes the sexual dysfunction or whether they arise from a common cause. The most common manifestations in individuals with anxiety disorder are avoidance of intercourse, premature ejaculation or erectile dysfunction among men and pain during intercourse among women. Sexual dysfunction is particularly common among people affected by panic disorder (who may fear that a panic attack will occur during sexual arousal) and posttraumatic stress disorder.[74]Differential diagnosisThe diagnosis of an anxiety disorder requires first ruling out an underlying medical cause.[5][68]Diseases that may present similar to an anxiety disorder, including certain endocrine diseases (hypo- and hyperthyroidism, hyperprolactinemia),[3][5][68][75]metabolic disorders (diabetes),[5][76]deficiency states (low levels of vitamin D, B2, B12, folic acid),[5]gastrointestinal diseases (celiac disease, non-celiac gluten sensitivity, inflammatory bowel disease),[77][78][79]heart diseases,[3][5]blood diseases (anemia),[5]and brain degenerative diseases (Parkinson's disease, dementia, multiple sclerosis, Huntington's disease).[5][80][81][82]Also, several drugs can cause or worsen anxiety, whether in intoxication, withdrawal, or from chronic use. These include alcohol, tobacco, cannabis, sedatives (including prescription benzodiazepines), opioids (including prescription pain killers and illicit drugs like heroin), stimulants (such as caffeine, cocaine and amphetamines), hallucinogens, and inhalants.[3][83]PreventionFocus is increasing on prevention of anxiety disorders.[84]There is tentative evidence to support the use of cognitive behavior therapy[84]and mindfulness therapy.[85][86]As of 2013, there are no effective measures to prevent GAD in adults.[87]TreatmentTreatment options include lifestyle changes, therapy, and medications. There is no good evidence as to whether therapy or medication is more effective; the choice of which is up to the person with the anxiety disorder and most choose therapy first.[88]The other may be offered in addition to the first choice or if the first choice fails to relieve symptoms.[88]Lifestyle changesLifestyle changes include exercise, for which there is moderate evidence for some improvement, regularizing sleep patterns, reducing caffeine intake, and stopping smoking.[88]Stopping smoking has benefits in anxiety as large as or larger than those of medications.[89]TherapyCognitive behavioral therapy (CBT) is effective for anxiety disorders and is a first line treatment.[88][90][91][92][93]CBT appears to be equally effective when carried out via the internet.[93]While evidence for mental health apps is promising it is preliminary.[94]Self-help books can contribute to the treatment of people with anxiety disorders.[95]Mindfulness based programs also appear to be effective for managing anxiety disorders.[96][97]It is unclear if meditation has an effect on anxiety and transcendental meditation appears to be no different than other types of meditation.[98]MedicationsMedications include SSRIs or SNRIs are first line choices for generalized anxiety disorder.[88][99]There is no good evidence for any member of the class being better than another, so cost often drives drug choice.[88][99]If they are effective, it is recommend that they be continued for at least a year.[100]Stopping these medications results in a greater risk of relapse.[101]Buspirone, quetiapine and pregabalin are second line treatments for people who do not respond to SSRIs or SNRIs; there is also evidence that benzodiazepines including diazepam and clonazepam are effective but have fallen out of favor due to the risk of dependence and abuse.[88]Medications need to be used with care among older adults, who are more likely to have side effects because of coexisting physical disorders. Adherence problems are more likely among older people, who may have difficulty understanding, seeing, or remembering instructions.[8]In general medications are not seen as helpful in specific phobia but a benzodiazepine is sometimes used to help resolve acute episodes; as 2007 data were sparse for efficacy of any drug.[102]Alternative medicineMany other remedies have been used for anxiety disorder. These include kava, where the potential for benefit seems greater than that for harm with short-term use in those with mild to moderate anxiety.[103][104]The American Academy of Family Physicians (AAFP) recommends use of kava for those with mild to moderate anxiety disorders who are not using alcohol or taking other medicines metabolized by the liver, and who wish to use "natural" remedies.[105]Side effects of kava in the clinical trials were rare and mild.Inositol has been found to have modest effects in people with panic disorder or obsessive-compulsive disorder.[106]There is insufficient evidence to support the use of St. John's wort, valerian or passionflower.[106]Aromatherapy has shown some tentative benefits for anxiety reduction in people with cancer when done with massages, although it not clear whether it could just enhance the effect of massage itself.[107]ChildrenBoth therapy and a number of medications have been found to be useful for treating childhood anxiety disorders.[108]Therapy is generally preferred to medication.[109]Cognitive behavioral therapy (CBT) is a good first therapy approach.[109]Studies have gathered substantial evidence for treatments that are not CBT based as being effective forms of treatment, expanding treatment options for those who do not respond to CBT.[109]Like adults, children may undergo psychotherapy, cognitive-behavioral therapy, or counseling. Family therapy is a form of treatment in which the child meets with a therapist together with the primary guardians and siblings.[110]Each family member may attend individual therapy, but family therapy is typically a form of group therapy. Art and play therapy are also used. Art therapy is most commonly used when the child will not or cannot verbally communicate, due to trauma or a disability in which they are nonverbal. Participating in art activities allows the child to express what they otherwise may not be able to communicate to others.[111]In play therapy, the child is allowed to play however they please as a therapist observes them. The therapist may intercede from time to time with a question, comment, or suggestion. This is often most effective when the family of the child plays a role in the treatment.[110][112]If a medication option is warranted, antidepressants such as SSRIs and SNRIs can be effective.[108]Minor side effects with medications, however, are common.[108]PrognosisThe prognosis varies on the severity of each case and utilization of treatment for each individual.[113]If these children are left untreated, they face risks such as poor results at school, avoidance of important social activities, and substance abuse. Children who have an anxiety disorder are likely to have other disorders such as depression, eating disorders, attention deficit disorders both hyperactive and inattentive.EpidemiologyGlobally as of 2010 approximately 273 million (4.5% of the population) had an anxiety disorder.[114]It is more common in females (5.2%) than males (2.8%).[114]In Europe, Africa and Asia, lifetime rates of anxiety disorders are between 9 and 16%, and yearly rates are between 4 and 7%.[115]In the United States, the lifetime prevalence of anxiety disorders is about 29%[116]and between 11 and 18% of adults have the condition in a given year.[115]This difference is affected by the range of ways in which different cultures interpret anxiety symptoms and what they consider to be normative behavior.[117][118]In general, anxiety disorders represent the most prevalent psychiatric condition in the United States, outside of substance use disorder.[119]ChildrenLike adults, children can experience anxiety disorders; between 10 and 20 percent of all children will develop a full-fledged anxiety disorder prior to the age of 18,[120]making anxiety the most common mental health issue in young people. Anxiety disorders in children are often more challenging to identify than their adult counterparts owing to the difficulty many parents face in discerning them from normal childhood fears. Likewise, anxiety in children is sometimes misdiagnosed as an attention deficit disorder or, due to the tendency of children to interpret their emotions physically (as stomach aches, head aches, etc.), anxiety disorders may initially be confused with physical ailments.[121]Anxiety in children has a variety of causes; sometimes anxiety is rooted in biology, and may be a product of another existing condition, such as autism or Asperger's disorder.[122]Gifted children are also often more prone to excessive anxiety than non-gifted children.[123]Other cases of anxiety arise from the child having experienced a traumatic event of some kind, and in some cases, the cause of the child's anxiety cannot be pinpointed.[124]Anxiety in children tends to manifest along age-appropriate themes, such as fear of going to school (not related to bullying) or not performing well enough at school, fear of social rejection, fear of something happening to loved ones, etc. What separates disordered anxiety from normal childhood anxiety is the duration and intensity of the fears involved.[121]A small child will usually experience separation anxiety, for example, but he or she will generally grow out of it by about the age of 6, whereas in an anxious child it may linger for years longer, hindering the child's development.[125]Similarly, most children will fear the dark or losing their parents at some point, but this fear will dissipate over time without interfering a great deal in that child's normal day-to-day activities. In a child with an anxiety disorder, fearing the dark or loss of loved ones may grow into a lasting obsession which the child tries to deal with in compulsive ways which erode his or her quality of life.[125]The presence of co- occurring depressive symptoms in anxiety disorders may mark the transition to a more severe and detrimental and impairing disorder in preschool and early school age.[126]Children, similar to adults, may suffer from a range of different anxiety disorders, including:Generalized anxiety disorder: The child experiences persistent anxiety regarding a wide variety of situations, and this anxiety may adapt to fit each new situation that arises or be based largely on imagined situations which have yet to occur. Reassurance often has little effect.[121][125]Separation anxiety disorder: A child who is older than 6 or 7 who has an extremely difficult time being away from his or her parents may be experiencing Separation Anxiety Disorder. Children with this disorder often fear that they will lose their loved ones during times of absence. As such, they frequently refuse to attend school.[127]Social anxiety disorder should not be confused with shyness or introversion; shyness is frequently normal, especially in very young children. Children with social anxiety disorder often wish to engage in social activity (unlike introverts) but find themselves held back by obsessive fears of being disliked. They often convince themselves they have made a poor impression on others, regardless of evidence to the contrary. Over time, they may develop a phobia of social situations.[128]This disorder affects older children and preteens more often than younger children. Social phobia in children may also be caused by some traumatic event, such as not knowing an answer when called on in class.[129]While uncommon in children, OCD can occur. Rates are between two and four percent.[130]Like adults, children rely on "magical thinking" in order to allay their anxiety, i.e., he or she must perform certain rituals (often based in counting, organizing, cleaning, etc.) in order to "prevent" the calamity he or she feels is imminent. Unlike normal children, who can leave their magical thinking-based activities behind when called upon to do so, children with OCD are literally unable to cease engaging in these activities, regardless of the consequences.[125][131]Panic disorder is more common in older children, though younger children sometimes also suffer from it. Panic disorder is frequently mistaken for a physical illness by children suffering from it, likely due to its strongly physical symptoms (a racing heartbeat, sweating, dizziness, nausea, etc.) These symptoms are, however, usually accompanied by extreme fear, particularly the fear of dying. Like adults with Panic Disorder, children may attempt to avoid any situation they feel is a "trigger" for their attacks.[125]

PolicyAetna considers gender-affirming surgery medically necessary when all of the following criteria are met:Requirements for breast removal: Single letter of referral from a qualified mental health professional (see Appendix); andPersistent, well-documented gender dysphoria (see Appendix); andCapacity to make a fully informed decision and to consent for treatment; andFor members less than 18 years of age, completion of one year of testosterone treatment; andIf significant medical or mental health concerns are present, they must be reasonably well controlled.Note: A trial of hormone therapy is not a pre-requisite to qualifying for a mastectomy in adults.Requirements for breast augmentation (implants/lipofilling):Single letter of referral from a qualified mental health professional (see Appendix); andPersistent, well-documented gender dysphoria (see Appendix); andCapacity to make a fully informed decision and to consent for treatment; andMember is 18 years of age or older; andCompletion of one year of feminizing hormone therapy prior to breast augmentation surgery (unless the member has a medical contraindication or is otherwise medically unable to take hormones); andIf significant medical or mental health concerns are present, they must be reasonably well controlled.Note: More than one breast augmentation is considered not medically necessary. This does not include the medically necessary replacement of breast implants (see CPB 0142 - Breast Implant Removal).Requirements for gonadectomy (hysterectomy and oophorectomy or orchiectomy):Two referral letters from qualified mental health professionals, one in a purely evaluative role (see appendix); andPersistent, well-documented gender dysphoria (see Appendix); andCapacity to make a fully informed decision and to consent for treatment; andAge 18 years or older; andIf significant medical or mental health concerns are present, they must be reasonably well controlled; andTwelve months of continuous hormone therapy as appropriate to the member's gender goals (unless the member has a medical contraindication or is otherwise unable or unwilling to take hormones).Requirements for genital reconstructive surgery (i.e., vaginectomy, urethroplasty, metoidioplasty, phalloplasty, scrotoplasty, placement of a testicular prosthesis and erectile prosthesis, penectomy, vaginoplasty, labiaplasty, and clitoroplasty)Two referral letters from qualified mental health professionals, one in a purely evaluative role (see appendix); andPersistent, well-documented gender dysphoria (see Appendix); andCapacity to make a fully informed decision and to consent for treatment; andAge 18 years and older; andIf significant medical or mental health concerns are present, they must be reasonably well controlled; andTwelve months of continuous hormone therapy as appropriate to the member’s gender goals (unless the member has a medical contraindication or is otherwise unable or unwilling to take hormones); andTwelve months of living in a gender role that is congruent with their gender identity (real life experience).Note on gender specific services for the transgender community:Gender-specific services may be medically necessary for transgender persons appropriate to their anatomy. Examples include:Breast cancer screening may be medically necessary for transmasculine persons who have not undergone chest masculinization surgery;Prostate cancer screening may be medically necessary for transfeminine persons who have retained their prostate.Aetna considers gonadotropin-releasing hormone medically necessary to suppress puberty in trans identified adolescents if they meet World Professional Association for Transgender Health (WPATH) criteria (see CPB 0501 - Gonadotropin-Releasing Hormone Analogs and Antagonists).Aetna considers reversal of gender affirming surgery for gender dysphoria not medically necessary.Aetna considers the following procedures that may be performed as a component of a gender transition as cosmetic (not an all-inclusive list) (see also CPB 0031 - Cosmetic Surgery):AbdominoplastyBlepharoplastyBody contouring (liposuction of waist)Brow liftCalf implantsCheek/malar implantsChin/nose implantsCollagen injectionsConstruction of a clitoral hoodDrugs for hair loss or growthFace liftingFacial bone reductionFacial feminization and masculinization surgeryFeminization of torsoForehead liftJaw reduction (jaw contouring)Hair removal (e.g., electrolysis, laser hair removal) (Exception: A limited number of electrolysis or laser hair removal sessions are considered medically necessary for skin graft preparation for genital surgery)Hair transplantationLip enhancementLip reductionLiposuctionMasculinization of torsoMastopexyNeck tighteningNipple reconstructionNose implantsPectoral implantsPitch-raising surgeryRemoval of redundant skinRhinoplastySkin resurfacing (dermabrasion/chemical peel)Tracheal shave (reduction thyroid chondroplasty)Voice modification surgery (laryngoplasty, cricothyroid approximation or shortening of the vocal cords)Voice therapy/voice lessons.BackgroundGender dysphoria refers to discomfort or distress that is caused by a discrepancy between an individual’s gender identity and the gender assigned at birth (and the associated gender role and/or primary and secondary sex characteristics). A diagnosis of gender dysphoria requires a marked difference between the individual’s expressed/experienced gender and the gender others would assign him or her, and it must continue for at least six months. This condition may cause clinically significant distress or impairment in social, occupational or other important areas of functioning.Gender affirming surgery is performed to change primary and/or secondary sex characteristics. For transfeminine (assigned male at birth) gender transition, surgical procedures may include genital reconstruction (vaginoplasty, penectomy, orchidectomy, clitoroplasty), breast augmentation (implants, lipofilling), and cosmetic surgery (facial reshaping, rhinoplasty, abdominoplasty, thyroid chondroplasty (laryngeal shaving), voice modification surgery (vocal cord shortening), hair transplants) (Day, 2002). For transmasculine (assigned female at birth) gender transition, surgical procedures may include mastectomy, genital reconstruction (phalloplasty, genitoplasty, hysterectomy, bilateral oophorectomy), mastectomy, and cosmetic procedures to enhance male features such as pectoral implants and chest wall recontouring (Day, 2002).The criterion noted above for some types of genital surgeries – i.e., that patients engage in 12 continuous months of living in a gender role that is congruent with their gender identity – is based on expert clinical consensus that this experience provides ample opportunity for patients to experience and socially adjust in their desired gender role, before undergoing irreversible surgery (Coleman, et al., 2011).It is recommended that transfeminine persons undergo feminizing hormone therapy (minimum 12 months) prior to breast augmentation surgery. The purpose is to maximize breast growth in order to obtain better surgical (aesthetic) results.In addition to hormone therapy and gender affirming surgery, psychological adjustments are necessary in affirming sex. Treatment should focus on psychological adjustment, with hormone therapy and gender affirming surgery being viewed as confirmatory procedures dependent on adequate psychological adjustment. Mental health care may need to be continued after gender affirming surgery. The overall success of treatment depends partly on the technical success of the surgery, but more crucially on the psychological adjustment of the trans identified person and the support from family, friends, employers and the medical profession.Nakatsuka (2012) noted that the third versions of the guideline for treatment of people with gender dysphoria (GD) of the Japanese Society of Psychiatry and Neurology recommends that feminizing/masculinizing hormone therapy and genital surgery should not be carried out until 18 years old and 20 years old, respectively. On the other hand, the sixth (2001) and the seventh (2011) versions of the standards of care for the health of transsexual, transgender, and gender non-conforming people of World Professional Association for Transgender Health (WPATH) recommend that transgender adolescents (Tanner stage 2, [mainly 12 to 13 years of age]) are treated by the endocrinologists to suppress puberty with gonadotropin-releasing hormone (GnRH) agonists until age 16 years old, after which gender-affirming hormones may be given. A questionnaire on 181 people with GID diagnosed in the Okayama University Hospital (Japan) showed that female to male (FTM) trans identified individuals hoped to begin masculinizing hormone therapy at age of 15.6 +/- 4.0 (mean +/- S.D.) whereas male to female (MTF) trans identified individuals hoped to begin feminizing hormone therapy as early as age 12.5 +/- 4.0, before presenting secondary sex characters. After confirmation of strong and persistent trans gender identification, adolescents with GD should be treated with gender-affirming hormone or puberty-delaying hormone to prevent developing undesired sex characters. These treatments may prevent transgender adolescents from attempting suicide, suffering from depression, and refusing to attend school.Spack (2013) stated that GD is poorly understood from both mechanistic and clinical standpoints. Awareness of the condition appears to be increasing, probably because of greater societal acceptance and available hormonal treatment. Therapeutic options include hormone and surgical treatments but may be limited by insurance coverage because costs are high. For patients seeking MTF affirmation, hormone treatment includes estrogens, finasteride, spironolactone, and GnRH analogs. Surgical options include feminizing genital and facial surgery, breast augmentation, and various fat transplantations. For patients seeking a FTM gender affirmation, medical therapy includes testosterone and GnRH analogs and surgical therapy includes mammoplasty and phalloplasty. Medical therapy for both FTM and MTF can be started in early puberty, although long-term effects are not known. All patients considering treatment need counseling and medical monitoring.Leinung and colleagues (2013) noted that the Endocrine Society's recently published clinical practice guidelines for the treatment of transgender persons acknowledged the need for further information on transgender health. These investigators reported the experience of one provider with the endocrine treatment of transgender persons over the past 2 decades. Data on demographics, clinical response to treatment, and psychosocial status were collected on all transgender persons receiving gender-affirming hormone therapy since 1991 at the endocrinology clinic at Albany Medical Center, a tertiary care referral center serving upstate New York. Through 2009, a total 192 MTF and 50 FTM transgender persons were seen. These patients had a high prevalence of mental health and psychiatric problems (over 50 %), with low rates of employment and high levels of disability. Mental health and psychiatric problems were inversely correlated with age at presentation. The prevalence of gender affirming surgery was low (31 % for MTF). The number of persons seeking treatment has increased substantially in recent years. Gender-affirming hormone therapy achieves very good results in FTM persons and is most successful in MTF persons when initiated at younger ages. The authors concluded that transgender persons seeking hormonal therapy are being seen with increasing frequency. The dysphoria present in many transgender persons is associated with significant mood disorders that interfere with successful careers. They stated that starting therapy at an earlier age may lessen the negative impact on mental health and lead to improved social outcomes.Meyer-Bahlburg (2013) summarized for the practicing endocrinologist the current literature on the psychobiology of the development of gender identity and its variants in individuals with disorders of sex development or with transgenderism. Gender reassignment remains the treatment of choice for strong and persistent gender dysphoria in both categories, but more research is needed on the short-term and long-term effects of puberty-suppressing medications and cross-sex hormones on brain and behavior.Irreversible Surgical Interventions for MinorsThe World Professional Association for Transgender Health (WPATH) recommendations version 7 (Coleman, et al., 2011) states, regarding irreversible surgical interventions, that "[g]enital surgery should not be carried out untilpatients reach the legal age of majority in a given country, andpatients have lived continuously for at least 12 months in the gender role that is congruent with their gender identity.patients reach the legal age of majority in a given country, andpatients have lived continuously for at least 12 months in the gender role that is congruent with their gender identity.The age threshold should be seen as a minimum criterion and not an indication in and of itself for active intervention." The WPATH guidelines state that "Chest surgery in FtM patients could be carried out earlier, preferably after ample time of living in the desired gender role and after one year of testosterone treatment. The intent of this suggested sequence is to give adolescents sufficient opportunity to experience and socially adjust in a more masculine gender role, before undergoing irreversible surgery. However, different approaches may be more suitable, depending on an adolescent’s specific clinical situation and goals for gender identity expression.”Note on Breast Reduction/Mastectomy and Nipple ReconstructionThe CPT codes for mastectomy (CPT codes 19303 and 19304) are for breast cancer, and are not appropriate to bill for reduction mammaplasty for female to male (transmasculine) gender affirmation surgery. CPT 2020 states that “Mastectomy procedures (with the exception of gynecomastia [19300]) are performed either for treatment or prevention of breast cancer.” CPT 2020 also states that "Code 19303 describes total removal of ipsilateral breast tissue with or without removal of skin and/or nipples (eg, nipple-sparing), for treatment or prevention of breast cancer.” There are important differences between a mastectomy for breast cancer and a mastectomy for gender reassignment. The former requires careful attention to removal of all breast tissue to reduce the risk of cancer. By contrast, careful removal of all breast tissue is not essential in mastectomy for gender reassignment. In mastectomy for gender reassignment, the nipple areola complex typically can be preserved.Some have tried to justify routinely billing CPT code 19350 for nipple reconstruction at the time of mastectomy for gender reassignment based upon the frequent need to reduce the size of the areola to give it a male appearance. However, the nipple reconstruction as defined by CPT code 19350 describes a much more involved procedure than areola reduction. The typical patient vignette for CPT code 19350, according to the AMA, is as follows: “The patient is measured in the standing position to ensure even balanced position for a location of the nipple and areola graft on the right breast. Under local anesthesia, a Skate flap is elevated at the site selected for the nipple reconstruction and constructed. A full-thickness skin graft is taken from the right groin to reconstruct the areola. The right groin donor site is closed primarily in layers.”The AMA vignette for CPT code 19318 (reduction mammaplasty) clarifies that this CPT code includes the work that is necessary to reposition and reshape the nipple to create an aesthetically pleasing result, as is necessary in female to male breast reduction. "The physician reduces the size of the breast, removing wedges of skin and breast tissue from a female patient. The physician makes a circular skin incision above the nipple, in the position to which the nipple will be elevated. Another skin incision is made around the circumference of the nipple. Two incisions are made from the circular cut above the nipple to the fold beneath the breast, one on either side of the nipple, creating a keyhole shaped skin and breast incision. Wedges of skin and breast tissue are removed until the desired size is achieved. Bleeding vessels may be ligated or cauterized. The physician elevates the nipple and its pedicle of subcutaneous tissue to its new position and sutures the nipple pedicle with layered closure. The remaining incision is repaired with layered closure" (EncoderPro, 2019). CPT code 19350 does not describe the work that that is being done, because that code describes the actual construction of a new nipple.Thus, Aetna considers nipple reconstruction, as defined by CPT code 19350, as cosmetic/not medically necessary for mastectomy for transmasculine gender reassignment, and that CPT code 19318 includes the extra work that may be necessary to reshape the nipple and create an aesthetically pleasing male chest.Vulvoplasty versus Vaginoplasty as Gender-Affirming Genital Surgery for Transgender WomenJiang and colleagues (2018) noted that gender-affirming vaginoplasty aims to create the external female genitalia (vulva) as well as the internal vaginal canal; however, not all patients desire nor can safely undergo vaginal canal creation. These investigators described the factors influencing patient choice or surgeon recommendation of vulvoplasty (creation of the external appearance of female genitalia without creation of a neovaginal canal) and evaluated the patient's satisfaction with this choice. Gender-affirming genital surgery consults were reviewed from March 2015 until December 2017, and patients scheduled for or who had completed vulvoplasty were interviewed by telephone. These investigators reported demographic data and the reasons for choosing vulvoplasty as gender-affirming surgery for patients who either completed or were scheduled for surgery, in addition to patient reports of satisfaction with choice of surgery, satisfaction with the surgery itself, and sexual activity after surgery. A total of 486 patients were seen in consultation for trans-feminine gender-affirming genital surgery: 396 requested vaginoplasty and 39 patients requested vulvoplasty; 30 Patients either completed or are scheduled for vulvoplasty. Vulvoplasty patients were older and had higher body mass index (BMI) than those seeking vaginoplasty. The majority (63 %) of the patients seeking vulvoplasty chose this surgery despite no contraindications to vaginoplasty. The remaining patients had risk factors leading the surgeon to recommend vulvoplasty. Of those who completed surgery, 93 % were satisfied with the surgery and their decision for vulvoplasty. The authors concluded that this was the first study of factors impacting a patient's choice of or a surgeon's recommendation for vulvoplasty over vaginoplasty as gender-affirming genital surgery; it also was the first reported series of patients undergoing vulvoplasty only.Drawbacks of this study included its retrospective nature, non-validated questions, short-term follow-up, and selection bias in how vulvoplasty was offered. Vulvoplasty is a form of gender-affirming feminizing surgery that does not involve creation of a neovagina, and it is associated with high satisfaction and low decision regret.Autologous Fibroblast-Seeded Amnion for Reconstruction of Neo-vagina in Transfeminine Reassignment SurgerySeyed-Forootan and colleagues (2018) stated that plastic surgeons have used several methods for the construction of neo-vaginas, including the utilization of penile skin, free skin grafts, small bowel or recto-sigmoid grafts, an amnion graft, and cultured cells. These researchers compared the results of amnion grafts with amnion seeded with autograft fibroblasts. Over 8 years, these investigators compared the results of 24 male-to-female transsexual patients retrospectively based on their complications and levels of satisfaction; 16 patients in group A received amnion grafts with fibroblasts, and the patients in group B received only amnion grafts without any additional cellular lining. The depths, sizes, secretions, and sensations of the vaginas were evaluated. The patients were monitored for any complications, including over-secretion, stenosis, stricture, fistula formation, infection, and bleeding. The mean age of group A was 28 ± 4 years and group B was 32 ± 3 years. Patients were followed-up from 30 months to 8 years (mean of 36 ± 4) after surgery. The depth of the vaginas for group A was 14 to 16 and 13 to 16 cm for group B. There was no stenosis in neither group. The diameter of the vaginal opening was 34 to 38 mm in group A and 33 to 38 cm in group B. These researchers only had 2 cases of stricture in the neo-vagina in group B, but no stricture was recorded for group A. All of the patients had good and acceptable sensation in the neo-vagina; 75 % of patients had sexual experience and of those, 93.7 % in group A and 87.5% in group B expressed satisfaction. The authors concluded that the creation of a neo-vaginal canal and its lining with allograft amnion and seeded autologous fibroblasts is an effective method for imitating a normal vagina. The size of neo-vagina, secretion, sensation, and orgasm was good and proper. More than 93.7 % of patients had satisfaction with sexual intercourse. They stated that amnion seeded with fibroblasts extracted from the patient's own cells will result in a vagina with the proper size and moisture that can eliminate the need for long-term dilatation. The constructed vagina has a 2-layer structure and is much more resistant to trauma and laceration. No cases of stenosis or stricture were recorded. Level of Evidence = IV. These preliminary findings need to be validated by well-designed studies.Pitch-Raising Surgery in Transfeminine PersonsVan Damme and colleagues (2017) reviewed the evidence of the effectiveness of pitch-raising surgery performed in male-to-female transsexuals. These investigators carried out a search for studies in PubMed, Web of Science, Science Direct, EBSCOhost, Google Scholar, and the references in retrieved manuscripts, using as keywords "transsexual" or "transgender" combined with terms related to voice surgery. They included 8 studies using cricothyroid approximation, 6 studies using anterior glottal web formation, and 6 studies using other surgery types or a combination of surgical techniques, leading to 20 studies in total. Objectively, a substantial rise in post-operative fundamental frequency was identified. Perceptually, mainly laryngeal web formation appeared risky for decreasing voice quality. The majority of patients appeared satisfied with the outcome. However, none of the studies used a control group and randomization process. The authors concluded that future research needs to investigate long-term effects of pitch-raising surgery using a stronger study design.Azul and associates (2017) evaluated the currently available discursive and empirical data relating to those aspects of trans-masculine people's vocal situations that are not primarily gender-related, and identified restrictions to voice function that have been observed in this population, and made suggestions for future voice research and clinical practice. These researchers conducted a comprehensive review of the voice literature. Publications were identified by searching 6 electronic databases and bibliographies of relevant articles. A total of 22 publications met inclusion criteria. Discourses and empirical data were analyzed for factors and practices that impact on voice function and for indications of voice function-related problems in trans-masculine people. The quality of the evidence was appraised. The extent and quality of studies investigating trans-masculine people's voice function was found to be limited. There was mixed evidence to suggest that trans-masculine people might experience restrictions to a range of domains of voice function, including vocal power, vocal control/stability, glottal function, pitch range/variability, vocal endurance, and voice quality. The authors concluded that more research into the different factors and practices affecting trans-masculine people's voice function that took account of a range of parameters of voice function and considered participants' self-evaluations is needed to establish how functional voice production can be best supported in this population.Facial Feminization SurgeryRaffaini and colleagues (2016) stated that gender dysphoria refers to the discomfort and distress that arise from a discrepancy between a person's gender identity and sex assigned at birth. The treatment plan for gender dysphoria varies and can include psychotherapy, hormone treatment, and gender affirmation surgery, which is, in part, an irreversible change of sexual identity. Procedures for transformation to the female sex include facial feminization surgery, vaginoplasty, clitoroplasty, and breast augmentation. Facial feminization surgery can include forehead re-modeling, rhinoplasty, mentoplasty, thyroid chondroplasty, and voice alteration procedures. These investigators reported patient satisfaction following facial feminization surgery, including outcome measurements after forehead slippage and chin re-modeling. A total of 33 patients between 19 and 40 years of age were referred for facial feminization surgery between January of 2003 and December of 2013, for a total of 180 procedures. Surgical outcome was analyzed both subjectively through questionnaires administered to patients and objectively by serial photographs. Most facial feminization surgery procedures could be safely completed in 6 months, barring complications. All patients showed excellent cosmetic results and were satisfied with their procedures. Both frontal and profile views achieved a loss of masculine features. The authors concluded that patient satisfaction following facial feminization surgery was high; they stated that the reduction of gender dysphoria had psychological and social benefits and significantly affected patient outcome. The level of evidence of this study was IV.Morrison and associates (2018) noted that facial feminization surgery encompasses a broad range of cranio-maxillofacial surgical procedures designed to change masculine facial features into feminine features. The surgical principles of facial feminization surgery could be applied to male-to-female transsexuals and anyone desiring feminization of the face. Although the prevalence of these procedures is difficult to quantify, because of the rising prevalence of transgenderism (approximately 1 in 14,000 men) along with improved insurance coverage for gender-confirming surgery, surgeons versed in techniques, outcomes, and challenges of facial feminization surgery are needed. These researchers appraised the current facial feminization surgery literature. They carried out a comprehensive literature search of the Medline, PubMed, and Embase databases was conducted for studies published through October 2014 with multiple search terms related to facial feminization. Data on techniques, outcomes, complications, and patient satisfaction were collected. A total of 15 articles were selected and reviewed from the 24 identified, all of which were either retrospective or case series/reports. Articles covered a variety of facial feminization procedures. A total of 1,121 patients underwent facial feminization surgery, with 7 complications reported, although many articles did not explicitly comment on complications. Satisfaction was high, although most studies did not use validated or quantified approaches to address satisfaction. The authors concluded that facial feminization surgery appeared to be safe and satisfactory for patients. These researchers stated that further studies are needed to better compare different techniques to more robustly establish best practices; prospective studies and patient-reported outcomes are needed to establish quality-of-life (QOL) outcomes for patients.Reversal of Gender Affirming Surgery for Gender DysphoriaThe WPATH Standards of Care (SOC) for the Health of Transsexual, Transgender, and Gender Nonconforming Peoples describe reversible and irreversible interventions, and the ideal order and timing of these approaches. Surgery as an intervention is considered irreversible by WPATH.AppendixDSM 5 Criteria for Gender Dysphoria in Adults and AdolescentsA marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months duration, as manifested by two or more of the following:A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or, in young adolescents, the anticipated secondary sex characteristics)A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or, in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics)A strong desire for the primary and/or secondary sex characteristics of the other genderA strong desire to be of the other gender (or some alternative gender different from one’s assigned gender)A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender)A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender)The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.Format for referral letters from Qualified Health Professional (From SOC-7)Client’s general identifying characteristics; andResults of the client’s psychosocial assessment, including any diagnoses; andThe duration of the mental health professional’s relationship with the client, including the type of evaluation and therapy or counseling to date; andAn explanation that the WPATH criteria for surgery have been met, and a brief description of the clinical rationale for supporting the patient’s request for surgery; andA statement about the fact that informed consent has been obtained from the patient; andA statement that the mental health professional is available for coordination of care and welcomes a phone call to establish this.Note: There is no minimum duration of relationship required with mental health professional. It is the professional’s judgment as to the appropriate length of time before a referral letter can appropriately be written. A common period of time is three months, but there is significant variation in both directions. When two letters are required, the second referral is intended to be an evaluative consultation, not a representation of an ongoing long-term therapeutic relationship, and can be written by a medical practitioner of sufficient experience with gender dysphoria.Note: Evaluation of candidacy for gender affirmation surgery by a mental health professional is covered under the member’s medical benefit, unless the services of a mental health professional are necessary to evaluate and treat a mental health problem, in which case the mental health professional’s services are covered under the member’s behavioral health benefit. Please check benefit plan descriptions.Characteristics of a Qualified Mental Health Professional (From SOC-7)Master’s degree or equivalent in a clinical behavioral science field granted by an institution accredited by the appropriate national accrediting board. The professional should also have documented credentials from the relevant licensing board or equivalent; andCompetence in using the Diagnostic Statistical Manual of Mental Disorders and/or the International Classification of Disease for diagnostic purposes; andAbility to recognize and diagnose co-existing mental health concerns and to distinguish these from gender dysphoria; andKnowledgeable about gender nonconforming identities and expressions, and the assessment and treatment of gender dysphoria; andContinuing education in the assessment and treatment of gender dysphoria. This may include attending relevant professional meetings, workshops, or seminars; obtaining supervision from a mental health professional with relevant experience; or participating in research related to gender nonconformity and gender dysphoria.