Anxiety and Panic Disorders Holistic Cure

Panic Away Program

The author of the Panic Away program, Barry began his research studying books on psychology, but he was not so happy with what he found there. The method described promise to teach people to get rid of the panic attacks and anxiety permanently, but they just teach methods for managing it. This new version, that includes videos of that women Jane experiencing Panic attacks and video demonstration of her using the one move technique is helping a lot more people. Various people have experienced awful success in either decreasing or eliminating the severity of their panic attacks. His technique is claimed to treat panic disorders within few minutes. With video presentations for people that prefer to learn by watching and listening rather than reading a book, members forum with caring and supportive environment where experienced people are on hand to help others achieve their goals and unique audio recordings the Panic Away course can be a great solution for most of the people that suffers from panic and anxiety. More here...

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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 interventions to...

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.

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...

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...

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...

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...

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.

Psychiatric Disorders 601411 Schizophrenia

Sedative, hypnotic, or anxiolytic related disorders Sedative, hypnotic, or anxiolytic use disorders Sedative, hypnotic, or anxiolytic induced disorders Anxiety disorders Panic disorder without agoraphobia Panic disorder with agoraphobia Social phobia Obsessive compulsive disorder Generalized anxiety disorder Anxiety Anxiety disorders (see 6.04 Anxiety) are characterized by an abnormal or inappropriate wariness. There are several disorders that fall under the heading of anxiety including panic disorders, phobias, generalized anxiety disorder (GAD), acute stress disorder, and posttraumatic stress disorder (PTSD). Panic disorder is characterized by rapid and unpredictable attacks of intense anxiety that are often without an obvious trigger. Phobias are examples of life-disrupting anxiety or fear associated with an object or situation, including social phobias. GAD develops over time and involves the generalization of fears and anxieties to other, usually inappropriate...

Tools For Traumarelated Problems

Central to approaches that focus on reduction of posttraumatic fear reactions is exposure therapy. Prolonged Exposure (PE) treatment is the most well-validated psychosocial treatment for PTSD. As described by Riggs, Cahill, and Foa in Chapter Four, it focuses on reducing trauma-related anxiety by encouraging the client to confront situations, activities, thoughts, and memories that are feared and avoided but that are not inherently dangerous. Treatment incorporates four primary procedures education about trauma and PTSD, breathing retraining, in vivo or real-world exposure to feared but safe trauma-related situations that the client normally avoids, and imaginal exposure in which the client repeatedly describes memories of the traumatic event.

Visual Loss of Uncertain Origin Diagnostic Strategies

The practicing ophthalmologist faces a common challenge on a daily basis A patient's vision is worse than was expected, based on the appearances of the initial examination. Usually, a renewed and more careful examination explains the discrepancy. Often, however, additional examination finds nothing to explain the conflicting findings. Time is limited, and one is tempted to refer the patient to a neurologist or another ophthalmic service. The diagnostic modalities available at the next site often lead to an unguided attempt at diagnosis when it is felt that some sort of explanation for the visual loss must be found. This scenario can be both expensive and dangerous, subjecting the patient to a random wandering through neurodiagnostic procedures. At the end of this process, the patient is unsatisfied and anxiety ridden and returns to the ophthalmologist or seeks the counsel of other physicians or even alternative medicine practitioners. If the ophthalmologist wishes to find the correct...

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...

Origins Of Drug Liking

For example, opioids and cannabinoids can inhibit activity in N-Ac directly, whereas stimulants such as cocaine and amphetamine act indirectly by binding to various DA transporters and either inhibiting the reuptake of DA into the VTA neurons (cocaine) or actively pumping DA out of the VTA (amphetamine) at its synapse with the N-Ac neurons (Kosten, 2002 Stahl, 1998). Since stimulation of the DA D2 receptor inhibits the cyclic AMP system, this increase in DA in the synapse leads to relative inhibition of the N-Ac neuron. The mechanism is more complex than this, however, since the D1 receptor has the opposite effect on the cyclic AMP system (e.g., it increases the amount of cyclic AMP) and both D1 and D2 receptors are present on the N-Ac neurons. The presumption is that the D2 receptor effects predominate perhaps simply due to more D2 receptors, or due to a higher affinity of the D2 than the Dt receptors for DA. Other substances may be even more indirect in their stimulation. For...

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

Psychophysical Studies Of Visceral Sensation

Depression, anxiety, and hypervigilance have identified differences between the clinically diseased populations and their associated healthy controls (17,25). As a consequence, dissociating potential psychological modifiers of sensory reports from other, more neuro-physiological pathologies has proved to be a difficult and at sometimes insurmountable methodological problem.

Dsmivtr Classification And Diagnostic Codes

The DSM-IV-TR Classification of Mental Disorders refers to the comprehensive listing of the official diagnostic codes, categories, subtypes, and specifiers (see below). It is divided into various diagnostic classes that group disorders together on the basis of common presenting symptoms (e.g., mood disorders, anxiety disorders), typical age at onset (e.g., disorders usually first diagnosed in infancy, childhood, and adolescence), and etiology (e.g., substance-related disorders, mental disorders due to a general medical condition).

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.

First Generation Typical Antipsychotic Drugs

The serendipitous finding in 1951 that the major tranquilizer, chlorpromazine 1, was effective in treating delusions and hallucinations associated with schizophrenia and other psychotic disorders marks the beginning of modern therapy for schizophrenia.3 Unfortunately, treatment with chlorpromazine was accompanied by the development of EPS, some appearing even after the first dose (e.g., dystonias, akathisia). Other adverse effects were delayed for days or weeks such as parkinsonism, and the sometimes fatal neuroleptic malignant syndrome. Tardive dyskinesia, characterized by abnormal involuntary movements of the tongue, facial muscles, or limb muscles, develops in about 20 of patients and may be irreversible. Chlorpromazine also increased prolactin secretion leading to gynecomastia, galactorrhea, menstrual irregularities, sexual dysfunction, and possibly bone loss over the long term. Sedation, hypotension, and weight gain were also common with chlorpromazine. Despite these concerns,...

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...

Anticipated Challenges And Achievements

Another important classification consideration on the horizon is whether or not acute stress disorder (ASD) and PTSD should be classified as anxiety disorders. Evidence supporting abandonment of the anxiety disorder placement indicates that a myriad of emotions, including guilt, shame, disgust, anger, and sadness, have been implicated in preventing recovery from posttraumatic symptoms (Resick, 2001). Moreover, Pitman (1993) has argued that the pathophysiology of arousal in posttraumatic reaction is not simply anxiety. The International Statistical Classification of Diseases, Injury, and Causes of Death-10th Edition (ICD-10 World Health Organization WHO , 1992) does not classify PTSD as an anxiety disorder rather, it is categorized within the spectrum of reactions to severe stress, and adjustment disorders, with the common denominator of stress-related precipitation. A recent taxometric study also buttresses the dimensional versus categorical system of trauma-related diagnoses (Ruscio,...

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...

Asian Proprietary Medicine or Asian Patent Medicine

Several studies of the chemical composition of these preparations have found that they frequently contain potentially toxic ingredients. Recent data indicate that approximately one-third of these products contain drugs or dangerous metals. Drugs that have been found include diazepam (Valium), steroids, and prescription asthma medications. Toxic metals sometimes found in these products are arsenic, mercury, lead, and cadmium.

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.

Neurogenesis creation of new neurons critical to antidepressant action

The seminal studies by Duman and co-workers14 on neurogenesis may help to explain why antidepressants typically take a few weeks to have an effect and may indicate why a rapid-acting antidepressant may not be a viable propositition.14 These workers created a strain of 5HT1A'knockout' mice that as adults show anxiety-related traits, such as a reluctance to begin eating in a novel environment. While unaffected by chronic treatment with the SSRI fluoxetine, the mice became less anxious after chronic treatment with TCAs that act via another neurotransmitter, NE, suggesting an independent molecular pathway. While chronic fluoxetine treatment doubled the number of new hippocampal neurons in normal mice, it had no effect in the knockout mice. The tricyclic imipramine boosted neurogenesis in both types of mice, indicating that the 5HT1A receptor is required for neurogenesis induced by fluoxetine but not imipramine. Chronic treatment with a 5HT1A-selective drug confirmed that activating the...

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

Suicidality in children and adolescents being treated with antidepressant medications

The suicidality risk associated with these agents was identified in a combined analysis of short-term (up to 4 months) placebo-controlled trials of nine antidepressant drugs, including the SSRIs among others, in children and adolescents with MDD, obsessive compulsive disorder (OCD), or other psychiatric disorders. A total of 24 trials involving over 4400 patients was included.32 The analysis showed a greater risk of suicidality during the first few months of treatment in those receiving antidepressants. The average risk of such an event on drug was 4 twice the risk on placebo (2 ). No suicides occurred in these trials. Based on these data, the FDA has determined that the following points are appropriate for inclusion in the boxed warning

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...

Why the Andrews Reiter Treatment Was Developed

Many individuals with epilepsy continue to experience seizures despite the best efforts of their neurologists. Antiepileptic drugs (AEDs) either do not control their seizures, lead to side effects, or both. Even if seizures are controlled, many patients experience fear, anxiety, and feelings of hopelessness that significantly impair their quality of life. Brain surgery is an option for some with uncontrolled seizures, but many do not want to risk possible injury from surgery others have seizures caused by bilateral or extensive unilateral brain damage that cannot be helped by brain surgery. The A R approach was developed to help individuals with these types of seizure disorders.

Studies in MS and Other Conditions

Symptoms of MS that have been investigated in some aromatherapy research are anxiety, depression, pain, and insomnia. For anxiety, studies of variable quality indicate that beneficial effects may be obtained with the use of lavender oil, Roman chamomile oil, and neroli (orange) oil. However, no large, well-designed clinical studies have examined this antianxiety effect. Preliminary information suggests that a lower dose of antidepressant medication may be needed by depressed men when the medication is used in combination with aromatherapy using a citrus fragrance. Lavender in bath water does not appear to relieve childbirth-associated pain. Positive and negative results have been obtained in other studies of aromatherapy and pain. Several fragrances, especially lavender, have been evaluated in sleep studies in animals and humans. Some positive results have been reported, but these studies are of variable quality.

Selective norepinephrine reuptake inhibitors

SNRIs are a class of antidepressants characterized by a mixed action on both major monoamines of depression NE and serotonin. In essence, SNRIs are improved TCAs with less off-target activity, e.g., muscarinic, histaminic and -adrenergic receptors, and MAOI. The combination of inhibition of 5HT and NE uptake confers a profile of effectiveness comparable to TCAs and is reported to be higher than SSRIs, especially in severe depression. SNRIs are purported to be better tolerated than TCAs and more similar to SSRIs without the associated sexual dysfunction seen with the latter. Venlafaxine (38) and milnacipran (4) have been approved so far, and several others are in development. They are active on depressive symptoms, as well as on certain comorbid symptoms (anxiety, sleep disorders) frequently associated with depression. SNRIs appear to have an improved rate of response and a significant rate of remission, decreasing the risk of relapse and recurrence in the medium and long term and...

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...

Neuropeptide approaches

SP is an 11 amino acid peptide belonging to the tachykinin family it mediates its biological actions through G tachykinin (NK1) receptors. Evidence to support a major role of the NK1 receptor system in stress-related behaviors has guided the clinical development of several NK1 receptor antagonists, including aprepitant (MK-869 72), lanepitant (73), dapitant (74), vestiptant (75), PD-174424 (76), and NBI 127914 (77). The antidepressant efficacy of the first NK1 receptor antagonist MK-0869 (Aprepitant 72) was demonstrated in patients with major depression and high anxiety, and has recently been replicated with a second compound, L759274. Aprepitant improved depression and anxiety symptoms in a quantitatively similar manner to SSRIs. However, it failed to show efficacy in Phase III clinical trials for depression.11,57 NK2 receptor ligands (e.g., NKP 608 (78), GR159897 (79)) are also under investigation for their potential role in depression and anxiety disorders.

Special Issues in Assessment of PTSD

High rates of comorbidity are common in PTSD across diverse samples (e.g., males, females, veterans, sexual assault victims, crime victims, the general population), traumatic events (e.g., military, combat, rape, physical assault, childhood sexual abuse, violence), and patient and nonpatient status (help-seeking patients vs. community-based groups Keane & Kaloupek, 1997 Kessler et al., 1994 Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995). The most commonly diagnosed comorbid disorders are substance use disorders, mood disorders (e.g., major depressive disorder and dysthymia), and anxiety disorders (e.g., panic and phobias). Unlike other forms of depression seen in the absence of PTSD, when combined with PTSD depression often seems unremitting and in many cases appears as a double depression (i.e., major depressive episodes combined with longstanding dysthymia). In many cases, substance abuse may be secondary to PTSD and represent an effort to self-medicate symptoms. The...

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...

Stress Management And Psychiatric Interventions

The modal stress management intervention tested in this regard is a 10-week cognitive behavioral stress management (CBSM) intervention for HIV-positive persons. Throughout previous trials, CBSM was tailored to psychosocial sequelae that may follow critical challenges for HIV-positive persons at various disease stages. In the initial trial, a cohort of 65 MSM awaiting HIV serostatus notification were randomly assigned to a 10-week CBSM intervention, a 10-week group-based aerobic exercise intervention, or a no-treatment control group. After 5 weeks of participating in one of these conditions, blood was drawn for antibody testing and the men received news of their HIV serostatus 72 hours later. Among the approximately one-third of men diagnosed as HIV positive (n 23), those in the control condition reported significant increases in anxiety and depression. In contrast, men in the CBSM and aerobic exercise conditions showed no significant changes in anxiety or depression scores (LaPerriere...

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...

Hair Head and Pubic 51 Forensic Evidence

Hair is most commonly sampled to detect body fluids or retrieve foreign hairs or particles. It has been known for many decades that numerous ingested, prescribed, and illicit drugs (e.g., barbiturates, amphetamines, opiates, cocaine, benzodiazepines, y-hydroxy butyrate, and cannabis) are deposited in the hair (44). Although toxicology of hair was originally used to detect drugs that had been repeatedly ingested, recent advances in analytical techniques have meant that toxicology may be useful after single-dose ingestion as would occur in a substance-facilitated sexual assault (45,46). This is particularly pertinent because complainants of possible drug-facilitated sexual assaults frequently do not report the incident expeditiously because of amnesia and or doubt about what might have happened, and drugs may be accessible to analysis for longer periods in hair compared to blood or urine (47). In addition, it may be used as a reference sample for DNA analysis.

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,...

Normal Grief Bereavement

Studies generally concur that uncomplicated grief or bereavement may include any or all of the features of major depression except suicidality, psychosis, severe loss of self-esteem and or functionality, and psychomotor retardation. Appetite and sleep disturbance, multiple somatic complaints, anhedonia, anxiety, mild feelings of self-deprecation, the passive wish to join the loved one, sadness, 1. The first few weeks after the death ofa loved one During this initial period, numbness, shock, disbelief, and emptiness are often accompanied by intense anxiety, sleep disturbance, and somatic complaints.

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...

Stress Induced Hyperthermia

Stress-induced hyperthermia is an autonomic response that occurs prior to and during stress and or stress-related events.66 The first paradigms used group housed mice and evaluated the change in rectal temperature twice at 10min intervals. The procedure produced reliable elevations in animal core temperatures with anxiolytics reducing the stress-induced hyperthermia response. Later studies showed that similarly robust effects could be produced using singly housed mice, allowing for an average of 10 fewer mice per study. Diazepam and chlordiazepoxide had anxiolytic activity in this model,67 although subunit selective GABAA compounds like Zolpidem exhibited only marginal activity.67 5HT1A receptor agonists (e.g., flesinoxan) have a dose-related inhibition of the hyperthermia response, while partial agonists like buspirone produce a lesser effect.66 In general, antidepressants (e.g., imipramine, chlomipramine, 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...

Ontogenic development

By UGT2B7.107 Morphine was found to undergo significant glucuronidation by the fetus liver. In vitro studies in hepatic microsomes obtained from fetuses (15-27 weeks) indicated that the glucuronidation rates were 10-20 of that observed in adult microsomes.108 In addition, the mean rate of morphine glucuronidation in fetal livers obtained after hysterectomy was twofold higher than that obtained from induced abortion livers, suggesting a possible regulatory mechanism for UGTactivity related to the birth process (Table 4).25 The glucuronidation of morphine in vivo has also been demonstrated in premature neonates as young as 24 weeks of gestation. Studies with other substrates which are mainly or partially glucuronidated by UGT2B7, such as naloxone, an opiate agonist, benzodiazepines, and nonsteroidal antiinflammatory drugs are all suggestive of a reduced glucuronidation ability in neonates compared to adults.109

Rates Of Psychiatric Disorders Among People Living With Hiv Infection

The landmark HIV Cost and Services Utilization Study (HCSUS) found that a large, nationally representative probability sample of adults receiving medical care for HIV in the United States in early 1996 (N 2,864 2,017 men, 847 women) reported major depression (36 ), anxiety disorder (16 ), and drug dependence (12 ) (Bing et al., 2001 Galvan et al., 2002), as well as heavy drinking at a rate (8 ) almost twice that found in the general population and high rates of drug use (50 ). The HCSUS study remains the most comprehensive view we have of the prevalence of psychiatric disorders among people living with HIV AIDS, though the study was not designed as a diagnostic assessment of psychiatric disorders among people with HIV AIDS and so rates of psychosis, bipolar disorder, alcohol abuse or dependence, and substance abuse, among others, were not obtained. Disorders of alcohol and other drug (AOD) abuse are differentiated from dependence in the Diagnostic and Statistical Manual of Mental...

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.

Monoamine Transport Inhibitors

The tricyclic antidepressants (TCAs) were originally designed to improve upon the efficacy and side effect profile of the phenothiazine class of antipsychotics. Their pharmacological spectrum was quite well understood in that these compounds interact with multiple brain neurotransmitter systems. The TCAs inhibit reuptake of monoamine neurotransmitters (dopamine (DA), 5HT, and NE) increasing their levels and function in the brain. TCAs include imipramine, desipramine, nortriptyline, amitriptyline, clomipramine, and doxepin (Figure 5). These compounds also interact with a variety of biological targets like muscarinic receptors, complicating their pharmacology and contributing to side effects such as orthostasis, dry mouth, and constipation. Clomipramine is the most effective TCA for panic disorder, OCD, and SAD87 but more selective reuptake inhibitors have displaced the use of the tricyclics due to their improved side effect profile.

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...

Allergic Conjunctivitis

Unfortunately, patients with asthma and eczema can experience recurrent itching and irritation of the conjunctiva. Although atopic conjunctivitis tends to improve over a period of many years, it might result in repeated discomfort and anxiety for the patient, especially as the cornea can become involved, showing a superficial punctate keratitis or, in the worst cases, ulcer formation and scarring.

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...

Substance Induced Mood Disorder

Two broad categories of substances can be distinguished in this context. The first comprises substances with primarily psychoactive properties that are prone to abuse and can become addictive. This category includes alcohol opiates and related compounds such as ketamine barbiturates benzodiazepines and other central nervous system depressants stimulants, including amphetamines cocaine and related compounds such as methylenedioxymethamphet-amine (MDMA Ecstasy) phencyclidine (PCP) marijuana and hashish hallucinogens such as lysergic acid diethylamide (LSD) and mescaline inhalants and miscellaneous substances such as y-hydroxybutyrate (GHB). The second category comprises substances whose psychoactive properties are incidental to their main therapeutic effects. This category includes numerous medications used for acute and chronic nonpsychiatric conditions. With regard to psychoactive substance induced depression, Bakken and colleagues (2003) found that 48 of 241 substance abusers (age...

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...

Variations in Clinical Presentation

The literature has long reflected awareness by clinicians that depression in the elderly can be masked by physical complaints (Kielholz 1973). In the classic version of this presentation, subjective complaints of mood changes per se are replaced or masked by multiple somatic complaints. In the course of medical diagnosis and treatment, these complaints are found to be either unaccompanied by anatomical or physiological abnormalities or out of proportion to the severity of these abnormalities. The prevalence of this syndrome in the elderly is not known. One study (Posse and Hallstrom 1998) found that major depression presented as somatic complaints in 13 (14 ) of 93 mixed-age primary care patients, and it is likely that this proportion is higher in elderly patients. Identification of this syndrome is particularly difficult when it occurs in patients with somatic complaints that are associated with clear physical causes. DSM-IV-TR criteria are usually adequate to diagnose such...

Endocrine Disorders Associated with Myofascial Pain

Menopause, secondary to estrogenic insufficiency may be difficult for the patient and associated with myofascial pain and TrPs, sweats, and hot flashes. On occasion, muscle pain, and or joint pain may be the primary complaints. Associated symptoms may include anxiety, weakness, depression, emotional difficulties, and loss of libido. These symptoms typically all improve with exogenous estrogen replacement.

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).

Conquering Fear In The 21th Century

Conquering Fear In The 21th Century

The Ultimate Guide To Overcoming Fear And Getting Breakthroughs. Fear is without doubt among the strongest and most influential emotional responses we have, and it may act as both a protective and destructive force depending upon the situation.

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