Anxiety and Panic Disorders Causes and Cure

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Project Title Anxiety Vagal Control Of The Heart In Coronary Disease

Summary Coronary heart disease continues to be the leading cause of death in the United States, despite risk factor reduction and technological advances in treatment options. Prospective studies implicate chronic anxiety as an independent risk factor for fatal coronary heart disease. In particular, anxiety increases the risk of sudden cardiac death substantially. The primary objective of the proposed research is to examine the role of reduced vagal control of heart rate in the increased risk of cardiac mortality associated with anxiety in a population with established coronary artery disease (CAD). A second objective is to determine whether the effects of anxiety are independent of the effects of depression. Nine hundred and fifty CAD patients will be recruited for this study from patients hospitalized for elective cardiac catheterization. Anxiety will be measured by the Hospital Anxiety Scale, the Spielberger Trait Anxiety Inventory, and the Crown-Crisp Phobic Anxiety Scale. Symptoms...

Cognitive Therapy for Anxiety Disorders

Cognitive therapy has been adapted for the full range of anxiety disorders generalised anxiety disorder (Beck & Emery with Greenberg, 1985) panic disorder (Clark, 1986 Craske & Barlow, 2001) social phobia (Heimberg & Becker, 2002) and obsessive-compulsive disorder (Frost & Steketee, 2002 Salkovskis, 1985). For generalised anxiety disorder, Chambless & Gillis (1993) computed effect sizes across five studies in which cognitive therapy was compared with one of several control conditions non-directive therapy (Borkovec & Costello, 1993) or waiting list (Butler etal., 1987, 1991). Substantial effect sizes (1.5-2) at post-test and follow up suggest that cognitive therapy is an efficacious intervention for generalised anxiety disorder. A review of 12 trials of cognitive therapy for panic suggested that 80 of patients achieved full remission at the end of treatment (Barlow & Lehman, 1996). De Rubeis & Crits-Christoph (1998) reviewed 11 outcome studies of cognitive therapy for panic disorder....

Prevalence Of Latelife Depression And Anxiety

The Epidemiological Catchment Area Study (ECA) (Regier et al., 1988) was a major study investigating rates of depression and anxiety in the community carried out across five sites in the US. The ECA prevalence rates of major depressive disorder amongst older adults were lower than for younger adults (for review see Powers et al., 2002). In the UK, Lindesay, Brigs & Murphy (1989) reported prevalence rates of 4.3 for severe depression and 13.5 for mild moderate depression in a community dwelling urban sample. Beekman, Copeland & Prince (1999) carried out a systematic review of community-based studies examining prevalence of depression in older adults. Overall, Beekman, Copeland & Prince (1999) calculated prevalence rates of 13.5 for clinically relevant depression but concluded that major depression is relatively rare in later life (1.8 ) whereas minor depression is relatively more common (9.8 ). Similar figures reported by Copeland et al. (1987) and Livingston et al. (1990) have led to...

Personal History of Untreated Depression or Anxiety or Prior Suicidal Ideation or Attempt

When cancer genetic counseling was first offered, there were few other adult onset conditions for which predisposition testing was available. One was Huntington's disease (HD), and as part of the testing protocol for HD, most centers involve mental health-care providers. However, suicidal ideation is part of the biology of HD, and studies have demonstrated that learning cancer mutation status can cause anxiety but not to the degree that requires professional referrals (57,58).

Social Anxiety In Children And Adolescents

Social anxiety is often evident early in life and may be diagnosed in children as young as eight years old (Beidel & Turner, 1998). Furthermore, when the social fears of children continue to be expressed through late adolescence they are more likely to be associated with a poor prognosis for recovery (Davidson et al., 1993 Mannuzza et al., 1995). The clinical presentation of social anxiety in children is similar to that of adults, with comparable somatic symptoms and feared situations. However, because of the limited cognitive development of younger children, they may not report specific negative cognitions (Beidel & Turner, 1998). Social anxiety in children is also associated with significant distress and impairment, including poor school achievement, greater loneliness, and difficulties with social relationships (Albano, Chorpita & Barlow, 1996a). Socially anxious children and adolescents may also suffer from elevated rates of general anxiety, depression, and secondary alcohol abuse...

Anxiety

Anxiety disorders are seen in approximately 40 of patients with PD (109). Despite their frequent occurrence and contribution to morbidity and caregiver burden (11), anxiety symptoms in PD have received relatively little attention, perhaps because they overlap with symptoms of depression, PD, and medication effects, and are thus difficult to measure (110). The relationship between anxiety and cognition in PD has received virtually no attention. Ryder et al. (111) found that self-reported symptoms of anxiety, but not depression, were related to cognitive functioning in a small sample of male patients with PD. Self-reported trait anxiety was negatively related to performance on a neuropsychological screening battery, accounting for approximately 70 of the variance. The authors posit that anxiety may partly explain the association between depression and cognition in PD, although replication of their findings and additional large-scale studies are needed.

Anxiety Epidemiology

In James Parkinson's original monograph, An Essay on the Shaking Palsy, little mention was made of the nonmotor symptoms of anxiety and depression (14). However, it is now known that clinically significant anxiety symptoms occur in 20 to 52 of PD patients, a frequency greater than that found in community dwelling age-matched controls (1,15-17). Menza et al. (18) reported a depressive disorder in 92 of PD patients diagnosed with an anxiety disorder, and an anxiety disorder was present in 67 of depressed PD patients. This is consistent with results by Starkstein et al. (16), reporting depression in 76 of patients with PD and anxiety. In addition to generalized anxiety disorder (GAD), patients with PD regardless of sex also experience panic disorders and social phobias with a prevalence of approximately 30 . (17,19,20). The presence of anxiety not only contributes to mental and somatic discomfort, but may also contribute to existing motor symptoms or fluctuations (7). For example,...

Benzodiazepines

Although benzodiazepines are commonly used in the management of anxiety, only one randomized controlled trial addressed this in the PD population (40). Bromazepam, a long-acting benzodiazepine, was reported to improve psychic and somatic (i.e., tremor) symptoms of anxiety. Anecdotally, other benzodiazepines have also been noted to be effective. Clonazepam was reported to be effective in a patient with anxiety and panic attacks that were refractory to alprazolam, lorazepam, and numerous antidepressants (45). Although benzodiazepines may be effective, its long-term use, especially in the elderly or frail patient, may be associated with unfavorable effects on alertness, cognition, and gait, and an increased risk of falls (46-48). Therefore, benzodiazepines should be used judiciously with careful evaluation of potential risks and benefits.

Conversion of Cholesterol to Pregnenolone

Conversion of cholesterol to pregnenolone appears to be the transport of cholesterol from extracellular sources to the inner mitochondrial membrane and the subsequent loading of the precursor into the active site of P450scc. In-tramitochondrial cholesterol movement appears to be due to coordinated activation of the recently cloned steroidogenic acute regulatory (StAR) protein and of the mitochondrial peripheral-type benzodiazepine receptor. Both the delivery of cholesterol to the enzyme and the

Parkinsonism In Young Adults

Early presentation may be a decline in memory and school performance. Patients may develop anxiety, moodiness, disinhibited behavior, and loss of insight. A characteristic feature is inappropriate laughter. Although eye movements are typically normal, some cases of Wilson's disease may show a saccadic pursuit, gaze distractibility, or difficulty in fixation (119).

Cognitive Therapy Draws on a Wide Range of Cognitive and Behavioural Techniques to Change Thinking Beliefs Emotions and

Development of a wide range of cognitive and behavioural therapeutic strategies on which a cognitive therapist can potentially draw. The main cognitive approaches involve teaching clients to be able to identify, evaluate and challenge cognitive distortions (such as all-or-nothing thinking) and maladaptive beliefs ('I have to be upbeat and bubbly at all times to be liked'). The main behavioural approaches involve increasing positively reinforcing behaviours (for example, behaviours that are pleasurable and generate a sense of mastery in people diagnosed with depression) and extinguishing or replacing negative behaviours (such as 'safety behaviours' that maintain a fear in people diagnosed with an anxiety disorder).

Glycocholate Breath Test

Breath test is a simple, inexpensive, and noninvasive technique to diagnose SBBO. The lactulose breath test is performed after 12 hours fasting previous to the test. Hydrogen breath samples are taken at baseline, and subsequently every 10-30 minutes after the test meal that contains 10-12 g of lactulose. The hydrogen breath samples are analyzed gas chromatographically (81). Baseline samples average 7.1 +5 parts per million (ppm) of H2 and 0-7 ppm for CH4 (82). Values of the baseline sample over 20 ppm H2 are suspect for bacterial overgrowth. Values between 10 and 20 suggest incomplete fasting before the test or ingestion of slowly digested foods the day before the test, the colon being the source of the elevated levels (82). Slowly digested foods like beans, bread, pasta, and fiber must not be consumed the night before the test because these foods produce prolonged hydrogen excretion (82). The patient is not allowed to eat during the complete test. Antibiotics and laxatives must be...

Personality Traits And Personality Disorders

These relationships can be best understood by going beyond individual categories and considering the three clusters of disorder on Axis II of the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV American Psychiatric Association, 2000). While personality disorders will undoubtedly be reclassified once we understand them better (Paris, 2000a), the existing Axis II clusters broadly correspond to trait dimensions. In Cluster A, all three categories fall into the schizophrenic spectrum (Paris, 2003 Siever & Davis, 1991), suggesting a common diathesis. In Cluster B, trait impulsiv-ity constitutes a diathesis for disorders (Siever & Davis, 1991 Zanarini, 1993). Trait anxiety is associated with Cluster C disorders (Kagan, 1994 Paris, 1997).

The Structure of Cognitive Therapy Behavioural Techniques Cognitive Techniques and Homework

For many clients, automatic images or picture, rather than thoughts, are powerfully associated with emotions and behaviours. Images are central to many anxiety disorders, such as post-traumatic stress disorder (PTSD), social phobia and panic disorder. Images are handled in similar ways but instead of verbally evaluating and challenging images, more visual techniques are used (J. Beck, 1995).

The Privileged Structure Approach

The discovery of the benzolactams demonstrated that potent nonpeptide GH secreta-gogue agonists could be discovered in the 500-600 Kda molecular weight range. This was quite a breakthrough. Although there were many nonpeptide antagonists known at the time, the only precedent for non-peptide agonists were the opioid peptide mimetics including morphine and the analgesic benzodiazepine tifluadom. Compound screening continued after the benzolactam discovery in an effort to find different core structures that might more easily be converted to an orally active drug. There was precedent for additional leads in numerous structural variants of morphine especially since GHRP-6 was itself derived from enkephalin. Nevertheless, the discovery of this camphorsulfonamide series was important. It demonstrated that GH secretagogue agonist activity need not be limited to a narrowly defined pharmacophore and it contributed to the selection of the spiroindanylpiperidine nucleus for use in a privileged...

Genetic Factors In Personality Disorders

Genetic factors influencing traits and disorders have also been supported by the findings of family history studies that have examined spectra of disorders on both Axis I and Axis II. Thus, first-degree relatives of patients with disorders in the A cluster have pathology in the schizophrenic spectrum (Siever & Davis, 1991), patients in the B cluster tend to have relatives with other impulsive disorders (Zanarini, 1993), and patients in the C cluster have first-degree relatives with anxiety disorders (Paris, 1997).

Cognitive Therapy Areas Of Application

The last few decades have seen cognitive therapy adapted for mood, anxiety, personality, eating and substance misuse disorders. As well as these formal psychiatric disorders, cognitive therapy has been adapted for relationship problems and the psychological aspects of a range of medical disorders. Most recently cognitive therapy has been applied to the problem of anger generally and its manifestations in conflict specifically, while colleagues, mainly in England, have applied cognitive therapy to people with psychosis. A thorough review of these applications is beyond the scope of this chapter, but a brief overview is provided for the main areas of application. Interested readers may wish to follow up the references describing these adaptations and the following excellent reviews of evidence-based psy-chotherapies (Compas et al, 1998 De Rubeis & Crits-Cristoph, 1998 Fonagy et al., 2002 Kazdin & Weisz, 1998 Rector & Beck, 2001).

General Versus Specific Habits

Studies, the habitual quality of negative self-thinking was pitted against the content of such thinking. Having negative self-thoughts every now and then is part of a healthy mental life, e.g., being self-critical at times, learning from past mistakes, or being aware of one's weaknesses. However, when negative self-thoughts occur frequently and automatically they may become dysfunctional. Verplanken et al (2007) indeed found that the mental habit component of negative self-thinking accounted for unique variance in explicit and implicit measures of self-esteem. Similar results were found in a longitudinal study over 9 months on anxiety and depression, even after controlling for traditional vulnerability measures such as previous symptoms, dysfunctional attitudes, and negative life events. Habitual negative thinking has also been found important in the more specific area of body image. Dissatisfied body image thinking is an increasing problem and is particularly associated with eating...

Cognitive Therapy for Different Populations and in Different Settings

There is increasing interest in cognitive therapy for children, in part because the approach appears acceptable to children and adolescents and pragmatic in these service settings (Friedberg & McClure, 2001). A comprehensive review of the outcome literature for children and adolescents suggests that cognitive therapy is effective for generalised anxiety, simple phobias, depression and suicidality (Fonagy et al., 2002 Kazdin & Weisz, 1998). As with adult populations, the evidence base is particularly compelling for depression (Lewinsohn & Clarke, 1999). Cognitive therapy has been adapted for older adults (Laidlaw et al., 2003) and for people with learning disabilities and mental retardation (Kroese, Dagnan & Loumides, 1997). Twenty-five years of increasingly sophisticated research suggests that cognitive therapy is effective to a clinically significant degree for a majority of patients with a variety of presenting problems in a range of populations and settings. An evidence-based...

Momentary Retrospective and Global Self Report

The third type of self-report, global report, does not have any time frame at all, but rather asks the respondent to generalize globally or universally. Generally speaking, how happy a person are you and Are you prone to anxiety are examples of global questions. These questions seek information about a person in general. They might be equivalent to retrospective summaries over a lifetime, but that is not clear.

Selecting Pain Scales For Seniors

It is easy to rationalize why such a phenomenon may occur. Inadequate pain control and analgesia administration go hand in hand. A patient who has experienced inconsistency in obtaining adequate analgesia may be reluctant to acknowledge improvement in pain due to anxiety about not maintaining sufficient medication. A physician colleague who had been in a severe motor vehicle accident with extensive trauma confided his reluctance in ever reporting his pain level at less than 7 points on a 10-point scale due to fear that his analgesics, which had finally started to provide some pain relief, would be decreased or even stopped. This was from someone who had extraordinary access to some of the most recognized physicians in the world. It is easy to understand how other patients might be moved to inflate their pain scale scores as well.

Rapid Eye Movement Behavior Disorder and Restless Legs Syndrome

The treatment of choice for RBD is clonazepam, a benzodiazepine, although the mechanism is unknown and there are no controlled trials (13). Other drugs thought to be helpful for RBD include pramipexole, levodopa, carbamazepine, donepezil, and melatonin (64,89-91). Caution needs to be exercised with the use of clonazepam, as in some cases, RBD may be confused with sleep apnea, which can be worsened by clonazepam. Nighttime dosing with drugs such as selegiline may aggravate RBD. Others have reported a paradoxical worsening of RBD with deep brain stimulation (DBS) of the subthalamic nucleus (STN) (92).

Interviewing Those Suspected Of Crime

Gudjonsson (2002) is one of the few researchers who has successfully contended, in court cases, that interviewees have been adversely affected by tactics. However, almost no research has gathered information about this from suspects themselves. Holmberg and Christianson (in press) recently conducted a pioneering study involving a questionnaire completed by men who were in prison for murder or for serious sexual offences. This postal questionnaire involved the prisoners rating, on seven-point scales, their judgements perceptions of the behaviour manner attitudes of the police officers who had interviewed them during the (relevant) investigation. The questionnaire also asked the prisoners to rate their emotional reactions to the interviewers' behaviour. The data revealed that only a few 'perceived their interviewers as having shown a great personal interest and having tried to create a personal conversation' or 'perceived their interviewers as highly sympathetic and empathetic' (p. 10)....

Conclusions On Death Dying And Ethnicity

Death, as part of the life process, affects every individual and culture. It produces anxiety and is disruptive to social dynamics. Each culture has its own beliefs, norms, and rituals about death and dying. Funerals function to provide people an outlet to commiserate and grieve together. This seems necessary in order to get on with life and alleviate the disruption caused by the departure of a group member.

General Assessment Issues

Concerns about floor or ceiling effects must be considered when working with those of considerably low or high levels of cognitive ability. In research and clinical contexts, it is necessary to consider known sociode-mographic influences on performance such as age, sex, education, race ethnicity, and socioeconomic status. Emotional status (e.g., symptoms of anxiety or depression), psychiatric disorders, sleep, and acute ingestive behaviors (e.g., smoking, caffeine, alcohol) are also highly relevant. Testers must be sure to make participants feel comfortable and promote motivation. For more detailed discussion see Lezak et al (2004). As we discuss below, a host of chronic diseases and their risk factors also influence cognitive performance.

Risk Factors and Neurocognition

Depression is such a factor that has long been known to have negative relations to brain and cognition. Other psychosocial factors such as hostility and anxiety may confer a negative influence on cognitive function whereas social support - a factor usually associated with better health outcomes - may have a protective relation to cognitive function.

Conceptualization Measurement and Analysis of Negative Affective Risk Factors

Since long before the inception of behavioral medicine as a scientific field, negative emotions have been described as contributing to the development and course of serious physical illness. A substantial and growing body of research now supports this hypothesis (Smith and MacKenzie, 2006 Steptoe, 2007a Suls and Bunde, 2005). Among the specific negative affects studied, anger and related constructs (e.g., hostility) have the longest history of research, especially in cardiovascular disease (Chida and Steptoe, 2009 see Chapter 13). More recently, depression has emerged as a major research focus as a risk factor for the development and adverse course of physical illness (Nicholson et al, 2006 Steptoe, 2007b). Anxiety and related constructs (e.g., worry) are increasingly documented as having similar effects (Roy-Byrne et al, 2008 Suls and Bunde, 2005). Whether studied as symptoms of emotional distress, diagnosed mood or anxiety disorders, or related personality traits, it is increasingly...

The Failure Of The Model Of Biological Classification For The Classification Of Psychopathology

We have discussed several differences between biological classification and psychiatric classification. The lack of mutually exclusive categories is the most obvious reason the model of biological classification does not fit psychiatric classification. In biological classification, if categories are not mutually exclusive, then the inclusion relation among categories is violated and the hierarchical nesting of categories makes little sense. In psychiatric classification, there is extensive overlap in category membership, even across wide branches of the hierarchical tree (e.g., patients with avoidant personality disorder are often very similar to patients with the subtype of anxiety disorder known as social phobia). Notice also that, although clinicians know that an important issue in diagnosis of avoidant personality disorder is its differentiation from social phobia, these two disorders are not included under the same superordinate category.

Overview of Recent Research

As in much of the literature on the health consequences of negative affect, the endpoints examined in studies of anger have predominantly included not only cardiovascular diseases such as coronary heart disease (CHD) and stroke but also other specific illnesses and all-cause mortality. A recent quantitative review found a significant association between initial levels of anger, hostility, and related traits and the subsequent development of CHD in initially healthy populations, as well as with negative outcomes (e.g., cardiac death, recurrent events) among patients with pre-existing CHD (Chida and Steptoe, 2009). Similar conclusions have been reached in quantitative (Nicholson et al, 2006) and qualitative reviews (Lett et al, 2007 Steptoe, 2007b) of the association of depression and CHD. The smaller and less conclusive literature on anxiety suggests similar effects (Roy-Byrne et al, 2008 Suls and Bunde, 2005). The few studies addressing the overlapping versus independent nature of...

Examples of use of stereotaxic injection for psychiatric research

In a Sapap3- - mouse, a model for OCD (obsessive-compulsive disorder), stereotaxic injection of a lentivirus-based overexpression of Sapap3 into striatum rescues OCD-like symptoms, which clearly suggests the specific significance of Sapap3 function in striatum for the development for OCD (Welch et al., 2007).

Essential Distinctions

Virtually all descriptions of basic emotions distinguish among anxiety and related emotions (e.g., fear), depression and related emotions (e.g., sadness), and anger (e.g., Beck, 1976 Izard, 1991 Lazarus, 1991). In contrast to a state of calm relaxation, anxiety reflects nervousness, tension, apprehension, and at the extreme is characterized by dread. In contrast, depression involves sadness, sorrow, unhappiness, and at the extreme includes despair. Anger varies from mild irritation and annoyance to rage. These emotional constructs are also distinguished in terms of the cognitive content that accompanies them. Threat and perceived vulnerability to harm are associated with anxiety loss, deprivation, separation, hopelessness, and failure are associated with depression and frustrated goals, interpersonal transgression, and victimization are associated with anger (Beck, 1976 Lazarus, 1991). These affective characteristics can also be distinguished in terms of the forms they take, ranging...

Empirical Challenges to Conceptual Distinctions

Although anxiety, depression, and anger can be clearly distinguished at a conceptual level, as can their various forms (i.e., symptoms, personality traits, and diagnosable disorders), these distinctions are difficult to support empirically (Suls and Bunde, 2005). Hence, research faces a difficult task in parsing what has been labeled a big mush of negative affective risk factors (Ketterer et al, 2002). This issue is illustrated by the high correlation between self-report inventories intended to measure symptoms of depression and those intended to assess symptoms of anxiety. In the parlance of construct validation (Campbell and Fiske, 1959), correlations between measures of anxiety and depression (i.e., hetero-trait correlations) often equal the correlations between multiple measures of either of these constructs considered alone (i.e., mono-trait correlations). This indicates a troublesome lack of discriminant validity, a key component of construct validity. Multiple studies across a...

Methods of Measurement

The vast majority of studies of negative emotions as risk factors for poor health outcomes rely on self-reports of anxiety, depression, or anger. This approach assumes that participants are willing and able to provide generally accurate descriptions of their emotional functioning. Even interview-based assessments (e.g., structured diagnostic interviews) rely heavily on what participants are willing and able to report. A small but growing literature suggests that self-reports of these risk factors have less predictive utility than do other methods, such as ratings provided by significant others (c.f., Smith et al, 2008). Hence, reliance on self-reports could produce an underestimate of the importance of negative affective risk factors. Here again, design and implementation of optimal interventions would be facilitated by attention to basic issues in measurement.

Relevance for vertebrate systems

To link sexual karyotype to the development of sex-specific characteristics. Arnold has proposed that regulatory genes on the X (that escape dosage compensation) and Y chromosomes may directly organize sex-specific CNS characteristics (Arnold, 2004). Indeed, there is some evidence that the Y-chromosome sex-determining gene Sry has such a role in the nervous system (Dewing et al., 2006). However, such a model may capture only one aspect of this process. It is also quite possible that sexual karyotype controls much more complex regulatory networks, such as those characteristic of C. elegans and Drosophila sex determination, that read the sex-determining signal and set into motion a cascade of interactions that only very indirectly lead to sex-specific gene expression. The potential existence of such a pathway in the mammalian nervous system has intriguing implications for the mechanisms that bring about sex differences in neuroanatomy and neural function moreover, genes in such a...

Approaches to Confounding and Statistical Control

As noted above, analysis of a single affective risk factor creates obvious alternative interpretations observed associations could involve not only the measured risk factor but also an unmeasured but correlated affective characteristic or a general affective characteristic. Further, these alternative risk factors could involve symptoms, traits, or disorders. These interpretive ambiguities inherent in the one-at-a-time approach are a clear impediment to progress. Inclusion of multiple affective risk factors raises the issue of optimal approaches to statistical analysis. Automated step-wise procedures in which predictors (e.g., symptoms of anxiety, depression, or anger) are entered into the analysis in order of magnitude of their association with the outcome (e.g., incident CHD) have severe limitations (see Chapter 54). When predictors are closely correlated, trivial differences in effect sizes across samples can result in highly unstable results. Selection as the first predictor...

Conclusions and Implications

Various measures and categorizations of negative affective characteristics have predictive utility in epidemiological and clinical studies of serious physical illness. Because anxiety, depression, and anger have typically been examined separately, as have related symptoms, personality traits, and diagnosed emotional disorders, several questions remain before this literature can optimally guide intervention research. The overlapping versus specific nature of these effects must be clarified to guide the focus of interventions. Similarly, clarification of the role of symptoms, traits, and disorders, as well as related temporal patterns, will be critical in the selection of individuals for treatment. Empirically supported theoretical models of this affective domain are invaluable as a guide to the measurement and analysis issues in this needed research.

Differential Therapeutics

As a clinician, when might you think of using IPT As a psychiatrist decides which antide-pressant medication to prescribe based on a patient's symptom constellation and research findings, so too should clinicians consider when to use IPT. The research to date supports that IPT works best for depressed patients who face distressing life events ranging from medical illness to job and relationship changes and conflicts. Patients with interpersonal deficits who report no recent life events or changes will probably fare better in CBT. Interpersonal therapy may also work well for patients with anxiety and personality disorders who report recent life events, but research is in these areas, although promising, is still in the early stages. Interpersonal therapy may be a good option for patients who want to augment

Components and Definitions

Another definitional issue that is important for behavioral medicine stems from the fact that measures of hostility are usually correlated with other health-related negative psychosocial factors such as depression, anxiety, and low social support (see Chapter 12). In addition, these psychosocial risk factors tend to co-occur in socially disadvantaged groups (Gallo and Matthews, 2003). This co-variation has prompted some researchers to focus on the variance that is shared among these constructs and search for genetic and physiological explanations that might account for this phenomenon (Raynor et al, 2002 Williams et al, 2003a). It has been suggested that a single underlying psychological tendency might account for the most important health effects (Suls and Bunde, 2005). We feel that this is a useful strategy with a great deal of potential, but we also recognize that much of the variance among these measures is not shared and that psychosocial factors like hostility may also have...

Guidelines for Survivorship Care

Guidelines can still be useful even when based more on consensus than evidence, however. Clinical practice guidelines can decrease variation in care, particularly overuse of investigations8 that can lead to inefficiencies in health care delivery. For example, breast cancer guidelines recommend against imaging studies and tumor markers to look for metastases,6,7 and colorectal surveillance guidelines caution against the overuse of nonspecific blood work.4 In addition to economic costs, overused surveillance tests and visits often lead to false positive results and further investigations, with inherent physical and psychological risk.9,10 Indeed, randomized trials have not been able to consistently find positive psychological effects associated with surveillance.10,11 While being told that there is no sign of cancer recurrence can understandably decrease anxiety,12 the stress leading up to it, inconvenience and often discomfort of testing, and not infrequent detection of incidental...

The Nature of Positive Well Being

There has been considerable debate about the importance of these differences in the concept of positive well-being, and the extent to which they reflect coherent measurable entities or relate differentially to other life outcomes such as health and success in relationships (Kashdan et al, 2008). From the perspective of research in health, perhaps the most important issue is whether the current interest in positive well-being reflects a meaningful agenda for investigation, or is a passing fashion. It is well established in psychiatry and behavioral medicine that negative psychological states such as depression, anxiety, and hostility are associated with adverse effects on physical health (see Chapters 12 and 13). If positive psychological states and traits are

Social History And Habits

Social history and habits can also play an important role in pain management therapy. Smoking and alcohol use can complicate acute pain management. Patients who use alcohol on a regular basis can experience various degrees of withdrawal symptoms if it is discontinued abruptly. This is especially important in postsurgical patients. Alcohol withdrawal symptoms can occur 24 to 48 hours after abrupt discontinuation. Alcohol withdrawal can cause anxiety and agitation, which can make the patient far less able to cope with pain. Patients who take several alcoholic drinks daily should be evaluated on hospital admission to receive benzodiaz-epine for withdrawal prevention. However, drug selection in the elderly population requires special care. For example, older adults' abilities to metabolize and eliminate fat-soluble sedative-hypnotics like diazepam and chlordiazepoxide are significantly decreased, and the half-life of these drugs increased. These facts can lead to excessive sedation. For...

Questionnaires Selfmonitoring and Observation of Behaviour

Questionnaires are often useful to generate a first impression of the problem behaviour. Depending on the problem behaviour (for example, anxiety, depression, substance abuse) the therapist can select from a number of questionnaires that collect domain-specific information. When the domain is depression, the therapist can administer the Beck Depression Inventory (Beck et al., 1996), which is developed to assess the behavioural manifestations of depression, as well as for example the Pleasant Events Schedule (MacPhillamy & Lewinsohn, 1976), which aims to assess to what extent the patient still initiates pleasant activities that may serve as reinforcers. In regards to substance use disorders, the Time Line Follow-Back (TLFB) method gives a good impression of the quantity and frequency of drinking drug taking during the past six months, as well as more detailed information on pattern of substance use (Sobell, Toneatto & Sobell, 1994). For a comprehensive review of behavioural assessment...

Genetic Counseling Provider Roles Service Delivery And Informed Consent

Given the complex nature of interpreting family histories and test results and the evolving literature about cancer risks and management options as well as the potentially life-changing implications of testing, comprehensive pre- and post-test genetic counseling is recommended when testing for a highly penetrant cancer syndrome is considered (16,17). Counseling can help to ensure that patients make autonomous decisions that are based on adequate information and which are consistent with their values and preferences (3,4,10,13). Anxiety and inflated risk perceptions sometimes drive patient interest in testing (18,19). Even if the objective risk of cancer or carrying a gene mutation is low, patients may still benefit from genetic counseling to gain a better understanding of their risk and available options. In general, research has demonstrated that genetic counseling results in improved knowledge and does not have significant adverse psychological effects (20). However, one of the...

Detection and Recognition

No standardized tool or method has been specifically developed to detect and assess anxiety in the PD population. Detection may be problematic, because several symptoms of anxiety overlap with mental and somatic symptoms commonly associated with PD. The Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV) criteria for GAD in the general population includes a period of at least six months with prominent tension, worry, and feelings of apprehension about everyday events and problems, along with the presence of at least four of 22 accompanying autonomic, psychic, and somatic symptoms (36). However, several of these accompanying symptoms, such as tremor, concentration difficulties, dizziness, muscle aches, and numbness or tingling, are also commonly attributed to PD and may not be recognized as components of an anxiety disorder. Given that anxiety appears to be common over the course of PD, periodic assessment would significantly enhance detection. In the absence...

Selective Serotonin Reuptake Inhibitors

Results from uncontrolled studies suggest that SSRIs are effective for anxiety in PD (42-44). In an open-label study (n 10), Menza et al. (42) reported that citalopram (mean dose 19mg d) improved anxiety in depressed PD patients. In a study of 30 patients, paroxetine (20 mg twice daily) reduced psychic and somatic anxiety symptoms, as well as depressive symptoms after six weeks (43). Sertraline was also found to have anxiolytic effects in PD patients (44). Although these data are derived from uncontrolled studies, many specialists prefer to use SSRIs for managing anxiety and depression in PD (49).

The Therapeutic Relationship

Arnold openly discusses a multitude of problems that bother him, cooperatively registers his problem behaviours (panic attacks), but consistently sabotages his homework assignments. The first session he forgot his assignments, the second session the neighbour visited, and the third session he spent five minutes on the scheduled exercise instead of the agreed upon 90 minutes. When something like this happens, the therapist should collaboratively re-examine the problem analysis with the patient. In this case it demonstrated that Arnold thought that the treatment approach was far too simplistic for his problems. How were a couple of homework assignments going to cure him of his anxiety attacks that had been haunting him for more than 10 years A 46 year-old woman suffered from social anxiety and agoraphobia. Initially, treatment (exposure in vivo) appeared to be going smoothly, but as the exercises progressed treatment halted. The patient started cancelling appointments and when she did...

Detection and Assessment

A physical examination and laboratory screening (e.g., complete blood count, liver function, serum testosterone level, serum vitamin B12, thyroid function) may be performed to exclude potential systemic causes of depressive symptomatology. Testosterone deficiency associated with depressive symptomatology (e.g., anhedo-nia, fatigue, and sexual dysfunction) has been described in males with PD and may possibly be managed with testosterone replacement therapy (120). Likewise, symptoms of hypothyroidism (e.g., anxiety, difficulty with concentration, dysphoria, fatigue, irritability, and motor retardation) resemble depressive symptomatology and are treatable with thyroid replacement. It is also important to ensure that patients are on optimal doses of antiparkinson drugs to minimize motor fluctuations that may contribute to mood fluctuations.

Presentation Of Testicular Cancer

The widespread availability of high-quality scro-tal ultrasonography with Doppler blood flow analysis has nearly eliminated much of the diagnostic difficulty for these patients. Today, patients who are misdiagnosed are mostly those for whom ultrasonography was not ordered. The caveat of the availability of ultrasonography, however, has been an increase in the finding of minor abnormalities such as microcalcifications, which has caused considerable anxiety and debate recently. A number of studies have shown that testicular microcalcifications are commonly found by modern ultrasonography, and their presence does not indicate an increased risk of subsequent testicular cancer.3-5

Assessment of Efficacy

The first step in treating a patient who fails to respond to treatment is to increase the dosage of the antidepressant. If a patient fails to respond to a maximal, tolerated therapeutic dosage, then the antidepressant should be discontinued and replaced by another from a different pharmacologic class. For example, if a patient fails to respond to an SSRI, a switch to a dual action antidepressant (e.g., duloxetine, venlafaxine) should be made. When anxiety is present with depression, there may initially be a slowed response to antidepressant therapy (13,173). Since depression is a potentially recurrent disorder, once depressive symptoms have improved or recovery has been achieved, it is recommended that maintaining treatment at the effective dose should continue for at least six months to reduce the risk for relapse. Persisting symptoms of concurrent anxiety have been found to increase the risk for relapse of depression (174).

Mental Harassment in the Context of Hostility and Cardiovascular Risk

The studies conducted by Suarez and colleagues (1989, 1990, 1993, 1998) yielded several, consistent findings. In studies of both men and women, those who scored high in hostility and also experienced mental harassment during the anagram task consistently exhibited increased cardiovascular and or neuroendocrine responses. For example, Suarez and colleagues (1998) demonstrated that increased (and protracted) blood pressure, heart rate, forearm blood flow, forearm vascular resistance, nore-pinephrine, testosterone, and cortisol responses resulted from harassment of those high in hostility. In addition, throughout the series of studies conducted by Suarez and colleagues, these same individuals also reported increased levels of negative affect including anger, anxiety, and depression. In contrast, individuals who were not harassed during the anagram task showed no increases in physiological or emotional arousal. Excessive cardiovascular reactivity has also been demonstrated in studies...

Human factors in functional neuroimaging

Another concern is that the neuroimaging environment itself may change performance of the task and other physiological measures. Changes may be due to anxiety about the scanning environment, changes in temperature (many scanner rooms are chilly), changes in posture that induce physiological changes (lying down reduces orthostatic load), practice, a response to the medical context presented by imaging suites, or other variables. It is advisable to test paradigms outside the scanner, and use objective measures of performance and other behaviors whenever possible.

Negative Affect and Forgetting

But what, in the first place, is the motive or cause that initiates and sustains the operation of the unconscious mechanism of repression before it produces its own later effects Apparently, Freud assumes axiomatically that distressing mental states, such as forbidden wishes, trauma, disgust, anxiety, anger, shame, hate, guilt, and sadness all of which are unpleasurable almost always actuate, and then fuel, forgetting to the point of repression. Thus, repression regulates pleasure and unpleasure by defending our consciousness against various sorts of negative affect. Indeed, Freud claimed perennially that repression is the paragon among our defense mechanisms (Thoma & Kachele, 1987, pp. 107-111). As Freud put it dogmatically The tendency to forget what is disagreeable seems to me to be a quite universal one (1901, p. 144), and The recollection of distressing impressions and the occurrence of distressing thoughts are opposed by a resistance (p. 146).

Intervention Research

Given the large body of evidence suggesting that low levels of social integration social support are predictive of cardiovascular disease outcomes, the Enhancing Recovery in Coronary Heart Disease (ENRICHD) trial was designed to provide psychosocial treatment to individuals who had recently suffered an MI and also perceived low social support availability (Berkman et al, 2003). Over 2000 individuals with low levels of perceived social support, high levels of depressive symptoms, or both, were randomized to either usual care (with private physician) or psychosocial treatment, which consisted of both individual cognitive behavioral therapy and group therapy. A tailored therapy program was designed for each participant that addressed social skill deficits, cognitive factors contributing to dissatisfaction with social support in one's network, network development, support needs and preferences, and individual factors (e.g., anxiety) that might be contributing to deficiencies with support...

Regulatory Status

Valerian was included as an official drug in the US Pharmacopeia until 1936 and in the National Formulary until 1946. Currently, the USP advisory panel does not recommend valerian's use owing to lack of adequate scientific evidence and conflicting study results. They encourage further research (4). Valerian is generally recognized as safe as a food and beverage flavoring by the FDA (2). The German Commission Monograph E has approved valerian as a sleep-promoting and calmative agent to be used in the treatment of unrest and sleep disturbances caused by anxiety (9). In Australia, valerian is accept able as an active ingredient in the listed products category of the Therapeutic Goods Administration. In Belgium, subterranean parts, powder extract, and tincture are allowed for use as traditional tranquilizers. The Health Protection Branch of Health Canada allows products containing valerian as a single agent in the form of crude dried root in tablets, capsules, powders, extracts,...

Drug Dependency Assessment

Embarrassed to tell the clinician the truth. Too often, the clinician finds out about the patient's alcohol usage only after the patient starts to experience withdrawal. By then, more aggressive therapeutic and medical interventions may be required, which could easily have been prevented with appropriate medications. At the earlier stages of withdrawal, the patient may only complain of spasms or unrelieved pain in addition to agitation and restlessness. Frequently, the clinicians attribute these symptoms to pain and give more opioids without success. However, appropriate assessment of and judicious use of benzodiazepines by patients with alcohol withdrawal can quickly bring the patient's pain and anxiety under control. The correct assessment will require clinician persistence in pursuing the clinical clues and the assistance of the patient's family members. Similar withdrawal symptoms can also occur with sedatives, anticonvulsants such as clonazepam and carbamazepine, and muscle...

Prioritization of Treatment Strategies

Behavioural couple therapy (BCT) is as effective as individual CBT not only with alcohol abuse but also with depression and anxiety disorders (Emmelkamp & Vedel, 2002). Because of Mick's early retirement and the consequences this was going to have on their relationship, and taking into account their overall low marital satisfaction, we decided to offer Dianne and her husband BCT, focusing on the drinking problem as well as their relationship. If still needed, the spouse-aided therapy for alcohol abuse could be supplemented by spouse-aided therapy for depression or anxiety. Because Dianne had already started using Acamprostate, we agreed that she would continue using the anti-craving agent during the course of our treatment.

Dean Filandrinos Thomas R Yentsch and Katie L Meyers

John's wort has demonstrated clinical efficacy for mild to moderate depression and compares favorably to other more potent or toxic antidepressants. Low side effects and potential benefits warrant its use as a first-line agent for select patients with mild to moderate depression or anxiety-related conditions. Benefits related to other reported uses such as an antimicrobial, agent to treat neuropathic pain, antiinflammatory, treatment alternative for atopic dermatitis, and antioxidant are either not well documented or evidence is encouraging but not conclusive and further study is needed. St. John's wort has an inherently wide margin of safety when taken by itself, with most reported adverse drug reactions (ADRs) being related to skin reactions. Isolated, but more significant ADRs have been reported in relation to neurological effects, impact on thyroid function, and increased prothrombin time. Of greatest concern is the potential for interactions between St. John's wort and...

Performance Characteristics And Quality Management Of Immunoassays

Many effective medicines share the same essential core structure as the abused drugs. Conversely, structurally unrelated medications can have three-dimensional conformations that possess weak but sufficient binding to certain antibodies. For instance, dextromethorphine and dextrorphine can bind to phencycline (PCP) receptors in vivo or anti-PCP antibodies in vitro (Nicholson et al., 1999 Schier, 2000). Examples of the published cases include oxaprozin with benzodiazepines (Fraser and Howell, 1998), various therapeutic drugs with LSD (Ritter et al., 1997 Rohrich et al., 1998), ranitidine with methampheta-mine (Dietzen et al., 2001), pholcodine, rifampicin, and ofloxacin with opiates (Maurer and Fritz, 1990 Johansen et al., 1991 de Paula et al., 1998 Meather-all and Dai, 1997), thioridazine with PCP (Long et al., 1996), diphenhydramine with PCP and propoxyphene (Levine and Smith, 1990 Schneider and Wennig, 1999), and nonsteroidal anti-inflammatory drugs with certain drug tests...

Management of Depressed Mood

Although Dianne's sleeping and eating improved to some extent, her worrying lessened and her panic attack disappeared, Dianne kept on feeling sad and low on energy. Thus, the probable diagnosis of general anxiety disorder was not confirmed however, the diagnosis of depressive disorder was reaffirmed. Therefore after seven sessions of alcohol treatment, the manual Spouse-aided Therapy with Depressive Disorders (Emanuels-Zuurveen & Emmelkamp, 1997) was incorporated into Dianne and Mick's treatment programme. Inactivity being one of Dianne's most salient high-risk situations, we introduced activity training as an intervention to tackle negative mood as well as her drinking problem. Activation training is a fairly common behavioural technique in treating depression, derived from Lewinson's theory of depression. We encouraged Mick to help his wife in organizing her week combining basic daily activities (like getting dressed in the morning), taking care of neglected activities (such as...

Communication Training

Communication training was introduced from session nine onwards. During this training both partners' personalities became more salient, this may be due to the fact the drinking and depressive symptoms had lessened. In addition, we addressed assertiveness, not only because of Dianne's social anxiety but also because both partners found it difficult to express disapproval and make a request. During these sessions it became clear that Mick had great

Inducible expression of the fragment of human DISC1

Consistent with previous reports (Morris et al., 2003 Ozeki et al., 2003 Brandon et al., 2004 Kamiya et al., 2006), DISC1-cc was found to bind to Nudel and Lis1 6 h after induction, but not 2 days after induction. Similar to the study by Pletnikov et al., binding of DISC1-cc to Nudel and Lis1 decreased endogenous DISC1 protein in DISC1 Nudel complexes (dominant-negative effects), indicating that this inducible transgenic system is useful for elucidating the neurobehavioral effects of disruption of endogenous DISC1 function during selective periods of brain development. Expression of the DISC1-cc protein was detected in the cortex, hippocampus, striatum, and cerebellum of the transgenic mice. Transgenic mice appeared normal and displayed no gross abnormalities. Locomotor activity in open field and anxiety-related responses in elevated plus maze were comparable between transgenic and control mice. Transgenic D2 receptors were functional and transgenic mice had 15 higher receptor-binding...

Project Title Depression In Adaptation To Openheart Surgery

Summary Applicant s The proposed study will examine the effects of depressive symptomatology on physical and psychological adaptation to open-heart surgery. There is growing evidence suggesting that depression may influence the development and progression of coronary heart disease as well as recovery following cardiac events. While several physiological and behavioral pathways have been proposed to explain these associations, potential psychological mechanisms have rarely been considered. In addition to evaluating effects of depression on adaptation to cardiac surgery, this study will examine the role of social cognitive variables as mediators of these effects. The specific aims of this study are to test the following hypotheses (1) Lower levels of preoperative depression will predict shorter hospitalizations following surgery (2) Lower levels of preoperative depression will predict less angina and better physical functioning six months after surgery (3) Lower levels of preoperative...

Polypeptides as Neurotransmitters

Spinal motor neurons that innervate skeletal muscles, the intravenous infusion of benzodiazepines acts to inhibit the muscular spasms in epileptic seizures and seizures resulting from drug overdose and poisons. Probably as a result of its general inhibitory effects on the brain, GABA also functions as a neurotransmitter involved in mood and emotion. Benzodiazepines such as Valium are thus given orally to treat anxiety and sleeplessness. Exogenous opioids such as opium and morphine can produce euphoria, and so endogenous opioids may mediate reward or positive reinforcement pathways. This is consistent with the observation that overeating in genetically obese mice can be blocked by naloxone. It has also been suggested that the feeling of well-being and reduced anxiety following exercise (the joggers high ) may be an effect of endogenous opioids. Blood levels of P-endorphin increase when exercise is performed at greater than 60 of the maximal oxygen uptake (see chapter 12) and peak 15...

Summary And Conclusions

Exposure therapies are the treatment of choice in adult specific phobia, social phobia, agoraphobia, and obsessive-compulsive disorder (Emmelkamp, 2004) and have also been found quite effective in phobic children (Nauta et al., 2003). Studies of the behavioural treatment of depression have come to a standstill due to the rise of cognitive therapy in this area but the lack of further research into the behavioural treatment of depression is not justified by the data. There are still a number of important issues that need to be addressed. For example, we have no idea why cognitive therapy, behavioural interventions, IPT and pharmacotherapy work equally well with depressed patients, although various researchers provide various theoretical explanations. Unfortunately, to date there is no evidence that There are marked differences between therapy as conducted in outcome studies and therapy in clinical practice, where it is usually adapted to the individual needs of the patient. For example,...

The Personality Hierarchy Reconsidered

These different models of genetic influence on personality traits may be explored using a model-fitting approach (Neale & Cardon, 1992). The common pathway model is structurally similar to the model of exploratory factor analysis used to specify the phenotypic structure of traits. It postulates a single latent variable (higher order trait) that mediates the covariation among a set of variables (lower order traits) that also have their own genetic and environmental basis. As shown in Figure 6.1, the covariation in a set of variables is hypothesized to be mediated by a single superordinate latent phenotypic variable (P), such as a higher order trait, which is influenced by a single additive genetic (Ap h. k), one shared (Ct c.k) and one nonshared environmental factor (Ep e. k). Genetic (A'k, a'k) and environmental effects (C'k, c'k and E'k, e'k) specific to each variable are also specified. As applied to each domain of the five-factor model, the model postulates a single latent factor...

Rationale for Assessment of Psychosocial Constructs

One issue that has been strongly debated in the literature on psychosocial factors and health is whether assessments include measures of clinical diagnoses (e.g., major depressive disorder, panic disorder) or measures of symptom severity or both. Within the context of studying the health impact of negative emotions and personality, questions have been raised as to whether assessment of symptoms without assessment of clinical conditions is sufficient. An example is the assessment of depressive symptoms versus major depressive disorder (i.e., clinical depression). The initial studies examining whether depression was linked to increased morbidity and mortality were conducted within psychiatric populations, so an early emphasis in the literature was on clinically diagnosed depression. However, because it is uncommon to have time or resources to complete clinical interviews within the context of large, population-based studies, much of the epidemiologic research on the relation of...

The Theoretical Basis For

When Marsha Linehan is asked to tell the story of her development of dialectical behaviour therapy (DBT) she says that she did not set out to invent a theoretical orientation for the treatment of borderline personality disorder (BPD). Linehan was treating suicidal clients, attempting to use standard behaviour therapy with them. However, it was not successful for many of the clients. They would present at an individual psychotherapy session with one problem, such as panic disorder and Linehan would choose an empirically supported treatment for that problem. When the clients returned for the next session they would not have completed the prescribed homework because other problems would have surfaced. Linehan realized that standard treatments were not working because the problems of the clients changed from session to session and moment to moment. Her laboratory developed DBT from an attempt to find a means of prioritizing the multiple problems presented by clients who engaged in...

Personality Characteristics

Shortened versions of this scale are most often employed, the most common of which are listed in Table 21.1. As with measurement of hostility, population-based measurement of most of the other personality characteristics listed in Table 21.1 are frequently accomplished with a dominant measure, namely the Spielberger scales for trait anger and anxiety (Spielberger, 1983, 1999), the NEO Five Factor Inventory (NEO-FFI) for the five empirically identified broad dimensions of personality (Costa and McCrae, 1992), and the Life Orientation Test (LOT) (Scheier and Carver, 1985) for the measurement of optimism. The measurement of Type D personality (the letter D refers to distressed and this is a trait characterized by both negative affectivity and social inhibition) is similarly accomplished with the DS14 (Denollet, 2005) however, this measure predominantly has been used in studies based in western Europe.

Cultural Framework of Assessment Tools

However, such translations by themselves do not explicitly address the cultural relevance of various psychosocial constructs across multiple and varied cultures. For example, the manifestation of symptoms of depression or anxiety in different cultures will reflect culturally accepted modes of expression but this issue is rarely addressed in research studies. Expanding our understanding of the impact of psychosocial factors on the health of populations in an increasingly multi-cultural world will require greater attention to such issues.

Structuring The Treatment In

Dialectical behaviour therapy consists of four primary treatment stages with pre-commitment occurring prior to beginning each stage. Currently, the main body of research on DBT is on what is called Stage 1 DBT. The first stage of DBT is usually one year of treatment designed to get the client's behaviours under control. Clients in Stage 1 are usually engaging in severely out of control behaviours. They are suicidal, engaging or having the urges to engage in non-suicidal self-injurious behaviours, are substance abusing, binging and or purging, criminal behaviour, gambling, and engaging in out of control, impulsive behaviours. Once the clients' behaviours are under control, they move into Stage 2 of DBT. In Stage 2, the behaviours are under control, but the clients' level of misery is still extremely high. Usually, Stage 2 is some form of structure exposure based treatment, usually for trauma. Because the out of control behaviours that lead clients into Stage 1 DBT are usually to avoid...

Diagnosis of HIV infection 18 months of age

The detection of anti-HIV antibodies does not prove an infection in infants. High titers of anti-HIV IgG are transferred transplacentally from mother to child. Maternal antibodies can be detected in children up to the age of 18 months. Therefore a direct method of detecting HIV is necessary. Identification by HIV DNA PCR is highly sensitive and specific. Detection of HIV can be achieved within the first 48 hours after birth in 38 of infected children, and within the first 2 weeks in 93 of children (Dunn 1995). Once a positive HIV PCR is found, a second independent blood sample should soon be taken for repeat PCR analysis. As diverse subtypes of HIV exist, it is advised to test paired samples from mother and infant by HIV DNA PCR. If the mothers virus is not amplified by the primer set used, then another set or another test can be used to avoid a false negative result in the infant. Cord blood is not useful for the diagnosis because maternal cells may be present and may cause a false...

Nonselective Agonists

Epinephrine may cause tachycardia, extra systoles, systemic hypertension, palpitation, and anxiety. Topical use can be uncomfortable, causing tearing and stinging. Long-term use leads to allergic blepharoconjunctivitis in a significant subset of patients, which resolves when the drug is discontinued. Epinephrine is contraindi-cated in patients with narrow anterior chamber angles, because the induced my-driasis can precipitate pupillary block, inciting a pupillary-block glaucoma attack. Epinephrine is also contraindicated in aphakic patients, because topical use is associated with symptomatic, usually reversible, cystoid macular edema (CME) in roughly 13 to 30 .17,18 Of note, epinephrine-related CME has been described in aphakic, but not pseudophakic, patients. This may therefore be a problem seen only if the anterior hyaloid is disrupted following traumatic extracapsular cataract surgery. Finally, epinephrine can cause black adrenochrome deposits in the palpebral conjunctiva, on...

Project Title Effects Of Meditation On Mechanisms Of Chd

Based on these and related data, we propose a randomized, blinded, controlled study of the effects of one CAM practice, the TM technique, compared to a control group, on the primary outcomes of (1) arterial vasomotor dysfunction (brachial artery reactivity) (2) autonomic nervous system imbalances (heart rate variability) (3) transient ambulatory myocardial ischemia (ST segment depression) and (4) the secondary outcomes of psychological stress and quality of life (anger, hostility, anxiety, depression, perceived health, disease-specific symptoms, and life stress social resources). We hypothesize that significance effects on these physiological and psychological mechanisms associated with practice of the TM program will elucidate the known effectiveness of certain CAM techniques as additive alternative approaches to prevention of acute cardiac events in CHD patients. Results of this randomized controlled trial will (a) yield new data regarding the reversal...

The Four Major Systems of the Personality Sphere

The personality-biopsychosocial sphere can be divided into four major interrelated systems, among which we can draw boundaries for heuristic purposes. These conceptualizations represent various levels of dynamical systems based on models developed over the past century by leading theorists from various orientations (Magnavita, 1997, 2000). They can be depicted as fluid triangular configurations and their subcomponent processes as follows (1) intrapsychic-biological triangle (affective cognitive-defensive-anxiety matrix), (2) interpersonal-dyadic triangle (early relational matrix-current relational matrix-expected relational matrix), (3) relational-triadic configuration (2 person + n system), and (4) sociocultural-familial triangle (individual personality system-culture-family Magnavita, 2004c). These four systems are depicted along with the theoretical models necessary for unification in Figure 8.2. The intrapsychic-biological domain system has been the major focus of...

Characteristics of Good Screening Tools

It is also important to consider the possible side effects of screening. Clearly a test with common and harmful side effects would not be useful for example, the risk of bowel perforation during colonoscopy must be considered when deciding whether it is suitable as a population-based screening tool. Consequences of screening follow-up must also be considered one reason why cervical screening is often deemed inappropriate for women under 25 years is that many HPV-related abnormalities regress spontaneously at this age while treatment can compromise future pregnancies. Distress and anxiety should also be considered when the costs and benefits of a screening test are evaluated. Another potential harm, which is gathering more attention at present, is the risk of over-diagnosis, i.e., detecting disease that may never have resulted in significant morbidity or mortality. Topical examples of screening tests that have attracted concern regarding possible over-diagnosis include PSA testing to...

Nonpsychotic Disorders

Other serious, nonpsychotic mental health problems includegeneralized anxiety, phobias, panic disorders, obsessive-compulsive behavior, and hypochondriasis. If untreated, these conditions can persist throughout life, often becoming more intense as the individual is confronted with the physical and psychological stresses of aging. Phobias are irrational, persisting fears of some object, person, or situation. One of the most common phobias is agoraphobia, an abnormal fear of being alone or in open, public places, where escape might be difficult in case of a panic attack. Recurring panic attacks triggered by specific stimuli or situations are usually diagnosed as panic disorder. The role ofgeneralized anxiety in neurotic conditions is particularly apparent in phobias and panic attacks, but it is also important in obsessive-compulsive behavior. In this disorder, obsessions recurring thoughts or ideas and compulsions specific behaviors performed in a rigid, repetitive manner-serve the...

Overall Impact of Screening Programs

It seems intuitively possible that merely recommending screening for a particular cancer might raise awareness and thereby anxiety about the disease across the population, and critics have argued that for some screening programs, such negative effects outweigh the health benefits. This has rarely been examined empirically but one study found that people receiving information about CRC screening were actually less worried about CRC and considered themselves less at risk than a control group. The only adverse impact of the information was an increased tendency to report bowel symptoms (Wardle et al, 1999). However, receiving an invitation for an unfamiliar screening test has been found to cause anxiety and fear. One small study of cervical screening non-attenders found that merely receiving an invitation letter was interpreted by some women as meaning that they had cervical cancer, causing high levels of distress (Nathoo, 1988).

Impact of Abnormal Results

There is little doubt that across types of cancer screening, receiving an abnormal result is a stressful experience (Brett et al, 2005 Parker et al, 2002 Rogstad, 2002). The exception to this is flexible sigmoidoscopy, where the discovery of polyps does not seem to be associated with increased anxiety, regardless of whether people are referred for further investigation or simply have the polyps removed (Wardle et al, 2003). This may be because of the provision of immediate clinical advice and reassurance, as well as a good explanation of what a polyp is. Following abnormal mammography, cytology or FOB test results, anxiety and distress tend to be highest while waiting for follow-up appointments, partly due to fear about cancer and future health, but also because of concerns about the follow-up procedures themselves. In countries like the USA with insurance-based health-care systems, concerns about insurance cover for follow-up procedures is likely to be an additional source of...

Interventions to Reduce Negative Psychological Consequences of Screening

Much research has been devoted to exploring ways of minimizing anxiety associated with abnormal results and follow-up procedures. Studies have focused on information provision by leaflets, booklets, or DVDs. However, a recent Cochrane review of interventions to reduce anxiety at colposcopy concluded that such information provision is ineffective at reducing anxiety, although it does improve knowledge and reduce psychosexual dysfunction (Galaal et al, 2007). Similar findings have been reported in relation to colorectal cancer screening and more research is needed to optimize the information provided to people prior to screening. In addition to information provision, shorter waiting times, or see-and-treat clinics may help to reduce anxiety.

Needs Of Dying Persons

An ethic of care for terminally ill persons must be responsive to needs. Generally, the needs of dying persons will span the needs of life itself, from physical and medical care issues to psychological and social needs and often to spiritual concerns. To focus the point, consider persons dying from cancer. Sometimes these people will have to experience the deterioration of their bodies over a period of weeks or months. Anxiety, fear, loneliness, and depression are common. Most people can expect to experience symptoms from the primary disease. When a curative therapy is no longer possible, sometimes quite complicated medical care issues arise not only from the primary disease but from secondary sources, issuing in pain and discomfort. These may include appetite disturbance, fever, dysphagia (swallowing problems), persistent constipation, infections, dyspnea (difficulty in breathing), bladder dysfunction and incontinence, and

The Effectiveness Of Counselling

Counsellors have been employed in primary care settings in the UK since the 1980s, generally receiving referrals from GPs for patients reporting problems in such areas as relationship difficulties, moderate depression, anxiety and stress. Counselling is available in more than 50 of GP practices in England (Mellor-Clark, 2000) and protocols have been developed which define the role and of counsellors in primary care (National Primary Care Research and Development Centre, 2001). A Scottish Office report conducted in the 1990s noted the potential value of counselling in primary care but called for further research to establish its effectiveness (National Medical Advisory Committee, 1998). A number of investigations of the effectiveness of counselling in primary care have been published, encompassing both controlled trials, and naturalistic studies. Early randomised trials have compared the effectiveness of counselling with treatment as usual from the GP (Ashurst & Ward, 1983 Boot et al.,...

Marshall L Silverstein

Kernberg's, Kohut's, nor any other psychodynamic theoretical viewpoint prominently influenced diagnostic conceptualizations of narcissistic personality disorder in any of the versions of the DSM since 1980 or in the mental disorders section of the International Classification of Diseases (ICD World Health Organization, 1992). Therefore, Kohut's and others' evolving views about narcissism and the self remained largely within the field of psychoanalysis proper, even as Kohut's thoughts about conditions such as addictions, perversions, and depletion depression or anxiety expanded the range of clinical disturbances associated with self-cohesion and self-esteem deficits.

Psychosocial Concerns

Cancer survivors with preexisting anxiety or affective disorders appear to be at greatest risk for ongoing distress.25 Changes to body image from cancer therapy, such as that resulting from mastectomy or colostomy, can be a source of problems with psychological adjustment.72 Distress appears to dissipate with time, however. There are a small proportion of patients who experience ongoing effects characteristic of posttraumatic stress disorder.73 Having a spouse or partner decreases the risk of psychological sequelae,74 although these caregivers may also themselves be adversely

What Do Children And Young People Need

Just attachments, and within these relationships the child needs to be valued and respected. The important task for the parent or carer is that of containment. The adult needs to be able to accept the child's hopes, fears, anxiety, longing, omnipotence, arrogance, self-doubt, terror and aggression. These feelings may be communicated verbally, non-verbally or unconsciously. The adult needs to be able to tolerate the feelings, reflect on the process, and help the child by reducing the intensity and showing that he or she is bearable and can be understood. The adult has to avoid retaliation or acting out by becoming caught up in the child's emotional state while remaining sensitive and thoughtful. Slowly, children manage to take in this capacity to bear the feeling and reflect, and can then 'contain' themselves, but they can only do this if they have had a relationship with such an adult for sufficient duration. Where parents never had this experience themselves, it may be that a nursery...

Theoretical Formulations Behavioural And Cognitive Models

In the behavioural model for OCD neutral internal stimuli, such as thoughts and images, become paired with an anxiety-provoking stimulus as the result of learning experiences. Because these previously neutral stimuli now cause anxiety, the patient develops avoidance behaviours, which result in an immediate reduction in anxiety. This encourages further use of the avoidance behaviours, which in time become more stereotyped and develop into a compulsive ritual. The ritual limits exposure to the initial stimulus and therefore there is no opportunity for the anxiety associated with it to be extinguished. The behavioural model is supported by evidence that obsessions cause anxiety and that compulsions reduce it (Hodgson & Rachman, 1972). Behavioural treatment involves exposure to the initial stimulus (which is now feared), while encouraging the patient not to carry out any behaviours to avoid this exposure and is known as exposure and response prevention (ERP). Beck's (1976) cognitive model...

The Evidence Base For Behaviour Therapy

Behaviour therapy has been shown to reduce symptoms compared with relaxation (Abramowitz, 1997) and anxiety management training (Lindsay, Crino & Andrews, 1997). Foa & Kozak (1996) reviewed 12 outcome studies and found 83 of patients who completed exposure and response prevention treatment were post-treatment responders. Stanley & Turner (1995) concluded that about 75 of OCD patients show substantial improvement after 12 to 15 sessions of behaviour therapy. O'Sullivan & Marks (1991) reviewed nine follow-up studies of OCD exposure and response prevention treatment completers. The follow-up duration was between one and six years with a mean follow up of three years. Seventy-nine per cent of patients had improved or were much improved and symptom improvement was maintained irrespective of the length of follow up. However, these results are for treatment completers. About 25 of OCD patients offered ERP refuse it (Kozak, 1999) and others drop out or do not improve with ERP. Hiss, Foa &...

Modifications And Variants Of Behaviour Therapy

Foa et al. (1984) showed that concurrent exposure and response prevention had superior outcome to using either component alone. To be effective the exposure must continue until there is a reduction in anxiety and urge to ritualise. Studies have shown that this takes approximately 90 minutes (Foa & Chambless, 1978 Rachman, Desilva & Roper, 1976) which can act as a guide. There is no clear evidence about the necessary frequency of exposure sessions but, in general, patients with more severe symptoms and those who have more difficulty complying with the treatment and homework may need more intensive treatment. Abramowitz, Foa & Franklin (2003) compared 15 sessions over three weeks (daily treatment) or eight weeks (twice-weekly treatment), with 20 patients in each group. Both treatment programmes were effective, with a trend towards more improvement in the intensive group at post treatment but no differences at follow up. A meta-analysis by Abramowitz (1996), found that...

Gene Stress Interaction Acute Stressors

As noted previously, a central component of most stress models is the primary appraisal of potential stressors along dimensions of threat or demand. A heightened sensitivity to threat-related cues might be expected therefore to enhance threat appraisals and potentiate stress responses. In this regard, genotypes containing the 5-HTTLPR S allele have been found to predict attentional biases toward words of negative emotional content (anxiety) in psychiatric inpa-tients (Beevers et al, 2007), pictures of phobic stimuli (spiders) in college students (Osinsky et al, 2008), and facial expressions of anger

An ultrashort introduction to the principles of learning

Instead of habituating to a constant stimulus, some people react in the opposite way. When my neighbor turns on his unpleasant music, a collection of Norwegian folk music tunes where the violins whine in a manner extremely aggressive to the human ear, I may not react for the first 15 minutes. Then I start to feel anxious and an intense activity in my sympathetic nervous system is evident. If it does not stop within another 15 minutes, I knock at the neighbor's door and ask him to turn the noise off. My reaction to a constant stimulus increased with repeated exposure. Please observe that all the folk music tunes sound identical to any non-expert, thereby satisfying the criterion of constant stimulus. This kind of learning is called sensitization. Another form of sensitization is observed when a completely irrelevant but strong or noxious stimulus is presented. The most famous case is certainly the enhanced gill and siphon withdrawal observed in response to a water jet in the sea hare,...

Sensitization of sexual responses

Regarding sensitization in the human, we are in a most unusual situation. The only experimental studies I know of were performed in women The purpose was not at all to study sensitization of sexual responses, but instead to determine the effects of activation of the sympathetic nervous system or the influence of anxiety on sexual arousal. The stimuli or actions employed for generating sympathetic activation and or anxiety were completely irrelevant as far as sex is concerned. Yet they were found to enhance responses to sexually relevant stimuli. This coincides perfectly with the definition of sensitization given earlier in this chapter. Thus, although the scientists performing the studies I soon will mention did not interpret their results in terms of learning, I will use their data as evidence in favor of sensi-tization of sexual responses. The oldest paper containing observations relevant to the issue of sensitization that I have been able to localize reports a study in which women...

Patient And Family Education

Patients and families require factual information regarding their particular diagnosis, treatment options, managing their medications, handling common symptoms and side effects, and recognizing medical emergencies. The key is to empower patients and families to effectively manage their own care. Also important are specific details on the likely course(s) of their illness and the supportive resources available to them over the course of their disease. The key is to provide accurate information so that patient and families can make informed decisions. Desperate families who have not been given adequate information may make decisions based on misinformation in the media, on the Internet, and from well-intentioned friends and family members. Information provided should be easy to understand and accurate. Adequate education can decrease anxiety and sustain confidence. Ideally, patient education materials need to be written at a ninth grade level or below...

Preoperative Education

Preoperative education for the patient with a high-grade CNS malignancy is a unique challenge to nurses. Management of this patient population involves multiple treatment modalities and requires ongoing vigilance of a multidisciplinary team to detect and treat newly diagnosed and recurrent tumors. Multiple studies have indicated that preoperative education significantly reduces pre- and postoperative anxiety. Certainly, with the addition of a potential malignant diagnosis, and the often rapid succession of events from diagnosis to surgery, patient and family education is a cornerstone in this population.

Psychosocial And Ethical Implications Of Germ Line P53 Mutation Testing

As genetic counseling and testing for cancer susceptibility has become more common, guidelines for testing have been updated. Current ASCO guidelines support genetic testing in the setting of pre- and posttest counseling if the individual has a personal or family history suggestive of a cancer susceptibility syndrome, the test can be adequately interpreted, and results will affect medical management (93). The increasing integration of p53 mutation status into medical management as evidenced by the recommendation for breast MRI screening and for relative avoidance of radiation therapy provides a more compelling rationale for genetic testing than previously available. As new therapies are developed that target specific lesions in the p53 pathway, additional benefits from knowledge of the p53 status may accrue. Others benefits of knowing one's genotype may come from the opportunity to make informative reproductive choices (94). For those at risk, the benefits also lie in the relief of...

Limitations In The Way Prototype Categorization Is Operationalized In Dsmiv

This method of operationalizing prototype diagnosis has several limitations. First, an accumulating body of research suggests that personality characteristics, including PD features, tend to be distributed continuously rather than categorically (Widiger, 1993 Widiger & Clark, 2000). Categorical diagnoses perform poorly relative to dimensional diagnoses most of the time in PD research, which has led many PD researchers to analyze their data primarily dimensionally (e.g., Lenzenweger, 1999). The dimensional distribution of many aspects of personality does not preclude the possibility that some personality characteristics can have categorically distinct variants (e.g., a heart attack is qualitatively different from a panic attack despite commonalities in subjective perception of symptoms). Taxo-metric analysis can be particularly useful in identifying such cases (Meehl, 1995 Waller & Meehl, 1998). There is little reason to believe, however, that the cutoffs currently used in DSM-IV...

Siblings And Other Relatives

Siblings usually have more in common with each other than with any other member of the immediate family. This is particularly true when siblings are of the same sex and close in age. In families in which parents express a great deal of dissatisfaction and hostility toward each other and or the children, or when a parent has been lost by death, separation, or divorce, siblings are likely to turn to each other and develop their own little social world or subfamily. Brothers and sisters may be intensely loyal toward each other, a loyalty and closeness that deepens with age (Dunn, 1984 Mosatche, Brady, & Noberini, 1983). Long after they have left their parents' home and even after the parents have died, siblings who were close as children continue to provide emotional and material support to each other in times of crisis (Matthews, Werkner, & Delaney, 1990 Rosenthal, 1985). Anxiety and depression are lifted when a brother or sister shows concern and an eagerness to be of help.

Emotional Distress and Social Support Issues

Diagnosis of a malignant brain tumor is a stressful and traumatic event for patients and families with a wide range of responses from anger, withdrawal, isolation, guilt, anxiety depression, and hopefully, acceptance. Adjustment to the many changes can take a dramatic toll on patients, family and caregivers (19). Patients require varying levels of support depending on the stage of their illness.

Hormonereplacement Therapy

Both prophylactic mastectomy and prophylactic oophorectomy are options available to a known carrier of a mutation in BRCA1 or BRCA2. The uptake of prophylactic mastectomy is greater in the United Kingdom and Holland61,62 than in the United States.63 The efficacy of this procedure has now been evaluated retrospectively in BRCA1 2 carriers. Two studies have found at least 90 reduction in the incidence of breast cancer in women with BRCA1 or BRCA2 mutations. Further evidence for a reduction in breast cancer risk following breast removal was found in a study that examined the incidence of breast cancer following surgical breast reduction.65 Women who had breast reduction had a relative risk of 0.61 of developing breast cancer (95 confidence interval 0.42-0.86). The relative risk was related to the amount of breast tissue removed those who had a greater amount of breast tissue removed had a lower relative risk of developing breast cancer. There is a report of a male having a prophylactic...

The Assessment of Cognitive Functions in the Haart Era The Typical Neuropsychological Assessment

In addition to the neuropsychological tests, it is also recommended to briefly assess the level of depressive complaints using a validated psychiatric scale as well as anxiety and cognitive complaints (for more information see 23, 24). Importantly, the assessment should be complemented by an examination of activities of daily living (25) as this assessment serves to ascertain the presence of dementia vs. milder stages of HAND (5, 6). In the context of HIV AIDS, a caregiver is not often available to provide a more objective assessment of everyday life functioning. Self-reported everyday functioning is used on scales such as the Instrumental Activities of Daily Living Scale (IADL, 26), the direct assessment of functional status instrument (DAFS, 27). The current research in this area shows that the reports of cognitive complaints, depressive complaints and IADL should be interpreted together, as the different types of complaints may be inter-related while they do remain for the most...

The Fivefactor Model In The Service Of Dsmiv Categories

The computer-administered version of the NEO-PI-R (Costa & McCrae, 1992b Costa, McCrae, & PAR Staff, 1994) generates an Interpretive Report, which includes a section of Clinical Hypotheses that is intended to serve that function. For each PD, a characteristic profile was first identified, based on judgments of the relevance of NEO-PI-R facets to its criteria and associated features (see Widiger, Trull, Clarkin, Sanderson, & Costa, 1994). For example, low A1 Trust was judged to be relevant to the criteria of the paranoid PD and assigned a prototypic T-score of 30 (very low). N1 Anxiety was judged to be an associated feature and assigned a T-score of 60 (high). Traits not relevant to a PD are not included in the profile. The computer plots the patient's profile, and overlays of the pro-totypic PD profiles can be used to judge how similar the person is to the prototype.

The Gamma Knife Nurse

Centers offering gamma knife radiosurgery usually have at least one nurse whose sole responsibility is caring for patients undergoing this unique procedure. The gamma knife nurse is the patient liaison from the pretreatment to the follow up visit. Nurses in this setting educate the patient on the procedure, what to expect, time frames, and help to reduce anxiety over the course of the day-long treatment. Hands-on care may include head frame application and removal, transport to scanning, medication administration, and patient monitoring throughout

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