Anxiety and Panic Disorders Holistic Cure

The 60 Second Panic Solution

The 60 Second Panic Solution' is a program created by Anna Gibson Steel to help sufferers of panic attacks triggered by their daily activities address and overcome them. In this program lies a method that when followed, you will be able to subdue your panic and in just a minute, you will attain a balanced emotional level. This program has undergone the test of time and in every situation, it has come out successful. It has been tested by various people of different backgrounds and age brackets and has produced a positive result in each case. As mentioned, with this program, it will be like you are seeing the fire burning and you calmly walk to a tank of water, fill up a bucket and gently quench the fire. So, all that is required of you is to simply follow the steps involved in this program as proposed by Anna and look forward to experiencing the best results. Use these steps to manipulate your brain into returning to its normal state. This program is available for purchase on their website at and is available in PDF format, videos and audio, whichever suits you. It is an awesome program meant mainly for those who suffer from these panic attacks. Although, if you are close to someone who has these attacks you can use this program to help them work their way through these attacks or better still introducing them to it for a firsthand experience. And then you can also follow the program and be enlightened for future purposes. More here...

The 60 Second Panic Solution Summary


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I've really worked on the chapters in this book and can only say that if you put in the time you will never revert back to your old methods.

All the modules inside this ebook are very detailed and explanatory, there is nothing as comprehensive as this guide.

Sedative Hypnotic or Anxiolytic Induced Disorders

292.89 Sedative, Hypnotic, or Anxiolytic Intoxication 292.0 Sedative, Hypnotic, or Anxiolytic Withdrawal Specify if With Perceptual Disturbances 292.81 Sedative, Hypnotic, or Anxiolytic Intoxication Delirium 292.81 Sedative, Hypnotic, or Anxiolytic Withdrawal Delirium 292.82 Sedative-, Hypnotic-, or Anxiolytic-Induced Persisting Dementia 292.83 Sedative-, Hypnotic-, or Anxiolytic-Induced Persisting Amnestic Disorder 292.xx Sedative-, Hypnotic-, or Anxiolytic-Induced Psychotic Disorder .11 With DelusionsIW .12 With HallucinationsIW 292.84 Sedative-, Hypnotic-, or Anxiolytic-Induced Mood DisorderI,W 292.89 Sedative-, Hypnotic-, or Anxiolytic-Induced Anxiety DisorderW 292.89 Sedative-, Hypnotic-, or Anxiolytic-Induced Sexual DysfunctionI 292.85 Sedative-, Hypnotic-, or Anxiolytic-Induced Sleep DisorderI,W 292.9 Sedative-, Hypnotic-, or Anxiolytic-Related Disorder NOS

Generalized Anxiety Disorder

GAD has a lifetime prevalence of approximately 5 3 with more than 90 of individuals having at least one other comorbid psychiatric disorder including depression or another anxiety disorder.3 GAD is second to only depression as the most frequent psychiatric disorder in the primary care setting. DSM IV-TR2 characterizes GAD as excessive anxiety and apprehension occurring more days than not, over at least a 6 month period. The anxiety and apprehension are accompanied by somatic symptoms such as restlessness, disturbed sleep, difficulty concentrating, and muscle tension. These symptoms, taken together, are also associated with a significant subjective distress and impairment in both social and work functioning. GAD tends to be a chronic and recurrent disease with less than one-half of cases remitting without medical treatment. Approximately 48 of GAD patients seek professional help with 25 of these patients receiving medication for the disorder.

Social Anxiety Disorder

SAD or social phobia is a common anxiety disorder often associated with serious role impairment. The 12-month prevalence rate for all types of SAD was estimated to be 8 with a lifetime prevalence of 13 . SAD is a chronic disease with a slightly higher prevalence in females than males (15 versus 11 , respectively), with retrospective studies showing an average duration of 25 years. Overall, females with poor baseline functioning at the time of diagnosis have the greatest risk of disease chronicity. DSM IV-TR defines SAD as a marked and persistent fear of social or performance situations in which embarrassment may occur. The diagnosis of SAD is only made when the fear, avoidance, or anxious anticipation of the event persists for at least 6 months and the phobia directly interferes with daily function or when the individual is distressed about having the phobia. Although SAD can relate to a specific set of circumstances (i.e., public speaking), there are cases in which there can be a...

Neurochemical Basis of Anxiety

Neurochemical modulators exist at every level within the complex neurocircuitry described above, providing a large number of potential therapeutic targets for the treatment of anxiety. Despite the variations in clinical presentation of the various anxiety disorders, extensive preclinical studies have provided significant evidence for the role of multiple neurochemical systems in the etiology of anxiety, in general, with a significant amount of overlap between the individual disorders themselves. The major neuromodulators and neuromodulatory systems that have been implicated both through preclinical and clinical studies include the monoamines (5-hydroxytryptamine (5HT), norepinephrine (NE), and dopamine), corticotrophin-releasing factor (CRF), g-amino-butyric acid (GABA), glutamate, neuropeptides (substance P, neuropeptide Y galanin), cholecystokinin, and neurotrophic factors.20

Genetic Basis of Anxiety

Both human and animal studies have provided evidence for a genetic influence in the etiology of anxiety. A growing number of genetically altered mice have been produced in an effort to identify specific genes conferring enhanced or reduced risk for anxiety disorders. A meta-analysis of family studies, as well as twin studies and prospective studies in children of anxious parents, have demonstrated a significant familial aggregation for all anxiety disorders. From these studies, the range of reported genetic effect has been 25-65 . It has also been postulated that anxiety disorders may represent a complex genetic trait in which genetic risk factors are probabilistic rather than deterministic in nature.21 The development of knockout and transgenic mice has facilitated investigations into the contribution of several classes of neurotransmitters receptors to anxiety.

Obsessive Compulsive Disorder

Double-blind, placebo-controlled multicenter trials are required to establish efficacy in OCD and require exclusion of patients with comorbid conditions of marked severity, including anxiety, depression, mixed schizoid, and schizotypal disorders. The Y-BOCS (Yale-Brown obsessive compulsive scale), a 10 item, clinician-administered scale, is the most

A role for CRF in anxietyrelated disorders

Whilst there is considerable data on the role of CRF in depression,89 CRF systems may also play a role in anxiety states. CRF has central, behavioral arousal properties characteristic of other anxiogenic compounds that relate directly to the hyperarousal that defines anxiety disorders. CRF has been implicated as a mediator in panic disorder based on the observation that patients with this disorder exhibit a blunted ACTH response to CRF as compared to normal individuals. This blunted response likely reflects processes occurring above the level of the hypothalamus related to hypersecretion of CRF. In rats, CRF disrupts PPI in a manner similar to that observed in patients with panic disorder where the CRF system is thought to be overactive.97 These effects could be reversed by CRF receptor antagonists.89

Potential CRF receptor antagonists for anxiety

As CRF appears to plays a major role in the regulation of stress responses and the subsequent anxiety a concerted effort has focused on the search for orally active, nonpeptide antagonists. Examples of the different compound classes with high affinity for the CRF1 receptor are shown in Figure 9.98 Interestingly, while these molecules are chemically distinct, they appear to fit a common pharmacophore indicating that the receptor has strict requirements to allow a high-affinity interaction.98

Benzodiazepine site ligands with partial efficacy

The imidazobenzodiazepines bretazenil, imidazenil, and FG-8205 (Figure 10a) are high-affinity partial agonists for GABAA receptor subtypes that contain a1, a2, a3, and a5 subunits. These compounds are anxiolytic in animal models, with a greater separation between doses required for anxiolytic versus sedative effects than that observed for diazepam. Where studied, these compounds also show little evidence for tolerance to the anxiolytic effects, do not display withdrawal, and have a lower abuse potential than full BZ agonists in nonhuman primates. Bretazenil (Figure 10a) entered clinical studies in the mid-1980s and was efficacious in GAD and panic disorder,112 with a lower abuse potential than diazepam.113 However, bretazenil was sedative, with little evidence for separation between anxiolytic and sedative effects,114 and its clinical development was discontinued. The b-carboline abecarnil (Figure 10a), has high affinity for a1-, a2-, a3-, and a5-subunit-containing GABAA receptors,...

GABAa subtypeselective benzodiazepine site ligands

No NCEs have yet been reported with a high degree of selective affinity for GABAA receptor subtypes believed to be important for anxiolysis. However, compounds have been identified that, despite having similar affinities, show a degree of functional selectivity for different a-subunit-containing GABAA receptors (i.e., they behave as full or partial modulators of certain subtypes and neutral modulators of others). A compound preferentially potentiating a2-subunit-containing GABAA receptor responses could provide anxiolytic effects with a separation from sedation and memory impairment. A pyridine-2-one derivative, which behaves as a negative allosteric modulator with functional selectivity for a3-subunit-containing GABAA receptors, increased anxiety responses in rodents82'118 suggesting that potentiation of a3-subunit-containing GABAA receptor responses may also provide anxiolysis. The triazalopyradizine, L-838417 (Figure 10b), had high affinity for a1-, a2-, a3-, and...

Alcohol Induced Anxiety Affective or Psychotic Disorder

If symptoms of an anxiety disorder, affective disorder (depressive, manic, or mixed), or psychotic disorder (hallucinations or delusions) develop during or within 1 month of intoxication or withdrawal, an alcohol-induced anxiety, affective, or psychotic disorder may be diagnosed. If the patient has insight that hallucinations are alcohol-induced, an alcohol-induced psychotic disorder is not diagnosed. The anxiety and affective symptoms must exceed the usual presentation of such symptoms as they commonly occur during intoxication or withdrawal (DSM-IV).

Anxiety Management Skills

It can be useful to provide anxiety management strategies early in therapy because (1) they can give patients a degree of control over their distress, and (2) these techniques are relatively simple to use. Be aware that most patients experience considerable distress during the initial sessions because they are confronting and expressing upsetting memories. The utility of reducing arousal in the acute posttrauma phase is also indicated by evidence that acute arousal is associated with chronic PTSD (Shalev et al., 1998). Giving the patient some tools to assist mastery over the acute anxiety can provide both a sense of relief and a motivation to comply with more demanding therapy tasks. Anxiety management often involves progressive muscle relaxation (Ost, 1987) and breathing retraining, which aims to achieve 10 breaths a minute. Although these techniques are simple, therapists need to be aware that focusing on bodily sensation or on breathing can trigger reminders of the trauma. First,...

Test or Performance Anxiety

Many children report a greater frequency of pain symptoms prior to a stressful event or competitive activity at school, including athletic events and examinations (4). Such circumscribed anxiety may benefit from the use of positive self-coaching statements, such as, I know I can do it if I just do my best. Negative self-statements, such as What if I fail , should be eliminated. The use of adaptive self-statements is important to enhance coping strategies and diminish distorted negative thoughts when approaching stressful tasks.

Anxiety Rating Scales

Both observer-rated measures, such as the Hamilton Anxiety Rating Scale (Hamilton 1959), and self-rated instruments, such the Spielberger State-Trait Anxiety Inventory (Spielberger et al. 1970) and the Worry Scale (Wisocki et al. 1986), assess severity and type of anxiety symptoms. The Hamilton scale, which consists of 14 items to assess 89 symptoms, has been the most widely used test in psychiatric research, and a few studies support its utility with el- Table 7-1. Autonomic and psychomotor features of anxiety Generalized anxiety disorder Sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep) Panic attack1 aPanic attack is diagnosed if four or more of these symptoms develop abruptly and reach a peak within 10 minutes. derly patients (J.G. Beck et al. 1996). The Spielberger scale includes items that assess both current ( state ) and habitual ( trait ) anxiety symptoms. It has proved useful as an outcome measure in studies of psychological...

Anxiety Through The Course Of Hiv And Aids

Persons with HIV and AIDS may experience anxiety from the first realization of being at risk to the existential anxiety that may accompany inexorable progression of illness near the end of life. Pathologic anxiety is differentiated from normal fear response in that it is out of proportion with respect to the environmental stimulus in question, has significant intensity and duration, and results in either impairment of coping, disruption of normal function, or abnormal behaviors (Pollack et al., 2004). The determinants of severity of anxiety are multifactorial and are related to social support and experience with prior stressors and illnesses, as well as coping capacity, defensive structure, adaptive capacity, resilience, and the presence or absence of other psychiatric disorders. In addition to the psychological and social factors, severity and presence of comorbid medical conditions play a significant role in the level of anxiety experienced.

Psychoimmunology Of Anxiety In Hiv Infection

The role of neuroendocrine pathways, namely the hypothalamic-pituitary-adrenal axis and the sympathetic adrenomedullary system, in anxiety disorders is only partially understood. To date, studies do not agree on the relationship between immune function and psychological distress in persons with HIV and AIDS (Antoni et al., 1991 Sahs et al., 1994 Kimmerling et al., 1999 Sewell et al., 2000 Antoni, 2003 Dela-hanty et al., 2004). One challenge of such studies is that the physiologic effects of HIV must be distinguished from those attributed to anxiety. For further details regarding the interaction between HIV, psychiatric illness, and the immune system, please refer to Chapter 3.

Micronutrients Anxiety

May decrease anxiety and nervous tension.4 Medications, illness, and stress can deplete magnesium stores and produce agitation and irritability possible sensitivities and eliminate the offending foods (see pp. 205). Although small amounts of caffeine can have mood-elevating properties, chronic high intake of coffee and black teas may aggravate anxiety and de-pression.2

Treatment Of Comorbid Depression And Anxiety

It is crucial that psychosocial and emotional factors be explored, because there is a high comorbidity of depression and anxiety disorders in patients with chronic pain. Moreover, given the similarities between the pharmacology of mood and depression and pain transmission (e.g., serotonin and norepinephrine), patients with concomitant systemic illness and stress may be at risk for depression and development of an abnormal chronic pain state. Pharmacologic management of depression may improve neuropathic pain by addressing overlapping, but distinct mechanisms.

Benzodiazepine site ligands

Required to produce functional GABAA receptors that exhibit all the pharmacological properties of native GABAA receptors. The diversity of subunits and their heterogeneous distribution between brain regions raises the question of whether GABAA receptors composed of different subunit combinations play different functional roles in the brain. GABAa receptors containing a1, a2, a3, or a5 subunits in combination with b,g subunits bind to and are potentiated by BZs. In contrast, a4- or a6-subunit-containing receptors are insensitive to classical BZs like diazepam (exceptions being the BZ antagonist, Ro15-1788 and the inverse agonist, Ro 15-4513, which show weaker activity at a4 and a6). Differences in BZ ligand affinity between a subunits results from a histidine (His 101 in rat a1) at the homologous position in a1, a2, a3, and a5, while an arginine is present in the homologous position in the a4 and a6 subunits. Transgenic mouse lines with a single histidine (H) to arginine (R) mutation...

Discontinuation of Benzodiazepine

Discontinuation of sedatives and hypnotics, including the benzodiazepines, can be divided into three categories (1) long-term low-dose benzodiazepine use, (2) high-dose benzodiazepine abuse and multiple drug abuse, and (3) high-dose abuse of nonbenzodiazepine sedatives and hypnotics (especially intermediate-acting barbiturates). The first group of patients can usually be discontinued on an outpatient basis. Some of the second and even the third group can be treated as outpatients, but most will require inpatient care. Inpatient discontinuation today with managed care is generally reserved for patients who fail at outpatient discontinuation and for those who demonstrate acutely life-threatening loss of control over their drug use. The pharmacological management of inpatient benzodiazepine withdrawal from nontherapeutically high doses of these medicines is covered in standard texts dealing with inpatient detoxification (Wesson et al., 2003). With respect to withdrawal from...

Sedatives Hypnotics and Benzodiazepines

The sedatives and the hypnotics, especially the benzodiazepines, are widely used in medical practice in the treatment of anxiety, insomnia, epilepsy, and for several other indications (Baldessarini, 2001). The combination of abuse by alcoholics and drug addicts, and the withdrawal symptoms on discontinuation leads to the view that these are addictive drugs (DuPont, 2000 Juergens & Cowley, 2003). The pharmacology and the epidemiology of sedatives and hypnotics are reviewed in this chapter, which focuses on the needs of the clinician. The benzodiazepines resemble the other sedatives, except that they do not produce surgical anesthesia, coma, or death, even at high doses, except when coadministered with other agents that suppress respiration. The benzodiazepines can be antagonized by specific agents that do not block the effects of other sedatives. The benzodiazepine antagonists do not produce significant effects in the absence of the benzodiazepines. These properties distinguish the...

Identification Of Problems Among Longterm Benzodiazepine Users

Physicians frequently encounter patients, or family members of patients, who are concerned about the possible adverse effects of long-term use of a benzo-diazepine in the treatment of anxiety or insomnia. In helping to structure the decision making for such a patient, we use the Benzodiazepine Checklist (DuPont, 1986 see Table 10.2). There are four questions to be answered 1. Diagnosis. Is there a current diagnosis that warrants the prolonged use of a prescription medicine The benzodiazepines are serious medicines that should only be used for serious illnesses. 2. Medical and nonmedical substance use. Is the benzodiazepine dose the patient is taking reasonable Is the clinical response to the benzodiazepine favorable Is there any use of nonmedical drugs, such as cocaine or marijuana Is there any excessive use of alcohol (e.g., a total of more than four drinks a week, or more than two drinks a day) Are other medicines being used that can depress CNS functioning 4. Family monitor. Does...

Distinguishing Medical And Nonmedical Use Of Benzodiazepines

A series of national surveys tracking the medical use of the benzodiazepines showed that their use peaked in 1976 and by the late 1980s had fallen about 25 off that peak rate (DuPont, 1988). A 1979 survey of medical use of the benzodiazepines (near the peak of benzodiazepine use in the United States), showed that 89 of Americans ages 18 years and older had not used a benzodiazepine within the previous 12 months. Of those who had used a benzodiazepine, most (9.5 of all adults) had used the benzodiazepine either less than every day or for less than 12 months, or both, whereas a minority (1.6 of the adult population) had used a benzodiazepine on a daily basis for 12 months or longer. This long-term user group was two-thirds female 71 were age 50 or older, and most had chronic medical problems, as well as anxiety (DuPont, 1988). Of those with anxiety disorders in a large community sample, three-fourths were receiving no treatment at all, including not using a benzodiazepine. The 1.6 of...

Anxiety Disorders

300.01 Panic Disorder Without Agoraphobia 300.21 Panic Disorder With Agoraphobia 300.22 Agoraphobia Without History of Panic Disorder 300.3 Obsessive-Compulsive Disorder Specify if With Poor Insight 300.02 Generalized Anxiety Disorder 293.89 Anxiety Disorder Due to Indicate the General Medical Condition Specify if With Generalized Anxiety With Panic Attacks With Obsessive-Compulsive Symptoms . Substance-Induced Anxiety Disorder (refer Specify if With Generalized Anxiety With Panic Attacks With Obsessive-Compulsive Symptoms With Phobic Symptoms Specify if With Onset During Intoxication With Onset During Withdrawal 300.00 Anxiety Disorder NOS


The origin of BZs stemmed from the 'diversity oriented,'81 search for a new tranquilizer. Chlordiazepoxide was synthesized in 1955 but was not evaluated in vivo until 3 years later when it was found to be a potent CNS depressant. The reason for not subjecting chlordiazepoxide to biological evaluation earlier was the fact that the compound was thought to be quinazoline-N-oxide 1, which resulted from the failed synthesis of heptoxdiazine 2 (Figure 2a). Several analogs of 1 were subjected to in vivo evaluation and all failed to show the desired effect. The attempted synthesis of 2 was performed simply because the compounds would be diverse relative to the known tranquilizers of the day

Worry Anxiety

Pain and anxiety often go together 31 . When pain is severe and continuous it is not surprising that patients become concerned about the meaning of the pain. Most will begin to entertain worrying thoughts about the pain and its consequences. (Does this herald cancer or serious disease How am I going to cope with this Is this ever going to stop How am I going to survive financially What will happen to the family ) These worries will not only influence how patients cope with their pain but also directly influence how much pain they experience. It is well known that anxiety augments pain experienced from any injury.

Extreme Anxiety

Some individuals present with very extreme anxiety that often may reflect pretrauma anxiety states. Moreover, many people present with panic attacks following trauma (Nixon & Bryant, 2003). Employing exposure therapy with these individuals in the acute phase can compound their anxiety state and their posttraumatic difficulties. Instead, these individuals may require containment, support, and anxiety reduction strategies. Some individuals benefit from techniques that limit panic attacks, including interoceptive exposure and cognitive restructuring (Craske & Barlow, 1993). Many people in the acute phase also require assistance in learning how to tolerate distress and in developing skills in reducing their anxiety states (see Cloitre & Rosenberg, Chapter 13, this volume).

Separation Anxiety

Separation anxiety refers to developmentally inappropriate and excessive anxiety concerning separation from home or from those to whom the child is attached (15). One symptom criterion for the diagnosis of separation anxiety disorder includes repeated complaints of physical symptoms (such as headaches or stomachaches, nausea or vomiting) when separation from major attachment figures occurs or is anticipated (p. 113). Typically, such symptoms occur on the morning of schooldays and are less pervasive on weekends when the child will not be separated from caregivers (4). Symptoms may reoccur on Sunday evening in anticipation of separation from caregivers to attend school on Monday. Other symptoms of separation anxiety include recurrent or excessive distress when separation from home or major attachment figures occurs or is anticipated persistent and excessive worry about losing, or possible harm befalling, major attachment figures persistent and excessive worry that an untoward event will...

Diet Anxiety

In people susceptible to reactive hypoglycemia (see pp. 185), consumption of refined carbohydrates or sugar may trigger increased anxiety and, in rare cases, panic attacks.1 In individuals prone to nervousness and anxiety, consumption of caffeine can worsen their symptoms.2

The History Of Biological Psychiatry

Anxiety disorder) a social practice (priesthood, cobblery, medicine, palmistry), an ideology (realism, idealism), or a construct (French Revolution, guilt, prostitution) For the purpose of this chapter, biological psychiatry will be defined as a package of changing ideas and social practices seeking to explain and manage13 deviant human behaviours in terms of a neurobiological discourse. This enables the historian to ask why biological psychiatry has been successful, what social needs it meets, its best selling point, and how it reconstitutes itself.14

Social Cost and Market

The pervasiveness of psychiatric disorders, e.g., depression, substance abuse, anxiety, schizophrenia, etc., and the comorbidity of depression and anxiety with neurological disease has enormous costs for society, estimated in the trillions of dollars. Additionally, it has been estimated that over 60 of individuals with diagnosable mental disorders do not seek treatment.

Central Nervous System Disorders Psychiatric and Neurodegenerative

Disorders of the CNS are broadly categorized as either psychiatric or neurodegenerative with a major degree of overlap in symptoms. Thus neurodegenerative disorders also have a high incidence of psychiatric comorbities including anxiety and depression. Psychiatric disease includes a variety of disorders such as schizophrenia, depression, obsessive compulsive disorder (OCD), attention deficit hyperactivity disorder (ADHD), and others. The underlying pathology is usually considered to be the result of synaptic dysfunction driven by (1) a dysregulation of neurotransmitter availability or (2) signaling, the latter at the receptor and or signal transduction levels. The net result is an alteration in neuronal circuitry involving multiple neurotransmitter neuromodulator systems.

The yAmino Butyric Acid GABA Hypothesis

G-Amino-butyric acid (GABA) is the major inhibitory transmitter in the CNS, and has many effects that are opposite to those of glutamate, some of which involve GABAergic inhibition of glutamate function. The GABA uptake inhibitor, CI-966 9, has been associated with psychotic episodes in humans,17 a similar phenotype to that seen with the psychotomimetics that block the effects of glutamate at the NMDA receptor. A role of GABA in the etiology of schizophrenia was first proposed in the early 1970s based on GABAergic regulation of DA neuronal function with a special focus on the role of GABA in working memory. GABA uptake sites are decreased in hippocampus, amygdala, and left temporal cortex in schizophrenics with some evidence of GABAa receptor upregulation18 and reductions in GABA interneurons.19 An extensive review of the use of benzodiazepines, the classical GABAA agonists, the GABAg agonist

Modern Medical Treatment of Epilepsy

Epilepsy is a broad spectrum of disorders that affects individuals in many ways. Behind the choice of a medication or treatment for epilepsy is concern for preventing discomfort and injury from seizure, preventing brain damage, lessening social stigma, and improving outcome. The modern medications for epilepsy are acetazolamide, barbiturates, benzodiazepines clonazepam, clobazam (not FDA-approved), clorazepate, lorazepam, valium carbamazepine, ethosuximide, felbamate (serious risks limit its use), gabapentin, levetiracetam, lamotrigine, methsuximide, oxcarbazepine, phenytoin, primidone, tiagabine, topiramate, valproate, vigabatrin (not FDA-approved retinal toxicity limits its use), and zonisamide.

How much information should be disclosed

The amount of information given to patients as part of the randomization and consent process varies greatly. The level of verbal information is often decided by doctors on an individual and sometimes ad hoc basis. Whilst some clinicians believe that only total disclosure of all information is ethical, others suggest that information overload can distress the patient unduly. An Australian randomized study, which compared two methods of seeking consent (an individual approach at the discretion of the doctor versus total disclosure) for entry to trials of different standard cancer treatments, found that patients who experienced total disclosure were less willing to enter the trial and were significantly more anxious 22 . A more recent randomized study comparing standard consent methods with the same plus a follow up telephone call from an oncology nurse found that the latter resulted in the patients being better informed about the trial and their treatment. It did not significantly...

Clinical Definition Overlap between Normal Aging and Cognitive Impairment

In 2000, the Canadian Study of Health and Aging (CSHA) defined the concept of cognitive impairment no dementia (CIND) on the basis of a consensus conference of physicians, nurses and neuropsychologists 8 . The CIND concept reflects essentially the presence of cognitive impairment in the absence of dementia, on the basis of clinical and neuropsychological examination, regardless of its causes (neurological, psychiatric or medical) and its degree 9 aging-associated cognitive decline (AACD) was operatively defined as a history of cognitive decline during at least 6 months, with difficulties in several cognitive domains including, but not limited to, memory, and with low test scores in the relevant domains, in absence of dementia 10 this concept reflect a somewhat different approach, focusing on patients' and families' complaints of memory and cognitive loss as starting point. It is well known that elderly subjects might complain of memory loss as a result of anxiety, mild depression or...

The Pediatric Pain Experience

The magnitude of the problem of inadequate pain treatment in children was brought to light in the late 1980s when studies in various institutions independently confirmed that children were undertreated despite the caregivers' recognition of the presence of pain (13,14). The incidence of pediatric pain is unknown because most studies addressed either one specific type of pain or pain treatment and not the general presence and intensity of pain. Anxiety during blood sampling via venipuncture has been cited as a major cause of distress for children. Up to

Preface and Acknowledgments

In their discussion of the molecular genetic basis of behavioral traits, Stephanie Sherman and Irwin Waldman describe current methods for finding genes for complex traits. They use schizophrenia, dyslexia, and anxiety as examples of successful investigations of the molecular basis of human behavior. The authors point to major advances in isolating the biological from the environmental components of complex behavioral traits.

Second Generation Atypical Antipsychotic Drugs

The discovery of the benzodiazepine, clozapine 12, in 1959 ushered in a new generation of potentially superior antipsychotic drugs. Clozapine was able to block DA-mediated behavior in animals and exerted antipsychotic effects in humans at doses that did not elicit EPS or produce sustained elevations in serum prolactin levels in humans. The motor symptom profile was sufficiently different from the first-generation antipsychotic drugs such that clozapine was labeled 'atypical' and clozapine became the blueprint for the development of other atypical antipsychotic drugs. Based on this blueprint, close clozapine analogs were developed that include loxapine 45, olanzapine 49, quetiapine 46, and asenapine 50, while the structurally dissimilar benzisoxidil group including risperidone 47, iloperidone 51, and ziprasidone 48, and the phenylindole derivative, sertindole 52.

Effects Of Stress On Visceral Pain

When nervous, one feels butterflies or a pit'' in the stomach. Gut wrenching'' emotions can also evoke profound changes in heart rate, breathing, and all other visceral functions. There is little doubt that the emotional state can alter sensations from and function of the viscera but the reverse situation also appears to be true visceral pain evokes strong emotions, stronger than those evoked by equal intensities of superficial pain. This has been demonstrated in numerous observational studies, but was most definitively demonstrated in the study by Strigo et al. (16) (discussed above), which compared balloon distension of the esophagus with thermal stimulation of the mid-chest skin. Matched intensities of both distending and thermal stimuli were presented and the magnitude of emotional responses was then quantified using several tools designed to dissect out the affective components of clinical pain. Word selection from the McGill Pain Questionnaire suggested a stronger affective...

Pharmacological Concerns 71 Drug Distribution

The intravenous route is the most direct and avoids the barriers of hepatic first-pass metabolism and tissue absorption. However, some drugs cause pain on intravascular injection. The discomfort can be lessened by slowing the rate of injection or by dilution of the drug in volume or with simultaneous infusion of maintenance fluids. Analgesics known to cause discomfort on injection, especially when minimally diluted, include morphine and ketorolac. Sedatives that cause discomfort on injection include diazepam and propofol. Intramuscular injections are discouraged in children because of the anxiety and pain caused by hypodermic injection.

Historical and Social Context of Psychoactive Substance Use Disorders

Psychoactive substances subserve several human functions that can enhance both individual and social existence. On the individual level, desirable ends include the following relief of adverse mental and emotional states (e.g., anticipatory anxiety before battle and social phobia at a party), relief of physical symptoms (e.g., pain and diarrhea), stimulation to function despite fatigue or boredom, and time-out from day-to-day existence through altered states of consciousness. Socially, alcohol and drugs are used in numerous rituals and ceremonies, from alcohol in Jewish Passover rites and the Roman Catholic Mass, to peyote in the Native American Church and the serving of opium at certain Hindu marriages. To a certain extent, the history of human civilization parallels the development of psychoactive substances (Westermeyer, 1999).

Functional Analytic Clinical Assessment The Purpose of Functional Analysis

The last criterion Haynes and O'Brien suggest is to identify causal variables. Causal in this context is not so much a notion of ultimate causality as a reference to those variables that, when changed, reliably precede and produce change in the targeted clinical problem. If the therapist can identify unique functional relationships that ameliorate specific individual problems for individual patients, then the therapist will also observe additional treatment effects to those derived by administering a protocol-driven treatment plan that is designed for the hypothetical average patient. For example, for a rape victim, a sexual encounter with a new romanitic partner may seemingly cause anxiety and distress. In fact, it is not the current romantic encouter that is the ultimate cause of symptoms the rape is. However, from a clinical standpoint, the current sexual stimuli such as touch, smells, and arousal can serve as cues for when and what desensitization strategies should be applied.

Dopamine transporter polymorphisms

DAT terminates dopaminergic neurotransmission by reuptake of dopamine (DA) in presynaptic neurons and plays a key role in DA recycling. DAT can also provide reverse transport of DA under certain circumstances. Psychostimulants such as cocaine and amphetamines and drugs used for attention deficit hyperactivity disorder (ADHD) such as methylphenidate exert their actions via DAT. Altered DAT function or density has been implicated in various types of psychopathology, including depression, BPAD, suicide, anxiety, aggression, and schizophrenia. Altered transport properties associated with some of the coding variants of DAT suggest that individuals with these DAT variants could display an altered DA system.17'20 Multiple human dopamine transporter (hDAT, SLC6A3) coding variants have been described, though to date they have been incompletely characterized. The antidepressant, bupropion (6) dose-dependently increases vesicular DA uptake an effect also associated with VMAT-2 protein...

Serotonin transporter polymorphisms

Reduced binding of imipramine and paroxetine to brain and platelet SERTs in patients with depression and suicide victims indicates that altered SERT function might contribute to aberrant behaviors. Two polymorphic regions have been identified in the SERT promoter and implicated in anxiety, mood disorders, alcohol abuse, and in various neuropsychiatric disorders.21 Thus, studies are emerging to support the notion that impaired regulation might contribute to human disease conditions such as those seen in human variants of the SERT coding region.

Transgenic and knockdown and out mice models of psychiatric disease

The most compelling evidence of a link between genetic variation and the role of the SERT in depression and anxiety led to SERT knockout mice that show increased anxiety-like behaviors, reduced aggression, and exaggerated stress responses. Appropriate functioning of SERT and monoamine oxidase A (MAO-A) during early life appear critical to the normal development of these systems. MAO-A and SERT knockout mice mimic in some respects the consequences of reduced genetic expression in humans. MAO-A knockout mice exhibit high levels of aggression, similar to the elevated impulsive aggression seen in humans lacking this gene. SERT knockout mice may thus represent a more exaggerated version of the reduced SERT expression found in certain subjects, and a partial model of the increased vulnerability to anxiety and affective disorders seen in human subjects with the low expressing allele. Table 5 lists some of the genetically modified mice that have been reported to show depressive or...

Privileged Organic Scaffolds

Privileged organic scaffolds249 include, for instance, the benzodiazepine scaffolds (Figure 21) that have been utilized by Evans et al.246 Benzodiazepine scaffolds are thought to mimic a reverse turn,250 and their analogs continue to generate leads against multiple peptide receptors.251-254 Further, Haskell-Luevano etal.255 screened a library of 951

Emotions Coping and Well Being

Although old age presents many personal and social obstacles, poor morale has been found to be the exception rather than the rule among older adults. Current cohorts of older adults are not more prone to depression or anxiety disorders than are young or middle-aged persons, and they do not show lowered self-esteem as a general rule. Not surprisingly, older adults with the highest morale tend to have better education and socioeconomic status when compared to those older adults who did not have such advantages. Specific stressful events have less of an effect on subjective well-being in old age than does attainment of personal goals or the onset of physical disability. Older adults maintain a sense of contentment in the face of functional declines through a combination of mobilizing additional resources, downsizing performance standards, and reducing the value placed on particular skills or attributes (Rothermund and Brandtstadter 2003). Throughout the adult life span, individuals...

Neil L Schechter Summary

Although there have been dramatic changes in attitude and practice in the treatment of children's pain in the hospital, pain management in outpatient settings is treated essentially the way it was 20 years ago. It is quite remarkable that many common illnesses and procedures universally acknowledged to be associated with significant discomfort and anxiety have received minimal research attention. In this chapter, some of the more common pain problems (minor procedures and acute illnesses) encountered in office practice are reviewed, and suggestions for pain relief based on the limited literature are offered. The following areas are addressed (1) pain associated with immunization, the most common painful procedure in office practice (2) pain associated with common illnesses, specifically otitis media, pharyngitis, and viral mouth infections and (3) chronic and recurrent pains, which require an alternative paradigm than acute pain. Through the uniform use of relatively simple...

Types of Assessment Measures

Although the administration of the full SCID-IV can be time consuming, the modular structure allows clinicians to limit their assessment to conditions that are frequently comorbid with PTSD. Within the context of a trauma clinic, it is recommended that modules for anxiety disorders, mood disorders, and substance use disorders be administered. Administration of the psychotic screen will also help to rule out conditions that require a different set of interventions (Keane & Barlow, 2002). ANXIETY DISORDERS INTERVIEW SCHEDULE-REVISED Originally developed by DiNardo, O'Brien, Barlow, Waddell, and Blanchard (1983), the Anxiety Disorders Interview Schedule (ADIS) was designed to permit differential diagnoses among the DSM-III (American Psychiatric Association, 1980) anxiety disorder categories and to provide detailed symp Psychometric studies on the ADIS-PTSD module provide mixed results. Originally tested in a small sample of Vietnam combat veterans, the ADIS-PTSD module yielded strong...

Acute Pain 21 Immunizations

Despite their undeniable value, these procedures are a mixed blessing. On the one hand, they protect the children from life-threatening illnesses. On the other hand, all health care providers who work with children are familiar with the anxiety that the anticipation of these procedures engenders. Every nurse or physician who works with children has entered the examining room and encountered a worried child cringing in the corner whose first question is, Am I going to get a shot For a subset of children, the concerns about these procedures dominate the entire encounter with their health care provider. Preoccupation with these procedures affects not only the child, however, but also has a significant impact on families and on the health care provider. In an attempt to understand the individual differences among children in response to injections, we studied the impact of a host of variables on the children's response to their 5-year preschool injection (17). At a home visit 1 month...

Posttraumatic Stress Disorder

DSM-IV-TR classifies PTSD as an anxiety disorder with the major criteria of an extreme precipitating stressor, intrusive recollections, emotional numbing, and hyperarousal. Individuals at risk for PTSD include, but are not limited to, soldiers and victims of motor accidents, sexual abuse, violent crime, accidents, terrorist attacks, or natural disasters such as floods, earthquakes or hurricanes.7 PTSD has acute and chronic forms. In the general population, the lifetime prevalence of PTSD ranges from 1 to 12 and is frequently comorbid with anxiety disorders, major depressive disorder, and substance abuse disorders with a lifetime prevalence of comorbid disease ranging from 5 to 75 . PTSD is often a persistent and chronic disorder and a longitudinal study of adolescents and youth with PTSD showed that more than one-half of individuals with full DSM-IV-TR PTSD criteria at baseline remained symptomatic for more than 3 years and 50 of those individuals with subthreshold PTSD at baseline...

David S Riggs Shawn P Cahill Edna B

Posttraumatic stress disorder (PTSD) is an anxiety disorder that develops in some individuals following exposure to a traumatic event such as combat, sexual or physical assault, a serious accident, or the witnessing of someone being injured or killed (American Psychiatric Association, 1994). The classification of PTSD as an anxiety disorder reflects the longstanding recognition that anxious arousal plays a prominent role in people who experience pathological responses to trauma. However, research and theory into the nature of PTSD have documented that pathological reactions to trauma incorporate many emotions other than anxiety. Accordingly, in addition to reducing trauma-related anxiety and avoidance, treatments for PTSD are expected to modify other negative emotions such as guilt, shame, depression, and general anxiety. Anxiety has played an especially important role in the development of many treatment programs that target PTSD. These programs tend to focus on reducing or managing...

The Theoretical Foundations For Pe

PE is founded on Foa and Kozak's (1986) theory of emotional processing that explains the pathological underpinnings of anxiety disorders and their treatment by exposure therapy. At its core, the emotional processing theory of exposure therapy rests on two basic propositions (1) anxiety disorders reflect the existence of pathological fear structures in memory, which are activated when information represented in the structures is encountered and (2) successful treatment modifies the pathological elements of the fear structure, such that information that used to evoke anxiety symptoms no longer does so. The process of modifying the pathological elements of the fear structure is called emotional processing. Foa and Kozak further proposed that for therapy to successfully modify the fear structure, the fear structure must be activated and corrective information must be incorporated in to it.

Elevated Plus Maze Tmaze

The EPM is a rodent model of anxiety that has been used extensively in the characterization of both established drugs and new chemical entities for anxiolytic activity.37 It is an ethologically based test that uses nonpainful, nonaversive stimuli to induce fear and anxiety thus reducing the possible confounds of motivational and perceptual states. The test is a modification of the Y-maze test that relies on the propensity of a rodent to spend less time in the open areas of the maze than the closed areas. A typical apparatus is the shape of a 'plus' sign and has two elevated arms, one open and one closed. The center of the maze is an open area, and the animal is placed on this center area at the start of the test. Over the course of a 5 min period, the time the animal spends in either the open or closed areas is recorded. Since rodents have an innate fear of height and openness untreated naive animals spend less time on the open versus closed arms, and anxiolytics like diazepam will...

Fear Potentiated Startle

The startle response is an autonomic, reflexive response that is seen across species.45 It consists of a rapid and sequential muscle contraction that is thought to protect the body and facilitate the flight reaction to avoid a sudden attack. The fear potentiated startle (FPS) test can be used to assess differences in startle reactivity and in both animals and humans is thought to represent a form of anticipatory anxiety. The amplitude of the startle reflex can be augmented in the presence of a cue that has previously been paired with foot shock to provide a conditioned stimulus. A light or visual stimulus can be used as the conditioned stimulus and either sound or air puff to induce startle. The basic training paradigm for the FPS test consists of two phases, conditioning and testing. The conditioning phase includes two sets of rats one set receives light-shock pairings at a fixed interval and the second set receives lights and shock in random pairings. During the testing phase,...

Emotional Processing Theory of Natural Recovery

Although a necessary condition for the development of PTSD, exposure to trauma per se does not inevitably lead to chronic PTSD. Prospective studies of traumatized individuals indicate that PTSD symptoms, general anxiety, depression, and disruption in social functioning are common immediately after the traumatic event. Over the subsequent weeks and months, the majority of individuals recover naturally, with symptoms declining most rapidly during the 1- to 3-month period immediately following the trauma. This pattern of natural recovery has been documented for female rape victims (Atkeson, Calhoun, Resick, & Ellis, 1982 Calhoun, Atkeson, & Resick, 1982 Resick, Calhoun, Atkeson, & Ellis, 1981 Rothbaum, Foa, Riggs, Murdock, & Walsh, 1992), male and female victims of nonsexual assault (Riggs, Rothbaum, Foa, 1995), and victims of motor vehicle accidents (Harvey & Bryant, 1998).

Defensive Test Battery

This test battery is based on rodent unconditioned behaviors such as freezing, hiding, taking flight, defensive threat attack, and risk assessment56,57 with the flight component being thought to relate to panic. NCEs that are clinically effective in treating panic disorder as well as anxiety are effective in this model. The fear defense test battery developed for rats uses a long (6 m) oval runway apparatus with a human experimenter representing the threat stimulus. When the runway is in the oval configuration, rats exhibit flight and escape behaviors changing the runway to a straight alleyway elicits a freezing response. This test is primarily conducted using wild trapped Rattus norvegicus and R. rattus since laboratory bred rats have blunted escape, freezing, and defensive behaviors.58 BZs selectively reduce defensive threat vocalizations while 5HT1A agonists reduce both defensive threat vocalizations and defensive attack while having no effect on flight avoidance or freezing.58-60...

Social Interaction SI Test

The SI test65 was the first ethologically based anxiety model that used natural behavior as a dependent variable. In general, rats are placed together in pairs in a test arena and the time spent interacting with each other (sniffing, grooming, following) is recorded. Environmental manipulations can increase or decrease the amount of time that the rats interact thus allowing for assessment of either anxiolytic (increased interaction) or anxiogenic (decreased interaction) effects of the NCE. The four test conditions are low light, familiar arena (LF lowest level of anxiety) high light, familiar and low light, unfamiliar arena (HU, LU moderate anxiety) and high light, unfamiliar arena (HU highest level of anxiety). To evaluate the anxiolytic effect of compounds, the HU environment is selected while anxiogenic effects can be evaluated using the LF condition. Although this test is relatively easy to set up and run, there are a number of behavioral (single versus grouped housing) and...

Ultrasonic Vocalization USV in Rat Pups

USV is an ethologically relevant anxiety model since it relies on the innate response of rat pups between 9 and 11 days postnatal to emit 35-45 kHz ultrasonic vocalization in response to separation from their mother and littermates.68 Basically, on the day of the study, the pups are separated from their mothers and kept in a warm environment (either home cage or test apparatus) until the NCE is administered. The USV response is assessed via a high-frequency microphone connected to a US signal detection device with data being analyzed to determine the occurrence, frequency, and amplitude of the response.69 Changes in body temperature, motor activity, and respiratory rate can confound USV, so there must be clear evidence that the compound being evaluated does not affect any of these parameters prior to using the USV to evaluate anxiolytic activity.69 BZs (e.g., diazepam), 5HT1A receptor agonists (e.g., flesinoxan, buspirone), and SSRIs (fluvoxamine, chlomipramine) effectively reduce rat...

Financial Considerations

Neurofeedback treatment is administered in 1-hour sessions, 1 to 3 times per week for periods ranging from 3 months to more than 1 year, depending on the nature of the seizure disorder. The cost of treatment varies, but it is usually about 100 per session and is often covered by health insurance under the outpatient mental health benefit of the insurance, especially if the patient suffers from symptoms such as anxiety. Outpatient mental health benefits may have a deductible amount separate from that of the medical benefit. After the patient meets the deductible, the insurance covers from 50 to 80 of the usual and customary fees. The practitioner may charge an initial QEEG and intake consultation fee.

Variations on a Theme Studies of Other Exposure Protocols

Power and colleagues (2002) utilized Marks et al.'s (1998) combined treatment protocol (imaginal and in vivo exposure plus CR), offering patients up to 10 sessions over 10 weeks of exposure therapy or EMDR or wait list. Both active treatments resulted in significant reductions in PTSD severity, anxiety, depression, and functional impairment, and both treatments were superior to the waiting-list condition, which showed very little change. Few differences were observed between the two active treatments, except that EMDR required, on average, fewer sessions (4.2 vs. 6.4) and achieved greater reduction in depression scores. Tarrier et al. (1999) compared an exposure therapy that included only imaginal exposure to CT. Both groups improved significantly from pre- to posttreatment on measures of PTSD, depression, and anxiety, and these improvements persisted through follow-up. There were no differences Bryant, Moulds, Guthrie, Dang, and Nixon (2003a) compared eight sessions of imaginal...

Concerns About Exposure Therapy

More recently, Tarrier et al. (1999) conducted a randomized controlled trial comparing imaginal exposure with CT and reported that overall, the two treatments produced comparable outcomes on measures of PTSD prevalence and severity, anxiety, and depression. However, significantly more participants in the imaginal exposure group (31 ) than in the CT condition (9 ) exhibited symptom worsening at posttreatment. Taken at face value, these data would seem to support concerns about the safety of exposure therapy in the treatment of PTSD. However, several considerations lend doubt to this conclusion. First, the operational definition of symptom worsening was a posttreatment PTSD severity score that was greater than the corresponding pretreatment score by 1 or more points the mean increase in PTSD severity scores was not reported. Given that an increase of just 1 point is within the measurement error of the instrument (CAPS), this definition may not reflect actual symptom worsening (for an...

The CRF hypothesis and stress

CRF is synthesized in the hypothalamus and elicits the release of adrenocorticotropic hormone (ACTH) from the pituitary. CRF was isolated from sheep hypothalamus and its structure as a 41-amino-acid peptide determined.96 The hypothalamic paraventricular nucleus (PVN) is the major region in the brain of CRF-containing cell bodies and through axonal projections to the capillaries of the median eminence can secrete CRF directly into the portal system where it acts at the pituitary to regulate ACTH secretion into the circulation. The principal role of ACTH is to stimulate the release of cortisol from the adrenal gland, thus completing the HPA axis, a primary component of the neuroendocrine response to stress. Similarly, projections from the PVN to the lower brainstem and spinal cord have been demonstrated to regulate autonomic function and help to further mediate the behavioral responses to stress. High densities of CRF-containing neurons are localized in particular to prefrontal,...

Subtype Selective GABAa Receptor Modulators

As noted, BZs have been the primary treatment for anxiety for nearly half a century. Despite their proven efficacy and rapid onset of action, their use is limited by side effects, e.g., sedation and amnesia, the development of tolerance, and concerns about dependence and withdrawal.82'102 These side effects are a natural extension of their mechanism of action. Considerable effort has been expended over the past three decades to discover and develop novel, anxioselective BZ ligands that have improved side effect profiles.

Approaches to anxioselective GABAa receptor modulators

Two approaches have been taken in the pursuit of improved anxiolytic compounds acting via the BZ receptor. Compounds with partial efficacy as positive allosteric modulators could elicit anxiolytic effects with a reduced propensity for sedation and amnesia. This approach assumes that only a limited degree of GABAA receptor potentiation is required to produce anxiolysis, whereas a greater potentiation is necessary to produce side effects. The second approach is focused on developing a positive allosteric modulator selective for a2- (and or a3-) subunit-containing GABAA receptors that would be anxiolytic lacking the sedative, amnestic, and tolerance properties of classical BZ ligands. These two approaches are not mutually exclusive and a compound with combined subtype selectivity and partial efficacy may be a superior anxiolytic. The challenge of finding such compounds has been such that no anxioselective BZs have advanced to the market.82,102,111

Metabotropic Glutamate Receptors

G protein-coupled receptors for glutamate, metabotropic glutamate receptors (mGlu), play a diverse modulatory role in neurotransmission and are potential targets for novel anxiolytic drugs.124 The eight known mGlu receptors are divided into three families, group I (mGlu15), group II (mGlu23) and group III (mGlu ), based on structure, pharmacology, and signal transduction. The focus for anxiolytics has been on group I and II mGlus, although data from mGlu7 and mGlu8 knockout mice suggest that group III receptors may also be relevant for altered anxiety and stress responses.

Group II mGlu agonists

MGlu2 and mGlu3 are expressed in brain areas important for anxiety disorders, e.g., amygdala, hippocampus, and prefrontal cortex. mGlu2 receptors are located on glutamate-releasing nerve terminals where they suppress glutamate release, whereas mGlu3 is found both pre- and postsynaptically, and on glia. Activation of group II mGlus also suppresses the release of GABA, monoamines, and neuropeptides.125 The constrained glutamate analogs LY354740 and MGS 0028 (Figure 11a) are potent, selective agonists of mGlu2 and mGlu3 receptors.124,126 Systemic administration of LY354740 produces anxiolytic effects in a range of animal models, including fear potentiated startle, EPM, and conflict tests. Where compared, the anxiolytic effects of these compounds are similar to those for standard BZs, but occur in the absence of sedation or ataxia. LY354740 may, however, disrupt memory processes in animals,127 although the compound reduced ketamine-induced deficits in working memory in humans.128 LY354740...

Group I mGlu antagonists

MGlu1 and mGlu5 have reciprocal distributions in the brain and are located predominantly postsynaptically where they are thought to augment neurotransmission. Antagonists of both mGlu1 and mGlu5 have shown anxiolytic activity in animal models.124 For mGlu1 antagonists, the glutamate analog AIDA (Figure 11c) and the allosteric antagonist JNJ16259685 are both effective after systemic administration in the Vogel test, and positive results were also reported for AIDA in the EPM and open field, but not the four-plate test.131,132 The mGlu5 allosteric antagonist MPEP was efficacious in fear-potentiated startle, EPM, conflict tests, and stress-induced hypothermia with systemic administration,124,133 as was the analog MTEP (Figure 11c).134 In general, anxiolytic effects were observed without sedation however, group I mGlu receptors are involved in learning and memory processes, consequently blockade of mGlu1 and mGlu5 may be problematic in this respect. Fenobam (Figure 11c), a drug...

Melanin Concentrating Hormone

The expression pattern of melanin-concentrating hormone (MCH) neurons and receptors in the CNS support a potential role for MCH in a variety of physiological functions including stress, regulation of neuroendocrine processes, and feeding. Of these functions, MCH effects on feeding behavior and energy homeostasis have been most studied,156 but MCHR1 antagonists may be a novel approach to the treatment of anxiety. MCH cell bodies are located in the lateral hypothalamus and zona incerta with widespread projections to limbic structures such as hippocampus, septum, amygdala, locus coeruleus, dorsal raphe nucleus, and the shell of the nucleus accumbens, areas that are involved in the regulation of emotion.157 The MCHR1 nonpeptide antagonists ATC-0065 and ATC-0175 (Figure 12c) reverse swim stress-induced anxiety in the EPM in rats and decrease temperature change in the stress-induced hyperthermia model in mice.158 ATC-0175 also increased social interaction between unfamiliar rats and...

Dissemination Of Pe For Ptsd

Over the last several years we have trained many professionals from various disciplines in workshops lasting from 2 hours to 5 days. Clinicians commonly report that they are attracted by the efficacy and efficiency of exposure therapy and are interested in using it with patients who have PTSD. However, they are also worried about being able to properly implement it without further assistance, and we strongly believe that few of these clinicians actually end up using PE in their practices. Although an extended workshop (e.g., 3-5 days) may be adequate for training clinicians who have a background in CBT and experience in utilizing exposure therapy with other disorders (e.g., phobias, panic disorder, obsessive-compulsive disorder), therapists trained in other models of psychotherapy (e.g., psychodynamic,

Model I Intensive Initial Training of Therapists Plus Ongoing Expert Supervision

In the first step of dissemination, Center for the Treatment and Study of Anxiety (CTSA) experts provided the community therapists with a 5-day intensive workshop that included an introduction to the theory and efficacy data supporting the use of PE in the treatment of PTSD as well as instruction Participants were recruited through the CTSA and the community agency and were randomly assigned to PE, PE CR, or waiting-list (WL) conditions at each location. Like the community therapists, CTSA therapists participated in weekly supervision meetings that included discussion about ongoing cases and the viewing of videotapes of therapy sessions. Indeed, the supervision established at the community agency was modeled after our standard supervision practices at the CTSA. As noted in the section on the efficacy of PE, the results from this study revealed that both treatments resulted in greater reductions in symptoms of PTSD, anxiety, and depression than the WL condition and that both treatments...

Measurement of symptoms

Symptoms of hypoglycaemia were first reported in relation to tumours of the pancreas (Wilder 1927). As early as 1927, the symptoms of hypoglycaemia were recognised as forming two groups the first occurring during mild reactions comprising anxiety, weakness, sweating, hunger, tremor and palpitations and the second more severe group including mood changes, speech and visual disturbances, drowsiness, convulsions and coma (Harrop 1927). It was also noted that some patients did not experience the usual symptoms of hypoglycaemia until their blood glucose had reached much lower concentrations (Lawrence 1941). Symptom profiles provoked by hypoglycaemia are idiosyncratic and vary in character, pattern and intensity between individuals and even within individuals over time (Pennebaker et al. 1981).

Pain Measurement by Methods Other Than Self Report

One of the formal behavioral observation tools is the Gauvain-Piquard scale developed for the measurement of chronic pain in children 2-6 years old with cancer. Fifteen items have a 0-4 scale with nine items specific to pain assessment, six indicative of psychomotor retardation, and four relating to anxiety are included in the revised version. A score greater than 12 of a possible maximum score of 60 is indicative of pain (22).

Cognitive Models Of Ptsd

Information-processing theory has been widely used to understand the development and maintenance of anxiety disorders, including PTSD (Lang, 1979, 1985). This theory suggests that emotions, such as fear, are encoded in memory in the form of networks, where representations of anxiety-provoking events are stored. Fear networks are hypothesized to contain three important types of information (1) information about the feared stimuli or situation (2) information about the person's response to the feared stimuli or situation and (3) information about the meaning of the feared stimuli and the consequent response. Foa and Kozak (1986) posited that the fear networks of individuals with PTSD differ from the fear networks of individuals with other anxiety disorders in three ways. First, the fear network of individuals with PTSD is larger because it contains a greater number of erroneous or inaccurate connections between stimulus, response, and meaning elements. Second, the network is more easily...

Communication Guidelines

Various guidelines for risk counselling are now available (Richards et al. 1995 Eisinger et al. 2004). A multistep process has been proposed (Julian-Reynier et al. 2003), starting with assessment of the counselee's preconceptions, knowledge, preferences, expectations, anxiety and coping style in order to tailor the risk communication process. The information to be given to the counselee (risk, magnitude, uncertainty, for

Transfection of GABAa Receptor Subunit EGFP Constructs in HEK Cells

The presence of specific subunit in the GABAA receptor complex determines selective pharmacological regulation by distinct pharmacological agents (11). Zinc has been widely used as a selective agent to determine the presence of the y2 subunit in the receptor channel complex (11). Figure 2B illustrates that currents elicited by ionophoretical application of GABA were blocked by ZnCl2. Among the distinct pharmacological agents that regulate GABAA receptor, the benzodiazepines and neurosteroids have a better characterized structural requirement in term of subunit composition (11). In Figure 2C, we illustrate GABA-activated currents in a HEK cell transfected with a1 3 and y2-GFP cDNAs. The allosteric modulator Zolpidem potentiated considerably the response to ionophoretically applied GABA, demonstrating that the benzodiazepine recognition site was not affected by the GFP tether on the y2 subunit. Coexpression of 5-GFP tandem strongly reduced the potentiation by the neuros-teroid THDOC...

How to Work with Your Doctor

When I was growing up, doctors behaved very differently from the way they do today. For one thing, they went out of their way to suppress information about alternative diagnoses, risks of treatment, and prognoses. They did this because they felt that part of their job was to shoulder the anxiety related to these sometimes horrible possibilities and conceal them from the patient and patient's family. When a fatal outcome was likely, telling the patient was taboo. Some physicians are still made uneasy by patients who read up on their disease and or proposed treatments and come to the office with a lot of difficult questions, or worse yet, with specific demands, for example, for specific drugs they have seen advertised. Patients want to trust their doctors, and to leave the anxiety to the doctor. But patients need to know that all of the possibilities have been taken into consideration, that their doctor is completely informed, and most of all, that he or she is really concerned about...

Frontotemporal Lobar Dementias

A selective degeneration of the frontal and temporal lobes is the distinctive feature of a group of dementias estimated to comprise 15 to 20 of all dementia cases. Frontotemporal lobar dementias (FTLD) are not common, but their incidence is increasing as more cases are recognized. Individuals from early to late midlife are affected, and the clinical course averages from 5 to 15 years. Most diseases are sporadic, but familial examples with autosomal dominant inheritance also have been identified. The clinical presentation varies greatly among the diseases but all share neuropsychiatric symptoms, cognitive decline, and neurologic disorders. Neuropsy-chiatric symptoms in various combinations are usually in the foreground of the clinical picture, including behavioral and personality changes, emotional lability, depression, anxiety, restlessness, agitation, social disinhibition, and lack of initiative, planning, organizing (executive functions), insight, and judgment. Adding to the...

Pain and its alleviation monitored by the neuroscience portfolio

Non-invasive brain imaging in human subjects To date, fMRI has revealed key brain areas (e.g., cingulate, insula, somatosensory, and motor cortices, the thalamus and basal ganglia) activated during the experience of pain, as shown in Fig. 3, (Peyron et al., 2000 Tracey et al., 2002a). This technique has also highlighted additional regions, such as the hippocampus (Ploghaus et al., 2001), which will contribute to states of anxiety that in turn exacerbate pain sensation. By the same token, other areas, such as the periaqueductal gray (PAG),

Utility of Electroencephalographic Techniques in Substance Abuse Research

Another type of acute drug effect on the EEG is a dissociation between EEG activity and behavior. During normal control states, behavioral alertness is usually accompanied by EEG desynchrony whereas behavioral sedation is usually accompanied by EEG synchrony. Examples of drug-induced dissociation are atropine-induced EEG synchrony accompanied with behavioral alertness (Longo, 1966) and reserpine-induced behavioral sedation accompanied by EEG desynchrony (Pscheidt et al., 1963). A third type of a drug-induced EEG change is an attenuation or stabilization of the normal fluctuations between the various stages of wakefulness such as phenobarbital-induced (Vastola and Rosen, 1960) and benzodiazepine-induced (Requin et al., 1963) stabilization of spontaneous EEG spikes.

Mary Ann Cohen and David Chao

Comprehensive psychiatric evaluations can provide diagnoses, inform treatment, and mitigate anguish, distress, depression, anxiety, and substance use in persons with HIV and AIDS. Furthermore, thorough and comprehensive assessment is crucial because HIV has an affinity for brain and neural tissue and can cause central nervous system (CNS) complications even in healthy seropositive individuals. These complications are described in Chapters 10, 17, and 19 of this book. Because of potential CNS complications as well as the multiplicity of other severe and complex medical illnesses in persons with HIV and AIDS (Huang et al., 2006), every person who is referred for a psychiatric consultation needs a full biopsychoso-cial evaluation. In this chapter, we provide a basic approach to persons with HIV and AIDS who are referred to an AIDS psychiatrist and a template for a comprehensive psychiatric evaluation. Neuropsycho-logical evaluation can be a valuable adjunct in some persons with HIV and...

To Communication Style

Various skills should be considered when communicating cancer genetic information or test results, such as the counsellor's sensitivity to individual and cultural differences, the language used (avoiding medical jargon), the ability to provide emotional support, and the counsellor's own anxiety level, which has been found to be inversely correlated with the counselee's capacity for understanding (Lobb et al. 2001). Butow and coworkers (2004) highlighted that increased use of supportive and counselling communications increased anxiety about cancer, suggesting that emotional issues may be raised without adequate resolution. It may be helpful for consultants to be able not only to assess psychological stress, but also to keep checking how the woman is coping during the consultation and to provide adequate support.

Overview of Treatment Approach

(4) emotion dysregulation (both heightened and inhibited emotional experiencing, specifically related to anxiety fear, anger, sadness, shame guilt) and Exposure is used frequently in stage II, both formally and informally. By formal exposure we are referring to a structured protocol for treating a particular disorder, such as panic disorder (e.g., Barlow & Craske, 1994) or PTSD (e.g., Foa & Rothbaum, 1998). Formal exposure is appropriate for the treatment of target problems that can be conceptualized similarly to the formulations upon which these treatments are based (e.g., when panic disorder can be conceptualized as a conditioned response to interoceptive cues that is maintained by avoidance or when PTSD can be conceptualized as overgeneralized conditioned responses that are maintained by cognitions and avoidance). In such cases, these protocols are embedded within the structure of the treatment (this is why DBT is referred to as a principle-driven treatment that includes...

Diseases with Akinetic Rigidity Idiopathic Parkinsons Disease

Combinations of extrapyramidal disorders and auto-nomic dysfunctions, frequently accompanied by neuro-psychiatric symptoms, define the disease. The cardinal motor symptoms are cogwheel rigidity of muscle tone, bradykinesia akinesia, postural instability, and pill-rolling tremor at rest. A stooped posture, shuffling and festinating gait, lack of facial expression, micrographia, weak monotonous speech, and dysphagia are additional characteristic features. In some patients, akinetic-rigidity predominates in others, resting tremor. Characteristic autonomic dysfunctions include orthostatic hypotension, seborrhea, sialorrhea, hyperhydrosis, constipation, bladder disorder, sleep disorder, and, rarely, sexual dysfunction. Anxiety, depression, psychosis, hallucination, and cognitive decline may emerge at any time during the course of the disease, which ranges from 10 to 20 years. No specific diagnostic tests are available. PET and SPECT show diminished striatal dopamine uptake.

Sexually Transmitted Infections

Some centers prescribe antibiotic prophylaxis for all complainants of penile penetrative sexual assaults at the time they present (6,207,208). The use of antibiotic prophylaxis reduces the need for repeated examinations, avoids the anxiety incurred in waiting for the results, and is acceptable to the majority of women to whom it is offered (209). Antibiotic prophylaxis should cover the prevalent, treatable organisms in the local population, and advice should be sought from the local center for disease control regarding an appropriate regimen.

Communication in the Family

Blandy and coworkers (2003) showed that results of BRCA tests were generally adequately transmitted to the family difficulties of transmission, however, correlated with a poorer understanding and a higher level of anxiety and avoidance. First-degree relatives were most frequently informed about the test results, but they only rarely requested genetic testing, which was essentially requested by sisters and daughters. The quality of family support and the level of understanding of the risk of transmission were positively and significantly correlated with the decision to perform the test in first-degree relatives.

Process of Psychiatric Outpatient Consultation

Patient's medical history and current condition as well as what medications are being prescribed for the patient. The psychiatrist can review the medical record in further detail. Ideally, if the patient is in the clinic for a scheduled visit with the HIV clinician when the AIDS psychiatrist is available, an introduction by the HIV clinician may prove invaluable and demonstrate the level of coordination of care being offered to the patient. The AIDS psychiatrist can be introduced as an integral member of the multidisciplinary team providing ongoing patient care. The HIV clinician can then discuss his or her concerns about the patient and the reasons for the psychiatric consultation. This open discussion by a sensitive and caring clinician with the psychiatric consultant in the presence of the patient can lead to better acceptance of the referral and set the stage for a continued collaborative relationship. It also serves to diminish anxiety in the patient and perhaps even serves to...

Comprehensive Outpatient Psychiatric Consultation

When the patient arrives for the first visit, the AIDS psychiatrist can set the tone for a nonjudgmental evaluation by starting with an introduction that is sensitive to the patient's potential anxiety surrounding the encounter. Suggestions for such an introduction include greeting and shaking hands. Shaking hands is especially important for persons with HIV and AIDS who are exquisitely sensitive to others' fears of contagion and may be reassured by a warm handshake. The introduction includes the AIDS psychiatrist addressing the patient by his or her title and last name (Mr. A), stating his or her title and last name (Dr. P), and accompanying the patient from the waiting area into the psychiatric consulting room. After closing the door to establish privacy and providing for appropriate seating and comfort, the psychiatrist asks the patient ''How are you feeling today '' After listening to the response and following leads if applicable, the psychiatrist then describes the reason for...

Pharmacology Of Alcohol

More important than the disruption of the cell membrane is the effect of alcohol on the gamma-aminobutyric acid (GABA) system and glutamate system of the brain. The brain has three types of GABA receptors A, B, and C. GABA A receptors are the targets for alcohol, benzodiazepines, barbituates, and neurosteroids. Stimulation of the GABA receptor by the binding of these compounds causes an ion channel to open temporarily and emit chloride ions into the cell. Alcohol enhances the influx of chloride ion, and the result is sedative and anxiolytic effects. Chronic use of alcohol down-regulates the GABA system, and the neuron eventually becomes dependent on alcohol to enable GABA to function. If alcohol is withdrawn, the opening of the chloride ion channel fails, because GABA is no longer capable of performing the task secondary to the cell, having adapted to the role of alcohol. Thus, the cell becomes hyperexcitable, leading to irritability, insomnia, hypertension, tachycardia, and possibly...

Guidelines for Client Selection

ACT can be used with a variety of clients and clinical presentations, with no specific limitations to its use. However, it is most useful when applied with clients who are assessed to be emotionally avoidant and or cognitively fused, have chronic conditions, or who have multiple treatment failures. ACT has been demonstrated to be effective when used in the treatment of PTSD (Follette et al., 1993 Walser, Loew, Westrup, Gregg, & Rogers, 2003a Walser, Westrup, Rogers, Gregg, & Loew, 2003b Batten & Hayes, 2005), anxiety and stress (Bond & Bunce, 2000 Twohig & Woods, 2004 Zettle, 2003), substance abuse dependence (Gifford etal., 2004 Hayes etal., 2002), coping with positive psychotic symptoms (Bach & Hayes, 2002), chronic pain (Dahl, Wilson, & Nilsson, 2004 McCracken, Vowles, & Eccleston, 2004), stigma and prejudice in drug abuse counselors (Hayes et al., 2004a), depression (Folke & Parling, 2004 Zettle & Hayes, 1986 Zettle & Raines, 1989), self-management of diabetes (Gregg, 2004), and a...

Cardiovascular Toxicity

Hypertension O2, benzodiazepines for sedation, vasodilatation with rapidly acting peripheral vasodilators-phentolamine, nitrogylcerine (NTG), and sodium nitroprusside (SCN). Pulmonary edema O2, furosemide, morphine sulfate (MS), NTG. Angina O2, benzodiazepines (BZs), MS, acetyl-salicylic acid (ASA), NTG, CCBs, (verapamil diltiazem), avoid beta-blockers.

Meditation as an Intervention in Epilepsy

Excellent studies by Sterman, beginning in the 1970s (27), suggested and then proved that by modifying one's own specific EEG rhythm using EEG biofeedback, uneven brain wave activity in epilepsy could be enhanced and the seizure threshold raised (28). Thus, meditation and biofeedback can have a normalizing influence on EEG patterns. Later findings, however, confirmed that these EEG abnormalities could also be reduced using antiepileptic medication.

The Causes Of The Clinical Effects Of Trauma

Other kinds of single-event traumas, such as rape, could also fit into this model. That is, the rape plus all of the previously neutral circumstances surrounding it would produce intense emotional arousal, via classical conditioning. The attempts to avoid stimuli that would produce the arousal, such as not approaching any aspect of the situation in which the rape occurred, could also cascade into a secondary set of life problems related to the avoidance strategy employed to reduce the anxiety incurred by the rape trauma.

General Appearance Manner and Attitude

It is also important to determine whether the patient appears his or her stated age and, if the patient is working, whether he or she is appropriately attired for the occupation. Observing for relational ability, eye contact, handshake, and ability to engage is also significant. The patient's cooperativeness, hostility, depression, anxiety, and fear should be noted.

Treatment For Circumscribed Ptsd And Empirical Support

Three necessary conditions and one highly desirable one must be met before this kind of exposure-based treatment can begin. First, the evocative stimuli must be known and specifiable. That is, the clinician must know what the evocative stimuli are before a method for exposure can be devised. Second, the client must be cooperative. That is, the client must be willing to talk about the trauma and tolerate a certain amount of anxiety by agreeing to place him- or herself in the presence of the evocative stimuli. Third, the therapist must also be willing to hear about the trauma and potentially experience emotional arousal as a part of the treatment. Finally, it is highly desirable that the evocative stimuli be presented in vivo. That is, it is always best when the evocative stimuli be presented in a real form rather than via talk or imagination (Goldfried, 1985).

The Foundation And Ascendance Of Affective Science

Darwin (1998) demonstrated the importance and function of affect, and Freud offered a theory about the place of affect in human psycho-pathology. The emphasis on repressed affect as a source of anxiety and symptom formation laid the foundation for today's affective science. The importance of affective functioning was emphasized by Silvan Tomkins (1962, 1963, 1991) who advanced our understanding of the central-ity of emotional experience (Ekman & Davidson, 1994). For the most part, however, The topic of emotion was downplayed until the 1960's, a decade characterized by the advent of neobehav-iorism and social learning theory, a movement toward cognitivism, and greater interest in systems theory (Lazarus, 1991, p. 40). Neuroscien-tists have also recognized the importance of emotion in understanding consciousness and brain structuralization and organization. Emotion primes the neuronal networks and assists in learning. We have come to understand why the

Collaborative Client Therapist Relationship

As stated above, avoidance is one of the sequelae of traumatic conditioning. If the client were completely avoidant, however, it would be impossible to do exposure treatment because he or she would avoid evocative stimuli. If forced to be physically present with the evocative stimuli, the client would use other forms of avoidance such as tuning out or dissociation. In fact, complete avoidance could lead the client to not talk about, or even remember, the traumatic conditioning. In this latter case, the client might seek treatment for problems but would not attribute the symptoms to the trauma or focus on it. A client with total avoidance of traumatization by a fire, for example, might seek treatment for other issues and if asked if he or she had ever experienced a trauma, would not recall the experience and thus would be unable to report it. Thus the willingness of the client to tolerate the anxiety and to remember and talk about the trauma is necessary for a successful exposure...

Studies in MS and Other Conditions

Guided imagery has not undergone extensive investigation in multiple sclerosis (MS). One study conducted in Pennsylvania evaluated the effects of imagery and relaxation techniques in 33 people with MS (1). For imagery, people were instructed to imagine the repair of injured myelin and beneficial immune system activity. People who practiced daily imagery along with relaxation experienced less anxiety and produced more active and powerful images of their disease process. No effect of imagery and relaxation was noted on depression or specific MS-associated symptoms. Studies in other conditions indicate that imagery may improve anxiety and pain, including cancer-related pain, postoperative pain, and headache.

The Relationship between Exercise and Seizures

Deep breathing, or hyperventilation, is used to activate abnormal discharges (epileptiform activity) in the brain during an electroencephalogram (EEG). This provocative measure is particularly useful to diagnose absence epilepsy of childhood, a condition characterized by brief staring spells with a stereotyped, corresponding EEG abnormality (3-Hz spike and wave). The ability to activate seizures and EEG abnormalities through hyperventilation infers a potential risk of seizures from increased respirations during strenuous exercise in patients with epilepsy. Esquivel and his colleagues studied this in patients with childhood absence epilepsy and concluded that hyperventilation and strenuous exercise are not the same. Seizures and EEG abnormalities increased during hyperventilation in these children, but seizures did not occur when the children exercised (9). The authors concluded that children with this type of epilepsy should not be discouraged from exercising.

Do Not Panic

Do Not Panic

This guide Don't Panic has tips and additional information on what you should do when you are experiencing an anxiety or panic attack. With so much going on in the world today with taking care of your family, working full time, dealing with office politics and other things, you could experience a serious meltdown. All of these things could at one point cause you to stress out and snap.

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