Monday, February 25, 2008
Sexual MasochismSexual masochism falls under the psychiatric sexual disorders category of paraphilias, meaning "abnormal or unnatural attraction." Sexual masochism refers to engaging in or frequently fantasizing about being beaten, bound, or otherwise made to suffer, resulting in sexual satisfaction. Blindfolding, spanking and humiliation in the form of defecation, urination, or forced imitation of animals are other methods used by these patients. Masochists may inflict their own pain through shocking, pricking or choking. Approximately 30 percent also participate in sadistic behavior.
One particularly dangerous method is called hypoxyphilia (near-asphyxiation) caused by reducing oxygen level in the brain. This results in the accidental death of one or two per million people per year. To achieve near-asphyxiation, masochists might place a noose around their necks, chest compression, put airtight bags over their heads or use amyl nitrates ("poppers").
Sadomasochistic relationships tend to be well planned, with partners deciding on a special word the masochist will use to indicate that the sadist should stop.
Symptoms
Sexually masochistic behavior is usually evident by early adulthood, and often begins with masochistic or sadistic play during childhood.
The fantasies, sexual urges, or behaviors cause clinically significant troubles or difficulty in social, occupational, or other important areas in life.
Causes
There is no universally accepted theory explaining the root of sexual masochism, or sadomasochism. However, some theories attempt to explain the presence of sexual paraphilias in general. One theory suggests that paraphilias originate because inappropriate sexual fantasies are suppressed, and they become stronger as they are forbidden. When they are finally acted upon, a person is in a state of considerable distress and/or arousal. In the case of sexual masochism, masochistic behavior becomes associated with and inextricably linked to sexual behavior. There is also a belief that masochistic individuals actually want to be in the dominating role, which causes them to become conflicted and thus submissive to others.
Another theory suggests that sadomasochistic behavior is a form of escape. Through acting out fantasies, these people feel new and different. Some theories stem from the psychoanalytic camp. They suggest that childhood trauma (for example, sexual abuse) or significant childhood experiences can manifest as exhibitionistic behavior.
Nathan, Gorman, and Salkind provide the following survey of theories on the topic: Behavioral learning models suggest that a child who is the victim or observer of inappropriate sexual behaviors learns to imitate and is reinforced for these behaviors. These individuals may be deprived of normal social sexual contacts and thus seek gratification through less acceptable means. Physiological models focus on the relationship between hormones, behavior, and the central nervous system with a particular focus on the role of aggression and male sexual hormones.
Treatment
Treatment typically involves psychotherapy aimed at uncovering and working through the underlying cause of the behavior.
Nathan, Gorman, and Salkind provide the following explanations regarding medication as treatment: Level of sex drive is not consistently related to the behavior of paraphiliacs, and high levels of circulating testosterone do not predispose a male to paraphilias. That said, hormones such as medroxyprogesterone acetate (Depo-Provera) and cyproterone acetate decrease the level of circulating testosterone, reducing frequency of erections, sexual fantasies, and initiations of sexual behaviors including masturbation and intercourse. Hormones are typically used in tandem with behavioral and cognitive treatments. Antidepressants such as fluoxetine (Prozac) have also successfully decreased the sex drive yet they do not effectively target sexual fantasies.
Research suggests that cognitive-behavioral models are effective in treating paraphiliacs: Aversive conditioning uses negative stimuli to reduce or eliminate a behavior. Covert sensitization entails the patient relaxing, visualizing scenes of deviant behavior and then immediately experiencing a negative event such as getting his penis stuck in the zipper of his pants. Assisted aversive conditioning is similar to covert sensitization except the negative event is most likely in the form of a foul odor pumped in the air by the therapist. The goal of aversive behavioral reversal (commonly known as "shame therapy") is to shame the offender into stopping the deviant behavior. For example, the offender might be made to watch videotapes of their crime with the goal that the experience will seem offensive to them. Vicarious sensitization entails showing videotapes of deviant behaviors and their consequences such as victims describing desired revenge or perhaps even watching surgical castrations.
Nathan also describes positive conditioning approaches centering on social skills training and alternate behaviors the patient might adapt. Reconditioning techniques center around providing the patient with immediate feedback so behavior will change quickly. A person might be connected to a biofeedback machine that is hooked up to a light and taught to keep the light within a specific range of color while the person is exposed to sexually stimulating material. Or masturbation training might focus on separating pleasure in masturbation with the deviant behavior.
Cognitive therapies include restructuring cognitive distortions and empathy training. Restructuring cognitive distortions involves correcting any beliefs a patient has which may lead to errors in behavior, such as seeing a victim and constructing erroneous logic that the victim deserves to be party to the deviant act. Empathy training involves helping the offender take on the perspective of the victim and in identifying with them, understand the harm that has been done.
Prognosis is good although often there are other issues that may surface once the behaviors are extinguished. If this is the case, these issues must be worked through as well.
Sources:
American Psychiatric Association: Diagnostic and statistical manual of mental disorders
Introductory Textbook of Psychiatry
Current Psychiatric Diagnosis & Treatment
Philadelphia: Current Medicine
Current Diagnosis & Treatment in Psychiatry
DSM-IV™ Made Easy: The Clinician's Guide to Diagnosis
Treating Mental Disorders: A Guide to What Works
Last Reviewed: 14 Nov 2006
Last Reviewed By: Laura Stephens
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Adjustment Disorder is an abnormal and excessive reaction to an identifiable life stressor. The reaction is severe compared with what would normally be expected, and can result in significant impairment in social, occupational or academic functioning. The response may be linked to a single event (a flood or fire, marriage, divorce, starting school, new job) or multiple events (marital problems or severe business difficulties). Stressors may be recurrent events (child witnessing parents constantly fighting, chemotherapy, financial difficulties) or continuous (living in a crime-ridden neighborhood).
Adjustment Disorder often occurs with one of the following: depressed mood (patient is tearful, sad, hopeless); anxiety (patient is nervous, fearful, worried); mixed anxiety and depressed mood; disturbance of conduct in which the patient violates rights of others or major age-appropriate societal norms or rules (e.g. truancy, vandalism, reckless driving or fighting); mixed disturbance of emotions and conduct; maladaptive reactions (problems related to job or school, physical complaints, social isolation). Adjustment disorders are associated with higher risk of suicide and suicidal behavior; substance abuse; prolonging of other medical disorders or interference with their treatment. Adjustment disorder that persists may progress to become a more serious mental disorder (major depressive disorder).
Symptoms
Depressed mood
Impaired occupational/social functioning
Agitation
Trembling or twitching
Physical complaints (e.g. general aches and pains, stomachache, headache, chest pain)
Palpitations
Conduct disturbances
Withdrawal
Anxiety, worry, stress and tension
Note: Symptoms may vary widely. The person may or may not be aware of the stressor causing the disturbance.
Diagnosis depends on the following:
The reaction clearly follows a life stressor. Within three months of stressor onset, emotional and behavioral symptoms develop in response to stressor
Symptoms seem excessive compared to what would normally be expected in relation to stressor and/or, symptoms significantly impair occupational, school or social functioning
Symptoms are not explained by another diagnosis
Symptoms are not part of bereavement
Symptoms do not last longer than six months after end of stressor
The diagnosis may be acute (symptoms last less than six months) or chronic (symptoms last six months or longer as when stressors are chronic or have lasting effects)
Causes
The cause is a life stressor. Adults usually develop adjustment disorders to stressors related to marital discord, finances, or work. In adolescents, common stressors include school problems, family or parents' marital problems, or sexuality issues. Other types of stressors include death of a loved one, life changes, unexpected catastrophes, medical conditions such as cancer and subsequent treatments.
There is no way to predict which people are likely to develop adjustment disorder, given the same stressor. Factors that influence how well a person reacts to stress may include economic conditions, availability of social supports, and occupational and recreational opportunities. Intrapersonal susceptibility to stress may include such factors as social skills, intelligence, genetics and coping strategies.
Treatment
The primary goal of treatment is to relieve symptoms and help the person achieve a level of functioning comparable to that before the stressful event. Most mental health professionals recommend a form of psychosocial treatment for this disorder. Treatments include individual psychotherapy, family therapy, behavior therapy and self-help groups. Realistic short-term goals should be made at the start of therapy, as the course of adjustment disorder is short-term in nature. Goals of therapy will often center around social supports available to the individual in his or her life in the form of family, friends and community. The individual's coping and problem solving skills will be explored and developed. Relaxation techniques might be explored to help the individual deal with feelings of stress. More specific goals of treatment will include eliciting the patient's concern and helping the individual understand his or her role in the stressors; reviewing and reinforcing positive steps the patient has taken to deal with the stress; teaching ways to cope or avoid stressors in the future; helping the individual to place stressors in perspective with relation to overall life; helping the individual to understand his reaction to the stressors; and helping the individual view stressors as chance for positive change or improvement.
Family therapy as well as effective communication and coping-with-stress skills may be recommended for cases in which the patient is younger (child, adolescent). When medications are used, it is in addition to psychosocial treatment. Prescription medication may be helpful in easing the depression or the anxiety associated with adjustment disorder. However, treatment of adjustment disorders usually excludes use of medication.
Course and Prognosis
Adjustment disorder is defined as beginning within three months of the onset of an identifiable stressor and lasts no longer that six months after the stressors have ceased. Most people recover from adjustment disorders without any remaining symptoms if they have no previous history of mental illness and have access to stable social support.
It is important for these individuals to maintain and develop healthy diets and sleeping patterns as well as develop and maintain a strong social support system.
Sources:
American Psychiatric Association
National Cancer Institute
National Institutes of Health
Pelkonen M, Marttunen M, Henriksson M: Suicidality in adjustment disorder
Last Reviewed: 07 May 2007
Last Reviewed By: Laura Stephens
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Creative Stress
Type A's should steer clear of complex, creative jobs.
If you're a driven type A in a complex, creative job, scrap it for something simple. It'll do your heart good
Though you'd think creativity and intellectual stimulation on the job would be cathartic for type A's, seven years of interviews with police and firefighters told John Schaubroeck, Ph.D., the opposite. "The combination of type A's in complex jobs, like that of a detective, leads to cardiovascular problems," Schaubroeck, a professor of organizational behavior at the University of Nebraska, reports in the Academy of Management Journal.
It's the easy-going, mellow folks -- your type B -- who should be in those coveted creative jobs. "Type B's in complex jobs are less likely to have heart trouble than type B's in less stimulating, mechanical jobs, like dispatchers," Schaubroeck finds.
But that's only the case for psychologically complex jobs -- those requiring reflection, multiple skills, and independence -- which shouldn't be confused with jobs that are only intellectually demanding, a different type of complexity. Just as exercise strengthens the heart, stimulating jobs may toughen the type B's autonomic nervous system -- the system that regulates the heart.
"Type A's should have fairly simple jobs that don't require a lot of independent reflection, skill variety, and autonomy -- the elements of job complexity," says Schaubroeck. "In a complex job, the type A becomes overstimulated and can't distance him or herself."
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Borderline personality disorder (BPD) is a serious mental illness characterized by pervasive instability in moods, interpersonal relationships, self-image, and behavior. This instability often disrupts family and work life, long-term planning, and the individual's sense of identity. Originally thought to be at the "borderline" of psychosis, people with BPD suffer from emotion regulation. While less well known than schizophrenia or bipolar disorder, BPD is more common, affecting 2 percent of adults, mostly young women. There is a high rate of self-injury without suicide intent, as well as a significant rate of suicide attempts and completed suicide in severe cases. Patients often need extensive mental health services, and account for 20 percent of psychiatric hospitalizations. Yet, with help, many improve over time and are eventually able to lead productive lives.
Symptoms
While a person with depression or bipolar disorder typically endures the same mood for weeks, a person with BPD may experience intense bouts of anger, depression, or anxiety that may last only hours, or at most a day. These may be associated with episodes of impulsive aggression, self-injury, and drug or alcohol abuse. Distortions in cognition and sense of self can lead to frequent changes in long-term goals, career plans, jobs, friendships, gender identity, and values. Sometimes people with BPD view themselves as fundamentally bad or unworthy. They may feel unfairly misunderstood or mistreated, bored, empty, and have little idea who they are. Such symptoms are most acute when people with BPD feel isolated and lacking in social support and may result in frantic efforts to avoid being alone.
People with BPD often have highly unstable patterns of social relationships. While they can develop intense but stormy attachments, their attitudes toward family, friends, and loved ones may suddenly shift from idealization (great admiration and love) to devaluation (intense anger and dislike). Thus, they may form an immediate attachment and idealize the other person, but when a slight separation or conflict occurs, they switch unexpectedly to the other extreme and angrily accuse the other person of not caring for them at all.
Most people can tolerate ambivalence where they experience two contradictory states at one time. People with BPD, however, shift back and forth to a good or a bad state. If they are in a bad state, for example, they have no awareness of the good state.
Even with family members, individuals with BPD are highly sensitive to rejection, reacting with anger and distress to mild separations. Even a vacation, a business trip, or a sudden change in plans can spur negative thoughts. These fears of abandonment seem to be related to difficulties feeling emotionally connected to important persons when they are physically absent, leaving the individual with BPD feeling lost and perhaps worthless. Suicide threats and attempts may occur along with anger at perceived abandonment and disappointments.
People with BPD exhibit other impulsive behaviors, such as excessive spending, binge eating, and risky sex. BPD often occurs with other psychiatric problems, particularly bipolar disorder, depression, anxiety disorders, substance abuse, and other personality disorders.
Causes
Although the cause of BPD is unknown, both environmental and genetic factors are thought to play a role in predisposing patients to BPD symptoms and traits. Studies show that many but not all individuals with BPD report a history of abuse, neglect, or separation as young children. Forty to 71 percent of BPD patients report having been sexually abused, usually by a noncaregiver. Researchers believe that BPD results from a combination of individual vulnerability to environmental stress, neglect, or abuse as young children, and a series of events that trigger the onset of the disorder as young adults. Adults with BPD are also considerably more likely to be the victim of violence, including rape and other crimes. This may result from both harmful environments as well as impulsivity and poor judgment in choosing partners and lifestyles.
Neuroscience is revealing brain mechanisms underlying the impulsivity, mood instability, aggression, anger, and negative emotion seen in BPD. Studies suggest that people predisposed to impulsive aggression have impaired regulation of the neural circuits that modulate emotion. The brain's amygdala, a small almond-shaped structure, is an important component of the circuit that regulates negative emotion. In response to signals from other brain centers indicating a perceived threat, it marshals fear and arousal. This might be more pronounced under the influence of drugs like alcohol or stress. Areas in the front of the brain (prefrontal area) act to dampen the activity of this circuit. Recent brain imaging studies show that individual differences in the ability to activate regions of the prefrontal cerebral cortex thought to be involved in inhibitory activity predict the ability to suppress negative emotion.
Serotonin, norepinephrine, and acetylcholine are among the chemical messengers in these circuits that play a role in the regulation of emotions, including sadness, anger, anxiety, and irritability. Drugs that enhance brain serotonin function may improve emotional symptoms in BPD. Likewise, mood-stabilizing drugs that are known to enhance the activity of GABA, the brain's major inhibitory neurotransmitter, may help people who experience BPD-like mood swings. Such brain-based vulnerabilities can be managed with help from behavioral interventions and medications, much like people manage susceptibility to diabetes or high blood pressure.
Treatment
Treatments for BPD have improved. Group and individual psychotherapy are at least partially effective for many patients. A new treatment termed dialectical behavior therapy (DBT) has been developed specifically to treat BPD, and this technique has looked promising in treatment studies. Pharmacological treatments are often prescribed based on specific target symptoms shown by the individual patient. Antidepressant drugs and mood stabilizers may be helpful for depressed and, or, labile mood. Antipsychotic drugs may also be used when there are distortions in thinking.
Sources:
National Institute of Mental Health
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Revised.
Washington, D.C.: American Psychiatric Association, 2000.
US Department of Health and Human Services
Journal of Personality Disorders
Psychiatric Clinics of North America
Comprehensive Psychiatry
Harvard Review of Psychiatry
Cerebrum, The Dana Forum on Brain Science
Psychological Bulletin
Science
Last Reviewed: 31 Jan 2008
Last Reviewed By: Laura Stephens
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Bipolar disorder is an illness that involves moods that swing between the highs of mania and the lows of depression.
It's one of the most missed diagnoses in psychiatry. Bipolar disorder, involving moods that swing between the highs of mania and the lows of depression, is typically confused with everything from unipolar depression to schizophrenia to substance abuse, to borderline personality disorder, with just about all stops in between. Patients themselves often resist diagnosis, because they may not see as pathologic the surge in energy that accompanies the mania or hypomania that distinguishes the condition.
But on a few points consensus is emerging. Bipolar disorder is a chronically recurring illness. And the age of onset is dropping—in less than one generation it has gone from age 32 to 19. Whether there is a genuine increase in prevalence of the disorder is a matter of some debate, but there does seem to be a genuine increase among the young.
What's more, the depression of manic-depression is emerging as a particularly thorny problem for both patients and their doctors.
"Depression is the bane of treatment of bipolar disorder," says Robert M.A. Hirschfeld, M.D., head of psychiatry at the University of Texas Medical Branch in Galveston.
It's what is most likely to motivate patients to accept care. People spend more time in the depression phase of the disorder. And unlike unipolar depression, the depression of bipolar illness tends to be treatment-resistant.
"Antidepressants don't work very well in bipolar depression," says Dr. Hirschfeld. "They are underwhelming in their ability to treat the depression." In fact, a shift away from antidepressants is formally recognized in new treatment guidelines for bipolar disorder just released by the American Psychiatric Association.
As physicians gain experience in treating the disorder, they are discovering that antidepressants have two negative effects on the course of the disorder. Used by themselves, antidepressants can induce manic episodes. And over time they can accelerate mood cycling, increasing the frequency of episodes of depression or of mania followed by depression.
Instead, research points to the value of drugs that work as mood stabilizers for the depression of bipolar disorder, either alone or in combination with antidepressants. If antidepressants have any use at all in bipolar disorder, it may be as acute treatment for bouts of severe depression before mood stabilizers are added or substituted.
Even in cases of severe depression, the new guidelines favor increasing the dosage of mood stabilizers over other strategies.
Not so long ago, mood stabilizers could be summed up in a single word—lithium, in use since the 1960s to tame mania. But research has additionally demonstrated the effectiveness of divalproex sodium (Depakote) and lamotrigine (Lamictal), drugs that were initially developed for use as anticonvulsants in seizure disorders. Divalproex sodium has been approved for use as a mood stabilizer in bipolar disorder for several years, while lamotrigine is undergoing clinical trials for such an application.
"Optimizing the dose of lithium or divalproex has good antidepressant effects," reports Dr. Hirschfeld. "We also now know that divalproex and lamotrigine are very good for preventing recurrence in bipolar patients." A study showed that lamotrigine not only delays the time to any mood events but is notably effective against the depressive lows of bipolar illness.
No one knows for sure exactly how anticonvulsants work in bipolar disorder. For that matter, the condition has been described since the time of Hippocrates, but it is still not clear what goes awry in manic-depression.
Despite the unknowns, medications for treating the disorder are proliferating. In contrast to downplaying antidepressants in the depressive phase of the disorder, clinical research is ramping up the value of antipsychotic drugs for combating the manic phase, albeit a new generation of such drugs, collectively called atypical antipsychotics. Chief among them are olanzapine (Zyprexa) and risperidone (Risperdal). They are now considered a first-line approach to acute mania, and adjuncts for long-term therapy along with mood stabilizers.
In the long term, however, observes Nassir Ghaemi, M.D., assistant professor of psychiatry at Harvard and head of bipolar research at Cambridge Hospital, medication goes only so far. "Drugs are not effective enough. It may have to do with the overuse of antidepressants; they interfere with the benefits of mood stabilizers.
"Medications don't take you to the finish line." There seem to be residual symptoms of depression that don't clear. Even when patients stabilize into a normal, or euthymic, mood state, he says, some troubling signs can appear.
"Sometimes we see in euthymic patients cognitive dysfunction that we didn't expect in the past—word-finding difficulties, trouble maintaining concentration," Dr. Ghaemi explains. "Cumulative cognitive impairment seems to emerge with time. It may be related to findings of decreased size of the hippocampus, a brain structure that serves memory. We are on the verge of recognizing long-term cognitive impairment as a result of bipolar disorder."
He believes there is a role for aggressive psychotherapy for keeping patients well, for keeping everyday ups and downs from becoming full-blown episodes. At the very least, he finds, psychotherapy can help patients resolve the work and relationship problems that often outlast symptoms.
In addition, psychotherapy can help patients learn new coping styles and interpersonal habits. "Many of the ways patients deal with their illness are not relevant when they are well," explains Dr. Ghaemi.
For example, he says, many people develop the habit of staying up late as a way of coping with the manic symptoms. "What they couldn't change before because of the illness needs to be changed after treatment if, for example, it bothers a spouse. People have to learn to change. But the longer one is ill, the harder it is to become completely well, because the harder it is to change the habits of one's life."
And for young people diagnosed with bipolar illness, he considers psychotherapy essential. "The younger patients are, the less convinced they are that they have bipolar disorder," he says. "They have impaired insight. They're especially concerned about the need to take medications. They should be in psychotherapy to get educated about the illness and medication."
He also stresses the value of support groups, especially for young people. "It's another, important layer of validation."
Psychology Today Magazine, May/Jun 2002
Last Reviewed 24 Jul 2007
Article ID: 2941
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Generalized anxiety disorder (GAD) is much more than the normal anxiety people experience day to day. Without provoking, it is chronic and exaggerated worry and tension. This disorder involves anticipating disaster, often worrying excessively about health, money, family or work. Sometimes, though, just the thought of getting through the day brings on anxiety.
People with GAD can't shake their concerns, even though they usually realize that much of their anxiety is unwarranted. People with GAD also seem unable to relax and often have trouble falling or staying asleep. Their worries are accompanied by physical symptoms, especially trembling, twitching, muscle tension, headaches, irritability, sweating, hot flashes and feeling lightheaded or out of breath.
Many individuals with GAD startle more easily than other people. They tend to feel tired, have trouble concentrating and may suffer from depression. GAD may involve nausea, frequent trips to the bathroom or feeling like there is a lump in the throat.
GAD affects about 4 million adult Americans and about twice as many women as men. The disorder comes on gradually and can begin at any time, though the risk is highest between childhood and middle age. It is diagnosed when someone spends at least six months worrying excessively about a number of everyday problems, and it is commonly treated with medications. Evidence shows that genes play a modest role in GAD.
GAD rarely occurs alone; it is usually accompanied by another anxiety disorder, depression or substance abuse. These other conditions must be treated along with GAD.
Symptoms
Generalized anxiety disorder (GAD) is characterized by six months or more of chronic, exaggerated worry and tension that is unfounded or much more severe than the normal anxiety most people experience. People with this disorder usually:
Expect the worst
Worry excessively about money, health, family or work, when there are no signs of trouble
Are unable to relax
Are irritable
Suffer from insomnia
Have physical symptoms, such as fatigue, trembling, muscle tension, headaches, irritability or hot flashes
Causes
Like heart disease and diabetes, anxiety disorders are complex and probably result from a combination of genetic, behavioral, developmental and other factors.
Using brain imaging technologies and neurochemical techniques, scientists are finding that a network of interacting structures is responsible for these emotions. Much research centers on the amygdala, an almond-shaped structure deep within the brain. The amygdala is believed to serve as a communications hub between the parts of the brain that process incoming sensory signals and the parts that interpret them. It can signal that a threat is present, thus triggering a fear response (anxiety). It appears that emotional memories stored in the central part of the amygdala may play a role in disorders involving very distinct fears, like phobias, while different parts may be involved in other forms of anxiety.
By learning more about brain circuitry involved in fear and anxiety, scientists may be able to devise more specific treatments for anxiety disorders. It someday may be possible to increase the influence of the thinking parts of the brain on the amygdala, thus placing the fear and anxiety response under conscious control. In addition, with new findings about neurogenesis (birth of new brain cells) throughout life, perhaps a method will be found to stimulate growth of new neurons in the hippocampus in people with severe anxiety.
Studies of twins and families suggest that genes play a role in the origin of anxiety disorders. However, experience also plays a part. In PTSD, for example, while trauma triggers the anxiety disorder, genetic factors may explain why only certain individuals exposed to similar traumatic events develop full-blown PTSD. Researchers are attempting to learn how genetics and experience interact in each of the anxiety disorders -- information they hope will yield clues to prevention and treatment.
Treatment
Medication and specific types of psychotherapy are the recommended treatments for this disorder. The choice of one or the other, or both, depends on the patient's and the doctor's preference, and also on the particular anxiety disorder.
Before treatment can begin, the doctor must conduct a careful diagnostic evaluation to determine whether your symptoms are due to an anxiety disorder, which anxiety disorder(s) you may have, and what coexisting conditions may be present. Anxiety disorders are not all treated the same, and it is important to determine the specific problem before embarking on a course of treatment. Sometimes alcoholism or some other coexisting condition will have such an impact that it is necessary to treat it at the same time or before treating the anxiety disorder.
If you have been treated previously for an anxiety disorder, be prepared to tell the doctor what treatment you tried. If it was a medication, what was the dosage, was it gradually increased and how long did you take it? If you had psychotherapy, what kind was it, and how often did you attend sessions? Oftentimes people believe they have "failed" at treatment, or that the treatment has failed them, when in fact it was never given an adequate trial.
When you undergo treatment for an anxiety disorder, you and your doctor or therapist will be working together as a team. Together, you will attempt to find the approach that is best for you. If one treatment doesn't work, the odds are good that another one will. And new treatments are continually being developed through research.
Antidepressants
A number of medications that were originally approved for treating depression have been found to be effective for anxiety disorders. These must be taken for several weeks before symptoms start to fade, so it is important not to get discouraged and stop taking these medications before they've had a chance to work.
Some of the newest antidepressants are called selective serotonin reuptake inhibitors, or SSRIs. These medications act on a chemical messenger in the brain called serotonin. SSRIs tend to have fewer side effects than older antidepressants. People do sometimes report feeling slightly nauseated or jittery when they first start taking SSRIs, but that usually disappears with time. Some people also experience sexual dysfunction when taking some of these medications. An adjustment in dosage or a switch to another SSRI will usually correct bothersome problems. It is important to discuss side effects with your doctor so that he or she will know when there is a need for a change in medication. Venlafaxine, a drug closely related to the SSRIs, is useful for treating GAD.
Similarly, antidepressant medications called tricyclics are started at low doses and gradually increased. Tricyclics have been around longer than SSRIs and have been more widely studied for treating anxiety disorders. For anxiety disorders other than OCD, they are as effective as the SSRIs, but many physicians and patients prefer the newer drugs because the tricyclics sometimes cause dizziness, drowsiness, dry mouth, and weight gain. When these problems persist or are bothersome, a change in dosage or a switch in medications may be needed. Tricyclics are useful in treating people with co-occurring anxiety disorders and depression. Imipramine, prescribed for panic disorder and GAD, is an example of such a tricyclic.
Antianxiety Medications
High-potency benzodiazepines relieve symptoms quickly and have few side effects, although drowsiness can be a problem. Because people can develop a tolerance to them -- and would have to continue increasing the dosage to get the same effect -- benzodiazepines are generally prescribed for short periods of time. People who have had problems with drug or alcohol abuse are not usually good candidates for these medications because they may become dependent.
Some people experience withdrawal symptoms when they stop taking benzodiazepines, although reducing the dosage gradually can diminish those symptoms. In certain instances, the symptoms of anxiety can rebound after stopping medication. Potential problems with benzodiazepines have led some physicians to shy away from using them, or to use them in inadequate doses, even when they are of potential benefit to the patient. Alprazolam is a benzodiazepine that is helpful for panic disorder and GAD.
Buspirone, a member of a class of drugs called azipirones, is a newer antianxiety medication that is used to treat GAD. Possible side effects include dizziness, headaches and nausea. Unlike the benzodiazepines, buspirone must be taken consistently for at least two weeks to achieve an antianxiety effect.
Other Medications
Beta-blockers, such as propanolol, are often used to treat heart conditions but have also been found to be helpful in certain anxiety disorders, particularly in social phobia. When a feared situation, such as giving an oral presentation, can be predicted in advance, your doctor may prescribe a beta-blocker to keep your heart from pounding, your hands from shaking and other physical symptoms from developing.
Psychotherapy
Psychotherapy involves talking with a trained mental health professional, such as a psychiatrist, psychologist, social worker or counselor to learn how to deal with problems like anxiety disorders.
Cognitive-Behavioral and Behavioral Therapy
Research has shown that cognitive-behavioral therapy (CBT), a form of psychotherapy, is effective for several anxiety disorders, particularly panic disorder and social phobia. It has two components. The cognitive component helps people change thinking patterns that keep them from overcoming their fears. For example, a person with panic disorder might be helped to see that his or her panic attacks are not really heart attacks; the tendency to put the worst possible interpretation on physical symptoms can be overcome. Similarly, a person with social phobia might be helped to overcome the belief that others are continually watching and harshly judging him or her.
The behavioral component of CBT seeks to change people's reactions to anxiety-provoking situations. A key element of this component is exposure, in which people confront the things they fear. Another behavioral technique is to teach the patient deep breathing as a relaxation aid.
Behavioral therapy alone, without a strong cognitive component, has long been used effectively to treat specific phobias. Here also, therapy involves exposure. The person is gradually exposed to the object or situation that is feared. At first, the exposure may be only through pictures or audiotapes. Later, if possible, the person actually confronts the feared object or situation. Often the therapist will accompany him or her to provide support and guidance.
If you undergo CBT or behavioral therapy, exposure will be carried out only when you are ready; it will be done gradually and only with your permission, and you will work with the therapist to determine how much you can handle and at what pace you can proceed.
A major aim of CBT and behavioral therapy is to reduce anxiety by eliminating beliefs or behaviors that help to maintain the disorder. For example, avoidance of a feared object or situation prevents a person from learning that it is harmless. Similarly, performance of compulsive rituals in OCD gives some relief from anxiety and prevents the person from testing rational thoughts about danger, contamination, and so forth.
To be effective, CBT or behavioral therapy must be directed at the person's specific anxieties. An approach that is effective for a person with a specific phobia about dogs is not going to help a person with OCD who has intrusive thoughts of harming loved ones. CBT and behavioral therapy have no adverse side effects other than the temporary discomfort of increased anxiety, but the therapist must be well trained in the techniques of the treatment in order for it to work as desired. During treatment, the therapist probably will assign homework -- specific problems that the patient will need to work on between sessions.
CBT or behavioral therapy generally lasts about 12 weeks. It may be conducted in a group, provided the people in the group have sufficiently similar problems. Group therapy is particularly effective for people with social phobia. There is some evidence that, after treatment is terminated, the beneficial effects of CBT last longer than those of medications for people with panic disorder; the same may be true for OCD, PTSD and social phobia.
For many people, the best approach to treatment is medication combined with therapy. As stated earlier, it is important to give any treatment a fair trial. And if one approach doesn't work, the odds are that another one will.
If you have recovered from an anxiety disorder, and at a later date it recurs, don't consider yourself a treatment failure. Recurrences can be treated effectively, just like an initial episode. The skills you learned in dealing with the initial episode can be helpful in coping with a setback.
Sources:
Archives of General Psychiatry
National Institute of Mental Health Anxiety Disorders
British Journal of Psychiatry Supplement
Psychiatric disorders in America: the Epidemiologic Catchment Area Study
Last Reviewed: 2 Nov 2005
Last Reviewed By: Laura Stephens
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Focuses on the cognitive benefits of keeping a journal. Relationship between working memory and academic performance; Description of a research undertaken among college freshmen in the U.S.
Stressed out? Write it out! Keeping a journal can jump-start your working memory--which impacts attention and problem-solving--and may improve academic performance, according to Kitty Klein, Ph.D., a psychology professor at North Carolina State University.
"Stressful events compete for attentional resources," explains Klein. "If you can't concentrate on something, you have all kinds of problems."
The researchers asked 71 college freshmen to write about adjusting to college, a stressful event, or to keep track of daily activities, decidedly less stressful. Each group wrote for 20 minutes on three occasions. After seven weeks, working memory skills were evaluated with arithmetic and vocabulary tests
Subjects who wrote about stressful feelings scored higher than those who simply recorded the days' events.
To find out why, Klein instructed 111 students to write about an extremely negative or extremely positive experience with the caveat that they think deeply about the subject. A control group focused on a neutral experience: time management.
Three months later, students who had written about unpleasant events reported a significant decrease in intrusive thoughts related to the experience. In addition, their working memories improved by 11 percent and their GPAs improved during that semester and the next.
The other groups showed little improvement in working memory or GPA. The results were published in the Journal of Experimental Psychology: General.
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Monday, February 11, 2008
Why Misery Isn't MiserlySad, Self-Focused People Spend More Money Than Other People, Study Shows
By Miranda Hitti
WebMD Medical News
Reviewed By Louise Chang, MD
Feb. 8, 2008 -- Watch your wallet if you're feeling sad and have the world on your shoulders.
"Misery is not miserly: Sad and self-focused individuals spend more." That's the title of a new study on why the blues can be a budget-buster.
Why do people spend more when they're sad and focused on themselves? The researchers' theory boils down to retail therapy.
"Our working model proposes that sad and self-focused individuals spend more on commodities because they seek self-enhancement," write the researchers, who included Carnegie Mellon University's Cynthia Cryder, PhD, and colleagues.
Sad Spending
Cyder's team studied 13 women and 20 men aged 18-30.
First, participants got $10 for their study participation. Then they watched a video clip.
Some saw a sad video clip from the film The Champ, in which a boy's father dies. Others watched an unemotional National Geographic video about Australia's Great Barrier Reef.
Next, participants got a writing assignment. Those who watched the sad video wrote an essay about how they would react if they were in a situation like the one shown in the video clip.
The people who watched the Great Barrier Reef video wrote an essay about their daily activities.
The researchers counted the number of times that people wrote "I," "me," and "myself" in their essays and used that to measure participants' degree of self-focus.
Finally, participants were invited to bid up to $10 from their study payment to get a water bottle.
Costly Emotions
People in the sad video group paid more than those in the nature video group for the water bottle.
The average bid for the water bottle was $2.11 in the sad video group, compared with $0.56 in the Great Barrier Reef video group.
It's not just about feeling sad. It's the mix of sadness and self-focus that tends to loosen the purse strings, according to the study.
The results will be presented tomorrow in Albuquerque, N.M., at the 9th annual conference of the Society for Personality and Social Psychology and in the June 2008 edition of Psychological Science.
SOURCES: Cryder, C. "Misery is not Miserly: Sad and Self-Focused Individuals Spend More," manuscript in advance of publication. News release, Association for Psychological Science.
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Severe Stress in First Trimester Could Increase Schizophrenia Risk for Offspring, Study Shows
Stress and Schizophrenia
Abel and colleagues from the University's Center for Women's Mental Health Research examined data from a comprehensive, nationwide Danish health registry, which recorded about 1.38 million births in the country between 1973 and 1995.
The same registry was used to determine if mothers who gave birth during this time had first-degree relatives who died, received a diagnosis of cancer, or had a heart attack or stroke during their pregnancies.
Roughly 22,000 women experienced the death of a close relative during pregnancy, and about 14,000 had a relative treated for a life-threatening illness.
A total of 7,331 schizophrenia cases were identified among Danes born between 1973 and 1995 over at least two decades of follow-up.
Being born to a mother who had a close relative die during her first trimester was found to be associated with a 67% increased risk for schizophrenia.
But a similar death up to six months before conception or at any other time during pregnancy did not appear to elevate risk, nor did having a seriously ill relative during pregnancy.
Abel tells WebMD that the research team plans to repeat the study using the Swedish health registry, which is more than twice the size of the Danish one.
The newly published study appears in the February issue of the journal Archives of General Psychiatry.
"We also want to expand the research to look for other mental health outcomes," Abel says. "I think it is highly likely that if we look at a broader spectrum of psychiatric disorders we will find that those are increased as well."
Some Stress May Be Good
Developmental psychologist Janet DiPietro, PhD, who also studies the impact of maternal stress on fetal brain development, says even if major traumatic events such as the death of a loved one do influence schizophrenia risk, the risk is still very small.
Having a family history of schizophrenia or another mental illness was associated with a much larger risk, in this study and in others.
DiPietro says much of the research linking pregnancy stress to negative outcomes has focused on early child development and relied on mothers' perceptions of their children's behavior.
"The problem is that mothers who are more anxious and stressed are more likely to view their child as having behavioral problems," she says.
In her own 2006 study, in which child behavior was independently assessed, moderate stress during pregnancy was actually associated with a good outcome -- advanced development at age 2.
One possible reason for this is that the chemicals the body produces in response to stress also play a role in fetal maturation, she tells WebMD.
DiPietro is associate dean for research and a professor at Baltimore's Johns Hopkins School of Public Health.
"The knee-jerk reaction is to think that all stress is bad, but this may not be so in pregnancy," she says. "The fetus is not as vulnerable as we may think to the day-to-day stresses women deal with, like working and meeting deadlines."
SOURCES: Khashan, A.S., Archives of General Psychiatry, February 2008; vol 65: pp 146-152. Kathryn M. Abel, PhD, MRCP, senior lecturer, Center for Women's Mental Health Research, University of Manchester, England. Janet DiPietro, PhD, associate dean for research and professor, Johns Hopkins School of Public Health, Baltimore. DiPietro, J. Child Development, May/June 2006.
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We and the critics
Category: Writing and Poetry
I use to receive some emails from readers that feel personally insulted when they read a bad review on my books.
First of all, I thank you for your solidarity.
Second: don't take the critics too seriously!
Just ask: "if you can do better, why don't you write a book?"
I am used to bad reviews (mostly Brazilian and French, because I use to commute between these two wonderful countries), and after 20 years of writing, I came to some few conclusions that helped a lot in my books. In "The Zahir", the main character knows already, even before his book is published, what critics are going to say.
And they say always the same thing – regardless the title or the plot of my new book. I have a funny collection of these reviews that one day I may post in my blogs.
It is not up to me to criticize the critics – I am a writer. At the end of the day, I believe that every critic wanted to be a writer. When I meet one of them (and I meet them very often) they are normally embarrassed. They try to be nice, as if I was insulted. They are normally surprised with my reaction ( "I don't take your comments as a personal offense").
Why am I writing this? Because I am convinced that most of you also feel hurt when someone criticizes your work. As I said before, don't take critics too seriously. They don't have the power to make (or to avoid) someone buying a book, a CD, or to go to an exhibition. Don't give them the importance they don't have. They are trying to make a living, and that's all.
If I did not manage to convince you, please read the comments below:
Do what you feel in your heart to be right, for you'll be criticized anyway. ~ Anna Eleanor Roosevelt
A successful person is one who can lay a firm foundation with the bricks that others throw at him or her. ~ David Brinkley
A painting in a museum probably hears more foolish remarks than anything else in the world. ~ Edmond and Jules De Goncourt
To escape criticism -- do nothing, say nothing, be nothing. ~ Elbert Hubbard
It isn't what they say about you, it's what they whisper. ~ Errol Flynn
If criticism had any power to harm, the skunk would be extinct by now. ~ Fred Allen
Don't be afraid of opposition. Remember, a kite rises against, not with, the wind. ~ Hamilton Mabie
Before you criticize people, you should walk a mile in their shoes. That way, when you criticize them, you're a mile away. And you have their shoes. ~ JK Lambert
A negative judgment gives you more satisfaction than praise, provided it smacks of jealousy. ~ Jean Baudrillard
There is no defense against criticism except obscurity. ~ Joseph Addison
I have always been very fond of them (drama critics) . . . I think it is so frightfully clever of them to go night after night to the theatre and know so little about it. ~ Noel Coward
Sticks and stones are hard on bones, aimed with angry art,
Words can sting like anything but silence breaks the heart.
~ Phyllis McGinley
A fly, Sir, may sting a stately horse and make him wince; but one is but an insect, and the other is a horse still. ~ Samuel Johnson
If any human being earnestly desire to push on to new discoveries instead of just retaining and using the old; to win victories over Nature as a worker rather than over hostile critics as a disputant; to attain , in fact, clear and demonstrative knowlegde instead of attractive and probable theory; we invite him as a true son of Science to join our ranks. ~Sir Francis Bacon
Critics are like eunuchs in a harem; they know how it's done, they've seen it done every day, but they're unable to do it themselves. ~ Brendan Francis Behan
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So many times you talk about very serious issues, yet you use everyday words which are familiar to most people – to people who may not even realize their true meanings. Have you ever given any thought as to what is the secret of your literary success?
PC: There is no such a thing as a secret to success. I try to talk directly because I believe that God talks directly to us, whithout using complicated words. God has sense of humor, why shouldn’t I?
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This fear can generally be seen in two forms: through aggression, or through submission. They are two sides of the same problem.
That is why, upon being confronted by a someone who inspires terror, the warrior recalls: the other man is just as insecure. He has overcome similar obstacles, and has lived the same problems.
But he knows how to deal with the situation better. Why? Because he uses fear as a motor, not as a brake.
Thus the warrior learns from his opponent, and acts in the same way.
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