Anxiety and Panic Attacks Holistic Cures

Panic Away System

Barry Joseph McDonagh is a very popular author of Panic Away eBook. He is more than just a program developer based on his long research and education. As a result of his personal experience and research, Joe Barry decided to take a new approach to dealing with panic attacks. 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. In reading over this program, I find that there is a lot in there that can be very helpful. It makes it easy to understand panic attacks, and gives readers techniques to deal with them on their own. It is a pretty decent option for those who want to find a non-medicating way of handling their panic. Read more...

Panic Away Summary


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Highly Recommended

I usually find books written on this category hard to understand and full of jargon. But the writer was capable of presenting advanced techniques in an extremely easy to understand language.

My opinion on this e-book is, if you do not have this e-book in your collection, your collection is incomplete. I have no regrets for purchasing this.

Alcoholinduced anxiety disorders

This diagnosis should only be used when anxiety symptoms are thought to be related to the direct physiological effects of alcohol. The symptomatology may involve anxiety, panic attacks, and phobias. Both alcohol-induced anxiety disorders and mood disorders can develop during intoxication, withdrawal, or up to 4 weeks after cessation of alcohol consumption. During intoxication or withdrawal, the diagnosis should only be given when the symptomatology clearly exceeds what would be expected from anxiety or depressive symptoms during a regular intoxication or withdrawal episode. Anxiety disorders are among the most common groups of psychiatric disorders in the general population, with prevalence rates of up to 25 per cent. (6) In clinical studies between 20 and 70 per cent of patients with alcoholism also suffer from anxiety disorders. (7) On the other hand, between 20 and 45 per cent of patients with anxiety disorders also have histories of alcoholism.(8) However, it has been argued that...

Anxiety and panic disorder

Some patients have had panic attacks for years before discovering that alcohol can end or prevent them. Others have a first panic attack during alcohol withdrawal, but the attacks continue independently even during sustained abstinence. In either case, cognitive-behavioural therapy and or medication are indicated. Three studies suggest that the serotonin agonist buspirone can help reduce both drinking and anxiety. (65) Tricyclic antidepressants and selective serotonin-reuptake inhibitors (SSRIs) have been shown to be effective in randomized controlled trials of panic disorders, but alcohol dependence has been an exclusion criterion in these trials. Newly abstaining alcohol-dependent patients seem particularly susceptible to the unwanted effects of serotonergic medication (see above). Some patients with long histories of alcohol dependence and severe panic disorders fail to respond to psychological or antidepressant treatments. For these patients the risk of complications from repeated...

Guidelines for management of misuse of nonprescribed benzodiazepines

Assessment should attempt to confirm evidence for benzodiazepine dependence. Assessment over a number of visits should involve obtaining urine specimens to determine objectively the regularity (or intermittent nature) of benzodiazepine consumption. Part of the initial assessment process should identify underlying psychiatric disorders that may have been the trigger for a doctor initiating a prescription or for the patient obtaining drugs for the purpose of self-medication. High levels of psychiatric morbidity have been found among samples of patients with severe benzodiazepine dependence. (18) The commonest conditions are probably anxiety disorders for which anxiolytics have been prescribed injudiciously however, in some instances major depressive disorders may be treated or self-medicated with benzodiazepines. Thorough assessment should explore for evidence of major depression and if identified, consideration should be given to the use of antidepressant medication combined with...

Benzodiazepine Antagonist

Flumazenil (Romazicon) is a benzodiazepine antagonist that specifically reverses the respiratory depression and hypnosis produced by the benzodiazepine receptor agonists. Its block of the amnesic effect of the agonists is less reliable. Flumazenil is particularly useful when an overdose of benzodiazepines has occurred. It is also employed when a benzodiazepine has been used to produce conscious sedation and rapid recovery of psy-chomotor competency is desirable. To avoid resedation, flumazenil may require administration by intravenous infusion.

Other benzodiazepines

Several other benzodiazepines appear to be effective as well, including clobazam (50 17 mg day) and lorazepam 3.8 1.3 mg day. Conclusion The benzodiazepines remain the most frequently utilized treatment for panic disorder worldwide, probably because of their quick onset of action, increased efficacy against anticipatory anxiety, low cost, and because they are well tolerated (Table ,). Interestingly, they are not associated with the frightening initial hyperstimulation reactions, an important difference. The principal drawback to benzodiazepines is the general concern with their abuse potential, particularly in alcoholics and opiate or pill addicts. Although there does appear to be increased risk in drug abusers, the risk for abuse in patients with uncomplicated panic disorder actually appears to be small. The more realistic issue is the high rate of withdrawal symptoms and relapse following discontinuation of benzodiazepines. Even with a 30-day taper in the large Cross-National Panic...

Management of anxiety and stressrelated disorders

Behaviour therapy, involving relaxation and gradual exposure to the precipitating situation, is of proven value in phobic disorders and in panic disorder when there is avoidance behaviour. A clinical psychologist should assess the patient and organise treatment if behaviour and cognitive therapy are considered appropriate. Phenelzine is a useful adjunct to psychological methods of treatment. Drug treatment is more important in spontaneous panic attacks phenelzine, imipramine, and paroxetine have been shown to be effective.

Genetic markers for fearfulnessanxiety

Shortly afterwards, the same American team(27) reported new data that suggested an association between the neuroticism trait and a chromosomal region linked to the serotonin neurotransmitter system, which is involved in modulating anxiety-related traits. The 5-hydroxytryptamine transporter protein (5-HTT) that promotes the reuptake of serotonin in cell membranes is encoded by a gene located in the q12 segment of chromosome 17. The particular region governing the transcriptional control of the protein shows a polymorphism that influences its expression and functioning. Individuals carrying the short variant of the polymorphism show a reduced efficiency of serotonin reuptake compared with those possessing the longer variant. The study measured several of these parameters in the lymphoblasts of two independent samples totalling more than 500 volunteers who had been recruited for different studies it also included the subsample that had been used in the previous study of the relationship...

Anxiety disorders

Insomnia is strongly associated with the symptom of anxiety most acute episodes of insomnia are triggered by stressful events or situations. Patients with anxiety disorders typically complain of difficulty sleeping. Sleep studies have been performed for various categories of anxiety disorders, including generalized anxiety disorder, panic disorder, post-traumatic stress disorder, and obsessive-compulsive disorder. Most groups of patients show evidence of sleep disruption, as evidenced by prolonged latency to sleep onset, increased time awake during the sleep period, early morning awakening, decreased sleep efficiency and reduced total sleep. Changes in REM sleep or SWS are not typically observed. Additional sleep abnormalities have been reported in conjunction with specific anxiety disorders.

Mood and anxietyrelated disorders

These are by far the most common mental disorders associated with pain in most settings. In the general population, 12 per cent of adults have experienced chronic widespread pain (defined according to the criteria of the American College of Rheumatologists) in the previous 3 months and their prevalence of mental disorders is three times that of the pain-free population. Most of these diagnoses are mood and anxiety disorders, with the former being more common in those with chronic pain. In pain clinic settings, the prevalence of mental disorders varies according to referral patterns, but about 30 to 40 per cent of patients have depressive disorders, and this is similar in those with and those without a relevant physical disorder. (3) Those without organic disorders tend to have lower ratings for both mood disorders and pain severity. Those with mood disorders report more severe pain. Diagnosis of mood and anxiety disorders is based on the usual standardized criteria, but may be...

Hyperventilation and THAM trishydroxymethylaminomethane

Neurosurgical patients with healthy lungs and systemic circulation often hyperventilate spontaneously down to a Paco2 of 30 mmHg.8,65 Hyperventilation reduces ICP via a reduction of cerebral blood volume. Unfortunately this reduction in cerebral blood volume also causes a reduction in cerebral blood flow, and therefore the main concern when patients are hyperventilated is whether there is a risk of inducing cerebral ischaemia or not. Prophylactic hyperventilation of head-injured patients to a Paco2 of 3 4 kPa has been shown to be detrimental to outcome135 and aggressive hyperventilation to below a Paco2 of 35 kPa is not recommended. There is an ongoing controversy about the risk of moderate hyperventilation (Paco2 4-5-3-5 kPa) causing ischaemia.136,137 Our means to monitor critical reductions of cerebral blood flow during hyperventilation are very limited. Jugular bulb venous oxygen saturation or arteriojugular oxygen content differences are generally used to avoid overaggressive...

Management of anxiety

The first treatment guideline is to be sure the patient has adequate information about their illness or treatment. Reassurance from the physician and psychiatrist and a chance to 'rehearse' frightening procedures before they occur can reduce anxiety, without additional intervention. Individual and group therapies are helpful. Increasingly, cognitive-behavioural therapy is used to help patients reframe their perceptions and concerns and learn relaxation techniques. However, significant anxiety will require psychopharmacological intervention. Xa.ble 1Q outlines the commonly used benzodiazepines, their equivalent doses, and initial and target doses. They are divided into short, intermediate, and long half-life. The benzodiazepine is chosen by its side-effect profile, half-life, and route of administration. Clearly, the shorter half-life permits more rapid control and reduces the problems of oversedation from poor elimination of drug. Other medications used in treatment of anxiety are...

Benzodiazepinereceptor partial agonists

As described earlier, the disadvantages of the benzodiazepines include sedation, psychomotor and cognitive impairment, and withdrawal symptoms after long-term use. Increased understanding of benzodiazepine-receptor mechanisms suggested that compounds might be developed which are partial agonists and or selective to some subtypes of receptor.(34) Such compounds would be less efficacious than full agonists but might have better adverse-effect profiles and less dependence potential, i.e. superior risk-benefit ratios. One such compound, alpidem, was actually marketed in France but had to be withdrawn because of liver toxicity. Initial data suggested that it was somewhat less effective than a typical full benzodiazepine agonist but that it had a distinctly better side-effect profile. (36). Abecarnil is a b-carboline which is anxiolytic in doses of 3 to 9 mg day. However, efficacy has been difficult to demonstrate convincingly, although the side-effect profile does appear to resemble that...

Uses Of Antianxiety Agents

Antianxiety agents are used in a variety of situations. Listed below are some of those situations. a. Control Moderate to Severe Stress and Anxiety in Neurotic and Depressed Patients. Some neurotic and depressed patients are prescribed antianxiety agents to reduce the amount of subjective anxiety thus enabling them to more productively participate in counseling or therapy. b. Control Stress and Anxiety in Previously Normal Persons in Periods of Overwhelming Stress. In most cases, normal individuals are able to cope with the stress and anxiety of life. However, when unusual circumstances of extreme stress arise, physicians sometimes prescribe antianxiety agents to assist people during these periods. Antianxiety agents should not be prescribed for dealing with the stresses of everyday life (Food and Drug Administration ruling). d. Treat Psychotic Patients in Periods of Acute Agitation. Sometimes patients who have certain psychotic conditions undergo periods of acute agitation....

AAntianxiety Agents Do Not Cause Excessive Loss of Alertness

Barbiturates were frequently used to calm patients. Unfortunately, the barbiturates sometimes calmed the patients to an undesirable degree. Although the antianxiety agents produce some degree of sedation during the initial days of therapy, this sedation is usually short-lived. b. Overdosage of Antianxiety Agents Rarely Results in Death to the Patient. As previously stated, the barbiturates were previously used to calm patients. Unfortunately, overdose of barbiturates can frequently result in coma, respiratory depression, and death. Antianxiety agents, on the other hand, are somewhat safe in terms of the amount of drug required to produce coma, respiratory depression, and death. This factor makes the wise use of antianxiety agents in special circumstances useful in the treatment of extremely anxious patients who are entertaining thoughts about suicide.

Is It An Advantage If Depression Or Anxiety Disorders Are Detected By

As discussed above some expert groups are very eager to stress how important it is that GPs detect depression and anxiety disorders. Implicit in this is the notion that more patients should be prescribed antidepressants (39). In only a few studies has the aim been to collect data about the social costs of undetected patients. In the study by Ormel et al. (30) it was found that the prognosis was much better for those patients who were detected by GPs compared with those who went undetected but were, nevertheless, depression anxiety cases according to the PSE. The Ormel et al. study went further by presenting data explaining why the detected cases had a more positive prognosis. The main reason was not that the detected cases were prescribed psychotropics more often. More than half of the non-severe detected cases were not given a drug but still had a more positive outcome than the non-severe non-detected cases. The explanation for this was that the GPs tended to pick up those cases...

How To Analyse The Therapy Provided By Gps For Patients With Depression And Anxiety Symptoms

Also, in analysing how GPs choose treatments for patients with symptoms of depression and anxiety it is necessary to combine an analysis of the drug prescribed with an analysis of the communication taking place during the encounter. There are both empirical and theoretical reasons for such a combined research strategy. The empirical reason is that a combination of pharmacological and counselling therapy in primary care might lead to better results than one of the treatment strategies alone (31). The theoretical reason is that beneficial long-term results from pharmacological treatment are very much dependent on the psychological coping strategies the patient develops during that kind of treatment. Of course the patient cannot develop new coping strategies on her own. These must normally be developed by interaction with people in the patient's social network. However, the GP might promote and facilitate the adoption of new coping strategies and the making of new contacts. The GP can...

Anxiety disorders Classification

Anxiety disorders consist of a set of syndromes, ranging from very circumscribed conditions such as specific monophobias (e.g. a fear of spiders) to broad disorders characterized by free floating anxiety and general worry exemplified by the diagnosis of generalized anxiety disorder. According to DSM-IV there are eight major separate diagnostic categories with two specific to the childhood period separation anxiety disorder and reactive attachment disorder. In contrast, ICD-10 denotes five anxiety syndromes specific to this period of life separation anxiety phobic anxiety social anxiety sibling rivalry disorder and generalized anxiety disorder. ICD-10 prefaces the classification of anxiety disorders with a general introduction, indicating that these conditions are mainly exaggerations of normal developmental trends rather than phenomena that are qualitatively different and abnormal in themselves. Developmental appropriateness is a key diagnostic feature in defining the difference...

Separation anxiety disorder

The defining feature of separation anxiety disorder is an excessive, unrealistic, and persistent fear of separation from the attachment figure. This level of worry is quantitatively beyond normal, but, as both diagnostic systems indicate, it must be distinguished from formal thought disorder and first-rank symptoms of psychoses and schizophrenia, such as thoughts being inserted into the child's mind. Whilst the former are common, the latter are extremely rare in the prepubertal child. The diagnostic systems show relatively good agreement on the nature and characteristics of separation anxiety disorder. Both require fear of separation as the focus of the anxiety and at least three symptoms of general worry from eight possibilities In addition, a duration of 4 weeks and the presence of personal impairment in the child's current social function must be present, although the exact nature or level of the latter is not specified. ICD-10 requires the disorder to have its onset before 6 years...

Other anxiety disorders

ICD-10 has retained phobic anxiety disorder, social anxiety disorder (avoidant disorder in DSM-IV and DSM-III), sibling rivalry disorder, and generalized anxiety disorders as specific diagnoses of emotional disorders in children. In contrast to ICD-10, DSM-IV has chosen not to emphasize the differences in the developmental timing of these disorders, even though the global clinical features of these conditions (including gender, race, and a range of comorbid characteristics) are broadly similar. A brief summary of the features of these disorders as they pertain to children is provided here. Detailed coverage of anxiety disorders can be found in Chapter 4.7.1,, Chapter. .4.7.2, and Chapter 4.7.3.

Schoolrefusal anxiety disorder

Non-attendance at school, although infrequent in the general population, may result in referral to child mental health services. Many of these children show anxious symptoms, but school phobia is uncommon and only one of a range of reasons for school non-attendance. (14 On psychiatric examination, many such children meet the criteria for one or more anxiety disorders, the most frequent being separation anxiety disorder. A small proportion may meet criteria for other disorders, including depression (generally mild). Physical symptoms are very evident in the presentation and include abdominal pain, frequency of micturition, anorexia, diarrhoea, pallor, and headache. They may be limited to mornings, reflecting the somatic consequences of physiological arousal associated with specific anticipatory worry about school. Invariably, the physical and emotional symptoms recede if avoidance is allowed.

Social anxiety disorder

In this disorder there is a wariness of strangers and social apprehension or anxiety when encountering new, strange, or socially threatening situations. The clinical characteristics are similar to those in adults (Chapter .Z. .), as are the rates of comorbidity with other anxious disorders.(1 l7' Children appear, however, to have a lower rate of negative cognitions (embarrassment, overconcern, self-consciousness) than adults. Children with simple avoidant disorders are younger than those with more socialized phobic conditions. There are no epidemiological studies of these conditions in childhood.

Clinical management of panic disorder A Tricyclic antidepressants

Imipramine (Tofranil) and clomipramine (Anafranil) are considered firstline treatment options for panic disorder. The onset of therapeutic action 3. One of the most burdensome adverse effects for patients with panic disorder is the activation syndrome, which occurs on initial titration in 25-40 . The syndrome often can be mitigated by initiating a low starting dosage (eg, 10 mg of imipramine per day), then increasing gradually at a rate of 10 mg every two to three days until a dosage of 50 to 75 mg is achieved. A withdrawal syndrome may occur following abrupt cessation of these agents. Drugs Used For Treating Panic Disorder Benzodiazepines Alprazolam (Xanax) Lorazepam (Ativan) Clonazepam (Klonopin)

Benzodiazepines includes midazolam diazepam and lorazepam Midazolam is the agent of choice due to its

Benzodiazepine reversal pharmacokinetics and exceptional amnestic properties. Short-acting agent (varies by route of administration and dosage), with rapid onset (1-2 minutes IV, 2-20 minutes transmucosally or enterally). Given alone, it is unlikely to induce sleep, although it will create a relaxed state in most children. Serves as an excellent adjunct to local anesthetic or concomitant narcotic or dissociative agents for painful procedures. Midazolam, as with all benzodiazepines, produces dose-dependent respiratory depression that is significantly exaggerated by use with narcotics. Up to 10 of children experience a paradoxic hyperexcited, irritable state that can be blunted with increased dosing or flumazenil. Adolescents are more susceptible and should not be dosed on a per-kilogram basis (see Table I-24). Midazolam is reversible with flumazenil. 3. Barbiturates. Barbiturates depress reticular activating system and serve as very good sleep-inducing agents. Commonly used agents...

Disadvantages Of The Use Of Antianxiety Agents

Although the antianxiety agents do have many advantages over previously used drugs, they are not free from potentially harmful effects. The discussion below focuses on two major disadvantages of the group of drugs classified as antianxiety agents. a. Drowsiness. Antianxiety agents, especially during the first few days of therapy, produce drowsiness in many patients. Further, many patients who take antianxiety drugs experience loss of judgment and a loss of mental powers. Consequently, patients who are on antianxiety therapy should be cautioned not to operate machinery. b. Drug Interaction Effects. The antianxiety agents can interact with central nervous system depressants to produce a further degree of depression to the central nervous system. Thus, patients who are on antianxiety therapy should be cautioned against drinking alcohol or taking other central nervous system depressants.

The potential of different benzodiazepines for misuse and dependence

In view of the frequency of prescribing of benzodiazepine drugs, it is an important question as to whether some benzodiazepines are more likely to be misused, or to lead to dependence, than others. The similarities between different benzodiazepines are much greater than the differences. Patients may maintain that they need a specific named benzodiazepine, but there is marked cross-tolerance, and patients changed to an equivalent dose of a different benzodiazepine under double-blind conditions show almost complete cross-dependence (i.e. no difference in withdrawal symptoms from those whose medication has been unchanged).(9) However, this cross-dependence was shown for patients who were already benzodiazepine dependent. It is possible that the properties of certain benzodiazepines lead to a stronger motivation for people to desire their effects, to escalate the dose, and to persist with their use. Factors that have been considered to influence the liability to misuse and development of...

ADHKD and anxiety disorder53 Diagnosis and differential diagnosis Assessment of children

An interview with or direct observation of the child is important to the assessment. However, the clinician may be unable to observe the child's symptoms first-hand in all cases. Children with AD-HKD are able to suppress their inattentiveness, restlessness, and impulsiveness to a great extent in novel and highly structured situations, such as those afforded by the typical visit to the physician's office. However, parents and teachers can provide a picture of the child's typical behavioural, developmental, and social history, and response to variations in the environment (e.g. family upset or changing teachers). Direct examination of the younger child may be limited by the child's apparent lack of insight into his or her behaviour or an inability to communicate as a result of language or learning difficulties. Nevertheless, the individual child assessment may be useful for identifying comorbidities (e.g. anxiety or depression), monitoring treatment, and establishing the rapport...

Introduction To Antianxiety Agents

It is not unusual for a person to experience stress and anxiety. Most people can deal with the minor stresses of life without using antianxiety agents. However, when the degree of anxiety increases to the point of causing social and or economic impairment, the attending physician may decide to prescribe an antianxiety agent. It should be remembered that the antianxiety agent will calm the patient, but the drug cannot remove the cause of anxiety. Often the antianxiety therapy is combined with counseling or therapy to help the patient deal with the stress and anxiety.

Therapeutic hyperventilation

The use of moderate hyperventilation is advocated for traumatic coma, but considerable controversy remains as to whether or not it is an effective or safe therapy. The rationale for hyperventilation is based on two premises. It reduces intracranial pressure and reverses cerebral lactic acidosis which, like intracranial hypertension, is correlated with poor outcome after brain injury. The fall in intracranial pressure induced by hyperventilation occurs secondary to constriction of cerebral vessels and a consequent reduction in cerebral blood flow and volume. Cerebral blood flow decreases by about 15 per cent for each 0.5-kPa reduction in PaCO2. The reactivity of cerebral vessels to CO2 appears to be maintained in many patients following head injury, and this argues for the effectiveness of hyperventilation as a therapy for intracranial hypertension. As might be expected, the response to hyperventilation is greatest in those with cerebral hyperemia or 'luxury perfusion'. Since these are...

Benzodiazepine dependence and alcohol dependence the overlap

There are high reported rates of alcohol dependence among the homeless, and there are substantial reports of benzodiazepine abuse and dependence in this population also. Cross-tolerance between benzodiazepines and alcohol permits individuals who are alcohol dependent to tolerate high doses of benzodiazepines. Patients may be prescribed benzodiazepines to manage alcohol withdrawal, but injudicious prescribing that is not targeted towards the management of alcohol withdrawal symptoms may result in iatrogenic benzodiazepine dependence. The extensive research on pharmacological interventions for management of alcohol withdrawal in alcohol-dependent patients has been examined in a meta-analysis by Mayo-Smith, who subsequently produced a systematic review with treatment guidelines. (17) This review supports the use of benzodiazepines as the treatment of choice for managing withdrawal symptoms for patients whose symptoms are of sufficient severity to warrant medication. Alternative agents...

Anxiety and intrusive thoughts

The current understanding of the impact of health screening is based almost exclusively on uncontrolled longitudinal reports and studies. Where screening results in the diagnosis of a serious condition, very high levels of anxiety are probably not uncommon. It has been suggested by some surgeons that anxiety may be more probable or severe after cancer is detected by screening rather than by investigation of symptoms although observation this requires further investigation. A high-risk screening result, as opposed to the diagnosis of a disease which has already fully developed, can also result in significant anxiety. Palmer et al.(12 found that women who had been diagnosed as having cervical intraepithelial neoplasia a week earlier showed levels of intrusions and avoidance that were similar to people having experienced trauma such as loss of a parent. Horowitz et al.(13 found that 3 years after cardiovascular screening a third of men reported some intrusive thoughts or attempts to...

Obsessive compulsive disorder

It is very plausible to view obsessive compulsive disorder (OCD) as an anxiety disorder, and it is so classified in the standard nosologies. Anxiety is typically involved in the phenomenology the person has preoccupying, anxiety-provoking thoughts, usually about some unrealistic danger, and compulsively attempts to neutralize these thoughts and to relieve the anxiety they engender by activities such as counting, cleaning or checking, carried out in stereotyped or ritualized ways. Anxiety is apparently implicated also in normal, non-clinical phenomena which may be akin to obsessive-compulsion phenomena, in children's magical thinking and actions, and in adult life, particularly in people with so-called obsessional traits. Broadly speaking, the classification of OCD as a kind of anxiety disorder goes along with emphasizing its intentionality. Obsessional fears are typically quite irrational, but it may be hypothesized that they have meaning, along the lines discussed in the previous...

Anxiolytics and hypnotics

These include benzodiazepines, non-benzodiazepine hypnotics such as zopiclone and zolpidem, and non-benzodiazepine anxiolytics such as meprobamate and buspirone. Benzodiazepines have sedative effects in humans, but this effect varies with dose, administration (single or repeated dose), age of subject, and state of the subject (normal, anxious, or depressed). Two recent non-benzodiazepine hypnotics (zopiclone and zolpidem) induce either no sleepiness at all or limited sleepiness in the morning immediately after awakening. Buspirone seems to induce less sleepiness than the benzodiazepines.

Aetiology of anxiety disorders

There is a relative lack of systematic research on specific anxiety syndromes in young people. This section covers what is currently known about the aetiology of these disorders in infants and school-age children. The mechanisms and process(es) that lead to the onset of anxiety disorders in this age range are multifactorial. (1Z There is good evidence that separation anxiety disorder is significantly more likely in probands whose first-degree relatives have high rates of anxiety disorders in general. l0,) The combination of parental anxiety and depression is particularly found in childhood probands with separation anxiety disorder. (19 A recent twin study suggested that genetic and environmental factors were additive and about equal in increasing the risk for children and adolescents reporting symptoms of separation anxiety disorder and other anxious disorders. (20) Prospective studies of behaviour inhibition (characterized by cautious, shy, and inhibited behaviour to the unfamiliar)...

Older Sedativehypnotic And Anxiolytic Agents

Before the introduction of the benzodiazepines, a number of drugs from different chemical and pharmacological classes were used in the treatment of anxiety and insomnia. However, these drugs are more toxic and produce more serious side effects than do the benzodi-azepines. Many also have significant abuse potential. Consequently, most of these compounds are no longer widely used. These drugs include the barbiturates (e.g., pentobarbital, amobarbital), carbamates (e.g., meproba-mate), piperidinediones (e.g., glutethimide), and alcohols (e.g., ethchlorvynol).

Treat anxiety pain and inadequate coping skills

Anxiety is a common reaction to physical or psychological trauma and to treatment in intensive care units (ICUs). It can be seen as a transient reaction in a previously healthy individual or as a manifestation of a pre-existing anxiety disorder. The treatment team should make every effort to put the patient at ease to avoid potentially harmful reactions (e.g. pulling out intravenous lines, refusing treatment, and leaving against medical advice). Direct discussion of the patient's medical condition and a compassionate stance by the clinician are crucial in guiding the anxious patient. A psychiatrist, a calm family member, benzodiazepines, and neuroleptics can each be helpful in reducing anxiety their uses are discussed below.

Generalized Anxiety Disorder

Generalized anxiety disorder (GAD), is characterized by unrealistic or excessive anxiety and worry about two or more life circumstances for at least six months. A. Chronic worry is a prominent feature of GAD as opposed to the intermittent terror that characterizes panic disorder. Patients may report that they can't stop worrying, which may revolve around life concerns relating to money, job, marriage, health, and safety of children. C. Symptoms of depression should be sought because 30-50 of patients with anxiety disorders will also have depression. Drugs and alcohol may contribute to anxiety disorders. II. Medical disorders causing anxiety symptoms A. Hyperthyroidism may cause anxiety, tachycardia, palpitations, sweating, dyspnea. B. Cardiac rhythm disturbances and mitral valve prolapse may cause anxiety symptoms. C. Substance abuse or dependence with withdrawal symptoms may resemble anxiety. D. Pharmacologic causes of anxiety include salicylate intoxication, NSAI Ds antihistamine...

Clinical diagnosis of panic disorder

Panic disorder is characterized by unexpected panic attacks. A panic attack is defined as a discrete episode of intense symptoms that peak within 10 minutes and primarily involve sympathetic nervous system manifestations. B. A diagnosis of panic disorder is made if the patient has experienced recurrent, unexpected panic attacks and shows at least one of the following characteristics (1) persistent concern about having another attack (anticipatory anxiety) (2) worry about the implications of an attack or its consequences (eg, suffering a catastrophic medical or mental consequence), or (3) a significant change in behavior related to the attacks. C. Agoraphobia usually accompanies panic disorder. Agoraphobia refers to avoidance behavior motivated by fear of having another panic attack. It may consist of avoidance of activities that patients fear could provoke an attack, situations where escape may not be readily available, or activities during which patients are not accompanied by a...

Cognitive content of anxiety disorders

Although there is no substitute for a careful assessment of each patient's ideation, research shows that most anxiety disorders are characterized by a specific type of fearful ideation and successful therapy generally focuses on such ideation. (7) Panic disorder Panic disorder is characterized by a fear of an immediately impending internal disaster (for example heart attack, cessation of breathing, mental derangement) and a sense of loss of control over physical and mental functions. Many of panic patients' negative thoughts can be viewed as misinterpretations of normal bodily sensations (such as palpitations or a slight feeling of breathlessness). Indeed, cognitive theorists (8.,9) argue that panic attacks result from a vicious circle in which catastrophic misinterpretations of body sensations lead to an increase in anxiety and associated sensations, which are in turn interpreted as further evidence of impending, internal disasters (e.g. heart attack, fainting, going mad). Panic...

Cognitivebehaviour therapy for anxiety disorders

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Managing anxiety and other emotional sequelae resulting from impaired cognition

Anxiety and depression are frequently seen in memory-impaired people. Kopelman and Crawford (29 found depression in over 40 per cent of 200 consecutive referrals to a memory clinic. Evans and Wilson (39 found anxiety to be common in attenders of a weekly memory group. Dealing with these emotional problems should be an integral part of memory rehabilitation. Obviously, listening, trying to understand, and providing information are key factors in encouraging families to cope with their difficulties. Wearing(31 provides a helpful reference on the problems faced by families of memory-impaired people, and makes suggestions as to what can be done to help. Providing information or explanations is one very simple and therapeutic strategy that can help reduce the fear and anxiety accompanying memory impairment. Written information is best, as most people, whether memory impaired or not, are unlikely to have good recall of information at times of stress. Memory Problems After Head Injury,(32...

Anxiety obsessional and stressrelated neuroses

Some mothers are overwhelmed by the fear that they will not be able to cope with the care of the newborn.(54) The panic and agitation seen in extreme examples is an exaggeration of the anxiety that many women experience when they first confront their awesome responsibility. The disorder is not limited to first-time mothers it can occur after the second pregnancy when the grandmother has supervised the first baby, or after a long gap between pregnancies. If no help is available, a mother's anxiety can get out of hand, and there is a risk that she will lose her baby. Another postpartum anxiety is the fear of sudden infant death.(55 These mothers suffer severe insomnia, because they lie awake listening to the baby's breathing they may sleep with their hand on the infant's chest, check the infant many times each night, or even wake the baby to ensure that he or she is still alive. This results in excruciating tension and exhaustion. A mother may be helped by ventilating these fears, and...

Peripheraltype Benzodiazepine Receptors Pbrs Pharmacological and Biochemical Characteristics

Benzodiazepines are widely used for their anxiolytic, anticonvulsant, and hypnotic actions. It has been well established that the major pharmacological effects of benzodiazepines are mediated by the y-aminobutyric acid (GABA)a receptors in the CNS (1,2). However, in search of specific binding sites for benzodiazepines outside the CNS another class of binding sites was first observed in the kidney (3) and later determined to be present in apparently all tissues including the CNS (4-7). This class of binding sites is commonly referred to as the peripheral-type benzodiazepine recognition sites or receptors (PBRs) owing to its initial discovery in peripheral tissues. PBRs were distinguished from GABAA benzodiazepine receptors by several criteria. Although both receptors bind diazepam with relatively high affinity, they exhibited very different binding specificities. In rodent species, PBRs bind 4'-chlorodiazepam with high affinity, whereas GABAa receptors show low affinity for this...

Anxiety and Depression

Many complementary therapies modulate levels of arousal. The most obvious examples are hypnosis and relaxation therapies. A systematic review included 15 randomized trials that assessed the effects of relaxation therapies on acute, treatment-related anxiety and depression in cancer patients. Scores of patients receiving relaxation therapy were approxi mately half a standard deviation better than controls, with differences between groups being statistically significant.101 Several randomized trials have explored the effects of relaxation treatments on anxiety and depression in out-patients. In a typical study, 109 cancer patients with varying diagnoses and different stages of disease were randomized to receive seven weekly 90-minute meditation classes and were encouraged to practice meditation at home. Anxiety and depression scores fell by nearly 50 in the meditation group with little change in controls (P 0.01 for difference between groups on reanalysis).102 The broad perception that...

Anxiety management stress inoculation

The goal of this treatment is to teach the patient a set of skills that will help them cope with stress. Examples include relaxation training, training in slow abdominal breathing, thought stopping of unwanted thoughts, assertiveness training, and training in positive thinking. (59) Anxiety management is more effective than supportive psychotherapy. In the long term it appears to be somewhat less effective than exposure treatment.(101) Relaxation treatment alone is less effective than exposure and cognitive therapy in the short and long term.(102)


Because of the exquisite sensitivity of CBF to PaCO2, hyperventilation will reduce CBF, and concomitantly cerebral blood volume (CBV), resulting in an acute decrease in ICP. Although the acute reduction in ICP and improvement in CPP is theoretically desirable, and hyperventilation has been traditionally used as an effective treatment modality, in recent years the concern for the risk of cerebral ischemia has curtailed its use. CBF studies have demonstrated that even moderate hyperventilation may increase brain regions with CBF below the ischemic threshold 3 . Reduction of jugular venous oxygen concentration (SjvO2) and brain tissue PO2 (PbrO2) have also been repeatedly demonstrated in studies in head-injured patients. Moreover, in the only randomized controlled trial conducted on this therapeutic modality, prophylactic hyperventilation has been shown to be associated with adverse outcome. Thus the Brain Trauma Foundation Guidelines suggest that hyperventilation should not be used for...

Anxiety disorder

Anxiety disorders are found in about 30 per cent of patients after head injury, and are at least as common in those who have suffered mild injury. (47* Anxiety symptoms, particularly those with a mild head injury, may develop over the weeks and months following a head injury. It is then more likely to be associated with depression, post-concussion syndrome, and with post-traumatic stress disorder. Phobic avoidance is seen, for example travel anxiety following a road traffic accident. Apprehension is a common complaint, perhaps reflecting problems caused by cognitive impairments, and the person may be indecisive. Therefore anxiety symptoms may emerge on return to work. Anxiety symptoms will be inflated in the presence of financial or family stress. Obsessive-compulsive disorder is a recognized sequela of head injury. This may partly reflect the inflexibility and rigidity of the brain-injured person, or a response to doubt resulting from memory disorder.


In another trial, 75 patients were randomly assigned to receive clonazepam or placebo. (57) Patients given clonazepam endorsed improvements on clinician-rated and self-report measures of social anxiety after 6 weeks. After 10 weeks, 78 per cent of clonazepam patients, compared with 20 per cent of patients given placebo, were classified as responders. Clonazepam-treated patients endorsed significantly more side-effects than patients given placebo anorgasmia (44 per cent versus 6 per cent), forgetfulness (44 per cent versus 21 per cent), unsteadiness (62 per cent versus 21 per cent), and impaired concentration (35 per cent versus 15 per cent).


In one study, 34 performance-anxious musicians were randomly assigned to 6 weeks of buspirone, placebo, cognitive-behavioural therapy, or buspirone plus cognitive-behavioural therapy, and it was found that buspirone was no better than placebo. (59) Another study randomly assigned 30 patients to 12 weeks of buspirone or placebo (60) only one patient from each condition qualified as a responder.


Anxiety disorders are among the most common forms of psychiatric illness. Anxiety often accompanies other psychiatric disease and such medical illnesses as angina pectoris, gastrointestinal disorders, and hypertension. Anxiety that results from fear caused by an acute illness or a stressful event, such as a divorce or the loss of a loved one, is usually self-limiting and can be of relatively short duration. Other disorders that have anxiety as a component are not necessarily associated with a life event, and may persist for considerable periods, even throughout the individual's life. Both acute and chronic anxiety can be treated with benzodiazepines, although it is anticipated that for most anxiety disorders counseling will also play an important role. Benzodiazepines employed in the treatment of anxiety should be used in the lowest effective dose for the shortest duration so that they will provide maximum benefit to the patient while minimizing the potential for adverse reactions....

Panic disorder

Most patients with panic disorder experience at least one sleep-related panic attack, and one-third or more of patients have recurrent nocturnal panic attacks. (2D Data from the few sleep panic attacks that have been recorded suggests that they occur more commonly during NREM sleep, at the transition to SWS. (22,23,) Symptoms of sleep panic attacks are essentially the same as those which occur during daytime attacks. Typically, patients report waking in a state of intense fear or anxiety, commonly with palpitations, shortness of breath, choking sensation, chest discomfort, and chills or hot flushes. They do not usually report dreaming just before the attacks. Unlike night terrors, which are characterized by incomplete arousal from sleep, patients having a sleep panic attack are awake and alert immediately after the attack begins. Patients with frequent sleep panic attacks may become fearful of going to sleep, which can contribute further to their insomnia.

The benzodiazepines

The use of barbiturates as anxiolytics has declined to the point of obsolescence. The main reason for this is the safety in overdose of the benzodiazepines compared with the quite marked toxicity of the barbiturates. In turn, concern has mounted concerning the benzodiazepines. (2) These drugs are widely prescribed by many physicians for patients with emotional problems, circulatory disorders, tension headaches, and pains in the chest and back as well as digestive disorders, all with the common symptom of anxiety. This widespread use, even overuse (the 'benzodiazepine bonanza'), and the induction of dependence even at normal therapeutic dose has led to official injunctions for greater care in prescribing. Nevertheless, the drug treatment of choice for anxiety, at least in the short term, remains a benzodiazepine. However, an alternative position held by some practitioners is to view these drugs as useful, safe, and underused in the management of anxiety. (4)


Anxiolytics are medications used to treat anxiety and insomnia. These have replaced sedatives that were traditionally used because they have fewer and less potent side effects, especially if an overdose of the medication is given to the patient. Benzodizepine is the major group of anxiolytics. Anxiolytics are prescribed when the patient's anxiety reaches a level where the patient becomes disabled and is unable to perform normal activities. Anxiolytics have a sedative-hypnotic effect on the patient, but not an antipsychotic effect. There are two types of anxiety primary anxiety and secondary anxiety. Primary anxiety is not caused by a medical condition or drug use but may be sit-uational. Secondary anxiety is caused by a medical condition or by drug use. Anxiolytics are usually not administered for secondary anxiety unless the secondary cause is severe or untreatable. Instead, the secondary cause is treated. Benzodizepines are prescribed to treat severe or prolonged anxiety, but are...

DClonazepam Klonopin

Clonazepam is used in the treatment of grand mal epilepsy. It is the alternate drug for the treatment of petit mal in patients who fail to respond to ethosuxamide (Zarontin ) therapy. (2) Adverse effects. The primary side effect associated with clonazepam is central nervous system depression. Drowsiness is frequently seen in patients who take this medication.

Buspirone BuSpar

Buspirone is a first line treatment of GAD. Buspirone requires 3-6 weeks at a dosage of 10-20 mg tid for efficacy. It lacks sedative effects. There is no physiologic dependence or withdrawal syndrome. 2. Combined benzodiazepine-buspirone therapy may be used for generalized anxiety disorder, with subsequent tapering of the benzodiazepine after 2-4 weeks. 3. Previous treatment with benzodiazepines or a history of substance abuse have a decreases the response to buspirone. Buspirone may have some antidepressant effects.

Anxiolytic drugs

Mankind has used anxiety-allaying drugs for thousands of years, dating back to the discovery that, among its psychotropic properties, alcohol could induce sedation. The nineteenth century saw the development of inorganic and, later, organic chemistry. Bromides were introduced as sedatives and became widely used despite their poor effectiveness, toxicity, and potential abuse. Organic chemists in the second half of the nineteenth century introduced sedatives such as chloral and paraldehyde. The former is still used as an hypnotic but paraldehyde is now obsolete. The benzodiazepines were first synthesized in the 1930s, but not developed until 2 years later. The prototype, chlordiazepoxide, had similar actions to meprobamate in cats but with several times the potency. Further evaluation followed in the clinic and it was soon introduced into medical practice. More than a 1000 benzodiazepines and related compounds have been synthesized, including diazepam, the most widely used of all ( Fig,...

And Anxiety

In any analysis of depression and anxiety these conditions can be viewed from several different perspectives (8). Here for pedagogical reasons we are 1. Depression and anxiety are caused by dysfunctional biochemical processes. This perspective is often called the biological perspective''. At least some of the people who apply this perspective think genetic factors play an important role in determining an individual's vulnerability. A doctor who has this perspective often recommends pharmacological treatment for patients who fulfil the criteria for depression or anxiety disorders. For example, by taking antidepressant drugs the patient's biochemical processes are expected to become more functional and the corresponding symptoms of depression are expected to decrease. Among psychiatrists such a biological perspective seems common (9). 2. Depression and anxiety are caused by an interaction between an individual's internal cognitive system and the demands of the indivi The interactional...

The burden of mental illness

Using the DALY as the basic statistic, the World Development Report(2) concludes that mental health problems make up 8.1 per cent of the total GBD. Of that 8.1 per cent, the largest contributors are depressive disorders, self-inflicted injuries. Alzheimer's disease and other dementia, and alcohol dependence, followed by epilepsy, psychoses, drug dependence, and post-traumatic stress disorder. Depressive and anxiety disorders account for between one-quarter and one-third of all primary-health-care visits worldwide.(3,,4) When appropriately diagnosed and treated, suffering is alleviated, disability prevented, and function restored when ignored, major losses persist.(5) By the year 2025, three-quarters of all elderly persons with dementia (about 80 million) will live in low-income societies. Mental retardation and epilepsy rates are three to five times higher in low-income societies compared with industrialized countries. In some Asian and African countries, up to 90 per cent of patients...

Year III of residencyspecific goals and objectives

The goal of this year is to enhance the resident's acquired competencies in ambulatory care by supervised experience in more complex arenas of psychiatric service. A whole variety of new competencies are derived from this emphasis on mastering the problems of psychiatric assessment and treatment in unique domains within the health-care system. The resident continues to treat patients in an office-based practice, but, through a comprehensive outpatient service, also has closely supervised experience in the assessment and treatment of chronic schizophrenia and affective disorders, anxiety disorders, drug and alcohol disorders, and sexual disorders. Special treatment experiences psychopharmacology for chronic disorders, couples therapy, family therapy are provided under close supervision along with an extended series of psychodynamically oriented lecture demonstrations. A significant exposure to community-based psychiatry is provided, including rehabilitative and outreach services....

Preface to the First Edition

Throughout the discussion philosophical theories are brought to bear on the particular questions of the explanation of behaviour, the nature of mental causation, and eventually the origins of major disorders including depression, anxiety disorders, schizophrenia, and personality disorder.

Medical Advice for the Public

Parkinson wrote several medical handbooks for the lay public. Medical Admonitions (first published in 1799) instructs families to recognize symptoms of both minor and major illnesses.18 The first section includes a table of common symptoms listed alphabetically from Anxiety, When fever is accompanied by extreme anxiety, the patient sustaining, at the same time, a considerable loss of spirits and strength, the fever may be judged to be of a malignant kind, and to require the most powerful aid, to Yawning, Generally occurs at the commencement of

Competing Classifications

It is of interest to see the effect of applying algorithms for the diagnostic categories defined by different systems to a common set of symptom data. The Schedules for Clinical Assessment in Neuropsychiatry (SCAN) (WHO, 1992) allows diagnosis under both DSM and ICD. In Table 1.2, I have illustrated the effect of applying ICD-10 and DSM-IV criteria to the data from the Derry Survey (McConnell et al., 2002) on the identification of cases of depressive episode (ICD) and depressive disorder (DSM). Of the 18 participants diagnosed as having a depressive condition by one classification, two-thirds were diagnosed by both. Five cases of depressive episode were not diagnosed as DSM depressive disorder, whereas only one case of depressive disorder was not diagnosed as ICD depressive episode. In contrast, DSM recognized many more cases of anxiety disorder. Fifteen of the cases No anxiety diagnosis Anxiety disorder ICD No anxiety diagnosis Anxiety disorder DSM defined by DSM were not classed as...

Leaky Classes And Comorbidity

Thus, Kessler (2000) has defended the status of generalized anxiety disorder (GAD) as an independent condition, despite its high comorbidity, arguing that it does, for example, precede major depression, and also outlasts it. However, this would be expected if GAD represented a low threshold disorder that could transmute into a higher threshold disorder with the addition of a few symptoms. GAD and depression certainly share a common genetic diathesis (Mineka et al., 1998). The superimposition of major depression on a long-lasting minor depressive disturbance (dysthymia) has been called double depression (Keller et al., 1997). The comorbidity of anxiety and depression may arise because anxiety states can transform into depressive disorders with the addition of relatively few symptoms (Parker et al., 1997). Depression anxiety is equally apparent in adolescents (Seligman & Ollendick,

Ethnic Considerations

Likewise, a genetic factor in African-Americans makes them less responsive to beta-blocking agents used in cardiac and antihypertensive medications. Asians have a genetic factor that causes undesirable side effects when given the typical dose of benzodiazepines (diazepam Valium ) alprazolam Xanax , tricyclic antidepressants, atropine, and propranol Inderal . Therefore, a lower dose must be given.

Clinical presentation

Minor degrees of obstruction may manifest during increased respiratory rate and inspiratory flow, as may occur during exercise. Advanced signs of obstruction are as follows extreme agitation and anxiety inability to phonate inspiratory stridor and gasping respirations use of respiratory accessory muscles, nasal flaring, and suprasternal and intercostal recession tracheal tug and paradoxical chest and abdominal wall movements upright posture dependence.

History Of Viral Vaccines

The first vaccine (Table 1.1), Jenner's smallpox (1798), was produced on the skin of living animals and was a very 'dirty' preparation. The next vaccine, rabies (1885) produced in spinal cord preparations, was equally contaminated with host proteins and caused severe anaphylactic shock and other side effects. The need for cleaner and safer vaccines led to the use of embryonated chicken eggs (yellow fever, 1935 influenza, 1936) and although an improvement, these preparations were still often contaminated with microorganisms. Thus the use of cultured primary cells was seen as a great breakthrough in terms of microbiological quality and purity (i.e. low levels of extraneous contaminating protein). However, subsequent research showed that monkey kidney cells were host to a wide range of intrinsic viruses such as a collection of simian viruses (SV), herpes B virus, etc. Some of these, like SV40, were known to be transforming viruses and thus concerns were felt over the possibility of...

Radiographic and Other Studies

If patient is oversedated with narcotics or benzodiazepines, consider administration of specific antidote. Electrolyte abnormalities (eg, hypokalemia, hypophosphatemia, hypocalcemia) may lead to muscular weakness and should be rapidly corrected. If patient has a neuromuscular disorder, noninvasive ventilation, such as continuous or bilevel positive airway pressure (CPAP or BiPAP), may be helpful. Extrinsic pulmonary disease (eg, pneumothorax, pleural effusion) should be treated specifically. Foreign bodies will require removal. Severe bron-choconstriction, as in asthma, should be aggressively treated with 0-agonists, steroids, ipratropium, and possibly magnesium. Endotracheal intubation and mechanical ventilation should be considered if mental status is abnormal, if patient appears to be tired from the high work of breathing, if there is poor response to initial therapies, or if oxygenation is compromised.

Fear of breathlessness

Subjective sensitivity to the perception of breathlessness is influenced by the emotional state of the patient. As well as the limitation in activity caused by chronic illnesses, some patients present with depression or panic attacks related to their emotional state or previous experience in crises of acute breathlessness.

Pharmacological intervention

Benzodiazepines have been considered to have a potential action in alleviating breathlessness. However, diazepam and alprazolam have proved ineffective in relieving this symptom. Buspirone is a non-benzodiazepine anxiolytic drug, and is better tolerated as it does not present sedative and anticholinergic actions. During buspirone treatment, chronic obstructive pulmonary disease patients show reduced anxiety and depression, and an improvement in exercise tolerance and sensations

Special Considerations

Drugs should be prescribed only if nonpharmaco-logical techniques are ineffective, such as for problems like sleeplessness and anxiety. When drugs are prescribed for these conditions, they should be given for a limited time and the patient closely monitored for adverse effects. Dosage should start at or below the lowest recommended levels.

Supplemental Reading

Answer Benzodiazepines are effective for short-term use as sedative-hypnotics. Long-acting types with active metabolites, such as diazepam, would normally be expected to have a prolonged half-life. The half-life would be even more prolonged in Mrs. Jones because of the increase in body fat and decreased renal excretion that are typical for persons of her age. After several weeks of administration, daytime confusion may occur in this patient and may put her at risk for a fall and another serious injury. A short-acting benzodiazepine with inactive metabolites, such as oxazepam, could provide the desired effect with minimal adverse effects.

Are the results relevant for your patient

To determine the relevance of the study to real-life patients, it is important to examine the inclusion and exclusion criteria of the trial. The main inclusion criteria are discussed above. Patients excluded from the trial were women who were pregnant or of child-bearing age but unwilling to use an effective contraceptive method. Exclusion criteria also included major medical conditions, bipolar disorder, psychosis, panic disorder, concurrent major depressive disorders, generalized anxiety disorder, history of alcohol or other drug dependency within the previous 12 months, serious suicidal risk, previous non-response to two or more adequate antidepressant trials, and use of psychotropic drugs within 2 weeks of enrolment. The use of the study results will have to take these inclusion and exclusion criteria into account, and the clinician needs to judge the relevance of the results for the individual patient.

The presence of coma without focal signs or meningism

In patients with drug overdose the possibility of using specific antidotes should be considered naloxone in patients in whom there is a high index of suspicion of opiate poisoning and benzodiazepine antagonists in self-poisoning with benzodiazepines. The use of analeptic agents in barbiturate poisoning cannot now be supported.32 Consideration should also be given to clearing the ingested toxin from the stomach. The passage of a nasogastric tube should usually be considered and this is one indication for intubation of the trachea to prevent the risk of aspiration. The importance of the diagnosis of drug overdose coma is that such patients have a good prognosis provided that they are given adequate respiratory and circulatory support during their unconsciousness. They are, however, particularly liable to show sudden depression of brain stem responses and if the possibility of drug overdose is not considered their level of coma may be misinterpreted and their prognosis might be thought...

Maintenance of Anesthesia

Anesthesia is maintained by inhalational agents or by an infusion of an intravenous agent such as propofol. Rapid awakening is desirable after neurosurgery to allow neurological assessment of the patient, and is best achieved with short-acting drugs. Opioid analgesics and muscle relaxants are given as needed and the patient's lungs are ventilated. Moderate hyperventilation is used for craniotomies in order to reduce CBF and brain volume, thereby providing good operating conditions. However, extreme hyperventilation may be associated with critical reduction in flow to compromised areas and focal ischemia, and is best avoided 13 .

Anesthesia for Aneurysm Surgery

The surgical exposure of the vessels at the base of the brain by retraction of brain tissue can be aided by positioning of the patient, withdrawal of CSF and dehydration with diuretics. The use of induced hypocapnia by hyperventilation is controversial in aneurysm patients as it may enhance vasoconstriction in those with cerebral vasospasm. It is probably safe to use mild hyperventilation, but in the presence of induced hypotension, normocapnia should be maintained.

Mechanical ventilation

The intensive care mortality in intubated severe chronic obstructive pulmonary disease (FEV 1 1 liter) patients varies between 10 and 30 per cent, with 1-year survival approximately 50 per cent. Prognostic criteria of a fatal outcome are scarce and their predictive ability is at best 70 to 80 per cent. Hence the decision to intubate or not must rest on patient history, in particular previous intubation with difficult weaning, and assessment of such difficult issues as quality of life before admission, nutritional state, age, and known FEV., in stable conditions. An endotracheal tube with an internal diameter of at least 8 mm reduces the work of breathing and allows flexible bronchoscopy to be performed if necessary. Most patients exhibit respiratory muscle fatigue at this stage. Controlled ventilatory modes are preferred for at least 48 h, or until the precipitating event is corrected the goal is to rest the fatigued respiratory muscles before weaning can start. Sedation with a...

Data analysis Clinical analysis

Structural MRI is most often used in clinical practice to exclude non-psychiatric causes for psychopathology. For example, it is routine in many centres to obtain an MRI examination in all first episodes of psychotic illness to exclude tumours, arteriovenous malformations, or other rare (but surgically treatable) causes of psychosis. Clinical examination of these cases may also sometimes reveal abnormalities such as hippocampal sclerosis or callosal agenesis which suggest that psychopathology has been determined by birth injury or abnormal development. In assessment of a patient with dementia, MRI may usefully demonstrate signs of vascular disease (such as infarcts or periventricular white matter changes), or a focal pattern of grey matter atrophy suggestive of Pick's disease (frontal cortex) or Huntington's disease (caudate nucleus and frontal cortex). All of these abnormalities may be detected simply by skilled visual examination of the data. However, clinical diagnosis of the...

Effects of psychoactive drugs

Drugs of abuse, particularly alcohol, have adverse effects on various aspects of immunity and susceptibility to infectious diseases. (3 35) Fetal alcohol exposure can permanently affect endocrine and immune responses. Alcohol inhibits production of proinflammatory cytokines, reduces NK cell activity and suppresses B- and T-cell immunity. Alcoholics are infection prone. Although HIV-seronegative heroin addicts generally have reduced immune functions, persons maintained on methadone in a state of steady tolerance have normal immunity. Marijuana suppresses production of a- and b-interferon and the cytolytic activity of macrophages. Other psychoative drugs often have immune effects. Benzodiazepines antagonize suppression of NK cell activity by corticotrophin-releasing factor and thus may modify stress effects on immunity 36)

Indirect Measures of Neuronal Output

The different isotopes that are used in PET scanning usually have a very short half-life, or time period in which it takes the measured emitted radioactivity to decrease by half of its original value. Examples of some commonly used isotopes and their half-lives are Oxygen15 2.1 minutes, Nitrogen13 10 minutes, Carbon11 20.1 minutes and Fluorine18110 minutes. These isotopes exist as tracers when they exist as a compound e.g. Oxygen15 is delivered to the participant as radioactive water, H125O and is used for determining cerebral blood flow. Fluorine18 is delivered as fluorodeoxyglucose and is used for measuring cerebral metabolic rates for glucose. Carbon11 is used to label quantitate biochemical changes in the brain, such as the determination of the density of various neuroreceptor types in the brain (e.g. benzodiazepine and opiate). The very short time in which these compounds degrade makes it necessary to produce them on-site in a device known as a cyclotron. In a cyclotron a reagent...

From the Other Side the Patients Viewpoint

I was able to keep my job, but between periods of work I spend a lot of time at home, recuperating. I was hopeful that going back to work would help keep my mind occupied with work-related issues. Thanks to my co-workers, this indeed helps a little, but my anxiety has only subsided, never disappeared. It is difficult for me to accept what has happened to me. I often fight myself over it, even though I know I have to accept it. I, who had spent so much time with my family building our home, gardening, cooking, now cannot find my place in society. Nothing can keep my mind occupied enough. I am impatient with those who are close to me. I gave up sports and the outdoors, which has further reduced my spirits. I am afraid that any physical strain will make my condition worse, even though I was informed that this is not the case. Now all I want is to live a simple, uneventful life.

Pathophysiologic Changes Occurring in Substance Abuse

Drug abusers are always at risk of overdosing because the active ingredient in illegal drugs are frequently adulterated with dangerous substances such as amphetamines, benzodiazepines, hallucinogens, and alcohol. This makes the potency of the drug unreliable and the risk of death from an accidental overdose is high.

Use of CTA in Drug Discrimination Learning

Serotonin agonists,25 opiate agonists,26 opiate antagonists,27 cholecystokinin,28 phen-cyclidine,29 benzodiazepines,30 alprazolam,31 and pentobarbital.32 Available evidence indicates that pharmacologic agents that function as DS in operant procedures can function as DS in the CTA design. Furthermore, the CTA design has been successfully extended to studies of drug-drug antagonism.33

Monitoring of Cerebral Blood Flow

CT Perfusion Scan Quantitative CBF can also be obtained using contrast CT. The computer algorithm examines the transit time of contrast and derives the regional CBF. Compared with stable xenon, only limited slices can be obtained. This technique also allows repetitive measurements, making it possible to assess the patient's response to therapeutic maneuvers such as hyperventilation or augmentation of blood pressure.

Emotions and affective style

The idea that the two cerebral hemispheres make different contributions to the development of dysphoric emotions (e.g. depression, anxiety) has attracted considerable attention in the past few years. Evidence for this idea comes from two separate research lines. The first is exemplified by the experimental work of Hugdahl,( 3) who directly manipulated hemisphere information processing (e.g. by confining visual stimuli to one visual field hemisphere) in order to examine the differential involvement of the two hemispheres in emotional reactions. His studies indicate that fear-relevant stimuli (e.g. pictures of snakes) evoke a cardiac defence reaction when they are flashed to the right hemisphere (i.e. left visual field) of healthy subjects, but not when they are flashed to the left hemisphere (i.e. right visual field) of these subjects. Also, the two hemispheres of normal subjects apparently differ in their conditionability. That is, when visual stimuli flashed to either the right or...

Psychophysiological parameters

Psychophysiological parameters such as electrodermal response or electromyographic activity are traditionally viewed as the peripheral ends of a chain. They may reflect central dysfunctions, but do not themselves serve as determinants of these dysfunctions. A further example of such a peripheral parameter is the eye-blink startle reflex. The central antecedents of startle reflex have been well studied because this reflex provides an objective index of defensive action tendencies. For example, patients with phobias, panic disorder, or post-traumatic stress disorder all exhibit exaggerated startle potentiation when startle reflexes are probed in the context of threatening stimuli (e.g. pictures of phobic objects). In contrast, psychopathic individuals fail to show any startle potentiation in the presence of threatening stimuli. Precisely because startle reflexes do not depend on introspection, startle probe analysis may be useful in assessing the effects of behavioural or...

Some Major Factor Models

The most prominent current factor model of personality is the Five-Factor Model (Costa & McCrae, 1989). The five-factor model was derived from analyses of various personality inventories, not words from the dictionary. Nevertheless, the results have proven similar, with some exceptions. As the name indicates, this model consists of five broad higher order dimensions. In turn, each dimension consists of several lower order facet traits, thus lending the model a hierarchical structure. Higher order traits make broad, but somewhat imprecise, predictions about behavior and lower order traits make predictions that are more precise but somewhat narrow. For example, individuals who are high on the first factor, neuroticism, are likely to feel anxious, angry and hostile, depressed, self-conscious, impulsive, and vulnerable. However, although being high in neuroticism increases the chances of impulsive behavior or feelings of depression, these are not inevitable. Likewise, many people are...

Chapter References

The neuropsychology of anxiety. An enquiry into the functions of the septo-hippocampal system. Clarendon Press, Oxford. 13. Hugdahl, K. (1989). Human Pavlovian aversive conditioning effects of brain asymmetry and stimulus lateralization. In Aversion, avoidance, and anxiety perspectives on aversively motivated behavior (ed. T. Archer and L.G. Nilsson), pp. 145-7. Erlbaum, Hillsdale, NJ. 16. Heller, W. and Nitschke, J.B. (1998). The puzzle of regional brain activity in depression and anxiety the importance of subtypes and comorbidity. Cognition and Emotion, 12, 421-47. 25. Gray, J.A. (1987). Discussions arising from Cloninger, C.R. A unified biosocial theory of personality and its role in the development of anxiety states. Psychiatric Developments, 4, 377-94. 28. Craske, M.G. (1997). Fear and anxiety in children and adolescents. Bulletin of the Menninger Clinic, 61, 4-36. 30. Biederman, J., Rosenbaum, J.F., Chaloff, J., and Kagan, J. (1995). Behavioural inhibition as...

Commonly used designs

At any of these levels, research directed at aetiology uses one of three designs cross-sectional, prospective longitudinal, or case-control. A cross-sectional study is often an excellent start, because it provides a picture of how much morbidity is present at one point in time and the variables most closely associated with this. But because it is only a 'snapshot', the cross-sectional study can rarely allow much to be said about causes. For example, suppose that in a community sample of several thousand adults one has a measure of the psychiatric symptoms each has experienced in the previous month and their self-reported exposure to adverse life events in the previous year. The data will show that persons who have had many adversities also tend to have more symptoms of anxiety or depression than those not so exposed. But it would be unwise to conclude from these findings alone that adversity contributes to the onset of symptoms. First, persons with anxiety or depression may be more...

Standardized psychiatric interviews

The Schedule for Clinical Assessment in Neuropsychiatry (SCAN) belongs to the first type. It is the successor to the groundbreaking Present State Examination ( PSE) developed by Wing et al.(39) and now revised(40) for the World Health Organization. SCAN is a clinician's instrument because it requires familiarity with the phenomenology of mental disorders. It assumes that the interviewer is comfortable in examining persons with a mental disorder. In complete contrast to interviews for use by laypersons, the clinician asks the main question, but is allowed to probe with further questions if necessary, before deciding if a symptom is present or not. The correct use of SCAN requires formal training in one of the designated centres around the world. SCAN has a number of modules, each dealing with a group of disorders such as anxiety states, affective disorders, substance abuse, or psychoses. It is available from the World Health Organization.

Personality variables

Although personality traits may contribute to how vulnerable individuals are to adverse experiences, it has not often been possible to measure personality traits in general populations, then follow the sample prospectively to demonstrate if the incidence of specific disorders is indeed higher in some types. Many measures of personality are too lengthy to be used in surveys. One exception is the Eysenck Personality Questionnaire ( EPQ-R)(87) in which the trait of neuroticism has consistently been found to confer increased risk of anxiety and depression.(6,8889)

Genetic Counseling The Discipline and the Provider

As our knowledge of genetic disorders and complex inheritance patterns has expanded, so have the options for molecular-based genetic testing. With this growth, complex ethical and social issues have come to the forefront, such as genetic discrimination. As medical research has advanced, we have come to appreciate the strong influence of genetics in common disorders, such as cancer, diabetes, Alzheimer disease, asthma, and hypercholesterolemia. The burden of passing on an abnormal gene or trait is not limited to individuals and families faced with rare disorders of Mendelian inheritance. It is a reality for everyone. Increasing anxiety about genetic risk for disease and concern about passing on abnormal genes to future generations for common conditions has expanded the need for genetic counseling. There are now subspecialties of genetic counseling, such as prenatal, pediatric, cancer, and neuro-genetics. Genetic counselors also are working in clinical molecular diagnostic laboratories...

From drive theory to object relations

Psychoanalysis started its life as a drive theory. By what means, Freud asked, did the instinctual life of the infant become tamed in the process of development so that the end result was the civilized man and woman of adult society To this he had two sets of answers. The first, roughly, was repression and sublimation. In the Oedipal situation the child experiences sexual desire for the opposite-sex parent. These feelings arouse anxiety ('castration anxiety'), and so are repressed, or diverted into harmless exploratory and creative sublimatory activities. If, however, the process of repression is excessive the consequence in adult life is emotional inhibition. When repression is insufficient, anxiety-based or psychosomatic disorders result, or, ultimately, psychosis. A second answer, coming later, and forged in the face of the horrors of the First World War, was to suggest that 'civilization' was only skin deep. Here Freud invoked the death instinct and regression. Eros, the love...

S Evidence statements

Three RCTs that assessed the utility of neuropsychological compensatory training, psychotherapy and coping skills training for persons with MS were identified (Ib). The first RCT assessed the effectiveness of traditional psychotherapy compared to participation in a 'current affairs' topic group or no intervention. The results showed psychotherapy to be superior on two of the four outcome measures assessed, namely depression and locus of control. However, it had no significant effect on either anxiety levels or levels of self-esteem.18 The second RCT examined a coping skills group compared to non-directive peer telephone support. The coping skills group entailed formal therapist support and considerable contact time, whilst the telephone support group was informal and only entailed one hour a month. No overall differences between the groups were observed on any of the five outcome measures.19 The last RCT compared neuropsychological compensatory training to supportive psychotherapy....

Operationalized diagnosis

The DSM-III system of classification is characterized by operationalized diagnosis. This means that diseases are described according to their phenomenology and independent of their aetiology (the so-called atheoretical approach) using typical criteria that include the intensity and duration of the symptoms. Following a diagnostic algorithm, certain criteria (e.g. psychopathological symptoms) are obligatory while others are optional to the constitution of a diagnosis. There are 'characteristic' symptoms pertinent to the diagnosis, such as the symptom of depression which is found in many different disorders, and there are 'discriminating' symptoms, such as the delusion of thoughts being inserted into the mind, which may be of less importance to the patient but are important for diagnosis since they are not found in other disorders. Apart from characteristic and discriminating symptoms, there may be a hierarchy of symptoms, arranged in order of importance (e.g. depression over anxiety,...

S Economic statements

The current resources devoted to emotional support are not known. Any recommendation to increase assessments for psychological symptoms and offer various types of counselling will result in increased resource use. However, savings may result from increased efficiency if counselling is being used inappropriately at present, and also if counselling reduces the need for other health interventions. The benefits for patients, carers and their families are potentially very large, including reduced stress and anxiety and improved functional status. Good quality cost effectiveness analyses of psychological support for people with MS, including the different ways in which this support could be provided, are required.

Twoperson context of treatment

This two-person model of the treatment situation has contributed to the demise of the classical psychoanalytical view of the therapist or analyst as a blank screen or a dispassionate observer. The influence of the clinician's biases and unconscious feelings toward the patient may have far-reaching implications for a variety of situations in psychiatry. Frustration about a patient's non-responsiveness to treatment, for example, can lead a clinician to recommend electroconvulsive therapy as a reaction to despair, rather than as a result of systematic decision trees or algorithms about refractory depression. Even in the case of physician-assisted suicide, countertransference may play a major, though hidden, role.(42) Within this context the patient's wish to die may stem from a self-concept as worthless and a burden to others that is, in part, a reflection of what the physician brings to the encounter. Similarly, the doctor's death-anxiety might underlie an omnipotent need to triumph...

Recent abortion Young boys with recent leg trauma are also at

Stress precipitates chest pain in both boys and girls at equal rates often anxiety and stress are not easily apparent. Not all such children present with hyperventilation or an anxious appearance. However, if child has had a recent major stressful event (eg, separation from friends, divorce in family, or school failure) that correlates temporally with the onset of chest pain, it is reasonable to conclude that symptoms are related to the underlying stress.

Raised Intracranial Pressure

Controlled hyperventilation Bringing the PC02 down to 3.5kPa by hyperventilating the sedated or paralysed patient causes vasoconstriction. Although this reduces intracranial pressure, the resultant reduction in cerebral blood flow may in itself cause brain damage. Maintaining the blood presssure and the cerebral perfusion pressure (CPP) ( 70 mmHg) appears to be as, if not more, important than lowering intracranial pressure. Only by monitoring the amount of oxygen extracted from the brain can one determine whether or not the brain tissue can withstand further vasoconstriction caused by hyperventilation (see page 227).

Stimulus Generalization

Training drug will display stimulus generalization only to agents having a similar effect (though not necessarily an identical mechanism of action). An example of the results obtained in generalization tests performed in rats trained to discriminate 1.0 mg kg of S (+)-amphetamine from saline is shown in Table 4.2. Stimulus generalization is said to have occurred when the animals, after being administered a given dose of a challenge drug, make 80 of their responses on the S(+)-amphetamine-appropriate lever. Where stimulus generalization occurs, an effective dose 50 (ED50) value can be calculated by the method of Finney2 and reflects the dose at which the animals would be expected to make 50 of their responses on the S(+)-amphet-amine-appropriate lever. Besides complete stimulus generalization, two other results might be obtained partial generalization and saline-appropriate responding. Partial generalization is said to have occurred when the animals, after being administered a thorough...

Functional Groups Considered as Pharmacophores the Privileged Structure Concept

Among the most popular privileged structures, historical representatives are arylethylamines (including indolylethylamines), diphenylmethane derivatives, tricyclic psychotropics and sulfonamides. Dihydropyridines 5 , benzodiazepines, 2, 5 , N-arylpiperazines, biphenyls and pyridazines 6 are more recent contributions.

Treatment and management

Currently, no treatment influences the course of illness of Huntington' disease, although advances in research on the function of the Huntington' disease gene may change that. Nevertheless, psychiatric treatments can relieve some of the troublesome symptoms. Clinical experience suggests that the depression, anxiety, and obsessive-compulsive disorder associated with Huntington' disease usually respond to the pharmacological treatments used for the similar idiopathic disorders. Because some patients seem unaware of their depressed mood (just as they can be unaware of their involuntary movements) an informant is needed to elicit the symptoms. It is also important to distinguish depression (from which the patient is miserable and sleepless) and apathy, which does not cause the patient distress. Occasionally, mood and anxiety disorders are chronic and unresponsive to treatment. Severe, unresponsive depression can be treated successfully with electroconvulsive therapy.( 8) Bipolar disorder...

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