Most Effective Anxiety and Panic Attacks Cures

The Panic Miracle

The Only Holistic System In Existence That Will Teach You How To Permanently Cure Your Panic Attacks and General Anxiety, Regain Your Self Confidence, and Enjoy Life Without Fear! Panic Miracle System is a 250 page downloadable e-book, jam-packed cover to cover with all the secret natural set of panic attack cure techniques, unique powerful protocols and the step-by step holistic panic attack system I've discovered in over 14 years of panic attack and anxiety research. This program contains all the information you'll ever need to eliminate your panic attack permanently without drugs, without therapy and without any side effects. A Clinically Proven Holistic Plan for Quickly and Permanently Stopping Panic Attacks and Anxiety Naturally and Safely, Boosting Self Confidence, and Regaining Your Life Back. Successfully Used by 1,000s of Men and Women World-wide. Panic Miracle is Customizable for Your Unique Condition Every person is completely different. No two reasons for panic attacks are exactly the same. That's why the Panic Miracle system includes guidelines as to how you can customize the strategies and methods for your unique situation. You will be taught, step-by-step, how to be your own 'scientist' and detect subtle factors within your own body, lifestyle and environment that need attention while working with the plan to overcome your anxiety. Continue reading...

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Animal Research in Fear and Anxiety

Animal tests of fear and anxiety are used both to screen new compounds for potential anxiolytic action and to study their neural substrates. Until the mid-1970s, animal tests consisted of delivering shocks as a punishment, most often for an operant lever-press response. These tests were developed as screening tests for the pharmaceutical industry. Matching particular tests of fear and anxiety to particular anxiety disorders is an extremely difficult task. The social interaction test (placing rats in an unfamiliar or brightly lit environment), the elevated plus-maze (placing the animal on an elevated open arm), predator exposure stress, forced swim, and social defeat or subordination stress are models of fear and anxiety. In the wide range of approaches used to study fear and anxiety in animal studies, two sets of tests probe their responses. The first set uses models of conditioned fear the second uses models of unconditioned fear. Both models presuppose that aversive stimuli, such as...

Tranquilizer Withdrawal

Elsesser et al. compared the effect of complaints management training with that of anxiety management training, the treatment that had previously been shown to be effective in facilitating benzodiazepine withdrawal. Immediately after treatment, the abstinence rate was higher in the complaints than in the anxiety management group (Fig. 2a), and patients in the former were also less anxious and depressed (Fig. 2b). At followup, there was no longer a significant difference between groups in terms of abstinence rate (65 ). Complaints management training appears, however, to ease withdrawal and to lower anxiety and depression more rapidly than anxiety management training. The evaluation of the efficacy of a single-treatment mode presents some difficulty, for treatment trials usually combine a number of approaches in any condition and group. Caution must therefore be exercised when attempting to interpret the outcome of trials in terms of the effect of any single component of treatment....

Psychological studies of anxiety and attention

Most psychological studies of anxiety and attention have employed between-subjects designs comparing chronically-anxious and non-anxious individuals. The majority of these studies have focused on individuals suffering from a clinically-diagnosed anxiety disorder, although others have sampled anxiety across a more normal range by comparing individuals who are above and below the median in terms of the personality dimension of 'trait anxiety'. These are reasonable research strategies in that both clinical and trait measures of anxiety are assumed to reflect chronic activation in the brain's defensive circuitry. It should be kept in mind, however, that many of these studies do not directly manipulate the individuals level of state anxiety, and when they do, the manipulations tend to promote relatively mild states of anxiety. Many of the earliest studies provided evidence that anxiety produces a focused state of attention characterized by impaired processing of peripheral or secondary...

Major Tranquilizers Thorazine and Relatives

Major tranquilizers revolutionized psychiatry when they were first introduced in the early 1950s. They provided a new and easy way to manage schizophrenia and other severe mental diseases, making patients calm and emotionally quiet. In some cases the major tranquilizers have enabled psychotic persons to lead reasonably normal lives and function outside hospitals. More often, they make them more manageable and docile rather than less crazy. In addition to their use in treating mental illness, the major tranquilizers can be used to end bad reactions to psychedelic drugs and other states of confusion. Some of them are also used to treat purely physical problems, such as itching, dizziness, nausea, vomiting, and hiccups. In normal people, small doses of these compounds cause drowsiness, lethargy, and boredom hardly the kinds of effects that encourage recreational use. In addition, the major tranquilizers regularly produce uncomfortable physical effects, such as dryness of the mouth. In...

Tranquilizer Rescinnamine

Rauwolfia alkaloids include reserpine, the first tranquilizer, rescinnamine, and deserpidine. Reserpine is a sedative and tranquilizer useful in treating hypertension. It is also used as a rodenticide. Hyperventilation, hypertension, hypotension (cat) LD50 (mouse, intraperitoneal) 350 mg kg Piperine black pepper (Piper nigrum) No information No information

Relationship between plasma anxiolytic concentrations and the therapeutic response

While the individual drugs in the benzodiazepine group differ in potency, all benzodiazepines in common use have anxiolytic, sedative-hypnotic, anticonvulsant and muscle-relaxant activity in ascending order of dose. The main clinical difference between the individual drugs lies in the time of onset of their therapeutic effect, and the intensity and duration of their clinical activity. All benzodiazepines are derived from weak organic acids and some, such as midazolam, form water-soluble salts at a low pH. However, at normal physiological pHs, all benzodiazepines are lipophilic, the lipid solubility varying from highly lipophilic in the case of drugs like midazolam, flurazepam, diazepam and triazolam to slightly lipophilic for drugs such as clonazepam, bromazepam and lormetazepam. The benzodiazepines are also highly protein bound, so that at the plasma pH the proportion of the drug in the free form will vary from only 2 in the case of diazepam to about 30 with alprazolam. However, for...

Application Of The Model Of The Neural Circuitry Of Anxiety And Fear To Anxiety Disorders

The primary goal of research in the clinical neuroscience of anxiety disorders is to apply findings related to the effects of stress on the brain in animals to patients with anxiety disorders. Different methods contributed to the working model of the neural circuitry of anxiety and anxiety disorders that is presented here. The neural circuits mediating symptoms of anxiety disorders can be studied by measuring neurotransmitters and hormone levels in blood, urine, and saliva by assessing behavioral and biochemical responses to pharmacological challenge to specific neurochemical systems by measuring key brain structures with structural neuroimaging by provoking Among the most characteristic features of anxiety disorders such as PTSD and PD is that anxiogenic memories (e.g., of the traumatic experience or first panic attack) can remain indelible for years or decades and can be easily reawakened by all sorts of stimuli and stressors. The strength of traumatic memories relates, in part, to...

Neural Circuits In Anxiety And Fear

The major afferent arm of neural circuitry includes exteroceptive sensory systems of the brain, consisting of serially organized relay channels that convey directly or through multisynaptic pathways information relevant to the experience of fear. The sensory information contained in a fear- or anxiety-inducing stimulus is transmitted from peripheral receptor cells in the eyes, ears, nose, skin, the body's own visceral information (e.g., blood glucose, arterial pressure, and CO2 levels), or any combination of these. Except for olfactory information, which goes directly to amygdala and enthorhinal cortex, these sensory inputs are relayed through the dorsal thalamus to amygdala and cortical brain areas, such as primary visual (occipital), auditory (temporal), or tactile (postcentral gyrus) cortical areas. Input from peripheral visceral organs As this primary sensory input comes into the brain stem and midbrain, it is matched against previously stored patterns of activation and if...

Key Brain Structures Mediating Fear And Anxiety Behaviors

The brain structures that constitute a neural circuit of fear and anxiety should have the following features 1. There is sufficient afferent sensory input to permit assessment of the fear- or anxiety-provoking nature of the external threat or internal stress. 3. Efferent projections from the brain structures should be able to mediate an individual's neuroendocrine, autonomic, and motor response to threat as well account for the pathological reactions that result in anxiety-related signs and symptoms. To underscore its survival importance, many brain areas with redundant circuits are involved to subserve this important constellation of behaviors. Critical brain structures capable of incorporating an individual's prior experience or memory into the appraisal of stimuli are amygdala, LC, hippocampus, thalamus, hypothalamus, periaqueductal grey (PAG), and pre-frontal cortex. Alterations in neurochemical and neurotransmitter systems that mediate the stress response also play a role in...

History of Neuroanatomical Modeling of Fear and Anxiety

There has been a long history of hypotheses related to the neurobiology of human anxiety. The central role of a subcortical network of brain structures in emotion in general was hypothesized by Papez in 1937. In 1949, MacLean coined the term limbic system, integrating Papez's original circuit (hypothalamus, anterior thalamus, cingulate gyrus, and hippocampus) and other anatomically and functionally related areas (amygdala, septum, and orbitofrontal cortex). Over the years, various regions have been added or removed from this emotion processing circuit. Papez hypothesized that several telencephalic and diencephalic structures which form a border ( limbic border) around the diencephalon constituted a circuit, which controlled the emotions. He suggested that blockage of information flow at any point along this circuit would cause disorders of affect (i.e., mood). Removal of the cerebral cortex of the cat, leaving only subcortical regions including amygdala, thalamus, hippocampus, and...

Observation of Early Signs of Anxiety

In order for applied relaxation to work optimally patients must use the relaxation technique as early as possible in the response to an anxiety reaction or a panic attack. Reacting quickly to the first signs of anxiety greatly increases the patients' ability to employ AR effectively. In order to increase the patient's awareness of the initial signs of anxiety, homework assignments involve observing and recording these reactions. In the panic diary the patient records the situation, the symptoms of the panic attack, and the severity of the attack (0-100), as well as the very first signs that were experienced. Therapist and patient examine the panic diary and focus on identifying the earliest signs of the onset of the panic attacks. An attempt is made to determine what the patient felt, thought about, or did just before the first symptom occurred. Sometimes it can be advantageous to let patients imagine their most recent panic attack. This procedure often assists patients in remembering...

Special Section on Drugs Anxiolytic of choice

A common anxiolytic that is used is lorazepam (Ativan), a benzodiazepine with rapid onset and moderate duration 0.5-2 mg IV is the recommended dose, but start with 0.5 mg at first and then give additional 0.5 mg doses every 5-10 min until the total dose is reached. Midazolam (versed), which is commonly used for procedures such as colonoscopy, is not ideal because it is too short acting and requires frequent dosing.

Working Model For The Neural Circuitry Of Anxiety Disorders

Neural Circuits Anxiety Disorders

Anxiety disorders are characterized by dysfunction of an interrelated neurochemical and neuroanatomical system. PTSD and PD share many biological and phenomenological similarities that allow them to be considered related. Phobic disorders and GAD are still in early stages of investigation. Although phenomen-ologically they are similar to PTSD and PD, it is premature to include them in a model for human anxiety disorders. PTSD is related more to the deleterious effects of environmental stress, whereas PD is not as clearly related to stress and may be related more to genetic variability in anxiety. In stress-related anxiety disorders (i.e., PTSD), PTSD symptoms as well as cognitive dysfunction associated with PTSD may be linked to hippocampal dysfunction. A model can be created which incorporates informatiom from animal and clinical research relevant to these disorders, keeping in mind that working models are subject to modification with new information, and that generalizations...

Social Avoidance And Anxiety

Beliefs about being defective and the importance of appearance to the self will drive varying degrees of social anxiety and avoidance. Thus, depending on the nature of their beliefs, patients will tend to avoid a range of public or social situations or intimate relationships because of the fear of negative evaluation of the imagined defects. Many patients endure social situations only if they use camouflage (for example, excessive makeup) and various safety behaviors. These are often idiosyncratic and depend on the perceived defect and cultural norms. Behaviors such as avoidance of eye contact or using long hair or excessive makeup for camouflage are obvious but others are subtler and are more difficult to detect unless the patient is asked or observed as to how they behave in social situations. For example, a BDD patient preoccupied by his nose avoided showing his profile in social situations and only stood face on to an individual. A patient preoccupied by blemishes under her eye...

Misattribution and Fear Anxiety

Schachter's misattribution studies were followed by a multitude of other misattribution studies, in which subjects were induced to attribute their natural arousal to various pills and procedures, such as white noise, strange rooms, and the lights or ventilation of a room (for reviews, see Ross & Olson, 1981 Reisenzein, 1983). The feelings that were successfully reduced by these procedures include anxiety, anger, cognitive dissonance, and the discomfort of social comparison (Tesser, Pilkington, & Mcintosh, 1989). Olson, both by himself (1988) and in conjunction with Ross (Olson & Ross, 1988), tested predictions of this model by inducing participants to misattribute the arousal of speech anxiety. Speech anxiety is a particularly good test of the analysis because three previous studies (Cotton, Baron, & Borkovec, 1980 Singerman, Borkovec, & Baron, 1976 Slivken & Buss, 1984) had failed to find misattribution effects, in studies that failed to meet Ross and Olson's criteria. In the three...

Conditioning of Anxiety Relief

In his monograph Psychotherapy by Reciprocal Inhibition published in 1958, which stimulated the widespread introduction of behavioral modification procedures to psychiatry and psychology, Wolpe suggested that anxiety-relief responses might be directly conditioned to convenient stimuli and subsequently used to counter anxiety. He based the suggestion on the observation that if a stimulus was repeatedly presented to an eating animal just before withdrawing its food, that stimulus acquired the property of inhibiting feeding even when the animal was in the middle of a meal. Wolpe argued that by analogy it might be expected that a stimulus that consistently coincided with the termination of a noxious stimulus might acquire anxiety-inhibiting effects. He pointed out the possibility was supported by experiments showing that approach responses were conditioned to a stimulus repeatedly presented at the moment of termination of an electric shock, in contrast to the avoidance that is conditioned...

Serotonin and anxiolytic activity

Although the benzodiazepine anxiolytics primarily interact with the GABA receptor complex, there is ample experimental evidence to show that secondary changes occur in the turnover, release and firing of 5-HT neurons as a consequence of the activation of the GABA-benzodiazepine receptor. Similar changes are observed in the raphe nuclei where a high density of 5-HT1A receptors occurs. Such findings suggest that 5-HT may play a key role in anxiety disorders. Undoubtedly one of the most important advances implicating serotonin in anxiety has been the development of the azaspirodecanone derivatives buspirone, gepirone and ipsapirone as novel anxiolytics. All three agents produce a common metabolite, namely 1-(2-pyrimidinyl) piperazine or 1-PP, which may contribute to the anxiolytic activity of the parent compounds. It soon became apparent that these anxiolytic agents do not act via the benzodiazepine or GABA receptors but show a relatively high affinity for the 5-HT1A sites the 1-PP...

Mood Anxiety and Somatoform Disorders

The cooccurrence of migraine and psychiatric disorders has been studied extensively in several population-based and longitudinal surveys. Migraine is associated with both affective and anxiety disorders. Breslau and colleagues reported on the association of International Headache Society (IHS)-defined migraine with higher lifetime rates of affective disorder, anxiety disorder, illicit drug use disorder, and nicotine dependence. Migraine with aura was associated with an increased lifetime prevalence of both suicidal ideation and suicide attempts, controlling for sex, major depression, and other concurring psychiatric disorders. The relative risk for the first onset of major depression in migraineurs after the onset of migraine versus no prior migraine was 4.1 (95 CI, 2.2-7.4), whereas the relative risk for the first onset of migraine in persons with prior major depression versus no history of major depression was 3.3 (95 CI, 1.6-6.6). These data indicate that the lifetime association...

Alterations in Neurochemical Stress Response Systems in Patients with Anxiety Disorders

Anxiety disorder patients have long-term alterations in neurochemical systems that are involved in mediating the stress response and are sensitive to chronic stress. The findings in PTSD and PD (most extensively studied of the anxiety disorders) are summarized in Table II. There is extensive evidence indicating that NE plays a role in human anxiety and is dysregulated in anxiety disorders. PTSD and PD seem to have similar alterations in noradrenergic function. However, the causes of the two syndromes may differ, with PD associated more with genetic factors and PTSD with the effects of severe psychological trauma.

Prevalence Of Anxiety Disorders

The American Psychiatric Association first recognized anxiety disorders in 1980 as a separate group of psychiatric disorders. The concept of neurosis (neurasthenic neurosis, anxiety neurosis, phobic neurosis, and obsessive-compulsive neurosis) in previous classifications was abandoned because it was considered too vague. Anxiety disorders now include PD, PTSD, social phobia, specific phobia, OCD, and GAD. Anxiety disorders are by far the most common of psychiatric disorders (25 ), followed by affective disorders (17 ). In the past decade, large epidemiological studies have provided information about the prevalence of anxiety disorders in the general population. A landmark epidemiological study in the United States in 1994 found lifetime prevalence rates for all anxiety disorders combined to be 19.2 for men and 30.5 for women. Phobic disorders are the most common diagnosis in broad-based assessments of psychiatric disorders in the community (affecting about 13 of individuals at any...

Benzodiazepine Abuse And Dependence

Genuine physiologic addiction to benzodiazepines may occur, particularly with prolonged and high doses. 37 However, the abuse potential of benzodiazepines appears to be low in comparison with that of agents such as alcohol, cocaine, opiates, and barbiturates. 89 Benzodiazepine abuse usually occurs in individuals with a history of abuse of other psychoactive drugs. Primary drug abuse with benzodiazepines is not common. Benzodiazepine withdrawal may occur on abrupt discontinuation and is more likely in patients with prolonged use and high doses. Because of the long biologic half-life of several derivatives, withdrawal manifestations may not occur for several days to over 1 week after the benzodiazepine has been discontinued. Unfortunately, it is often difficult to distinguish between withdrawal and underlying symptoms for which the drugs were prescribed initially. Reported withdrawal manifestations include anxiety, irritability, insomnia, nausea, vomiting, tremor, sweating, and...

Cognitivebehavioral Therapy For Anxiety Disorders

Cognitive-behavioral therapy is the most empirically supported psychosocial treatment for anxiety disorders. The cognitive-behavioral understanding of anxiety disorders is largely based on learning theory. Mowrer's two-factor theory suggests that anxiety disorders are created initially via classical conditioning, and then maintained via operant conditioning. According to this theory, anxiety develops when a neutral stimulus becomes paired with an aversive response. For example, someone who was bitten by a spider begins to pair the concept of spider with anxious feelings through classical conditioning. The person then realizes that he or she feels better by avoiding spiders, and the drop in anxiety that follows that avoidance acts as a negative reinforcer, Cognitive factors can also play a large role in the development and maintenance of anxiety disorders, because in addition to learned associations, anxiety can also result from people's perceptions of a given situation. For example,...

Panic Disorder And Agoraphobia

Panic disorder is characterized by unexpected panic attacks. These may be followed by panic attacks in response to particular stimuli, and by agoraphobia. Panic disorder with or without agoraphobia is a prevalent and disabling disorder. Panic-depression is a particularly common comorbidity, and contributes to the potentially negative impact of panic disorder 28 . Alcohol and substance abuse and dependence are also frequent comorbidities in panic and other anxiety disorders. A biological perspective suggests that there are multiple risk factors for the onset of panic disorder 29 , including both biological risk factors (e.g. family history) and environmental ones (e.g. separation). Genetic variants may well be important in the pathogenesis of panic, but at present are not clinically useful as risk markers. Long-term studies of anxiety disorders are relatively few, but these provide additional information about resilience and vulnerability factors 30 . Anxiety sensitivity is a trait...

Screening For Anxiety Disorders

In the above discussion of each of the major anxiety disorders, there are overlapping themes. These are highly prevalent, disabling and costly conditions. Despite the availability of effective pharmacotherapy and psychotherapy, they remain underdiagnosed and undertreated 74-77 . Cross-sectional studies of rates of appropriate diagnosis are partly flawed insofar as prevalence of psychiatric disorders is higher in follow-up patients nevertheless, underdiagnosis is a real problem 78,79 . Thus, there is clearly need for more widespread screening to maximize the chance of early detection and management. Screening would seem to be particularly relevant in primary care settings 80 , although there are also important opportunities for screening in other contexts, including direct screening of the public 81 . A range of screening instruments for anxiety disorders is available for use in primary care 82 . A number have also been studied in more specialized populations, settings and cultures...

Social Anxiety Disorder

Social anxiety disorder (SAD) is characterized by fear of embarrassing oneself in social or performance situations. Subjects with generalized SAD fear several different social situations. SAD is a particularly prevalent and disabling anxiety disorder 59,60 . Thus, subjects with SAD are more likely to be single, are less likely to complete high school or tertiary studies, and are more likely to be unemployed and receive a lower income 6 . It seems reasonable to argue that early intervention for SAD, even in childhood and adolescence, may prevent the negative impact of this disorder. Long-term studies are, however, needed in this area. SAD has a relatively early onset, and can persist for many years. Comorbid disorders often begin later on 61 . These include major depression, other anxiety disorders and substance use disorders. Simple screening questions 62 or scales, such as the Liebowitz Social Anxiety Scale (LSAS) and the Mini-Social Phobia Inventory (SPIN), are useful for screening...

Prevention Of Anxiety Disorders

As our understanding of the pathogenesis of anxiety disorders becomes increasingly sophisticated, it may also be possible to develop effective interventions to help prevent their onset 73,103 . In addition, screening strategies discussed above may yield a group of individuals who do not yet have an anxiety disorder, but who are nevertheless at risk should they not receive help. Thus, there is increasing interest in the prevention of childhood anxiety disorders by child-focused methods, parent-focused methods and environmental restructuring methods. Such strategies can be universal, selective or indicated 104 . We discuss each of them in turn. Universal prevention strategies are provided to entire populations. Lowry-Webster et al. 105 assigned 594 children aged 10-13 to CBT conducted by classroom teachers or to assessment only. Barrett and Turner 106 assigned 489 children aged 10-12 years to a psychologist-led programme, a teacher-led programme or to usual care. In both studies,...

Anxiolytics and the Treatment of Anxiety Disorders

Until the late 1960s, the symptoms of anxiety and insomnia were mainly treated with barbiturates. The barbiturates are known to cause dependence, and severe withdrawal effects were sometimes reported following the abrupt termination of their administration. Furthermore, their efficacy in the treatment of anxiety disorders was limited. The discovery of the benzodiazepine anxiolytic chlordiazepoxide some 30 years ago, and the subsequent development of numerous analogues with an essentially similar pharmacological profile, rapidly led to the replacement of the barbiturates with a group of drugs that have been widely used for the treatment of anxiety disorders, insomnia, muscle spasm and epilepsy and as a preoperative medication. The benzodiazepines have also been shown to have fewer side effects than the barbiturates, to be relatively safe in overdose and to be less liable to produce dependence than the barbiturates. They have now become the most widely used of all psychotropic drugs...

Exacerbating and alleviating anxiety

A frequent criticism of the publicity surrounding hereditary cancer risk is that it simply promotes anxiety while doing nothing practical to counter it. Setting aside the fact that publicity is generated largely by the popular media, over which cancer geneticists have no control, several studies of patients who have made use of cancer family clinical services provide a measure of reassurance. They have, in the main, confirmed that perceptions of risk before clinic attendance are often unrealistic, that there is some improvement in accuracy after attendance and that levels of anxiety tend to decline, at least in the short term, regardless of changes in risk perception. Hence there is some justification for the claim that cancer family clinics are responding to a pre-existing and hitherto unmet need and that they fulfil a useful function, even before they have been shown to influence cancer morbidity or mortality (Evans et al., 1994 Lloyd et al., 1996 Cull et al., 1999).

Sources of Information on Test Anxiety

Test takers who want help in coping with test anxiety will find a wealth of materials available in bookstores and on the Internet. Examples include the following Taking the anxiety out of taking tests A step-by-step guide, by S.Johnson. New York Barnes & Noble Books, 2000. No more test anxiety Effective steps for taking tests and achieving better grades, by E. Newman (available with audio CD). Los Angeles Learning Skills Publications, 1996. The Test Anxiety Scale (Saranson, 1980), which provides a quick way to gauge the extent to which one may be prone to experience test anxiety and is available free of charge from Learning Skills Publications (at http www.learning skills.com test.html) and several other Internet sites. Many Web sites sponsored by university counseling centers are accessible by searching for test anxiety on the Internet these sites provide tips on study habits and other information on coping with test anxiety. test anxiety, the following works are recommended Sapp, M....

Beta Blockers and Anxiety Fear

One class of drugs is an exception to the uncertainty about central versus peripheral effects. The beta-adrenergic blocking agents are specifically presumed to work peripherally in the body outside the central nervous system. These drugs act by interfering with the action of adrenalin at the peripheral neural sites, where adrenalin produces the characteristic visceral arousal symptoms. If Schachter is correct, then these antiadrenergic drugs that act peripherally should effectively reduce anxiety, anger, and perhaps other emotions. Once again, the evidence seems to be contradictory. In laboratory studies of the effects of beta-blockers, the effects seem to be difficult to demonstrate (Reisenzein, 1994). However, extensive reviews demonstrate successful practical uses of beta-blockers for some kinds of anxiety disorders (Noyes, 1985) and also for reducing performance anxiety (Dimsdale, Newton, & Joist, 1989). Despite the mixed results with experimental populations, little question...

TABLE 1581 Benzodiazepines Approved for Use in the United States

Benzodiazepines are frequently agents of accidental and intentional overdose. In the 1996 Annual Report of the American Association of Poison Control Centers Toxic Exposure Surveillance System, benzodiazepines accounted for 39,029 exposures, both as single agents and in combination with other drugs. 1 Although the ingestion of benzodiazepines alone appears to result in relatively few deaths, increased rates of morbidity and mortality do result from mixed overdose. Parenteral administration of benzodiazepines may also result in significant complications, particularly respiratory depression and hypotension.

Serotonin and aggression panic attack and related disorders

The possible overlap between anxiety, depression, panic attack, aggression and obsessive-compulsive disorders, and the involvement of serotonin in the symptoms of these disorders, has recently led to the investigation of various selective serotonin reuptake inhibitors (SSRIs) and selective 5-HT receptor agonists antagonists in the treatment of these conditions. In experimental studies, there is evidence that drugs such as eltoprazine, which binds with high affinity to 5-HT1A, 5-HT1B and 5-HT2c sites, are active antiaggressive agents, whereas selective 5-HT1A agonists and 5-HT2 and 5-HT3 antagonists are inactive. There is also preliminary evidence to suggest that SSRIs such as fluoxetine reduce impulsive behaviour which may contribute to their therapeutic action in the treatment of obsessive-compulsive disorders and possibly in reducing suicidal attempts. Zohar and Insel have suggested that the symptoms of obsessive-compulsive disorder are due to supersensitive 5-HT1-type receptors and...

Generalized Anxiety Disorder

Generalized anxiety disorder (GAD) is characterized by psychic and somatic tension. Although the DSM has focused increasingly on the cognitive aspects of GAD, this disorder often presents with somatic symptoms, and indeed it is the most common anxiety disorder in primary care settings 6 . Although GAD has at times been considered a residual disorder, there is growing evidence that it is in fact an independent disorder, characterized by specific symptomatology, high prevalence and significant disability 7 . GAD is associated with a good deal of psychiatric comorbidity, but no more so than is major depression 8 . The condition has a later onset than most other anxiety disorders, but it tends to precede other comorbid disorders, especially major depression 9 . Other important comorbidities in GAD include somatization disorder, other anxiety disorders, and substance use disorders. The disability that is associated with comorbid GAD and depression is significantly higher than the...

Anxiety and distress Table 173

Of the eight etiologic studies identified, four studies showed a lack of clear effect. Two papers, both published from the Israeli civil servant cohort, reported strong or moderate association between anxiety and the incidence of angina.39,40 The remaining two studies gave evidence for an association between phobic anxiety and fatal CHD, but did not show a clear effect on non-fatal CHD or of free-floating anxiety.41,42 Furthermore, the studies with longer follow up were less likely to find a positive association than the studies with less extended follow up. This is exemplified by the Northwick Park Heart Study where the association between anxiety and fatal CHD found after 10 years of follow up,41 disappeared when the follow up was extended by another decade.43 Hence, anxiety may be a result of preclinical CHD rather than a cause of fatal CHD. Of the 18 prognostic studies, half found a lack of clear association and one reported results significantly contrary to the hypothesis. Four...

Panic Disorder

A number of different techniques have been employed to bring under control somatic responses that are related to panic. The most frequently used technique is respiratory training. David H. Barlow and his associates have termed this approach panic control training. Eleven sessions of a combination of cognitive restructuring with breathing retraining und interoceptive exposure constitute a highly effective treatment in panic disorder. This treatment worked equally well with and without imipramine, a tricyclic antidepressant, and appeared more durable than imipramine alone six months after treatment cessation. Psychological treatments of panic disorder have previously been shown to be more effective than alprazolam, a benzodiazepine. In 1988, Gudrun Sartory and Deli Olajide compared breathing retraining with Valsalva, a vagal innervation technique, and found a slight advantage of the latter. Both groups received progressive relaxation and the instruction that panic could be brought under...

Benzodiazepines

The use of benzodiazepines is poorly studied in palliative care despite their very widespread use for a number of 'indications'. In breathlessness (but not necessarily anxiety), a double-blind, placebo-controlled randomized trial on 24 people with COPD was carried out using 0.5 mg of alprazolam twice daily for one week and placebo for two weeks (including one week of washout).32 Although exercise parameters were evaluated, the subjective sensation of dyspnoea at rest and with exercise was not significantly different on the final day of the active arm. This study was powered to detect only a major reduction in dyspnoea scores and, of concern, the trend for PaO2 was downwards, and PaCO2 upwards on the active arm. A case study (that would have made a perfect n 1 trial) suggests that in the presence of both breathlessness and anxiety, there may be a role for alprazolam without significant toxicity.33 A single-blinded study in four patients with dyspnoea and COPD suggests that further...

Azopirones buspirone

As with most medications in the therapy of dyspnoea, there are limited data to inform the use of buspirone in clinical practice. Buspirone is a non-sedating anxiolytic with a gradual onset of action after it is commenced. There are two double-blind, RCTs that explore the effect of buspirone in people with COPD. The first of these explored in a placebo-controlled study the use of 10-20mg of buspirone three times daily on dyspnoea measured on Borg scale and physiological parameters of exercise. The cohort of 11 males had moderate to severe COPD and anxiety. Neither dyspnoea scores nor anxiety scores (measured on the State Trait Anxiety Inventory) dropped by the end of the six-week study. There was no improvement in exercise workload including 12-minute walking distance.41 A study that was reported the same year explored the use of 20mg of buspirone per day in 16 people for 2 weeks. All had moderate to severe COPD with FEV1 of 1.15 + -0.42 and FEV1 FVC of 50.7 + -15.0 per cent. At the...

Phase 1 Anxiety

The first level of behavior seen in a potentially violent patient is anxiety. This may not only occur with the patient. Family and visitors waiting long periods in the emergency department waiting room may also exhibit anxiety and should be dealt with before visiting the patient so as not to intensify the patient's behavior. In general, the signs of increasing anxiety are indicated by body language. Movements that seem to have no purpose other than to expend energy may be the first clue. These may include pacing, wringing of hands, clenching of fists, unwillingness to stay in the treatment area, or a disheveled appearance. Speech may be pressured and loud. Questions such as Why am I here or How long is this going to take may be asked. It is not necessarily what is said, but the manner of speech that gives a clue to the presence of anxiety. One of the most common reasons that a patient's condition may evolve beyond anxiety is that the staff ignores these signals, rather than...

Anxiety Disorders

Anxiety has been demonstrated to be a very common mental health problem in people with DD. The complete spectrum of anxiety disorders is represented in this population as opposed to their noncognitively challenged counterparts. Relaxation training is a common component in a CBT approach to treating anxiety. Individuals with MR DD are reported to have better results learning relaxation training when modeling and physical guidance were used to teach the difference between tense and relaxed states. It is essential to include methods of physical relief in anxiety management with dually diagnosed individuals as it may be more difficult to teach and convince these individuals that some physical sensations can be psychological in nature, i.e., that there is nothing physically wrong and that they are not sick. Without this acknowledgment, cognitive methods to relabel and address the physical sensations may be ineffective. Self-instruction training has much potential for use with people with...

Hyperventilation

Hyperventilation induces rapid, transient reductions in ICP because substantial decreases in CO2 cause vasoconstriction and decreased cerebral blood flow. Autoregulatory capability is required for this response. This measure is effective in many forms of edema, although there is a theoretical risk of causing injury due to hypoxia associated with excessively diminished cerebral blood flow. A target CO2 of 2530 mm Hg is recommended when hyperventilation is employed.

Buspirone

Buspirone is a prototype anxiolytic drug from the azapirone family introduced in 1984. The agent is not chemically or pharmacologically related to the other sedative-hypnotics, although its efficacy profile is comparable with that of the benzodiazepines. Clinical indications for buspirone are not fully delineated however, it appears most useful in the treatment of conditions such as chronic anxiety, especially in the elderly, and mixed anxiety-depression states. It does not affect GABA or benzodiazepine receptors and therefore produces less sedation, euphoria, psychomotor impairment, and ethanol potentiation. It does affect CNS serotonergic, dopaminergic, and noradrenergic neurotransmission, but the mechanisms are not fully understood. Buspirone appears to have several merits when compared with the other sedative-hypnotics. It exhibits a virtual absence of potential for addiction, a wide margin of therapeutic safety, and no documented delayed toxicity or withdrawal reactions with...

Benzodiazepine

Alterations in Bz receptor function are involved in the stress response and anxiety. Animals exposed to stress develop a decrease in Bz receptor binding in different brain sites. Decreases in Bz receptor binding are also associated with alterations in memory. Bz receptors are present throughout the brain, with the highest concentration in cortical grey matter. Bzs potentiate and prolong the synaptic actions of the inhibitory neurotransmitter g-aminobutyric acid (GABA). Central Bz receptors and GABA receptors are part of the same macromolecular complex. These receptors have distinct binding sites, although they are functionally coupled and regulate each other in an allosteric manner. Administration of inverse agonists of Bz receptors results in behavioral and biological effects similar to those seen in anxiety and stress. These effects are blocked by administration of Bzs or pretreatment with the Bz antagonist flumazenil.

Anxiety

The Expression of Fear and Anxiety II. Prevalence of Anxiety Disorders III. Etiology of Anxiety and Anxiety Disorders IV. Functional Neuroanatomical Models of Fear and Anxiety V. Key Brain Structures Mediating Fear and Anxiety Behaviors VI. Neural Circuits in Anxiety and Fear VIII. Application of the Model of the Neural Circuitry of Anxiety and Fear to Anxiety Disorders IX. A Working Model for the Neural Circuitry of Anxiety Disorders

Anxiolytics

The prototypical anxiolytics in common use for CS in the ED are the benzodiazepines, which potentiate the inhibitory activity of g-aminobutyric acid (GABA) in the CNS by binding to benzodiazepine-specific receptors on the GABAA-benzodiazepine receptor complex, which induces a conformational change that potentiates GABA-mediated chloride influx. This activity results in sedation, amnesia, anxiolysis, and anticonvulsant effects, as well as respiratory depression. The benzodiazepine most commonly used for CS in the ED is midazolam, which produces earlier sedation, more frequent amnesia, less pain on injection, and improved 90-min alertness and readiness for discharge when compared with diazepam.18 Midazolam has a number of characteristics favorable for use in ED CS. Its diazepine ring opens at pH values of less than 4, in which form it is quite water soluble. At physiologic pH, the ring closes, rendering midazolam highly lipid soluble, with associated rapid CNS uptake producing peak...

Empirical Studies

According to the principles of operant conditioning, and specifically of negative reinforcement, the client should behave in ways that would minimize contact with the aversive stimulus, in this case the precipitative events and the deviant behavior. If the client does pursue the deviant behavior further, hopefully the treatments will have at least reduced the effectiveness of the reinforcement for the deviant behavior, which should lead to a lower frequency of the behavior. It would also be possible for classical conditioning to work alone, if the CR was so powerful that it rendered the person unable to engage in the deviant behavior, or consisted of a response that was incompatible with the deviant behavior. For example, if the CR was extreme anxiety or fear, and the deviant behavior required an erect penis, it may be the case that the CR would preclude the possibility

The Therapeutic Environment Animals as an Aspect of Milieu Therapy

For example, Aaron Katcher, Arline Segal, and Alan Beck reported, in their study on anxiety and discomfort before and during dental surgery, that subjects viewing the aquarium appeared more comfortable and less anxious than those subjects in a control group not viewing an aquarium. Watching a school of fish can be quite relaxing for some. With proper lighting and an attractively designed tank, clients can feel more at ease when they enter an office or while in therapy.

Cognitivebehavioral Model Of Bulimia Nervosa Precipitation And Maintenance

And manipulation of body weight and shape. BN-related dysfunctional beliefs occur in several domains, including (a) body weight expectation, (b) meaning of body weight and shape, and (c) food and eating pattern. In particular, persons with BN often hold unrealistic expectations for how low their own body weight should be, and believe that acquiring a specific (usually thin) body appearance will result in a host of desired consequences (e.g., increased interpersonal popularity and prowess, increased self-esteem, decreased negative emotion). Thus, obtaining the ideal body is viewed as a principal strategy for achieving idiosyncratically defined positive life outcomes and coping with or solving life problems. Dietary restriction is employed in an attempt to conform the body to ideal specifications. Dietary restriction typically includes restricting how often food is eaten, how much food is eaten, and what types of foods are eaten. This restrictive eating pattern results in both...

Description Of Treatment

The next section provides a theoretical overview of BGT. Immediately following this overview we present two case illustrations of BGT. The first involves a protocol for panic disorder with agoraphobia, and serves to highlight different types of exposure techniques in BGT. The second BGT protocol has more cognitive components and is designed to treat generalized social phobia. The chapter concludes with a brief discussion of applications and exclusions for BGT, along with a summary of the current empirical knowledge base.

TABLE 114 Drugs Used for Induction of Anesthesiax

KETAMINE Unlike any of the other induction agents, ketamine tends to increase heart rate, blood pressure, and cardiac output. These effects appear to be mediated through central sympathetic stimulation, since ketamine appears to be a weak myocardial depressant in isolated heart preparations. Such effects enhance its attractiveness in settings such as trauma with hypovolemia. It is also a bronchodilator with no suppression of ventilatory drive, making it an excellent choice for patients with known reactive airway disease. In addition, it has significant analgesic and amnestic properties. It can be given intramuscularly in a dose of 4 to 6 mg kg with onset of anesthesia within 5 min. This may be desirable in the combative patient in whom intravenous access has not been secured. Unfortunately, it also carries a number of undesirable side effects. Despite the bronchodilatation, there are marked increases in upper airway secretions, which can occur briskly and complicate airway management....

Behavior Therapy True to Its Conceptual Roots

At present, there is no indication that behavior therapy true to its roots has failed. What has happened, however, is that many behavior therapists have failed to see the conceptual richness of behaviorism and the promise of what behavioral science has to offer. For example, many behavior therapists, including nonbehav-ioral practitioners, would likely be surprised to learn that behavior analysts are increasingly addressing complex human phenomena such as the self, knowing, meaning, purpose, cognition, attention, emotion, verbal-regulatory processes involved in psychopathology, attributions, expectancies, and topics familiar to clinical psychologists such as transference and counter-transference, resistance, suicide, anxiety, depression, and the most vexing clinical question as to how the talk that goes on between therapist and client in psychotherapy leads to clinically meaningful change outside of therapy (where it really counts). These and other developments, including new...

Activation Procedures

Activation procedures, hyperventilation, intermittent photic stimulation and sleep enhance the epileptiform abnormalities and also help to identify seizure precipitating factors. Absence seizures have a special tendency to get precipitated during hyperventilation. The photoparoxysmal response, defined as the occurrence of generalized spike, spike-wave or polyspike wave discharges consistently elicited by intermittent photic stimulation,49 has a high correlation with primary generalized epilepsy.13,50 A proportion of patients with photosensitivity may exhibit a similar EEG response to geometric patterns.13,50 There are some racial differences in the reported prevalence of photoparoxysmal response. In White subjects with epilepsy it varied between 4 to 6 .49-51 A lower prevalence was reported in the African and Asian population with epilepsy, 0.4 to 1.6 .52-54 However, in a recent study from south India, the prevalence was similar to the studies among Whites, 3.5 .55 The wide variations...

Impact on Health and Quality of Life

Cognition, and motor deficits are perceived as severe deficits, greatly reducing quality of life. Initial stroke symptoms include weakness in 88 of stroke survivors, sensory deficits in 50 , and visual, cognitive, or speech impairments in 30-48 . Depression affects almost one-third of patients with stroke and half of those with left frontal lobe stroke. Caregivers are susceptible to anxiety (58 ), depression (50 ), fear, frustration, impatience, and resentment. Functional impairments following stroke may become the responsibility of these caregivers if other sources of social support are not sufficient, and such caregivers may be forced to leave the workforce temporarily or permanently. These intangible and indirect costs of stroke are among the most devastating to the family and the most difficult to measure. Thus, stroke substantially diminishes caregiver quality of life, and only recently have quality of life assessments begun to reveal the true impact of cerebrovascular disease.

Symptoms and Treatment

Visiting the GP with vague abdominal symptoms may cause the patient anxiety, because the diagnosis may result in a serious condition. The GP has only an allotted time to see the patient, take the history, perform an examination and arrive at a diagnosis. Patients are not always good at describing their symptoms concisely and accurately when asked. Many patients are unable to name parts of their bodies when giving a history tummy ache is usually a general description of abdominal pain without being specific to the actual location (Thompson and Patel, 1986). This can present the GP without a complete picture on which to base diagnosis and could result in the patient being referred to a rapid access clinic. These clinics have been set up to fast-track suspected colorectal cancer.

Energy Adaptation and Susceptibility to Leanness and Fatness

Instead, body weight tends to fluctuate or oscillate around a mean constant value, with deviations from a set or preferred value being triggered by events that are cultural (e.g., weekend parties and holiday seasons), psychological (e.g., stress, anxiety, or emotions), and pathophysio-logical (ranging from minor health perturbations to more serious disease states). Very short-term day-today changes in body weight have a standard deviation of approximately 0.5 of body weight, whereas longitudinal observations over periods of between 10 and 30 years indicate that individuals experience slow trends and reversal of body weight amounting to between 7 and 20 of mean weight. In such a dynamic state within which weight home-ostasis occurs, it is likely that long-term constancy of body weight is achieved through a network of regulatory systems and subsystems through which autoregulatory changes in food intake, body composition, and energy expenditure are interlinked.

Correlates of Success and Failure

There appear to be a variety of factors that are associated with treatment failures. A high frequency of wetting prior to treatment and a tendency for parents to punish the child for enuretic episodes tend to correlate with failed treatment. Children that tend to display a good deal of deviant behavior and those living in a dysfunctional family environment do not do well. Maternal anxiety, failure of the child to awaken in response to the alarm, the absence of parental concern over nighttime wetting, the absence of any distress on the part of

Nonconvulsive Status Epilepticus

Spike, multiple spikes and slow waves in various combinations or may be indistinguishable from that of generalized NCSE.69,71 Attenuation of epileptiform activity with intravenous administration of benzodiazepines with marked improvement in consciousness and responsiveness is characteristic of NCSE.

General Principles Of The Developmental Approach

Children are best approached in a positive and gentle manner, with an awareness that the first impression sets the tone for the encounter. Review the emergency record for patient name and age so that an introduction and a developmentally structured interaction may be planned. An awareness of the child's age-related communication skills and perspective will result in a more meaningful evaluation. Whenever possible, look at the child from his or her own eye level. Use the child's motor skills, vocabulary, and specific life experiences as reference points. Hunger, discomfort, fear of separation or pain, and feelings of loss of control should be directly addressed. Recognize that the emergency department is a strange and threatening environment and, whenever possible, isolate the child from the sights and sounds of other patient care experiences that may heighten their own anxiety. Most importantly, be honest with children regarding expectations for their experience so that trust can be...

Late Infancy 6 to 18 Months

NEUROLOGIC ASPECTS The normal infant sits with minimal support, transfers objects from hand to hand, and babbles by 6 months. By 9 months of age, the infant is crawling, pulling to a standing position, and verbalizing with nonspecific jargon. By 12 months, the infant has a mature pincer-type grasp, begins to walk, and acquires specific words. The developmental combination of mobility and grasp results in increasing risk of toxic and foreign-body ingestion. Between 9 and 12 months, a strong sense of stranger anxiety, related to fear of separation from parents, is acquired and complicates every aspect of physical assessment. Conversely, the failure of an older infant or toddler to recognize and preferentially respond to parents suggests significant disease. should see the examiner approach gradually and engage his or her caretakers first. An entire examination requiring any degree of cooperation is best performed while the child is held on the parent's lap or shoulder so that perception...

Applications And Exclusions

Some may not know how to rearrange cues and consequences related to outcomes of interest. Contraindications to use of bibliotherapy include limited reading ability and small probability that the client will follow instructions, perhaps because of personal or environmental obstacles. Countervailing personal characteristics include high anxiety that may interfere with successful use of material. Written material may not address key related factors, for example, excessive alcohol drinking may be maintained by peer support and written material may not address this. Literature on behavior change suggests that practice is related to acquiring new skills. Thus, arranging such practice will be needed, and this will require related self-management skills. Effective use of bibliographic methods requires generalization and maintenance of valued behaviors. This also requires self-management skills. Many clients do not have the self-management skills required to make effective use of...

Links between behavioural symptoms and clinical disease

Case in any species it is important to remember that alterations in behaviour can also be associated with the presence of clinical disease. In a feline context, links between lower urinary tract disease (FLUTD) and indoor house soiling highlight the need for any animal presented with a potentially behavioural condition to be given a full clinical examination before any attempts at behavioural therapy are instituted. Cats with a history of FLUTD are not only overrepre-sented among cats that are referred for problems of house soiling (Olm & Houpt, 1988) but also presented in behavioural practice as a result of over-grooming, especially over the caudal lower abdomen. It is important to remember that pathological conditions can lead to continuing behavioural issues even when the disease condition has been resolved, and problems of both house soiling and overgrooming may continue when FLUTD appears to be clinically resolved. Diabetes mellitus has also been diagnosed in cats that were...

Common Misconceptions

Special follow up after the procedure. Although sedation may suppress the arrhythmia it will often alleviate the anxiety experienced by the patient before and during the procedure. (5) Ablation should be reserved for patients failing antiarrhythmic drugs Ablation for most SVT has such a low complication rate and high success rate that it is more cost effective and may be safer than antiarrhythmic drugs.

Neurobehavioral Problems

Neurobehavioral sequelae are a consequence of both the client's reaction to loss of ability and neurophysiological changes in the brain. Researchers have found that behavioral and emotional problems cause greater impairments in family and emotional functioning than neuropsychological and physical disabilities. Behavioral problems related to depression, anxiety, and social withdrawal have been shown to be predominant.

Empathyrelated responding and prosocial behaviour

Empathy can also lead to personal distress. Personal distress is a self-focused, aversive affective reaction to the apprehension of another's emotion (e.g. discomfort, anxiety). As for sympathy, personal distress sometimes may stem from empathy if the empathic response is experienced as too arousing and as aversive. However, it is also possible that personal distress sometimes stems from other emotion-related processes (e.g. guilt) or from retrieving certain information from mental storage.

Explanation and reassurance

Patients and carers should receive as full an explanation as possible of the factors contributing to their breathlessness and possible management strategies. Breathlessness is a symptom frequently accompanied by fear and anxiety these components should be identified to help understand the patient's whole experience of breathlessness. A calm, cohesive, team-orientated approach is particularly useful in allaying patient and carer anxiety. Allowing patients to explore fears and difficulties associated with breathlessness, and to identify losses with respect to activity levels and lifestyle, may assist in the relief of the patients' distress.

Assisted Covert Sensitization

In covert sensitization, the aversive stimulus usually consists of an anxiety-inducing or nausea-inducing image that may be presented verbally by the therapist or imagined by the client. The aversive scene is individually created, and is specific to each client's problem behavior. Covert sensitization has frequently been successfully employed by itself (as described by Brownwell and Barlow in 1976 Curtis and Presley in 1972 Dougher, Crossen, Ferraro, and Garland in 1987 Haydn-Smith, Marks, Buchaya, and Repper in 1987 Hayes, Brownwell, and Barlow in 1978 Hughes in 1977 King in 1990 Mc-Nally and Lukach in 1991 and Maletzky and George in 1973) as well as in combination with other techniques (as discussed by Kendrick and McCullough in 1972 Moergen, Merkel, and Brown in 1990 Rangaswamy in

Chemicals Reducing Arousal

A second body of work concerns the effects of drugs intended to reduce arousal. Most of the drugs used in this kind of research are administered for clinical purposes, and relatively few studies are experimental tests on normal subjects. However, one of Schachter's early studies was just such an experiment. Schachter and Wheeler (1962) administered epinephrine to one of their experimental groups, but another group received chlorpro-mazine, which Schachter and Wheeler describe as an epinephrine antagonist. The chlorpromazine group did exhibit a drop in amused behavior. However, this result suffers from the same problem that was noted in regard to drugs that increase arousal, namely, that chlorpromazine may very well work in the brain, rather than just changing the amount of peripheral arousal. Indeed, most antianxiety drugs are assumed to work centrally, in ways that are irrelevant to self-perception theory.

Clinical Features

Clinical findings in a child with pneumonia are highly variable and are dependent on the specific respiratory pathogen, age, the severity of the disease, and any underlying illnesses. Tachypnea is the most frequent sign of pneumonia in children and may be an otherwise isolated finding. The best physical examination finding for ruling out pneumonia in an infant or child is the absence of tachypnea. 25 However, tachypnea is a nonspecific symptom and may occur secondary to fever, anxiety, metabolic disease, cardiac disease, or other respiratory problems. Fever can increase an infant's respiratory rate by 10 breaths per minute for each degree centigrade of elevation.26 Respiratory rates should be counted over 1 min. Several studies have shown that rates counted over less time tend to overestimate the rate. Generally accepted standards for tachypnea in an infant or child are shown in Table 119-2 '

NonST Segment Elevation Myocardial Infarction Nstemi and Unstable Angina

-Morphine sulfate 2-4 mg IV push prn chest pain. -Acetaminophen (Tylenol) 325-650 mg PO q4-6h prn headache. -Lorazepam (Ativan) 1-2 mg PO tid-qid prn anxiety. -Zolpidem (Ambien) 5-10 mg qhs prn insomnia. -Docusate (Colace) 100 mg PO bid. -Ondansetron (Zofran) 2-4 mg IV q4h prn N V. -Famotidine (Pepcid) 20 mg IV PO bid OR -Lansoprazole (Prevacid) 30 mg qd.

Raymond G Romanczyk and Jennifer M Gillis

Keywords autism, autism spectrum disorder, fears phobias, Asperger's disorder, social skills anxiety Autism, Asperger's Disorder, and PDD-NOS are heterogeneous disorders. Diagnostic criteria encompass a wide range of specific symptoms, which can vary substantially in their expression from individual to individual. Comorbidity is also an important factor with respect to heterogeneity as autism can occur with other disorders or conditions such as fragile X disorder, Anxiety Disorder, mental retardation, or epilepsy. While many hypotheses exist as to etiology, the cause (s) remains unknown. It is clear that these disorders have a neurobiological basis. However, the specific mechanisms and links between pathophysiology and behavior remain unidentified. These disorders are most likely present at birth, but may not manifest for several years. There is currently no physical or medical test for these disorders.

The Need for Genetic Counseling

On the other hand, a family member who was spared a genetic disorder that other family members developed frequently suffered survivor guilt. Health-care providers also noted that family members at risk for developing a late-onset disorder live with intense anxiety about the future and often needed support and counseling. Finally, counseling was seen to be of potential help for family members who incorrectly inferred that they were at risk for having a child with a genetic disorder. Attempts to meet these varied needs and help give people a sense of control over their situation resulted in the emergence of a model of genetic education and support that came to be called genetic counseling.

Drug Treatment of Mania

The diagnosis of mania is made on the basis of clinical history plus a mental state examination. Key features of mania include elevated, expansive or irritable mood accompanied by hyperactivity, pressure of speech, flight of ideas, grandiosity, hyposomnia and distractibility. Such episodes may alternate with severe depression, hence the term ''bipolar illness'', which is clinically similar to that seen in patients with ''unipolar depression''. In such cases, the mood can range from sadness to profound melancholia with feelings of guilt, anxiety, apprehension and suicidal ideation accompanied by anhedonia (lack of interest in work, food, sex, etc.).

TABLE 1215 Doses for Status Epilepticus in Children

Absence seizures (petit mal) rarely require emergency care, and an EEG should be obtained for confirmation before one starts AEDs, since absence seizures could mimic partial status and an AED such as ethosuximide will be ineffective. Valproate, ethosuximide and, more recently, lamotrigine are the appropriate AEDs for absence epilepsy chronic management, with the benzodiazepines effective in the acute management of status absence epilepticus.

Toxicology Suffocation and Smothering

In plastic bag suicides, ethanol is present in about one-fifth to one-third of cases (257,307,309). Certain drugs (benzodiazepines, diphenhydramine, antidepressants) are commonly found (307). Above-therapeutic concentrations and toxic and fatal levels of medications occur (307,309).

Physiological Factors

Unlike previous theories, the somatization model embraces the idea that normal physical processes (e.g., the physical component of an emotional state) and minor pathological events may contribute to the development of unexplained symptoms. For example, anxiety is typically associated with increased auto-nomic arousal that may result in physical changes such as shaking, sweating, and tachycardia moreover, fear-related hyperventilation can produce symptoms such as breathlessness, chest pain, and fatigue. Similarly, the sleep problems and physical inactivity often associated with depression may give rise to fatigue, pain, and the feeling that increased effort is required to execute everyday tasks. Other physical processes unrelated to emotional states may also contribute to the development of medically unexplained symptoms. For example, muscle wasting resulting from illness-related inactivity may produce fatigue that perpetuates itself by preventing the resumption of physical exercise...

Theoretical Bases

The relationship between disordered breathing and psychological-psychiatric disorders is not broadly understood. Part of the reason for this probably harks back to the separation of body and mind or corpse and spirit life begins with inspiration (the body incorporating the spirit) and ends with expiration (the body giving up the spirit). Although few scientists would openly support the Descartian notion of body-mind dualism, some would argue that there is a clear distinction between psychology and physiology beyond that of a convenient dialectic convention within biology. A simple example from respiratory psychophysiology that demonstrates how breathing provides a bridge between psychology and physiology is volitional overbreathing. Self-initiation of rapid and strong contractions of the diaphragm and intercostal muscles while resting (i.e., low metabolic demand for oxygen) will lead quickly to hyperventilatory hypocapnia (diminished arterial CO2 and consequent rise in pH) and produce...

Management of breathlessness in the terminal phase

Midazolam is a very effective, short acting anxiolytic that is well absorbed subcutaneously in our experience small doses, e.g. 5-20mg 24h may be adequate to relieve fear and anxiety associated with breathlessness at the end of life in patients with advanced neurological disease. Where terminal agitation is contributing to symptom distress at the end of life, higher doses of midazolam are often required. Alternative drugs in this setting would include antipsychotics, such as levomepromazine (25-100mg 24h) or haloperidol (3-5mg 24h). Diamorphine is effective in relieving the sensation of breathlessness, again used in low dose, e.g. 5-10mg 24h. These drugs can be mixed together in a CSCI given via a syringe driver.

Fluid Resuscitation

Appropriate fluid replacement should be instituted promptly. Water and electrolyte losses occur secondary to polyuria caused by the osmotic diuresis produced by glycosuria, hyperventilation, vomiting, and diarrhea. Dry mucous membranes, poor skin turgor, and orthostatic hypotension in the older child are the most accurate clinical indications of dehydration. Virtually all patients with DKA are at least 5 to 10 percent dehydrated and require both maintenance and replacement fluid therapy. However, fluid resuscitation that is too aggressive can result in cerebral edema, the most lethal complication of DKA. For initial rehydration, 10 to 20 mL kg h of 0.9 NS solution should be given for the first 1 to 2 h of resuscitation to establish adequate vascular volume and improve tissue perfusion. If signs of shock are present, a 20 mL kg bolus of 0.9 normal saline solution should be given and may need to be repeated if dehydration and shock are severe. However, for the majority of patients, the...

Courtship and Marriage

Once a person decides that a particular individual fits their ideal, or comes close to most of their criteria, there is a pronounced tendency to fantasize about the other, which can often result in one becoming overwhelmed with romantic anticipation. It was common for individuals who entered into a more formal courtship to become infatuated after a marital agreement had been reached. Romantic infatuation may arise in either form of courtship and is characterized by emotional intensity, a kind of anxiety, expressions of romantic endearment, and the idealization of the other. The two styles differ only in the domain of public expression but not necessarily the intensity of involvement. In the countryside, the two forms of dating continue.

Pure Autonomic Failure

They also had much lower scores on the Hamilton Anxiety Scale (Critchley, Mathias, & Dolan, 2002). Caution is certainly appropriate in interpreting these results for at least two reasons. One is simply the general uncertainty attached to the interpretation of any life-changing disorder. The second is that PAF sufferers might have sustained some damage to the central nervous system that simply has not been identified yet. Nonetheless, the results appear on face value to be especially strong support for the necessity of arousal for intense emotional experiences, particularly of anxiety and distress.

Husband Wife Relationship

Those couples who enjoy one another's company and accommodate, if not actually enjoy, their spouse's personality style and individual quirks seem to have the more couples in satisfactory marriages. In addition to acceptance of a spouse's personality, couples in satisfactory marriages communicated their anxiety, especially fears of losing the other's love.

Benefits of Informed Consent

Approaching the issue of informed consent, we may, as clinicians, fear that providing adequate information to clients and explicitly obtaining their consent will somehow derail therapy and may in fact have detrimental consequences for our clients. The research has not supported these fears. The process of informed consent tends to be beneficial. A variety of studies have indicated that the use of informed consent procedures makes it more likely that clients will become less anxious, follow the treatment plan, recover more quickly, and be more alert to unintended negative consequences of the treatment (Handler, 1990).

Prevalence Of Psychosocial Distress

Although there is a great deal of variability in individuals' responses to the challenges of providing care, family caregiving is associated with higher rates of psychosocial distress and mental health problems. This is especially true for family caregivers of individuals with dementia. Studies of dementia family caregivers have found elevated rates of depressed, irritated, and anxious mood, clinical depression, and generalized anxiety disorder among this population. In addition, dementia family caregivers tend to report poorer perceived sleep and general health, and an increased use of psychotropic medications (Ory et al., 2000). These declines in psychosocial functioning not only affect the caregivers' general well-being and quality of life, they also can affect their ability to provide care. Thus, interventions that aim to reduce caregiver psychosocial distress are extremely important. Before we begin our review of such interventions, however, we want to highlight that levels of...

Epidemiology Of Depression

And emotional consequences of depression. Almost 75 of individuals who reported a lifetime history of depression also reported experience with one or more other psychiatric disorders, including anxiety disorders (58 ) and substance use disorders (39 ). Up to 15 of individuals with severe major depressive disorder will attempt to commit suicide.

Objective Nonself Report Pain Assessment

Physiologic changes from pain include tachycardia, tachypnea, crying, sweating, blood pressure elevation, decreased oxygen saturation, pupil dilation, flushing or pallor, nausea, and muscle tension. These parameters can be muted in persistent pain and can be confounded by fear, anxiety, or fever. Specific behaviors associated with pain include withdrawal of the painful part, pulling ears, or refusing to use a body part. The characteristic facial features of an infant in pain have been described brows lowered, drawn together forehead bulge between brows, vertical furrows eyes tightly closed cheeks raised nose broadened, bulging mouth open, squarish.

Elaboration Likelihood Model

Or anxiety (as employed in the so-called lie detection or polygraph procedure). However, this assumption has proven difficult to substantiate, and it is probably best to consider it merely as a general measure of physiological arousal. See also EMOTIONS, THEORIES LAWS OF. REFERENCES

Psychological wellbeing

Twenty studies - nine RCTs, eight non-randomized studies, and three observational studies - found that exercise training - with or without other cardiac rehabilitation services -generally results in decrease in anxiety and depression and improved physical function.6 Exercise is therefore recommended to enhance psychological wellbeing, particularly when it is one component of a multifactorial rehabilitation program. Studies of exercise training in a supervised group setting as a sole intervention do not show consistent improvement in anxiety and depression. Studies of exercise training as a sole intervention are confounded by the consequences of group interactions, formation of social support networks, peer and professional support, and counseling and guidance, all of which may affect depression, anxiety, and self-confidence.

Presymptomatic Testing

Presymptomatic testing (that is, testing a healthy person before symptoms appear) may be considered for a genetic disorder for which there is a family history. The decision to undergo this type of testing is not usually straightforward and should always be accompanied by genetic counseling. There are a number of considerations to take into account when deciding whether to proceed with testing. The first is the usefulness of the information. How will knowing the genetic information benefit the person Testing is more favorable when preventive treatment is available, when results might have a significant impact upon life decisions, such as having children or getting married, or if it will ease extreme anxiety to learn one's genetic status. If no treatment is available, as in the case of Huntington's disease and other triplet repeat diseases, the information may be of less benefit. In some cases it may even be psychologically harmful.

Pharmacological intervention

Drug classes that have been advocated for the treatment of fear-related behaviours in cats include benzodiazepines, barbiturates, P-blockers, tricyclic antidepressants and monoamine oxidase inhibitors (Bishop, 2001). As with behavioural therapy, it is important not simply to transfer treatment regimens from the canine world, and to consider the differences between cats and dogs in terms of metabolism and potential side-effects. Some authors have advocated combination therapy using drugs from more than one class, for example using phenobarbitone and propanolol in combination. Anecdotal results have been promising, but there is a lack of scientific evidence to support this therapy. Benzodiazepines have very limited application in the treatment of fears in cats owing to the potential hepatotoxic side-effects, and when cats are allowed access to outdoors the effect of diazepam on depth perception can lead to problems in relation to traffic and the risk of road accidents. Tricyclic...

Nature And Effectiveness Of

Cognitive-behavioral treatments of GAD have differed in their nature and emphasis. Early approaches consisted of biofeedback, relaxation therapies, and anxiety management training with later combinations of cognitive and behavioral strategies. The cognitive therapy component has been based around self-instructional training or the cognitive methods of Beck and Emery (1985). Controlled trials with DSM-III-R-or DSM-IV-diagnosed GAD patients demonstrate that cognitive-behavioral treatments are associated with significant clinical improvement. Moreover, these studies show that treatment gains are maintained at 6 and 12 months following the end of therapy. In one study there was evidence of maintenance of gains at 2 years (Borkovec, Newman, Pincus, & Lytle, 2002). Cognitive-behavioral therapy (CBT) appears to be associated with the largest treatment effect when compared with anxiety management, nondirective psychotherapy, or psychoanalytic psychotherapy (Durham et al., 1994). Fisher and...

Theoretical Approaches

Advances in treating pathological worry in GAD should emerge from a specification of cognitive factors involved in the escalation and persistence of worrying. Initial theoretical attempts and hypotheses concerning the function and origin of worry emphasized concepts of blocked emotional processing (Borkovec & Inz, 1990). Borkovec and colleagues suggest that worry is an attempt to avoid future aversive events. It may also divert attention away from negative thought intrusions in the form of imagery. Worrying itself can be negatively reinforced by its suppressing effects on aspects of somatic anxiety experience. The long-term consequences of this process include inhibition of emotional processing and the maintenance of anxious meanings. A detailed cognitive model of pathological worry and GAD was subsequently advanced by Wells (1995, 1997). The model emphasizes the role of metacognitive beliefs and metacognitive appraisals in the development and persistence of excessive and...

Aims Of Dynamic Psychotherapy

As trial action in thought, fantasy is a testing ground that serves as a refuge from the disappointment of wishes that cannot be fulfilled by reality. When the child is not yet able to give up certain wishes and has been unable to find acceptable alternatives for satisfying the underlying urges, fantasy may serve as both a retreat and as a means of titrating their intensity as new solutions are sought. Thus, fantasy can serve as a respite and as a staging ground on which new responses to internal and external demands and new solutions to conflicts can be practiced. Fantasy solutions themselves may prove to be enormous sources of anxiety and guilt. While serving as a retreat from conflicts aroused by disappointment and or by frightening reality, fantasy solutions for conflict can also become a distorting lens through which the child now perceives his or her world. These phenomena may best be demonstrated in the case of a child whose experience of real danger invokes fantasy solutions...

Therapeutic Tasks

For psychodynamic psychotherapists, children's play in the context of the clinical setting provides an important window into the inner life. The play themes, materials chosen, and the child's affects and verbalizations are viewed by the clinician as revealing complex aspects of the child's internal life of which he or she may be unaware and unable to verbalize directly. In the course of treatment and in the context of a developing therapeutic relationship, the clinician makes observations about the unfolding narratives that emerge in the play activities and what they reveal about children's conflicts, defenses, and consequent behaviors and modes of relating. The clinician does not comment on everything that is observed. The therapist chooses the material to be interpreted based on his clinical judgment about what is uppermost or closest to consciousness in the child's mind at that particular point in time. The clinician's goal in interpreting this material is to increase the child's...

Overview Of Group Therapy Models

The third approach placed individuals into the group who, ideally, had similar problems, e.g., depression or anxiety disorders. In some cases, the shared problem might be that all of the members were in the same treatment unit. The shared problem groups were generally held in hospitals or community mental health centers and combined both the intrapersonal and interpersonal foci with the group work specific to some area of mutual concern, e.g., reducing anxiety. In inpatient hospital-based units, for example, patients are automatically entered into a psychoeducational group, even if formal group therapy is not prescribed.

Psychiatric and Psychological Problems

Psychiatric and psychological problems develop related to loss of independence and impairments of body image. Depression, severe uncontrolled anger, panic attacks, and temper tantrums can make care of these children difficult. Most difficulties of this type can be handled on an outpatient basis by a psychologist, social worker, or physician experienced in working with this population. For severe depression, suicidal ideation, or other emotional problems that are out of control, hospitalization and or psychiatric evaluation may be needed.

Misattribution and Cognitive Dissonance

Dissonance theory presumes that the arousal of cognitive dissonance is like the arousal of other unpleasant feeling states, such as anxiety or fear. If dissonance is like other negative, aversive states, we might expect that dissonance would be accompanied by arousal, and indeed it is. After a person makes counterattitudinal speeches or statements, arousal indices are raised (e.g., Cooper et al., 1978 Croyle & Cooper, 1983). Presumably this arousal leads to the unpleasant feelings of dissonance and therefore could be misattributed away. In a number of studies, research participants made counterattitudinal speeches and then were led to attribute their arousal to a pill or other actually neutral characteristics of the situation. When dissonance-produced arousal was misattributed to other neutral features of the experiment, participants did not change their attitudes (Losch & Cacioppo, 1990 Zanna & Cooper, 1974). Stepping back a little further, misattribution techniques have consistently...

Ongoing Ethical Concerns in the Practice of Behavior Therapy

Researchers have also validated a number of computerassisted and administered treatments using virtual reality and computer-assisted interviewing to treat panic disorder (Newman, Kenardy, Herman, and Taylor), anger (Timmons, Oehlert, Sumerall, Timmons, et al.), acrophobia (Vincelli), and problem drinking (Hester and Delaney). To the extent that these treatments have been found to be as effective as their human-delivered counterparts, they pose no more ethical concerns than do other behavioral therapies. However, there is a danger that untested approaches and methods will be used, possibly to the detriment of patients, and it is incumbent upon all behavior therapists to insure that computer or Internet-based treatments are subjected to thorough research testing prior to full dissemination.

Neurologic Complications

AIDS DEMENTIA AIDS dementia complex (also referred to as HIV encephalopathy or subacute encephalitis) is a progressive process commonly heralded by subtle impairment of recent memory and other cognitive deficits caused by direct HIV infection. In the early stages, diagnosis can be confused with depression, anxiety disorders, or substance abuse. Later phases of the illness are characterized by obvious changes in mental status and more severe disturbances, including aphasia and motor abnormalities. When a patient presents to the emergency department with an established diagnosis of AIDS dementia, with progressive signs or symptoms, it is important to rule out other CNS processes. A computed tomography (CT) scan in AIDS dementia typically shows cortical atrophy and ventricular enlargement.

Psychiatric Disorders

Management of HIV-positive patients with psychiatric complaints must include attention to violent behavior and suicidality. Assessment and stabilization may require physical restraints and acute pharmacologic intervention. Neuroleptics and benzodiazepines may be used in combination. Haloperidol and diazepam are often used alternatives include droperidol (which has a rapid onset and short half-life) and lorazepam (which offers improved intramuscular absorption). 21

Neuropsychiatry Implications

Emotion is a topic of paramount importance to the diagnosis, treatment, and theoretical understanding of many neuropsychiatric disorders. The amygdala has received considerable attention in this regard and has been shown to be involved in disorders that feature fear and anxiety. Moreover, specific neurotransmit-ters, acting within the amygdala and surrounding structures, have been shown to contribute importantly to fear and anxiety. Anxiolytic drugs such as valium

Mark A Reinecke and Joseph B Dilley

Keywords health anxiety, hypochondriasis, cognitive-behavioral therapy Anxiety is not fear, being afraid of this or that definite object, but the uncanny feeling of being afraid of nothing at all. The irony implied in William Barrett's (1958) observation of pronounced, but unnecessary apprehension is perhaps nowhere more salient than in the experience of health anxiety. Health anxiety is the relatively new term for the phenomenon conventionally referred to as hypochondriasis. Hypochondriasis is defined by the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition, Text Revision (DSM-IV-TR) as a misinterpretation of bodily symptoms that results in preoccupation with fears of having, or the idea that one has, a serious disease, despite medical evaluation and reassurance (American Psychiatric Association, 2000). In short, hypochondriasis is severe health anxiety (Salkovskis, 1989). Hypochondriasis is bound by explicit definitional parameters not common to the more general...

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