Latest Cure for Anxiety Attacks

Panic Away End Anxiety and Panic Attacks

Panic Away, developed by Barry McDonagh uses the 21/7 technique. It means doing a twenty one second countdown followed by seven second exercise. These are easy and can be done anywhere. Moreover, there are a number of different exercises too, both mental (including affirmations, visualization, and breathing techniques) and physical to help the stages along. The two main goals of Panic Away are to stop panic attacks and to eliminate general anxiety and the 21 7 Technique is the core of the Panic Away program. Barry McDonagh describes the 21 7 technique as first aid for anxiety and it is made up of two components: 1. The 21 Second Countdown Technique which is designed to stop panic attacks, and 2. The Seven Minute Exercise which is designed to reduce general feelings of anxiety. The best thing about this eBook is that its simple and detailed course. Moreover, audio series, video presentations, 60-Day money back Guarantee, members forum and the one on one coaching and counseling with Barry made this program very affordable for me. More here...

Panic Away Summary


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Highly Recommended

This is one of the best books I have read on this field. The writing style was simple and engaging. Content included was worth reading spending my precious time.

As a whole, this manual contains everything you need to know about this subject. I would recommend it as a guide for beginners as well as experts and everyone in between.

The Effects of Anxiolytic Drugs

In a massive review of the literature, Gray (1977) attempted to identify the behavioral effects of anxiolytic drugs or minor tranquilizers, the underlying psychological processes altered by these drugs, and the brain structures involved in these effects of minor tranquilizers. Although numerous other papers addressed the second and third questions, this publication provided the definitive answer to the first question. In order to conceptually organize this literature, Gray provided a brief summary of a theoretical context derived from animal learning, taken from his earlier book-length presentation (Gray, 1975). In this view, organisms are seen as maximizing exposure to rewarding (appetitive) events and minimizing exposure to punishing (aversive) events. Rewarding or appetitive events consist of presentation of a reward (Rew), termination of punishment (Pun ), or omission of an expected punishment (nonPun), while punishing or aversive events consist of presentation of punishment...

The Behavioral Inhibition System and the Effects of Anxiolytic Drugs

The effects of the anxiolytic drugs map nicely onto the stimuli that activate the BIS and the response-inhibitory effects of the BIS, allowing the elegantly simple proposal that anxiolytic drugs antagonize the BIS. Two experimental paradigms were important in showing that this effect was not just one of disinhibiting behavior, but rather included the emotional arousing aspects of the BIS. The first had to do with the partial reinforcement acquisition effect (PRAE). In the alley runway, it is often found that at the end of training, animals receiving reward only 50 of the time (on a random schedule) run faster than animals receiving 100 reinforcement. This PRAE is abolished by anxiolytic drugs, which is noteworthy, because this reduced behavioral vigor is the opposite of the disinhibition seen in most of the paradigms affected by anxiolytic drugs. The PRAE can be understood, however, by attributing the increased running speed to the BIS-produced arousal associated with its processing...

The BIS and the Neural Substrate for an Anxiety System circa 1976

During the 1970s, Gray published several papers proposing that the BIS is the anxiety system that is, with titles such as The Neuropsychology of Anxiety or A Neuropsychological Theory of Anxiety (Gray, 1976b, 1978, 1979) and The Behavioural Inhibition System A Possible Substrate for Anxiety (Gray, 1976a). The compelling logic of calling the BIS the anxiety system was that (1) he had demonstrated that a behavioral system largely conceptualized on the basis of the animal learning literature was antagonized by the anxiolytic drugs and (2) the function of the BIS is to process CSs for aversive outcomes (punishment, frustrative nonreward), as would be expected for an anxiety system. Gray had then proceeded to map the BIS and the effects of anxiolytic drugs onto structures in the central nervous system (CNS). On the basis of a similarity between the behavioral effects of lesions and the behavioral effects of anxiolytic drugs, the septal area and the hippocampus had emerged as key structures...

Psychopathology as Related to Systems Underlying Personality Anxiety Disorders

The obvious application of Gray's work to psychopathology is to anxiety disorders. As already discussed, Gray and McNaughton (2000) related the BIS to GAD and the fight-flight system to panic attacks and responses to phobic stimuli. This conceptualization plays a central role in Barlow's (e.g., 2000, 2002) comprehensive theory of the anxiety disorders, and Barlow cites Gray's work as a basis for some of his theorizing. In addition, Gray and McNaughton (pp. 34-35, 289-290) proposed that the well-established strong cognitive attentional components (an excessively strong focus on potential threats) of GAD can be understood as manifestations of excessive activity in the BIS. As noted above, Gray and McNaughton (2000) viewed the BIS as activated only when danger stimuli must be approached and when stimulus input produces conflict between incompatible goals. In their theoretical approach, by definition, only BIS activation constitutes anxiety. In consequence, they suggested that neuroticism...

Fear anxiety and stress

Fear, anxiety and stress are related but slightly different phenomena. Fear is obviously an anticipation of an event, but often with an unknown outcome. Information from the periphery, including the eyes and ears, as well as our memory and thinking processes can stimulate a feeling of fear. The feeling becomes anxiety when focused on a particular event or situation, such as an examination or a visit to the dentist, or an operation. However, some people do experience what is known as 'free floating' anxiety, which does not seem to have a focus. Stress is a word that refers to the stimulus and to the response. The use of the word stressor as the threat or stimulus helps to clarify things, with the word stress as the response (Lazarus and Folkman 1984). Cannon and Baird (1929 and 1934 respectively) first identified the psychological and physical links embodying anxiety. They argued that this response created three alternative reactions fright, flight or fight. There are both physical and...

The experience of anxiety and fear

Some people get a sense of thrill from putting themselves in a fear-provoking situation, but one in which there are safeguards against anything actually happening. Thus frightening and horrifying films can be 'enjoyed' from the safety of a cinema seat, or one's own sitting room. Similarly some sport and other recreational activities can offer the thrill of fear as part of their attraction. However, real fear, of an event over which one has little or no control, is a rather different thing. Here there is a physiological reaction and a mental response that is far more acute than anything offered in the cinema or sport. In many ways one would expect feelings of fear and anxiety to be experienced prior to surgery for example or before a visit to the dentist. Most people will have experienced the latter, and

Social Anxiety Disorder

The essential feature of social phobia is a marked and persistent fear of performance situations when patients feel they will be the centre of attention and will do something humiliating or embarrassing. The situations that provoke this fear can be quite specific, for example public speaking, or be of a much more generalised nature involving fear of most social interactions, for example initiating or maintaining conversations, participating in small groups, dating, speaking to anyone in authority. Exposure to the feared situation almost invariably provokes anxiety with similar symptoms to those experienced by patients with panic attacks but some seem to be particularly prominent and difficult i.e. blushing, tremor, sweating and a feeling of 'drying up' when speaking. TABLE I9.S Relative effectiveness of pharmacological treatments for anxiety disorders

General Comments On Drug Treatment Foranxiety Disorders

The effective dose of antidepressant for anxiety is generally higher than that for antidepressant effect and takes longer for improvements to be seen (at least 4-8 weeks compared to 2-3 weeks for depression). The patient should be maintained on as high a dose as can be tolerated for at least 8 weeks before changing a medication. Educating the patient is crucial to obtaining cooperation. The duration of treatment is often a controversial issue. Anxiety disorders (apart from the self-limiting acute stress reaction) are chronic conditions and may require treatment for as long as that used in depression. In a first episode, patients may need medication for at least 6 months, withdrawing over a further 4-8 weeks if they are well. Those with recurrent illness may need treatment for 1-2 years to enable them to learn and put into place psychological approaches to their problems. In many cases the illnesses are lifelong and chronic maintenance

Mediating Mechanisms Motivation versus Anxiety

The developmental predictions regarding how susceptible children are to CL and AL might be further explained by differences in the mechanisms that are triggered by these labels. Mainly, there are two main explanations that have been used to interpret the significant effects in the gender labeling studies. Initially, the results were explained in terms of motivational factors (e.g., Bradbard et al., 1986 Davies, 1986, 1989 Helper & Quinlivan, 1973 Montemayor, 1974). For example, cognitive theories suggest that children do not explore, choose, or perform well in opposite-sex tasks because they are motivated to define themselves according to the gender norms set forth by society. In this view, children make value judgements according to their self-categorization as either a boy or a girl and seek to behave in ways consistent with these values. Similarly, the proposed mechanism by social learning or social cognitive theory is also motivation. Children's motivation to avoid doing well...

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

Mood And Anxiety Disorders

Almost one in five people will experience a significant mood or anxiety disorder at some stage in life. The lifetime prevalence rates of Diagnostic and Statistical Manual of Mental Disorders, third edition, revised (DSM-III-R) mood and anxiety disorders are shown in Table 11.1. As can be seen, the lifetime prevalence of major depression is almost twice as high for females as for males, and this is a robust finding in the literature (Blazer, Kessler, McGonagle, & Swartz, 1994 Breslau, Schultz, & Peterson, 1995 Kendler & Prescott, 1999 Newman, Bland, & Orn, 1988 Parker & Hadzi-Pavlovic, 2001). Anxiety disorders represent the most common comorbid diagnoses (Sanderson, Beck, & Beck, 1990). Like that of mood disorders, the prevalence of anxiety disorders is higher among females (Kessler et al., 1994). When based on the DSM-III-R, the lifetime prevalence for generalized anxiety disorder (GAD) in the United States is 3.6 for males and 6.6 for females. In reality, the...

Anxiety Animal studies

Musty et al. (1985) found CBD increased licking for water in the lick suppression test in a dose related fashion (mg kg). Equivalent effects were found with the classic anxiolytic drug diazepam. In an effort to find more potent effects, they tested two analogs, 2-pinyl-5-dimethylheptyl resorcinol (PR-DMH) and Mono-methyl canna-bidiol (ME-CBD-2). ME-CBD-2 had anxiolytic activity, but was less potent than CBD, while PR-DMH had no anxiolytic properities. Of the two active compounds, both were less potent than diazepam. a measure of anxiety or fear. Both CBD and diazepam decreased the amount of time spent in the enclosed arms. Since these studies were conducted, Petitet et al. (1998) reported CBD is an antagonist of the CBX receptor in the micromolar range suggesting that CBD may have pharmacological effects as an antagonist of the CBj receptor. Since the discovery of the synthetic, highly potent CBX receptor antagonist, SR 141716, by Rinaldi-Carmona, Barth, Heaulme et al., several other...

Genetic Epidemiology of Anxiety Disorders

Evidence for a genetic contribution to anxiety disorders is equally compelling and also comes from a variety of study designs (Chantarujikapong et al., 2001 Hettema, Prescott, & Kendler, 2001 Hudson et al., 2003 Kendler, Neale, Kessler, Heath, & Eaves, 1992b, 1992c Kendler, Walters, et al., 1995 Koenen et al., 2002 Mendlewicz, Papadimitriou, & Wilmotte, 1993 Noyes, Clarkson, Crowe, Yates, & McChesney, 1987 Scherrer et al., 2000 Skre, Onstad, Torgersen, Lygren, & Kringlen, 1993 Sullivan, Kovalenko, York, Prescott, & Kendler, 2003 Torgersen, 1983). Hettema, Neale, and Kendler (2001) meta-analyzed data from family and twin studies of panic disorder, GAD, phobias, and OCD. Their results based on the twin studies are summarized in Table 11.5. Three twin studies TABLE 11.5. Summary of Population-Based Twin Studies that Have Investigated the Genetic (A) and Environmental (C E) Etiology of Anxiety Disorders TABLE 11.5. Summary of Population-Based Twin Studies that Have...

Sources of Covariance among Neuroticism Mood Disorders and Anxiety Disorders

Based on data from the Australian Twin Registry, Jardine and colleagues (1984) examined the covariance between the symptoms of anxiety and depression, using a shortened version of the Delusion Symptoms States Inventory (Bedford & Deary, 1997 Foulds & Bedford, 1975) as well as the Neuroticism scale from the EPQ (Eysenck & Eysenck, 1975). Their results revealed that the phenotypic covariation between the two measures could be best explained by a single genetic factor common to both measures. There was no evidence for genetic factors specific to one measure and having no influence on the other. In a longitudinal design based on 1733 same-sex female twin pairs, Kendler and colleagues (1993b) have estimated that the proportion in the observed correlation between neuroticism and the liability to major depression that could be explained by a shared genetic risk was approximately 70 . In the same study, extraversion was unrelated to lifetime or 1-year prevalence of major depression....

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.

TABLE 163 Anxiety Disorders

Anxiety disorders cause great distress and impair function, but those affected are not psychotic. The disorders are distinguished by the symptoms, the entities feared, or the stressors. Panic Disorder Generalized Anxiety Disorder A panic disorder is defined by recurrent, unexpected panic attacks, at least one of which has been followed by a month or more of persistent concern about further attacks, worry over their implications or consequences, or a significant change in behavior in relation to the attacks. A panic attack is a discrete period of intense fear or discomfort that develops abruptly and peaks within 10 minutes. It involves at least four of the following symptoms (1) palpitations, pounding heart, or accelerated heart rate, (2) sweating, (3) trembling or shaking, (4) shortness of breath or a sense of smothering, (5) a feeling of choking, (6) chest pain or discomfort, (7) nausea or abdominal distress, (8) feeling dizzy, unsteady, lightheaded, or faint, (9) feelings of...

Anxiety Sensitivity and Anxiety

Within the field of cognitive risk factors for anxiety, one that has been attracting increasing attention is anxiety sensitivity. This is defined as the fear of anxiety sensations which arises from beliefs that these sensations have harmful somatic, social or psychological consequences (Taylor, 1999). Originally, anxiety sensitivity was proposed as a unitary construct that increases risk for anxiety in general and panic in particular. However, subsequent analyses of relevant data indicated the presence of subfactors within the construct. These two approaches were brought together by the proposal of a hierarchical factor structure, with one first-order factor and several (usually three) second-order factors (Zinbarg & Barlow, 1997). These second-order factors reflect concerns about physical phenomena (e.g., worry about fast heart rate), concerns about mental illness (e.g., worry about loss of cognitive control), and social concerns that apply to visible symptoms of anxiety (e.g.,...

State and Trait Anxiety

It has been recognized for some time that anxiety is not a unitary construct, but instead may be composed of various dimensions underlying different aspects of vulnerability to the phenotype (Smoller & Tsuang, 1998). One common distinction that has been made is between state anxiety and trait anxiety (Spielberger, 1966). State anxiety is the transitory pattern of emotions elicited by environmental stressors, including physiological arousal and symptoms of apprehension, worry, and tension. It therefore represents the environmentally reactive component of anxiety. Trait anxiety, however, refers to individual differences in the predisposition to respond to threatening situations, and is often characterized as a personality disposition toward anxiety. Although both of these independently define anxiety, it is the association between the two the expression of trait anxiety as state anxiety that may be suggestive of how vulnerability to anxiety symptoms is expressed. Specifically,...

Effects on Anxiety and Insomnia

Cannabis smoking produces a relaxant effect which most users value and it has been suggested that the beneficial effects of cannabis and THC observed in neurological disorders such as motor tics, dystonias and Huntingdon's chorea are due to sedative and anxiolytic actions. In addition, sedation is by far the most common side effect of cannabis, and in particular THC, observed in clinical trials against a range of disorders. This has lead to the suggestion that cannabis and some cannabinoids may be useful in disorders accompanied by anxiety and or insomnia. Sethi et al. (1986) noted a reduction of anxiety in 50 chronic cannabis users compared to controls, in terms of scores on the Taylor Manifest Anxiety Scale. Oral preparations of cannabis have a sedative or tranquillising effect in man, accompanied by diminished anxiety at doses much lower than those producing psychoactivity (Graham and Li, 1976). However, anxiety and panic, possibly due to depersonalisation, intoxication and loss of...

Grays Later Theory Of Anxiety

In the interest of saving space, we can now skip forward to the last comprehensive summary of this work on anxiety (Gray & McNaughton, 2000), entitled The Neuropsychology of Anxiety An Enquiry into the Functions of the Septo-Hippocampal System (2nd ed.). This work was published with Gray's one-time student Neil McNaughton, who was for many years his colleague collaborator and now is the heir apparent to this approach to anxiety and anxiety disorders. Although McNaughton was a major contributor to this 2000 revision of the earlier book (Gray, 1982), their collective effort constitutes an excellent statement of the evolution of Gray's contributions. A more recent review of the theory with revisions by McNaughton and Corr (2004) is highly recommended, but it is not included here because Gray was not involved. The first part of the present summary describes the continuity and change with respect to the core theory already described, while the second part describes the expansion of the...

Behavioral Genetic Studies Of Anxiety And Depression

Behavioral genetic studies seek to understand the causes of variation in behavioral outcomes (for an introduction to the study of behavioral genetics, the reader is referred to Plomin, DeFries, McClearn, & McGuffin, 2001). These causes can be divided into those that are genetic and those that can be attributed to the environment. Indexing and quantifying these different sources of influence form the basis of most behavioral genetic designs (see Table 16.1). Through such twin and family studies, the importance of genetic factors in the etiology of anxiety and depression in childhood and adolescence has now been well accepted. Estimates of heritability typically account for about a third of the variance in anxiety symptoms, with the remainder of the risk being attributable to moderate shared environmental influences and substantial nonshared environmental influences (Eley & Gregory, 2004). For depression, a similar profile of effects is obtained, but with a somewhat lesser...

HT1A receptor knockout and anxiety

The converging lines of evidence that 5-HT1A receptor deficiency or dysfunction is involved in depression and anxiety disorders led to the genetic inactiva-tion of this receptor in mice (for reviews, see Lesch, 2005 Lesch et al., 2003). Htrla knockout (KO) mice show a complete lack of ligand binding to brain 5-HT1A receptors in null-mutant Htrla- - mice, with intermediate binding in the heterozygote Htr1a+ - mice. Importantly, a similar behavioral phenotype characterized by increased anxiety-related behavior and stress reactivity in several avoidance and behavioral despair paradigms was observed in three different KO mouse strains (Lesch & Mossner, 1999). Htr1a KO mice consistently display a spontaneous phenotype that is associated with a gender-modulated and gene- dose-dependent increase of anxiety-related behaviors (Heisler et al., 1998 Parks, Robinson, Sibille, Shenk, & Toth, 1998 Ramboz et al., 1998). With the exception of an enhanced sensitivity of terminal 5-HT1B...

How anxiety works

There is evidence of direct links between the reception of the information and the motor behavioural responses, bypassing the cognitive processes. This allows an immediate, perhaps survival reaction to occur if the stimulus is very intense or suggests danger (Le Doux 1986). This response seems however to be influenced by the 'mental set' of the individual which relates to the level of trait anxiety (a personality characteristic). State anxiety is the level or kind of anxiety that results from a particular situation or stimulus, as opposed to trait anxiety which is an ongoing level of awareness or sensitivity to anxiety-provoking stimuli.

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

Anxiety Disorders

Comorbid anxiety and anxiety disorders appear to be associated with increased suicidal behavior in bipolar disorder. Simon et al. (2004) found that a history of an anxiety disorder was an independent risk factor for a more severe and debilitative course of bipolar illness, and brought on higher risk of attempting suicide (odds ratio 2.45, 95 CI 1.4-4.2). Anxiety disorders were highly prevalent in this study, with a lifetime history of an anxiety disorder in 51.2 of the sample. A current anxiety disorder was present in 30.5 of subjects. Henry et al. (2003) did not find such an association in a smaller sample of 318 subjects with bipolar disorder. Only 24 of this sample had a lifetime anxiety disorder, and there was no increase in suicide attempts in the subjects with a history of an anxiety disorder. This sample may not have had enough statistical power to find such a difference, and their negative finding may represent a type II error (i.e., failing to find a difference when one...

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...

Test Anxiety

In one of the first longitudinal studies of performance anxiety, Hill and Sarason (1966) found that anxiety both increases across the elementary and junior high school years and becomes more negatively related to subsequent grades and test scores. They also found that highly anxious children's achievement test scores were up to 2 years behind the scores of their low anxious peers and that girls' anxiety scores were higher than boys'. Subsequent research has provided estimates of just how many children in the United States suffer from extreme forms of test anxiety For example, Hill and Wig-field (1984) estimated that as many as 10 million U.S. children and adolescents experience significant evaluation anxiety. What explains individual differences in test anxiety Researchers point to both biological and social factors. For example, some research suggests that having parents who have overly high expectations and put too much pressure on their children contributes to high levels of test...

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...

Patients with Severe Cardiac Failure

Patients with chronic stable heart failure are disabled by breathlessness and fatigue. There is no constant correlation between these symptoms, which limit exercise tolerance, and the degree of left ventricular dysfunction. The decreased muscular function may be due either to hypoperfusion during exercise or to prolonged deconditioning. Respiratory discomfort is caused both by hyperventilation, which provokes premature fatigue of the respiratory muscles, and to some extent by an increase in pulmonary vascular pressures, which gives rise to a feeling of suffocation.11,24-27

Series editors preface

The most controversial area concerns the relationship between chronic fatigue syndrome and psychiatric illness. Specifically, chronic fatigue syndrome has been related to anxiety or depression and a disorder where patients have these conditions but relate them to physical complaints. How patients relate their symptoms to a consideration of these having a

Components of Cardiac Rehabilitation

The physiologic parameters targeted by cardiac rehabilitation interventions include an improvement in exercise tolerance and in exercise habits optimization of coronary risk factors, including improvement in lipid and lipoprotein profiles, body weight, blood glucose levels and blood pressure levels, and cessation of smoking. There should be attention to the emotional responses to living with heart disease, specifically reduction of stress and anxiety and lessening of depression. An essential goal, particularly for elderly patients, is functional independence. Return to appropriate and satisfactory occupation is thought to benefit both patients and society.

Emotion Regulation and Later Adaptation

Further evidence connects early self-regulation with behavior problems. Emotion dysregulation has been described as the common dimension of most categories of psychopathology (Cole, Michel, & Teti, 1994). Cole, Michel, and Teti (1994) described emotional dysregulation as emotional patterns that disrupt other processes such as attention and social relations. Similarly, Cicchetti et al. (1995) defined emotional dysregulation as existing control structures that operate in a maladaptive manner and direct emotion toward inappropriate sources. Researchers have described pathological consequences of both overcontrol (e.g., internalizing behavior, depression) and undercontrol (e.g., externalizing behavior, aggression). Children with undercontrolled behavior problems tend to show difficulty with emotion regulation in the laboratory (Calkins & Dedmon, 2000) and children's emotion regulation has been linked to externalizing behavior in school (Eisenberg et al., 2001 Chang, Schwartz, Dodge,...

Conclusion On Preclinical Testing

As drugs are developed and promoted for long-term use in more and relatively trivial conditions, e.g. minor anxiety, and affluent societies become less and less willing to tolerate small physical or mental discomforts, the demand for and the supply of new safer medicines will continue to increase. Only profound knowledge of molecular mechanisms will reduce risk in the introduction of new drugs. Occasional failures of prediction are inevitable, with consequent public outcry.

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...

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

Clinical Observations

Many innovative drugs have originated from the astute observations of physicians who recognized that what appeared to be apparent side effects of drugs were actually novel therapeutic properties. The discovery of the diuretic and glucose-lowering activities of the antibacterial sulfonilamides, which were developed into three distinct classes of sulfonamide drugs (i.e., antibacterials, diuretics, and hy-poglycemics), is often cited as an example (6). Consider as well, the antidepres-sant effects of the tuberculostat, iproniazid the anxiolytic properties of the neuro-leptic, buspiron and the antirheumatic effects of the antibacterial, penicillamine (5,6). This source of drug discovery has slowed markedly in recent years, possibly because of the imposition of regulatory guidelines needed to ensure the safety of drug development (5).

The Behavioral Inhibition System

Gray and McNaughton (2000) reaffirmed the earlier conclusions regarding the pattern of behavioral effects of anxiolytic drugs (pp. 72-82), including the novel anxiolytics however, the conclusions were based on far fewer studies for the latter drugs, and the effects were clearer when chronic administration or other means of preventing short-term interaction with the pituitary-adrenal system was used (McNaughton, Panickar, & Logan, 1996 Zhu & McNaughton, 1995). These effects included the familiar passive avoidance and extinction paradigms, as well as the conceptually similar tasks involving successive discrimination, fixed-interval reward schedules, and differential reinforcement of low rates of response. In addition, the authors included approach-approach conflict tasks, in which correct performance requires inhibiting a response that was previously correct but currently is incorrect. As in earlier writings, these effects can be understood as inhibiting prepotent or at least...

The Septo Hippocampal System

The results above constitute core findings regarding the effects of anxiolytic drugs and the nature of inputs to and outputs from the BIS. They were, however, only a beginning for Gray's efforts to understand the structure and functioning of the neural substrate for the BIS, beginning with the SHS. This attempt constituted a major part of his research and evolved throughout his career. Helpful references to track this evolution of theory are two book-length reviews of his own and others' research in their original versions (Gray, 1971, 1982) and in second editions (Gray, 1987 Gray & McNaughton,

Pain from disease acute

Pain associated with disease is usually located in or near the affected organ or structure. Again it is mainly caused by damage to the tissues involved, or to stretching of, or pressure on, structures. Sometimes the pain can seem to 'run' from one part of the body to another, or to be 'referred' to another (related) part (Procacci et al. 1994). This often reflects the way in which the different parts of the body are linked through nerves. Thus if one part of such a section is affected by disease, then the pain may also be experienced in the remaining parts of that section. This can make it difficult sometimes to confirm a diagnosis. The site of the pain as reported by the patient may not seem to make sense in terms of disease. This can happen in appendicitis, or in a case of myocardial infarction, where referred pain is in fact a common diagnostic sign. With appendicitis the pain may be reported from various parts of the abdomen, or even seem to move from one part to another, before...

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.

Stress Echocardiography

Exercise stress echocardiography can be performed using a traditional treadmill or bicycle ergometry. The use of pharmacological agents minimizes factors that make the ultrasonic examination difficult during exercise, including hyperventilation, tachycardia, and excessive chest wall movement. The most well-studied and clinically available method is dobutamine stress echocar-diography. Dobutamine increases heart rate and myocardial contractility and produces diagnostic changes in regional wall motion and systolic wall thickening as ischemia develops. Low-dose dobutamine infusion (5-10 g kg min) is also valuable for assessing contractile reserve in

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.

Pharmacological Basis Of Drug Interactions

Pharmacodynamic interaction both drugs act on the target site of clinical effect, exerting synergism (below) or antagonism. The drugs may act on the same or different receptors or processes, mediating similar biological consequences. Examples include alcohol + benzodiazepine (to produce sedation), morphine + naloxone (to reverse opioid overdose), rifampicin + isoniazid (effective antituberculosis combination). Antagonism occurs when the action of one drug opposes the action of another. The two drugs simply have opposite pharmacodynamic effects, e.g. histamine and adrenaline on the bronchi exhibit physiological or functional antagonism or they compete reversibly for the same drug receptor, e.g. flumazenil and benzodiazepines exhibit competitive antagonism.

Case of Chronic Headache

The Christy family members were seen together for an assessment. Mr. Christy was devastated by his wife's accident. Yet, at the same time, he was somewhat mystified by her degree of disability in view of all the negative medical findings. Mr. Christy had become short-tempered, withdrawn, sad, and angry, and he made very little effort to conceal his thoughts and feelings. Throughout their marriage he had depended on his wife to manage the household, the finances, and the day-to-day needs, of the children, a duty she had fulfilled admirably with joy and pride. Now he could no longer depend on her. The problems were complicated by his periodic need to go on business trips. Mr. Christy's anxiety centered on the uncertain nature of his wife's condition. Some days she was well, but sometimes she would be confined to bed for many days at a time. He could no longer rely on her. He had to assume an increasing amount of responsibilities in the running of the household as well as in looking...

Depressive Phenomenology

Outside of psychomotor agitated depression, there is also the question of whether anxious depression is related to bipolar disorder. The presence of anxiety along with the major depressive episode is a com mon occurrence. It is not generally considered diagnostically informative, though often such patients will have manic symptoms that can represent a depressive mixed state. The interesting clinical question is whether anxious depression, in the absence of other manic-like symptoms, is more common in bipolar than unipolar depression. Anxiety symptoms are extremely common in bipolar disorder, so that when the diagnostic criteria for anxiety are applied, lifetime comorbidity ranges from 55 to 90 (Boylan et al. 2004) consequently, comorbidity with anxiety has been reported to be more frequent than with unipolar depression. On the basis of extensive clinical experience, Koukopoulos and Koukopoulos (1999) suggest a link between anxiety and bipolar disorder, as does Perugi (Perugi and...

Physiologically Active Substances A

Ethylene is effective when given 5-30 days before irradiation (202). Other inhibitors of mitosis, however, can enhance survival these include demecolcine (Colcemid), sodium ar-senite, epinephrine, cortisone, and typhoid paratyphoid vaccine (203). Tranquilizers and other psychotropic drugs possess only moderate radioprotective activities. These compounds probably are active by depression of whole-body metabolism through diminished oxygen uptake (35).

Initial Assessment And Resuscitation

The initial clinical review should include a search for known consequences of poisoning, which include impaired consciousness with flaccidity (benzodiazepines, alcohol, trichloroethanol) or with hypertonia (tricyclic antidepressants, antimuscarinic agents), hypotension, shock, cardiac arrhythmia, evidence of convulsions, behavioural disturbances (psychotropic drugs), hypothermia, aspiration pneumonia and cutaneous blisters, burns in the mouth (corrosives).

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...

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).

What Is an Appropriate Reaction

Davies's response to the multitude of losses was predictable and understandable, and had virtually nothing to do with the burden factor, which is predicated on the stress of caring for a sick and disabled partner. Mr. Davies not only lost his major source of support, he developed inordinate guilt over his wife's condition. He remained a patient at the pain clinic for 2 years, and during the entire period Mrs. Davies showed little sign of improvement. An unanswered question was whether Mrs. Davies had slipped into a dysthymic disorder. Prolonged grief is often associated with anxiety or mood disorders (Roy, 2004).

Treatment Of Dependence

Young illicit users by i.v. injection (heroin, benzodiazepines, amphetamine) have a high mortality. Either death follows overdose, or septicaemia, endocarditis, hepatitis, AIDS, gas gangrene, tetanus and pulmonary embolism ensue from the contaminated materials used without aseptic precautions (schemes to provide clean equipment mitigate this). Smugglers of illicit cocaine or heroin sometimes carry the drug in plastic bags concealed by swallowing or in the rectum ('body packing'). Leakage of the packages, not surprisingly, may have a fatal result.7

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...

Withdrawal Of Alcohol

Abrupt withdrawal of alcohol from a person who has developed physical dependence, such as may occur when an ill or injured alcoholic is admitted to hospital, can precipitate withdrawal syndrome (agitation, anxiety and excess sympathetic autonomic activity) in 6 h and an acute psychotic attack (delirium tremens) and seizures (at 72 h).

Xanthinecontaining Drinks

Excessive prolonged consumption of caffeine causes anxiety, restlessness, tremors, insomnia headache, cardiac extrasystoles and confusion diarrhoea may occur with coffee and constipation with tea. The cause can easily be overlooked if specific enquiry into habits is not made including children regarding cola drinks. Of coffee drinkers, up to 25 who complain of anxiety may benefit from reduction of caffeine intake. An adult heavy user may be defined as one who takes more than 300 mg caffeine day, i.e. 4 cups of 150 ml of brewed coffee, each containing 80 20 mg caffeine per cup or 5 cups (60 20) of instant coffee. The equivalent for tea would be 10 cups at approximately 30 mg caffeine per cup and of cola drinks about 2.01. Plainly, caffeine drinks brewed to personal taste of consumer or vendor must have an extremely variable concentration according to source of coffee or tea, amount used, method and duration of brewing. There is also great individual variation in the...

Waters Unique Role in the Fitness of the Environment

Hyperventilation, defined as a breathing rate more rapid than necessary for normal CO2 elimination from the body, can result in an inappropriately low CO2(g) in the blood. Central nervous system disorders such as meningitis, encephalitis, or cerebral hemorrhage, as well as a number of drug- or hormone-induced physiological changes, can lead to hyperventilation. As CO2(g) drops due to excessive exhalation, H2CO3 in the blood plasma falls, followed by decline in H + and HCO3 in the blood plasma. Blood pH rises within 20 sec of the onset of hyperventilation, becoming maximal within 15 min. H + can change from Hypoventilation is the opposite of hyperventilation and is characterized by an inability to excrete CO2 rapidly enough to meet physiological needs. Hypoventilation can be caused by narcotics, sedatives, anesthetics, and depressant drugs diseases of the lung also lead to hypoventilation. Hypoventilation results in respiratory acidosis, as CO2(g) accumulates, giving rise to H2CO3,...

Gross Chromosomal Aberrations

While minor Indel polymorphisms are thought to be relatively common in human populations, gross chromosomal abnormalities such as deletions, inversions or translocations were thought to be rare. Nevertheless as our knowledge of the genome develops an increasing number of clinically characterized genomic syndromes are being identified. Some of these affect multiple genes and cause pronounced phenotypes including velocardiofacial syndrome (VCFS) a deletion syndrome on 22q11.2 (Gong et al., 1996) and Charcot-Marie-Tooth disease type 1A (CMT1A) a duplication syndrome on 17p11.2 (Thomas, 1999). Other much more subtle genomic syndromes are emerging which suggest that these syndromes may in fact be more common than previously believed. DUP25 is an interstitial duplication of 17 Mb at 15q24-26, which is associated with joint laxity and panic disorder (Gratacos et al., 2001). Changes in dosage of one or more of the 59+ genes in the DUP25 region are likely to contribute to the subtle clinical...

Sexually Transmitted Infections

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

Psychosomatic Disorders

Nail Biting Adults Photos

Foreign objects (e.g., pencils or pipes) nail biting or excessive use of tobacco, which are all potentially injurious to the periodontium.Self-inflicted gingival injuries such as gingival recession have been described in both children and adults. Correlation between psychiatric and anxiety states and the occurrence of periodontal disease have been reported, but these reports have been questioned by some investigators.''1,1 Psychologic factors in the cause of necrotizing ulcerative gingivitis are discussed in Chapter 19.

Mapping coproduction sites methods and partial perspectives

It has long been acknowledged in anthropology that the positioning and identity of the researcher is always something of a negotiation that influences and to an extent informs ethnographic research. This process is heightened in research that spans numerous different persons, groups and intersecting contexts and where the anthropologist and their research are in Riles's terms, both 'inside' and instrumental to such networks (2001). Moreover, given the way that the developments of interest in this book are inseparable from, as well as having consequences for, the politics of women's health many questions are raised about the (critical) perspective of the author. As a feminist academic anthropologist I have discovered that there are no comfortable positions. Anxiety about 'medicalising' health care interventions co-exists with the recognition of long denied rights to equality of access and care in medicine or scientific research. Moreover despite the dangers of co-option, I continue to...

The ABCG White Subfamily

The human white or ABCG subfamily consists of five fully cloned genes (ABCG1, ABCG2, ABCG4, ABCG5, and ABCG8) and one gene so far only found in rodents (ABCG3) 22 . The ABCGs are thought to dimerize to form active membrane transporters. Among the half-size molecules ABCG proteins have a peculiar domain organization characterized by a nucleotide binding domain (ATP binding cassette) at the N-terminus followed by six transmembrane-spanning domains (Tab. 3.1 and Fig. 3.1). The founding member of this group, ABCG1, was independently described by Chen et al. and Croop et al. as the human homolog of the Dro-sophila white gene 112, 113 and its genomic organization, including the promoter region, has been described recently 114, 115 . Earlier indications linked ABCG1 with the congenital recessive deafness (DFNB10) syndrome, based on its chromosomal localization on chromosome 21q22.3 116 . However, a recent report 117 has excluded ABCG1 along with five other known genes as candidates for...

Central nervous system findings

For people with CFS, emotional changes can be just as unsettling as the physical symptoms produced by the illness. Many people do not understand that the emotional roller coaster is as organic as the fever, swollen glands, low blood pressure or any other symptoms of the illness. That is, the illness can produce 'negative emotions' -overwhelming grief, irritability, anxiety, depression and guilt, and these symptoms come and go like all the other symptoms the illness throws at you. If the CFS impairment occurs at or above the hypothalamic level, neurotransmitters may play a key role in the dysregulation. Neurotransmitters are bodily chemicals which are responsible for the transmission of nerve impulses across cells. Central neurotransmitters are involved in the regulation of a number of hypothalamic functions. For instance, the neurotransmitter serotonin assists in activating the hypothalamus, while fenfluramine and buspirone stimulate the release of pituitary hormones. Two of the...

Ten Aspects To Consider for Future Research into Brain Mechanisms Involved in Wasting and Cachexia

Links and feedbacks exist among neurological, psychological and psychiatric manifestations of diseases accompanied by wasting and cachexia. Symptoms or signs such as anxiety, depression, cognitive impairment, fatigue and asthenia, and anorexia can exacerbate wasting and cachexia due to deleterious positive feedback cycles. This increases the frequency of complications, decreases the quality of life and activities of daily living and performance, and has an impact on overall morbidity and mortality. What are the main mechanistic interactions and magnitude of the individual contributions responsible for symptomatology interface

The latest diagnostic test

As discussed earlier, the Johns Hopkins study of neurally mediated hypotension was an uncontrolled trial conducted on a small sample of CFS patients. Similar responses have been made to the earlier claims, and at different points in time patients may have been eagerly awaiting results from viral antibody titres, hyperventilation tests, or maybe NK cell counts. Clearly, the need to have a legitimate marker for the illness is paramount for CFS patients.

Clinical Approach

Respiratory distress is an acute emergency and necessitates rapid assessment and therapy. Oxygen is the most important substrate for the human body, and even 5 or 10 min of hypoxemia can lead to devastating consequences. Hence, a quick evaluation of the patient's respiratory condition, including the respiratory rate and effort use of accessory muscles, such as intercostal and supraclavicular muscles anxiety and cyanosis may indicate mild or severe disease. (Figure 22-1 shows one algorithm for evaluating dyspnea in pregnancy). The highest priority is to identify impending respiratory failure, because this condition requires immediate intubation and mechanical ventilation. Pulse oximetry and arterial blood gas studies should be ordered while information is gathered during the history and physical. A cursory and targeted history directed at the pulmonary or cardiac organs, such as a history of reactive airway disease, exposure to anaphylactoid stimuli such as penicillin or bee sting,...

Suggested Readings And Resources

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC Author. All mental health professionals must be familiar with this standard for diagnostic classification of mental disorders. Foley, R., & Sharf, B. F. (1981). The five interviewing techniques most frequently overlooked by primary care physicians. Behavioral Medicine, 8, 2631. This is a brief article outlining one temporal structure model for clinical interviews. The authors discuss the criteria they view as basic for effective client interviewing. Meehl, P. E. (1954). Clinical versus statistical prediction A theoretical analysis and a review of the evidence. Northvale, NJ Jason Aronson, Inc. Although this is a dated publication, its arguments about the relative merits of clinical versus statistical prediction are still interesting and pertinent. In fact, in 1986, Meehl claimed that 90 of what he wrote in 1954 was still true. Othmer, E., & Othmer,...

Summary and conclusions

The possibility that the immune alterations are secondary to a more central dysfunction led to the formation of new hypotheses about the involvement of the CNS. There is some evidence that CFS patients may have a mild form of hypocortisolism which is associated with a centrally mediated increase in serotonin function. Neuroimaging studies have also found evidence for altered cerebral blood flow in CFS patients, while sleep studies suggest alterations in sleep patterns. However, there is great variability between studies and no distinct abnormality seems to distinguish CFS patients. A disrupted HPA axis seems to be the most plausible hypothesis at this stage as it could account for altered sleep patterns as well as changes in the immune system. However, as neuroendocrine changes similar to those found in CFS patients have been associated with both shift work and stress levels in healthy people, it is possible that the HPA disturbances are a result, rather than a cause of the illness....

Bodily continuities and discontinuities the evidence of danger

For her, these bodily connections were more than enough evidence to suggest that there was a high probability she would develop the same condition. Donna also discussed the way physical parity between family members fuelled her disquiet. At the same time, this sharing of symptoms could not be separated from a sense of anxiety and trauma that had passed through the lives of many generations that included her mother and grandmother. For her, lived experiences became caught up with the anticipated danger of genes While physical similarities between related family members were seen by some as evidence of genetic risk, others expressed an underlying fear and uncertainty about their bodies, which also informed and fed the perceived need and rationale for referral to a specialist clinic. Although a sense of connection with others' bodies might provide the background to perceptions of risk for these persons, this was less the locus of concern than a sense of detachment and feelings of...

The Various Aspects Of Pain

Suffering is a consequence of pain and of lack of understanding by patients of the meaning of the pain it comprises anxiety and fear (particularly in acute pain) and depression (particularly in chronic pain), which will be affected by patients' personalities, and their beliefs about the significance of the pain, e.g. whether merely a postponed holiday, or death, or a future of disability with loss of independence. Depression makes a major contribution to suffering it is treatable, as are the other affective concomitants of pain.

Developmental Origins and Outcomes of Social Aggression

As a first step toward answering some of these questions, we are beginning a large, longitudinal study of 300 children and their families beginning when the children are 9 years old. Our overarching goal is to understand developmental origins and outcomes related to social aggression. We are measuring children's social aggression in laboratory observational studies, and also using peer nominations, teacher reports, parent reports, friend reports and self-reports. We seek to refine definitions of social aggression, to understand which behaviors do and do not belong in this construct describing behaviors that harm friendships and social status by using multiple measures to assess social aggression in different social contexts. We acknowledge that most aggressive behaviors hurt in more than one way and serve multiple goals, and that children who behave aggressively likely hurt peers in multiple ways. We believe that at particular points in development, both social and physical aggression...

Pain Measurement by Methods Other Than Self Report

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

Psychiatric illness and the social context of chronic fatigue syndrome

Many of the organic hypotheses arose from the observation that CFS shares a number of symptoms with certain medical conditions. However, it could be argued that there is even greater symptom overlap with primary psychiatric disorder. Debilitating fatigue and sleep disturbances are consistently associated with psychiatric disorder in studies of the community, primary care and tertiary care (David et al. 1990 Pawlikowska et al. 1994). Up to 85 per cent of CFS patients report depression as a key symptom, while between 50 and 70 per cent report anxiety (Komaroff and Buchwald 1991). Further, the current definitions of CFS are based on descriptive phenomenology, the traditional domain of psychiatric, rather than medical, diagnoses.

Clinical Use Of Agents

Current drugs on the market include barbiturates, benzodiazepines, halogenated sedative-hypnotics, heterocyclic sedative-hypnotics, antihistamines, and other sedative-hypnotics. The toxic effects of an overdosage result from profound central depression and may include coma, respiratory and cardiovascular depression with hypertension, and shock leading to renal failure. Withdrawal of the drug is more frequently a problem with barbiturates than with benzodiazepines. Withdrawal of barbiturates leads to rapid eye movement (REM) sleep rebound and rebound insomnia.

Psychiatric Comorbidity

Smokers more often suffer from psychiatric diseases, namely depression, anxiety disorder and schizophrenia, than do non-smokers. At least 70-90 of all schizophrenia patients smoke.15 There is a clear connection between smoking and depression and anxiety disorders. On the one hand, depression makes smoking lead to nicotine addiction more easily and, on the other hand, smoking promotes the development of depression. The same holds for anxiety and panic disorders. Smoking cessation can cause a temporary aggravation of the depression or anxiety.15

Psychological and Behavioral Support

The concept of stress and of stress management procedures suited to a cardiac setting is described. This is coupled with a general chapter on the educational role intrinsic in good care for cardiac patients. It is a reminder of the need to see the busy cardiac setting from the perspective of the patient and family members and to be ever mindful that what is a daily job for professionals is a unique, almost always anxiety-provoking and even possibly a very frightening experience for the patient and family.

Psychosocial Aspects in Prevention and Rehabilitation

Evidence that psychosocial factors are important in the development and prognosis of cardiovascular disease is outlined. Psychosocial problems are common among patients with psychosocial risk factors fitting broadly into two categories external factors (such as financial and socioeconomic circumstances,life events, and work stress) and internal factors (such as anxiety, depression, hostility anger, and perception of external circumstances). The most extensive evidence that psychosocial factors are involved in prognosis in coronary heart disease (CHD) derives from work related to depression. In established CHD, depression is associated with a significantly increased risk for recurrent major cardiac events, particularly if there is also a lack of social support. The exact pathophysiological nature of the influence of psychosocial factors remains to be determined, as does the temporal sequence of events. Several interventions have been investigated, both to reduce psychosocial risk...

Some Special Techniques

Sedation and amnesia without analgesia are provided by midazolam i.v. or, less commonly nowadays, diazepam. These drugs can be used alone for procedures causing mild discomfort, e.g. endoscopy, and with a local anaesthetic where more pain is expected, e.g., removal of impacted wisdom teeth. Benzodiazepines produce anterograde, but not retrograde, amnesia. By definition, the sedated patient remains responsive and cooperative. (For a general account of benzodiazepines and the competitive antagonist flumazenil, see Ch. 19.) Benzodiazepines can cause respiratory depression and apnoea especially in the elderly and in patients with respiratory insufficiency. The combination of an opioid and a benzodiazepine is particularly dangerous. Benzodiazepines depress laryngeal reflexes and place the patient at risk of inhalation of oral secretions or dental debris.

Evidence That Psychosocial Factors Predict CHD Events

Psychosocial risk factors fall broadly into two different categories first those that represent external factors, such as financial and socioeconomic circumstances, life events, work stress, and second, those that have to do with factors within the individual, such as anxiety or depression, as well as hostility and anger, and perception of external circumstances. To some extent, perceived control and social support may modify other psychosocial factors, whether external or internal.

Neuromuscular Blocking Drugs

Thetic techniques and monitoring, awareness while paralysed for a surgical procedure is extremely rare. In the UK, general anaesthesia using volatile agents should always be monitored with agent analysers, which measure and display the end-tidal concentration of volatile agent. In the past, misguided concerns about the effect of volatile anaesthetics on the newborn led many anaesthetists to use little, if any, volatile agent when giving general anaesthesia for caesarean section. Under these conditions some mothers were conscious and experienced pain while paralysed and therefore unable to move. Despite its extreme rarity nowadays, fear of awareness under anaesthesia is still a leading cause of anxiety in patients awaiting surgery.

Choosing the Structure and Content of Your Report

John Smith, a 53 year-old married Caucasian male, was referred for psychotherapy by his primary care physician, Nancy Jones, MD (509-555-5555). Dr. Jones described Mr. Smith as moderately depressed and as suffering from intermittent anxiety, insomnia, and general distress associated with his recent job loss. During his initial session, Mr. Smith confirmed these problems and added that troubles at home with the wife and finances were furthering his overall discomfort and shame. When asked if he had ever previously experienced such deep sadness or anxiety, Mr. Smith responded by saying, Never. He claimed that this is the first time he's ever had any head problems. Mr. Smith denied experiencing recurrent panic attacks and minimized the significance of his panic during the job interview by claiming I was just getting in touch with reality. I don't have much to offer an employer.

Choosing What to Include in Your Intake Report

Jane Doe, a 21-year-old, single, Hispanic female, reported being raped by her stepfather when she was age 16. Following the rape, Ms. Doe was examined at the Baylor Medical Center emergency room. This examination revealed vaginal tearing and semen residue. Eventually, Ms. Doe's stepfather was arrested and convicted of sexual assault. His conviction followed a lengthy trial, during which he denied the assault, even in the face of positive DNA evidence. Currently, Ms. Doe's symptoms, including anxiety, hypervigilence, nightmares, flashbacks of the rape incident, and ruminative guilt, seem to have resurfaced in direct association with her stepfather's scheduled release from the Texas state penitentiary. Ms. Doe reports she is currently in a committed romantic relationship with a man by the name of William Mills. She notes that Mr. Mills is White, which her mother finds undesirable. However, Ms. Doe describes Mr. Mills as sensitive and supportive of her sexual hang-ups, but adds that...

Drug Therapy In Relation To Psychologicaltreatment

As a general rule, psychotic illnesses (e.g. schizophrenia, mania and depressive psychosis) require drugs as first-line treatment, with psychotherapeutic approaches limited to an adjunctive role, for instance in promoting drug compliance, improving family relationships and helping individuals cope with distressing symptoms. By contrast, for non-psychotic depression and anxiety disorders such as panic disorder and obsessive-compulsive disorder, forms of psychotherapy are available which provide alternative first-line treatment to medication. The choice between drugs and psychotherapy depends on treatment availability, previous history of response, patient preference and the ability of the patient to work appropriately with the chosen therapy In many cases there is scope to use drugs and psychotherapy in combination.

Dimension Specific Measures

Some of these have been widely studied before the concept of HRQoL was popularized. In the cardiac situation, the dimensions focus on social and emotional aspects of well-being. Some examples were highlighted in Table 31-1. This gives some idea of the variety of instruments - for instance in the area of emotional well-being there is a generic measure of depression available since 1983 (the Hospital Anxiety and Depression Scale,14,15 a cardiac-specific measure of depression developed in the mid-1990s (Cardiac Depression Scale11), a measure of positive and negative affect developed with cardiac patients but not exclusive to them (the Global Mood Scale),12 and the Heart Patients' Psychological Questionnaire - a disease-specific measure including subscales on well-being, feelings of disability, despondency, and social inhibition.13 Use of these scales will depend on the focus of the research - for instance a cardiac rehabilitation intervention might aim to increase HRQoL for...

Voluntary False Confessions

Alternatively, a voluntary false confession may result from the individual's unconscious need to expiate guilty feelings through receiving punishment. The guilt may concern real or imagined past transgressions or, occasionally, may be part of the constant feeling of guilt felt by some individuals with a poor self-image and high levels of trait anxiety.

Myocardial Infarction

Heart-disease-specific instruments.8'9'12'13 A widely used MI-specific HRQoL instrument is the Quality of Life after Myocardial Infarction (QLMI) questionnaire.8 Since development, it has been further modified to a version called the MacNew QLMI.9 This consists of 26 items in three dimensions -Limitations, Emotions, and Social - with an overall HRQoL score as the sum of the MacNew QLMI dimensions (see Hoefer et al.45 for a review). A number of studies with the MacNew QLMI have shown it predicts later adverse health events.46'47 Predictors of quality of life have also been examined for MI patients. In a large British study, 288 MI patients were followed over the subsequent year. Levels of depression and anxiety during hospitalization did not predict mortality but did predict HRQoL, measured with a generic instrument, at one year.48

Motivational aspects of pain

Even with acute pain in an accident, there is motivation to prevent pain or to prevent further pain. The victim usually is motivated to adopt protective mechanisms such as restriction of movement or weight bearing. The victim will seek help if these protective measures or the self-administration of analgesics do not do the trick or are not feasible. The victim may struggle, limping or crawling for help, in extreme circumstances, enduring much discomfort and even pain in the search for help. This drive can be very powerful. It is related to the arousal that is part of stress and anxiety. It could be seen as the fight part of the stress response, and involves the expenditure of much energy. If unsuccessful and prolonged this drive can absorb so much energy that the person enters into shock, with exhaustion (Selye 1956).

Suggestibility and Compliance

Appearing to have special knowledge about the alleged offense. This special knowledge may seriously mislead the police and the courts to assume the suspect's guilt erroneously. Suggestibility correlates with anxiety, lack of assertiveness, poor self-esteem, and low intelligence (56).

Is There a Synergistic Interaction Between Peripheral Impulse Input and Central Facilitation

These phenomena may be integrally related to hypervigi-lance, level of somatic focus, or other factors related to emotional regulation. The relationship of negative affect to pain conditions is well documented in the literature (66). In nearly all published reports, the presence of negative mood is associated with higher levels of pain. Induction of negative mood has also been shown to be related to pain report and pain behavior, with some specificity to the type of emotion induced (67-70). Interventions or instructional sets that reduce negative emotion also reduce pain report (62,71). Our work in IBS patients indicates that the magnitude of placebo analgesia is related to changes in expectations of pain (and anxiety), desire for pain relief, and somatic focus (72). That hyperalgesia can be completely normalized by either reducing a peripheral source of tonic impulse input or removing CNS facilitation is puzzling. It may be the case that there exists...

Summary of the psychiatric findings

In summary, prospective studies suggest that psychological factors such as premorbid distress and a past history of psychiatric illness, particularly depression, play a significant role in the development of CFS. Other factors such as anxiety, somatisation, achievement orientated personality traits, neuroticism, a past history of traumatic events and perceived stress also appear to play a role in either the onset or maintenance of the condition. While these results do not negate the likelihood that organic factors are also involved in CFS, they certainly provide convincing evidence for the role of psychological factors in this illness. Despite this, the majority of CFS patients adamantly claim that their illness is largely physical in origin. As we saw in the previous chapter, they eagerly await results from organic investigations of their illnesses, and are easily swayed by the dramatic claims of preliminary work. In contrast, they ridicule any psychological findings from even...

Pretreatment Evaluation And Education

The next critical step in education is to reduce the anxiety the patient may feel about commencing an injection-based therapy, and to counsel on the management of side effects. The authors utilize both physician assistants and nurse practitioners to educate patients and families on self-injection techniques. The patient is usually requested to bring his significant other or family member to the initial session, where injection techniques are discussed. This also allows the opportunity to counsel the family member about side effects of therapy, and to advise them about the potential neuropsychiatric problems associated with IFN-based therapy. As discussed in, family members can be critical in both diagnosing and helping to manage these neuropsychiatric problems later, during therapy. The authors have found that the new self-injection pens or pre-filled syringes are associated with greater patient comfort and compliance. In particular, patients with a prior history of iv drug use do not...

Implications for Patient Management

The research on depression following MI has clear implications for patient management. As soon as MI patients are medically stable, as determined by a cardiologist, they should undergo routine screening to identify those that are severely distressed. There are many self-report questionnaires available53 to assess depression, with the Beck Depression Inventory,54 and the Hospital Anxiety and Depression Scale55 being among those most commonly employed. Symptoms of depression should be assessed using a self-report instrument during hospitalization (3 to 7 days post-MI), and 6 weeks or so after discharge (usually when formal cardiac rehabilitation classes begin), to identify those patients who are experiencing significant emotional distress. Appropriate referral to a mental health professional should be considered for those patients demonstrating persistent elevated symptoms of depression, to allow for assessment of clinical depression and appropriate treatment. For those patients who are...

HBGAM and Nsyndecan in Synaptic Plasticity

Another molecule that binds to heparin is the heparin-binding growth-associated molecule (HB-GAM). It has been implicated in the regulation of neurite outgrowth, axon guidance and synaptogenesis in vitro (for a review see Rauvala and Peng 1997). HB-GAM is expressed in an activity-dependent manner (Lauri et al. 1996). In the adult hippocampus, application of HB-GAM inhibited NMDA receptor-dependent LTP, but did not affect L-type VDCC-dependent LTP, that was induced by application of the K+ channel blocker tetraethylammonium. This indicates that the action of HB-GAM is limited to NMDA receptor-dependent LTP (Lauri et al. 1998). In HB-GAM-deficient mice, a lower threshold for induction of LTP was observed, which was restored to the wild-type level by application of HB-GAM (Amet et al. 2001). The observation that LTP is attenuated in transgenic mice that overexpress HB-GAM is consistent with these findings. These changes in LTP are accompanied by behavioral alterations. Paradoxically,...

The Impact of Psychiatric Illnesses

There has been a considerable amount of research on the manner in which certain functional psychiatric illnesses can affect the reliability of testimony (78,79). Thus, anxiety increases a suspect's suggestibility and depression can lead to feelings of guilt and poor self-esteem that render a suspect vulnerable to providing a false confession (52). Psychiatric illness may also render a person unfit for interview by virtue of its effect on cognitive processes or because of associated thought disorder (80,81). However, careful questioning that avoids the use of leading questions and coercive pressures can often elicit reliable testimony. That a suspect suffers from an illness, such as schizophrenia, does not necessarily mean that he or she is unfit for interview (82) such an opinion would depend on the likely demand characteristics of the interview and the functional assessment by the doctor.

Psychological Reactions to Coronary Heart Disease

A coronary event for most patients and their families is a traumatic experience with major consequences for daily life. Typically, to be diagnosed with CHD causes fears, anxiety, and depres-sion,5 and has implications for the dynamics within the family.6 Research shows that prognosis may be more related to emotional factors than to the seriousness of the event. Outcome of rehabilitation is better predicted by emotional factors than by anatomical features and size of infarction. Thus, anxiety and depression may present major obstacles to successful rehabilitation and secondary prevention. A comprehensive cardiac rehabilitation program should allow a forum for patients to share experiences with other patients in similar situations. The opportunity to reflect on emotional reactions usually has a normalizing effect, reducing the uncertainties related to feelings that seem alien and strange. Patients learn that such previously unknown strong emotional reactions are normal in this stage,...

The Meaning of Social Support

Two conclusions can be drawn from the above. First, positive social support is important for the prognosis of CHD patients. This entails emotional (understanding and acceptance of feelings), appraisal (good advice and opportunity to discuss how to manage the new life situation), informational (knowledge about CHD, risk factors, and lifestyle), and instrumental (help with practical problems). All of these aspects should be included in comprehensive cardiac rehabilitation and secondary prevention. Second, in order for spouses and family members to be able to provide adequate social support, they themselves need social support. There is evidence that when spouses exhibit higher levels of anxiety and depression and lower sense of control than the patient, the patient's psychosocial adjustment to illness is adversely affected.6 It is a good investment to offer some structured support to spouses and family members of CHD patients. There are at least three reasons for this. First, family...

Who Should Be Referred

Numerous studies consistently show that psychological and psychosocial factors contribute to increased risk for CHD. A cluster of negative emotions are related to increased risk, such as depression, anxiety, hostility, type D personality. Among psychosocial risk factors are low socioeconomic status (SES) and social isolation. These have been described in detail in Chapter 30. When CHD has manifested itself, the risk factor pattern is more complex, and findings are less consistent. However, the overall conclusions from studies point to hostility, depression, low SES, and social isolation contributing to increased risk for recurrence. Depression in particular has received considerable attention in recent studies.15 These issues are discussed in other chapters, particularly depression (Chapter 32) and stress management (Chapter 34). Research has shown that such psychological risks are more prevalent among women. Since they are also generally older, the presence of social isolation and...

The Effect of Physical Illnesses on Fitness for Interview

The presence of any physical illness renders an individual more vulnerable when faced with a stressful situation, such as a custodial interrogation. Features, such as anxiety or depression, affect a person's ability to function during the police interview, and physical illness especially if severe is as likely to cause anxiety and depression as any other form of stress (87). The severity of the emotional response will depend on the nature of the illness itself, the personality of the individual, and social circumstances. Suspects who are already coping with physical illness are more likely to focus on the short-term consequences of their behavior than the long-term outcomes, thus increasing the risk that they might provide a false confession (52).

Utility of Electroencephalographic Techniques in Substance Abuse Research

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

Clinical Presentation

Dyspnea 011 exertion is the most sensitive symptom for the diagnosis of CHF, but its specificity is much lower. Other symptoms, which are common but less sensitive for the diagnosis, include dyspnea at rest, anxiety, orthopnea, paroxysmal nocturnal dyspnea, and cough productive of pink, frothy sputum. Nonspecific symptoms sometimes reported are weakness, lightheadedness, abdominal pain, malaise, wheezing, and nausea. Patients may have a medical history of hypertension, coronary artery disease, or other heart diseases (cardiomyopathy, valvular disease). Histories of cigarette smoking and alcohol abuse may also be found.

Muscle cardiovascular and respiratory abnormalities

Hyperventilation or over-breathing is yet another posited cause for CFS. Based on patients' perceptions of their feelings of shortness of breath following voluntary hyperventilation, Rosen and colleagues (Rosen et al. 1990) concluded that CFS was nothing more than chronic hyperventilation. Subsequent studies using more rigorous methods to measure hyperventilation, such as measuring decreased levels of carbon dioxide in the system, have shown that carbon dioxide levels cannot account for either the degree of symptoms nor functional impairment reported by CFS patients (Lavietes et al. 1996 Saisch et al. 1994). CFS patients with and without hyperventilation report the same severity of fatigue-related symptoms (Bazelmans et al. 1997). Saisch et al. (1994) also found that CFS patients with unequivocal hyperventilation had either panic disorder or asthma which would account for the decreased levels of carbon dioxide in their system. Consequently, while hyperventilation may contribute to the...

Guide To Further Reading

Anderson IM, Nutt D J et al 2000 Evidence-based guidelines for treating depressive disorders with antidepressants a revision of the 1993 British Association for Psychopharmacology guidelines. Journal of Psychopharmacology 14 3-20 Ballenger J C et al 1998 Consensus statement on panic disorder from the International Consensus Group on Depression and Anxiety. Journal of Clinical Psychiatry 59 47-54 Ballenger J C et al 1998 Consensus statement on social anxiety disorder from the International Consensus Group on Depression and Anxiety. Journal of Clinical Psychiatry 59 54-60 Ballenger J C et al 2000 Consensus statement on posttraumatic stress disorder from the International Consensus Group on Depression and Anxiety. Journal of Clinical Psychiatry 61 60-66 Ballenger J C et al 2001 Consensus statement on generalized anxiety disorder. Journal of Clinical Psychiatry 62 53-58 Davies S J C et al 1999 Association of panic disorder and panic attacks with hypertension. American Journal of Medicine...

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