THE NATURE AND TREATMENT OF ANXIETY DISORDERS

Barr Taylor & Bruce Arnow, 1988.

For the existentialist Rollo May (1950), anxiety <is described on the philosophical level as the realization that one may cease to exist as a self. . . i.e., the threat of meaninglessness> (p. 193).”

Etimologia greco-latina: sendo pressionado para baixo por tristezas e misérias (pesares).

Jablensky (1985) notes that the English word anxiety does not cover the same semantic space as the French anxieté or the Spanish ansiedad although they all derive from a common root. In French, angoisse is used as a near-synonym for anxiety but connotes more strongly the physical sensations accompanying the experience and may be closer to the English anguish than to anxiety. And the German word angst implies, besides anxiety and anguish, agony, dread, fear, fright, terror, consternation, alarm and apprehension.”

the indefinable nature of the feeling gives it its peculiarly unpleasant and intolerable quality.”

Lay people, in particular, use the terms anxiety, stress and tension interchangeably. There is little agreement in the scientific community as to the definition and nature of stress, and the term is best avoided as it only causes confusion.”

Se o paciente é prejudicado pela ansiedade, procura tratamento, ou se envolve em comportamentos auto-destrutivos a fim de controlá-la, a ansiedade deve ser considerada clínica.”

Generalizada e/ou episódica (ataque de pânico)

CORE CHAT

palpitação do coração

não deixe estranhos dar

palpite, não

pit of emotions

the inverted peak

shadow&light

negative&positive

yes and no world against

you

who am I

a genius, a demon,

Socrates or a man

a single and

pitagorean

human being

that was not

and will not be

just live

with the leaves

leave me

alone

can you?

all of you

levee of emotions

lake of discharge

storm and thunder

revenge

vengeance

action of genius

evil genius

gentle

until

kindle the

sweetness

draw

out

now!

* * *

jittery

The bullied are afterwards the greatest bullies” Juice R, pessoa sem-graça nota 7 que não quis se identificar. Possui características de liderança. Falam mal nas suas costas, mas ela não está nem aí…

Queria ter consulta com o dentista a qualquer dia menos hoje!

aquiescente com o tumulto

Eu já havia lido Sartre, mas fui saber o que é náusea quando trabalhei na DRI.

depois eu começo a sentir que estou separado do meu corpo e, sabe, que vou cair ou/hmm/como se eu estivesse fora do meu corpo e não tivesse mais controle sobre minhas funções motoras – não consigo nem caminhar nem conversar”

mas finjo para os trouxas

terapia de impacto

tratamento de choque

de coxinhas estou cheio,

ops, grogue

boxeador

madVanity beats

but the countdown never comes in…

minha boca mais seca que a tua consciência

verme sem olhos, ouvidos, miolos!

miolo mole miolo-oco

guacamole

cabeça-de-ovo

azedo

como abacate

eXtra-

(degra)

(d/g)ado

GG

gado.golpista

odeiam regras então

meu K.O.

será letal

matarei em

legítima defesa

dessa vez

eis meu lema

tímido

em time que está ganhando

mexe-se sim,

para fazer cera

between dizziness and almost vertigo”

Não se sabe o que é mais irritante, se, numa palestra, ninguém prestar atenção… ou todo mundo prestar atenção.

Sintomas muscular-esqueléticos da ansiedade: dores, espasmos, paralisias, rigidez, mioclonia (contrações musculares involuntárias), bater de dentes, voz irregular, tônus muscular crescente, tremores, sensação constante de cansaço, pernas bambas, corpo desajeitado.

No sistema sensório: Tinnitus (doença do ouvido mais freqüente em depressivos; condição também associada com a gradual perda da audição), vista embaçada, hiper-sensibilidade ao calor e frio, sensação generalizada de fraqueza, arrepios repentinos, face corada, face pálida, suor, coceiras.

(…) respiratório: (…) sensação de engasgo. (…) gastro-intestinal: (…) flatulências, dor abdominal, azia, desconforto abdominal, náusea, vômitos, frouxidão intestinal, perda de peso, perda do apetite, constipação (…) genital-urinário: urina freqüente, perda da menstruação, menstruação excessiva, ejaculação precoce, perda da libido. (…) sistema automático: boca seca, tontura, dor de cabeça de tensão, cabelos eriçados.

sentimentos de irrealidade”

impotência para controlar o pensamento”

perda de objetividade e perspectiva”

medo de não conseguir lidar”

medo de se machucar ou morrer”

medo de ficar louco ou incapaz”

medo de avaliações negativas”

imagens visuais aterradoras”

ideação de medo repetitiva”

mobilização do corpo para enfrentar/fugir”

Immobility is classified as attentiveness, in which the animal remains inert while carefully observing its environment—a phenomenon suggested by the phrase <freeze in your tracks,> or as tonic immobility, in which a previously active animal exhibits prolonged freezing and decreased responsiveness.”

For instance, during anxiety episodes some patients feel that their coordination is impaired, that they might faint and that they can’t move their feet.”

vista evitativa

The behavior associated with anxiety frequently becomes independent of the anxiety itself. Furthermore, behavior engaged in for the purpose of controlling anxiety sometimes exacerbates the anxiety. For example, some patients drink excessive amounts of coffee when they feel anxious, yet the caffeine in coffee produces anxiety and even panic.”

The most serious complications of anxiety disorders are often associated with the patient’s attempts to cope with anxiety. Patients may become severely avoidant or depressed, abuse drugs or alcohol, or become helplessly dependent on their family, friends, and the medical system. The avoidance, when manifested as agoraphobia, may be one of the most disabling of all psychiatric problems. (…) Thus, chronic symptoms such as avoidance, which result from efforts to cope with anxiety, are often more disabling than the anxiety itself and need to become the focus of treatment. [lógica da insistência dos terapeutas]

Very uncomfortable. Shopping in store. Unable to wait through check-out stand. I went and sat in car while my Mom paid for the items.”

The septo-hippocampus, thalamus, locus coeruleus, and their afferents and efferents, and various neurotransmitters are clearly involved with anxiety.”

Contemporary psychodynamic theories of anxiety began with Freud. His first major discussion of anxiety was published in 1894 and his last in 1926, but his writings before and after these also address major issues of anxiety. New insight, observations, experience, and discussions led Freud to reformulate and elaborate his views. In his final model, and the one still followed by most psychoanalysts, Freud argued that the generation of anxiety occurs unconsciously, outside of the individual’s awareness.” “The dangers signaling anxiety involve fantasized situations regarding separation from, or loss of, a loved object or a loss of its love.”

She reported that the number of the street the bus was approaching corresponded to the age at which her father had died and that her father had had his heart attack near the hour that corresponded to the time her anxiety attack on the bus occurred.”

Deutsch (1929) presented four cases of agoraphobia where defense against aggressive impulses towards parents or parental figures resulted in panic attacks.”

catástrofe narcisista

all the awful sexual things that I was always taught can happen to you when you walk around the streets in the dark”

Threat of loss creates anxiety, and actual loss causes sorrow; both, moreover, are likely to arouse anger.”

beta-blockers, which block many of the peripheral sensations of anxiety, are not effective in blocking panic.”

We have glimpses of some of the systems involved with anxiety, but an integrated model will require new neuroscientific methods capable of observing the actual functioning of the central nervous system under various conditions.”

The limbic system is concerned with integrating emotional and motivational behavior, particularly motor coordination in emotional responses (Watson et al., 1986).”

For instance, low intensity stimulation of the LC causes head and body turning, eye scanning, chewing, tongue movement, grasping and clutching, scratching, biting fingers or nails, pulling hair or skin, hand wringing, yawning, and spasmodic total body jerking (Redmond et al., 1976).”

Neurotransmitter systems are distributed only partially in the classical anatomic pathways. Neurotransmitters are the chemical <messengers> that control transmission between nerves. In general, they are released at the end of a nerve into the synaptic cleft, the space between the end of one nerve and the beginning of another. These neurotransmitters diffuse across the synaptic cleft to the postsynaptic neuron, where they activate specific sites on the cell membrane called receptors. Attachment to the receptor causes the postsynaptic neuron to alter its standing electrical charge, which in turn may cause it to discharge.” “Already, over 40 neurotransmitters and neurohormones have been isolated from the CNS. However, two neurotransmitter systems, the noradrenergic and serotinergic, seem particularly important to anxiety, and each has strong proponents arguing for its central role in anxiety disorders.”

It is possible that patients prone to anxiety disorders have too few noradrenergic receptors, that their system is too sensitive to input (it tends to overshoot), and that their receptors are subsensitive. Neurotransmitter systems are dynamic and it may be that environmental events, like a traumatic experience or separation, are necessary for the noradrenergic system to become disequilibrated.”

Experimentally, the serotonergic system seems to be involved in behavioral inhibition. The suppression of behavioral inhibition following punishment is a phenomenon that seems to be affected by drugs with antianxiety properties.”

The antianxiety drugs counteract the behavioral effects of three classes of stimuli: those associated with punishment, those associated with the omission of expected reward, and those associated with novelty.”

VOCÊ É UM HOMEM OU EU MATO?

a rat conditioned to expect a shock when a red light is flashed (stimulus of punishment), will exhibit freezing (behavioral inhibition), increase in heart rate and other physiological functions (increment in arousal), and scanning (increased attention).”

TODO GARÇOM TEM CARA DE BUNDA

toughening up by repeated exposure to a feared situation should be enhanced by drugs that increase noradrenergic activity. Exposure combined with imipramine is more effective than exposure alone.”

5. Mild episodic anxiety. Mild episodic anxiety occurs for reasons that are difficult for the patient to identify. Such anxiety is a common phenomenon in therapy. We include so-called death or existential anxiety in this category.

6. Mild anxiety and mild depression, sometimes called distress. This is probably the most common anxiety disorder. Patients with mild anxiety and depression and concomitant medical problems are the most frequent users of sedative medications.

7. Anxiety related to specific social, family, or work situations. In such patients the anxiety is usually bearable and is seen as secondary to the primary problem. Such patients sometimes meet the criteria for social phobia.”

Traditionally, psychoanalysts have classified distress and generalized and panic anxiety together.”

Panic disorder with agoraphobia is the most severe condition and includes all of the pathology of the other disorders.”

The extreme rituals and obsessive thoughts characteristic of individuals with obsessive-compulsive disorder distinguish this group from other anxiety sufferers.”

DSM-III-R is a necessary evil. It is necessary because it often determines reimbursement, helps with clinical formulation and treatment, and facilitates communication of scientific and clinical information. The drawbacks of DSM-III-R are that it forces clinicians to classify patients into categories that only partially fit their complex problems; it makes assumptions not shared by many therapists (for instance, that mental health problems should be considered medical problems), and it gives undue emphasis to psychiatry over other mental health disciplines since psychiatrists were the ones who mainly developed and implemented the system.”

Pennys-silvana

The syndrome of recurrent panic attacks was recognized as a separate disorder as far back as 1871 when Da Costa described the <irritable heart> and later in 1894 when Freud first applied the name anxiety neurosis to the syndrome, separating it from the category of neurasthenia.”

The 1869 American Medico-Psychological Association diagnostic system included only simple, epileptic, paralytic, senile and organic dementia, idiocy, cretinism, and ill-defined forms. The next major change in the U.S. occurred in 1917 when the American Psychiatric Association developed a 22-item nosology based on etiology. By then psychoanalytic theory had introduced the concept of neurosis, in which anxious symptoms were attributed to unconscious conflicts. Thus <psychoneurosis> was introduced as a diagnostic category. Disorders subsumed under this heading included hysteria (of which anxiety hysteria was a variant), psychasthenia or compulsive states, neurasthenia, hypochondriasis, reactive depression, anxiety state, and mixed psychoneurosis.”

DSM-I: 1952

DSM-II: 1968

DSM-III-R: 1980 “In 1980 the term <neurosis> was replaced by <disorder>.”

DSM-IV: 1992 (previsão – livro velho!)

A patient often meets the criteria for generalized anxiety disorder, panic disorder, and agoraphobia simultaneously, or, over time, exhibits changing symptomology that at one time may seem most consistent with one diagnosis and at another time with an alternative one. (…) the rigid hierarchical system of DSM-III, in which one anxiety diagnosis precluded another, is loosened.”

feelings of impending doom.”

Attacks usually last minutes; occasionally they will last for an hour or more. The individual often develops varying degrees of nervousness and apprehension between attacks. The initial attacks are unexpected or spontaneous, although over time, they may become associated with specific situations, persons or places.”

Não precisa ser um DSM recente para me deixar “apreensivo” (mas o que é isso na vida de um eternamente apreensivo?):

PANIDOG SYMPTOMS – Spair!

(1) shortness of breath (dyspnea) or smothering [asfixia] sensations

(2) dizziness, unsteady feelings, or faintness

(3) palpitations or accelerated heart rate

(4) trembling or shaking

(5) sweating

(6) choking

(7) nausea or abdominal distress

(8) depersonalization or derealization

(9) numbness or tingling sensations (paresthesias)

(10) flushes (hot flashes) or chills [rubores (quentura) ou calafrios]

(11) chest pain or discomfort

(12) fear of dying [more like fear of never dying…]

(13) fear of going crazy or doing something uncontrolled

“As a result of this fear, the person either restricts travel or needs a companion when away from home, or else endures agoraphobic situations despite intense anxiety.”

WORKABHORRENT

anxiety is almost invariably experienced if the individual attempts to resist the obsessions or compulsions.” “Obsessions and compulsions secondary to panic and agoraphobia are often readily amenable to treatment; obsessions and compulsions characteristic of obsessive compulsive disorder are far more refractory to change.”

recurrent and intrusive recollections”

TRAUMATIC SYMPTOMS – Strike!!

Part I

(1) recurrent and intrusive recollections

(2) recurrent and distressing dreams of the event

(3) sudden acting or feeling as if the traumatic event were recurring

(4) intense psychological distress at exposure to events that resemble the traumatic event [syndrome de E. temote]”

Espere, uma pausa para distender os músculos…

LITTLE JEW SYNDROME

remote memory

remote control

of your own business

dare your church [synagogue?] matters

and live the secular world

for us sinners you ultra-fool

you’re fuel

for my combustions

my hellish combustions

oh how does it feel to be alone

like some Achilles standing by

beneath the shadows,

repentlessly?

YouReaTraumA

IRA @ YOU

Assunto: Re: calque (Recalc. de cimento – retificação)

To (destino otário): vai.a.a.merda.com.agua.sanitaria@no.teu.cu

cof cof, more coffee coffee please!

Part II

(1) efforts to avoid thoughts, or feelings associated with the trauma

(2) efforts to avoid activities or situations that arouse recollections of the trauma

(3) inability to recall an important aspect of the trauma

(4) marked diminished interest in significant activities

(5) feeling of detachment or estrangement from others

(6) restricted range of affect

(7) sense of foreshortened future”

What about “sense of being superior”?!

Part III

(1) difficulty falling or staying asleep [Grande Bog!]

(2) irritability or outbursts of anger

(3) difficulty concentrating

(4) hypervigilance

(5) exaggerated startle response (?)

(6) physiologic reactivity upon exposure to events that symbolize or resemble an aspect of the trauma

GENERALIZED A. SYMPTOMS

Motor Tension

(1) trembling, twitching, or feeling shaky [“enrolado”, como dizem alguns]

(2) muscle tension, aches, or soreness

(3) restlessness

(4) easy fatigability

Autonomic hyperactivity

(5) Shortness of breath or smothering sensations

(6) palpitations or accelerated heart rate

(7) sweating, or cold clammy hands

(8) dry mouth

(9) dizziness or lightheadedness

(10) nausea, diarrhea, or other abdominal distress

(11) flushes (hot flashes) or chills

(12) frequent urination

(13) trouble swallowing or <lump in throat> [Pomo de Adão? Sensação de ter engolido um tubo?!]

Vigilance and scanning

(14) feeling keyed up or on edge

(15) exaggerated startle response (?)

(16) difficulty concentrating or <mind going blank>because of anxiety

(17) trouble falling or staying asleep

(18) irritability

<The Europeans have taken a slightly different approach to the classification of anxiety disorders. The main European classification system is the International Classification of Diseases (ICD). ICD is not a true nomenclature in that it has a limited number of categories that are not systematically ordered. ICD does not use operational rules but describes the classification for purposes of making the diagnosis. Anxiety states are defined in ICD-9 as ‘various combinations of physical and medical manifestations of anxiety, not attributable to real danger and occurring either in attacks or as a persisting state.’ The anxiety is usually diffuse and may extend to panic. Other neurotic features such as obsessional or hysterical symptoms may be present but do not dominate the clinical picture> (Jablensky, 1985, p. 755). Presumably, there will be some reconciliation between ICD-10 and DSM-IV when they are published in the future.”

a patient may come close to meeting the DSM-III-R criteria for panic disorder but may have too few panic attack episodes to qualify for that diagnosis. The focus of treatment should still be on the panic attacks if they are disabling.”

Some patients with recent onset of panic attacks may see a psychotherapist early in the course of their disorder, but this is rare, as most consult a medical specialist first.”

Hipotensão ortostática: condição fisiológica de quem tem níveis de pressão abaixo da média exclusivamente após mais de 3 minutos na posição vertical (em pé); pode ser ignorada e confundida com a condição da tontura ou náusea ansiosas.

lightheadedness (a feeling that one might be about to faint)” Alarme falso desde sempre.

Vertigem de fumar na sacada.

Comer não dá prazer antes de grandes eventos.

Intolerância ao calor e suor excessivo: hipertireoidismo também pode ser a resposta.

Depersonalization or derealization: (may be attributed to) Temporal lobe epilepsy: (Symptoms) Perceptual distortions, hallucinations” Jesus tinha um rombo no lobo.

Keep in mind that anxiety disorder patients often overuse the medical system and caution must be taken to make the appropriate diagnosis while avoiding or minimizing unnecessary tests.”

Drogas ansiosas”: aspirina, cocaína, anfetamina, alucinógenos. Álcool, cafeína e nicotina são conhecidas facas de dois gumes. Qual seria a taxa de nicotina “com moderação”? O antitabagista da rodada.

Fluxograma habitual da nicotina: leve excitação seguida de tensão-relaxação. Abuso: ansiedade (superexcitação).

Café: ansiedade quando abusivo ou em pessoas predeterminadas à sensibilidade.

Somatoform Disorders. (…) The two types of somatoform disorders most likely to present with panic-like symptoms are somatization disorder and hypochondriasis.”

Somatization disorder is distinguished from the anxiety disorders by its course, number of symptoms, and phenomenology. The main feature of somatization disorder is a history of physical symptoms of several years’ duration, beginning before the age of 30. To meet the DSM-III- R criteria, patients must complain of at least 12 symptoms in four different body systems, to have sought medical evaluation and treatment of these symptoms without a medical explanation being uncovered. At any one time, these patients usually have at least one or two symptoms that dominate the clinical picture and are present night and day.” Voilà! My research has finally ended…

O QUE É, O QUÉ? SÓ GANHAMOS, MAS COM ISSO SÓ PERDEMOS? O fato de que a cada dia somos brindados com o diagnóstico de novos transtornos e desordens.

compared to patients with somatoform disorders, most panic patients have symptom-free episodes and times when they are not bothered by somatic symptoms.”

Assessing the presence and extent of avoidance is somewhat problematic, particularly for patients who must work or take transportation despite dread of doing so. They may appear to have little restriction, when in fact they live with frequent dread. Four self-report instruments are available to assess avoidance: the Mobility Inventory (Chambless et al., 1985), the Phobic Avoidance Inventory (Telch, 1985), (see Appendix 2), the Stanford Agoraphobia Severity Scale (Telch, 1985), and the Fear Inventory (Marks & Mathews, 1979). Of these, the latter two are easiest to use.”

APPENDIX 2

The Hamilton Anxiety Rating Scale (Hamilton, 1959) is the standard pharmacology outcome rating scale for anxiety. It is designed to be completed by an interviewer. The Stanford Panic Appraisal Inventory (Telch, 1985) was designed to assess patients’ panic

cognitions. The Common Fears and Phobias questionnaire is an adaption of the Fear Survey (Wolpe & Lang, 1964). The Stanford Panic Diary is used to collect information on the intensity, symptomatology, place of occurrence, cognition, and patient response to panic attacks. Patients should be given a sufficient number of forms for them to be able to record this information on all the panic attacks they may experience from one visit to another. The Panic Attack Self-Efficacy form is used to monitor treatment. Patients need to be taught how to use the form. Finally, the Phobic Avoidance Inventory, developed by Michael Telch, Ph.D., for the Stanford Agoraphobia Avoidance Research Projects, is a useful clinical tool. Some of the items will need to be changed if the form is used in geographic locations other than the San Francisco Bay area. For instance, the <Driving an Automobile> section refers to Route 280 and Highway 101.”

~(Neste ponto: consultar caderno Goethe com anotações pessoais.)~

OUT OF THE BLUE: randomly, “do nada”…

o nada é o limite

pálido ponto abstrato

vórtice zero do buraco negro

fedro

belo

fim

HAMILTON ANXIETY RATING SCALE

Anxious mood – 68,75%

Tension – 45,75%

Fears – 41,5%

Insomnia – 45,75%

Insomnia during UnB – 54% (only!)

Intellectual compromising – 25%

Depressed mood – 31,25% (Am+Dm=100%!)

Somatic (muscular) – 39,27%

Somatic II – 40%

Cardiovascular symptoms – 41,5%

Respiratory symptoms – 37,5%

Gastrointestinal symptons – 30,5%

Genitourinary – 31,25%

Autonomic symptoms (boca seca, suor, dor de cabeça) – 58,25%

Behavior at interview – 63,75%

Se meu humor fosse dividido em 10 pedaços, eu seria “6 torrões de ansiedade”, “3 torrões de depressão” e 1 de capricho indeciso. Olá, garçom, vou querer um café. O que vai ser, (ran)cinzas ou azedante? Soda cáustica.

Mais volátil que pedras de granizo em precipitação.

* * *

As many therapists are ambivalent about or opposed to symptom-focused treatment we would like to begin this chapter by briefly attempting to persuade the reader of our point of view, if he or she does not already share it.” “In general, psychodynamic approaches proceed with somewhat diffuse or general goals, while behavioral, cognitive, and pharmacological treatments are more specific in their foci. Specific and non-specific therapies, which have often seen themselves in competition with one another—witness the sometimes acrimonious exchanges between behaviorally oriented clinicians and their dynamic counterparts—have dissimilar goals. (…) To oversimplify a bit, psychodynamic therapy primarily offers insight, self-awareness, and general growth and development, while behavioral and other forms of brief, symptom-focused treatment concentrate on helping the patient achieve palpable relief from certain specific complaints.”

Saia mais!” – talvez signifique: saia mais da sala destes analistas superficiais.

Several authorities on psychodynamic treatment have noted that patients with phobic and other anxiety-related complaints are not receptive to such therapy, or that they do not respond well once engaged in psychodynamic psychotherapy.” “Consider, for example, the agoraphobic patient. In the most severe cases, all facets of the person’s day-to-day life are compromised: work is problematic and often impossible because of the difficulty traveling far from, or even leaving, home; personal and family relationships are distorted by the demands imposed upon intimates to organize their lives to protect the agoraphobic from exposure to anxiety; mundane, everyday tasks such as grocery shopping are either delegated to others, or are undertaken only after carehil [sic – careful?] planning to minimize <unsafe> features of the situation such as lines or traffic; and socializing and other recreational activities are severely curtailed or entirely avoided.” “they would like to be able to grocery-shop independently, or travel more freely, or shop in a department store, or attend a movie, or return to work. And it is here that treatment must begin.” “Often what they want to deal with is another problem such as a difficulty in establishing close relationships or ambivalence about a particular partner, but they seem to need to formulate a more disabling problem in order to justify the need for psychotherapy to themselves or to others. Some, who may have a well-defined anxiety disorder, enter treatment with an a priori bias against behavioral or symptom-focused treatment as <superficial> and seek a therapy that is focused on the promotion of insight and self-understanding. But for the vast majority of patients presenting with anxiety disorders, symptom relief is the most salient initial goal.”

PROFUNDEZA DEMAIS NÃO É REALEZA

even if one assumes that behavioral symptoms have their roots in unconscious conflict, they may become functionally autonomous (Freud, 1936; Sluzki, 1981), and be maintained by a variety of other factors. Stated differently, the processes that <cause> a problem and those that maintain the problem are likely to be distinct. As the etiological factors may no longer be significant at the time of treatment, symptoms may be relieved without fresh outbreaks [meu caso na fase Victor Hugo].”

ALIMENTE-SE DE COISAS BOAS (MAS PODE CONTINUAR COMENDO FAST FOOD)

as he begins to behave in a less helpless fashion, others in his relationship network are likely to come to treat him as though he is more competent, which will, in turn, enhance his self-perception.”

Just as many psychiatrists never receive training in the administration of exposure therapy and so confine their treatment of anxious patients to pharmacotherapy, many psychologists and social workers trained to conduct exposure therapy are negatively disposed toward the use of medication and do not seek a medical consultation for patients who are failing to carry out therapeutic tasks because the symptoms are too distressing. Further, even when it is employed, medication is often improperly or inadequately applied. That is, the dosage is often too small to reduce the symptoms or it is so great that the anxious symptoms temporarily disappear, and the patient fails to learn to cope more effectively with them should they arise.”

For example, one elderly agoraphobic patient, Mrs. H., with a 40-year history of avoidances of various kinds, made considerable progress in her ability to travel freely and comfortably over a 6-month period. After years of being housebound, she was able to visit her children and grandchildren who lived nearby, take a course at a local college, attend church, and shop in department stores, all without a companion. At one point, she and the therapist agreed that the next task was for her to drive to a nearby city by herself to visit a relative. Like most other activities involving travel, this was something that she had always done with her husband. At this point, progress stopped. For several weeks, she would arrive for her sessions not having done the task, offering a variety of explanations involving inconvenience, but it quickly became clear that there were other issues involved.”

SÍNDROME DA HONESTIDADE: “At the time of the initial consultation, symptoms of panic, which includedpalpitations, sweatiness, chest pain, dizziness, nausea, and fears of death and insanitywere a daily occurrence. (…) She described her parents as very supportive and loving, but when she talked about her interaction with them it was clear that they were extremely demanding, with a very rigid sense of right and wrong. The family had clear and definite rules regarding virtually all areas of behavior—what church to attend and how often, what kind of car one should and shouldn’t drive, what kind of furniture one should have in one’s house, when was a proper time to go to bed, how a dinner table was to be set, what color the napkins should be, and so on. Virtually all behavior was evaluated in terms of its <rightness> or <wrongness> (…) Mrs. K. was the clear favorite among the three siblings in her family.” “K. was somewhat envious of her siblings, who had been <rebellious> as children but seemed to her to have developed a sense of adventure and to enjoy life considerably more than she.” “Considerable time was spent addressing her compliance as it manifested itself in the transference, including her overenthusiasm for the therapist’s interpretations and her beliefs that she would be abandoned and the therapy relationship terminated if she failed to please the therapist and meet the expectations she imagined he had for her.” “During the course of treatment, Mrs. K. became considerably more assertive, and reported losing the general sense of bemused detachment that formerly had characterized her relationships and activities and were a direct outgrowth of her compliant posture.”

one particular agoraphobic patient of ours dealt with the demands of others in an outwardly compliant way, but when uncomfortable or unhappy with such demands found ways to sabotage them passively. The way this emerged in the therapy was that when the patient felt the therapist did not understand the severity of her problem and was <pushing> too hard for her to complete certain tasks on her own, she would agree to carry out the tasks and then <not find the time>.”

While some patients elect to stay in treatment beyond the point where their presenting symptoms have been reduced or have remitted, it is beyond the scope of our current effort to describe the longterm treatment of the anxious patient.”

The main symptomology of patients with acute anxiety was reviewed in the first chapter. The patient feels anxious, tense, nervous; he is preoccupied and worried and ruminates about some, perhaps, indefinable problem; he may appear worried, with a furrowed brow or tense muscles; he may sweat excessively and have trouble sleeping and concentrating. (…) It is usually not possible to determine when an acute problem will become chronic, but most acute anxiety and tension disorders resolve within six months.”

Past history of vulnerability to stress suggests continuation of the same vulnerability to stress, other factors being similar. We have seen patients with panic disorder, for instance, who experience recurrence of panic symptoms only when they feel stressed. In these people stress always seems to produce recurrence of the panic symptoms. Effective and early coping with stress minimizes adverse consequences.”

THE THIN LINE BETWEEN… “The boundary between generalized anxiety disorder and panic disorder is somewhat arbitrary. Generalized anxiety is often a feature of panic disorder, although some patients with panic disorder have all the symptoms of generalized anxiety; conversely, patients with generalized anxiety disorder are likely to have at least infrequent panic attacks, perhaps occurring with only one or two symptoms. Patients with chronic anxiety score high on <neuroticism> on standard personality inventories. The neuroticism factor includes anxious, depressive, and somatic symptoms, low self-esteem and low self-confidence, and irritability.” “Patients report that they are frequently preoccupied, worried, or ruminative; their preoccupations often concern events that are highly improbable. For instance, a wealthy patient may worry that he will become a pauper; an excellent college student may worry that he will fail his classes. When the content of the ruminations involves anticipated problems whose occurrence is more probable, the experience is more accurately described as anticipatory anxiety [parrifobia].”

When compared with those who did not suffer panic attacks, patients who did found their thoughts more clearly articulated, instrusive, credible, and difficult to exclude. Most patients who had experienced panic attacks reported a physical feeling as the most frequent precipitant to episodes of anxiety, whereas patients in the generalized anxiety disorder group reported an anxious thought or a change in mood as the trigger. These data suggest that generalized anxiety disorder patients may be less likely than patients with panic attacks to systematically misconstrue their somatic experiences as dangerous.”

Patients with generalized anxiety disorder also have a number of motor and autonomic symptoms characteristic of autonomic hyperactivity. Symptoms of motor tension include trembling, twitching or feeling shaky, muscle tension, aches or soreness, restlessness, and easy fatigability. Symptoms of autonomic hyperactivity include shortness of breath or smothering sensations; palpitations or accelerated heart rate; sweating or cold, clammy hands; dry mouth, dizziness or lightheadedness; nausea; diarrhea or other abdominal distress; flushes or chills; frequent urination; trouble swallowing or a lump in the throat. Patients may also report vigilance and scanning, including feeling keyed up or on edge, exaggerated startle response, difficulty concentrating, mind going blank, trouble falling or staying asleep, and irritability.”

O balão de pensamentos dos quadrinhos foi a invenção literária mais genial do século XX. Talvez a invenção humana por excelência deste século, tirante o avião.

rivotril, nicotine, ecstasy, vicodin, marijuana and alcohol…

In retrospect, she decided that her asthma attack was actually a panic attack. Medical examination was normal. She reported feeling anxious 80-90 percent of the time even when she was not having panic attacks. She reported worrying continuously about her children, her health, and the health of her children. On a scale from 0 to 10, with 10 being the highest anxiety and 0 being none, she rated her anxiety a 10 most of the time.”

Although the electromyographic activity recorded from the frontalis muscle is reliably higher in anxious patients than in controls, EMG activity from forearm, masseter, and other muscle sites does not appear to differ (Lader & Marks, 1971). (…) There is no evidence of EEG abnormalities among anxious patients. Respiration is more rapid and shallow. Finally, although dry mouth is a common symptom of anxiety, there do not appear to be differences in salivation between anxious subjects and controls (Peck, 1966).” “individual differences are sufficient to prevent generalizations regarding the physiological reactivity of anxious patients as a group.” “Evans et al. (1986) found that average daily heart rate was not correlated with anxiety measures.” “at present, we lack a reliable peripheral biologic measure of anxiety.”

As anxiety and depression are closely associated, distinguishing between the two can pose a problem. In a community sample, 67 percent of subjects with a psychiatric disorder had features of both anxiety and depression that could not be differentiated (Tennant et al., 1981).”

Thyer et al. (1985a) reported that the mean age of onset for GAD[Generalized Anxiety Disorder]patients was 22.8 years. Noyes et al. (1980) have suggested that the onset is gradual. Studies indicating the stability of <neurotic traits> are also relevant here; in adults such traits seem stable from one decade to another. Given the chronic nature of the problem, helping patients learn to tolerate symptoms without abusing prescribed medications or other substances seems particularly important.”

Among the most interesting theories regarding etiology is that generalized anxiety disorder in humans is analogous to sensitization observed in animals. There are two basic processes involved in defensive learning: habituation, which is the response decrement that occurs on repeated presentation of a noxious stimulus, and sensitization, which is the increase in defense evoked by strong or noxious stimuli. Habituation is the process that allows an animal to eventually ignore repeated innocuous events, and sensitization is the process that leads it to attend to potentially dangerous ones. (…) Perhaps generalized anxiety disorder represents chronic sensitization characterized by continuous over-attention to potentially noxious or dangerous stimuli.”

Benson notes that hypnosis, autogenic training, relaxation and transcendental meditation have been shown to lower oxygen consumption, respiration, and heart rate while increasing alpha activity and skin resistance—all responses compatible with inhibited sympathetic activity.”

For instance, the subject is invited to imagine floating in a hot bath or a lake and may be told that each breath out will leave him feeling a bit more comfortable and that he will be able to breathe more deeply and easily. Spiegel encourages the patient to picture an imaginary screen in his mind’s eye, a movie screen or a TV screen, and to visualize on that screen a pleasant scene, somewhere the patient enjoys being. After the patient has achieved the ability to produce a comforting scene and is able to achieve body relaxation, he is asked to imagine anxious images. The patient moves from anxious scenes back to comfort and floating—a process similar to desensitization.”

After patients have identified what they would like to say to whom, we model and role-play the situation. Often we suggest the kinds of things that the patient might say and play the role of the patient in the feared situation. We then reverse roles and have the patient practice the interaction. We provide feedback. When the patient feels comfortable with the role-played interaction we then encourage them to use the skills in the actual situation, cautioning them that such situations are rarely identical to the ones created in the office but offer some variations and challenges for them to work on. We agree on the situation they will try and then review it during the next session. Such review may also be useful in elaborating troublesome thoughts. Patients will usually downplay obviously successful interactions or attribute their success to some external factor. Thus, developing a proper cognitive appraisal of their performance is a part of the assertion training.”

many anxious patients have a combination of both excessive worry and significant problems; the extent of worry may appear excessive, but the problems nevertheless demand attention.”

It is probably unrealistic to expect patients presenting with GAD to adopt what amounts to a <heart-healthy> life-style (i.e., avoidance of smoking; exercising at aerobic levels 3-5 times per week for 20-30 minutes; eating a low-fat, low cholesterol diet, and maintaining a serum cholesterol below 200 mg/dl; blood pressure below 140 systolic and 90 diastolic; and weight no more than 10-20 pounds above ideal for height sex, and age).” “Patients with GAD who drink several cups of caffeinated coffee daily should certainly be encouraged to cut down to no more than one. Those who clearly work an excessive amount of hours should be encouraged to reduce their work load if possible and to build in time for recreation.”

The longterm pharmacologic treatment of chronic or generalized anxiety is one of the most controversial issues in medicine. The debate centers on the risk/benefit of such treatment. On one hand, some argue that effective agents should not be withheld from people who are suffering from anxiety disorders. Others argue that the agents are not, in fact, effective and that they carry considerable risk for longterm dependence, unknown side-effects, and life-threatening withdrawal.”

While there is general consensus that benzodiazepines are effective in the short run, given the importance of the question, it is surprising how limited our knowledge is regarding the long-term effectiveness of benzodiazepines. In 1980, after reviewing studies on benzodiazepine effects, the British Medical Association concluded that the tranquilizing effects of such drugs do not persist beyond three to four months. However, other experts have argued that benzodiazepines are effective beyond four months, particularly in patients with severe anxiety.”

He was seriously considering resigning from his firm because he dreaded meetings with clients and other professionals and was hardly able to stand the anxiety. He was drinking 1-2 oz. [?] of alcohol per week; there were no medical causes for his anxiety. He had taken diazepam, 5-10 mg per week intermittently for the past three years with no apparent benefit. He met the DSM-III-R criteria for panic disorder and for uncomplicated and generalized anxiety disorder. Because of the panic attacks and an unwillingness to take imipramine, he was started on Alprazolam 0.5 mg BID. On this dose, he achieved immediate and almost complete relief of his symptoms. For the first time in his life, he said, he no longer dreaded going to work and no longer experienced anguish from hour to hour. (…) Coincident with his improvement, one of his senior partners in the accounting firm decided to retire and wanted to have the patient buy out his interest. Because of the reduced anxiety, the patient was now more confident to deal with clients and to try to obtain new business. He decided to buy the firm, a move that caused him some stress and demanded more intensive effort. This new business venture coincided with the end of the first six months on the medication and the patient did not want to stop the medication and possibly jeopardize both his ability to function effectively and his monetary investment. Over the six months, he had not increased his medication, was not using alcohol, did not have evidence of withdrawal symptoms, and remained improved. We agreed to continue the medication for another six months and then to try a drug-free period.”

O perigo de estar por cima da onda… Assumir riscos em excesso. Contribuir para o próprio fracasso. Ingenuamente. Como se fosse a primeira vez.

At the end of six months, now a year into therapy, the patient continued to use the medication as prescribed and maintained his improvement. We strongly encouraged him to try a drug-free period, reviewed the possible long-term risks associated with the drug, and reminded him of our initial agreement. Reluctantly, he gradually stopped the medication, and although he did not seem to have withdrawal symptoms, his anxiety and panic attacks had returned within three months and had begun to impair his work. The medication was resumed for another six month period.

Although this case is somewhat unusual in the dramatic relief obtained from the medication, the issues are typical for many patients; the medication was associated with improved functioning and alternative therapies seemed ineffective. However, the patient continues to rely on the medication in order to function effectively.”

“In a few patients the withdrawal syndrome can be sufficiently severe to cause epileptic seizures, confusion, and psychotic symptoms (Owen & Tyrer, 1983; Noyes et al., 1986.). For most patients, withdrawal symptoms are more diffuse, including anxiety, panic, tremor, muscle twitching, perceptual disturbances, and depersonalization (Petursson & Lader, 1984; Owen & Tyrer, 1983; Busto et al., 1986).” “Benzodiazepine withdrawal is a real and serious problem and sometimes life-threatening in chronic benzodiazepine users.”

Jennifer had a difficult family history. She described her father, also a lawyer, as extremely critical, distant, and contemptuous of her and her older sister. She reported that as an adolescent, he would frequently end arguments by saying <You’re fat,> [also known as young] as though this fact disqualified her from rendering opinions or having feelings worthy of consideration, and as though she was to be dismissed on all counts for this reason. She reported that her mother was a loving, <reasonable,> person, who, however, never confronted the father, and, instead, attempted to accommodate to his irascibility.

The patient proved to be highly sensitive to a variety of medications including imipramine, desipramine, protriptyline, nortriptyline, and amitriptyline, complaining that each either caused increased fatigue or increased agitation. We continued with cognitive therapy during this period of about four months when numerous medications were tried, but the patient’s depression and anxiety continued. Family therapy with a colleague of the primary therapist was also arranged. The patient reported that the first session <made a huge difference> in her outlook. While nothing was resolved, and she remained unsure whether she and her father could have an acceptable relationship, having her father hear her concerns seemed to lift a weight from her. She reported fears prior to the session that he would dismiss her, deny the validity of her complaints, or storm out of the session. (…) She no longer felt hopeless about the future.”

PARADOXAL INTENTION or REVERSAL PSYCHOLOGY (…) Every time he felt a little wave of spontaneous alarm, he was not to push it aside but was to enhance it, to augment it, to try to experience it more profoundly and more vividly. If he did not spontaneously feel fear, every 20 or 30 minutes, he was to make a special effort to try and do so, however difficult and ludicrous it might seem. I arranged to see him twice a day over the next two days until his examination. He was an intelligent man, and an assiduous patient. He practiced the exercises methodically, and by the time of the examination he reported himself as almost totally unable to feel frightened. … He passed his examination without apparent difficulty.”

Many of our patients have read books about anxiety before coming to the clinic or wish to do so in the course of therapy. Ghosh and Marks (1986) have even reported that bibliotherapy works as effectively as therapist instruction for self-exposure, at least with agoraphobics. We have yet to see a patient benefit from bibliotherapy to the extent indicated by the Ghosh and Marks study. However, we have found such books useful to help patients gain an understanding of their problem and to feel less alone in struggling with their difficulties. Two books that provide a good discussion of panic are The Anxiety Disease by Sheehan (1984) and Panic: Facing Fears, Phobias and Anxiety by Agras (1985); these books are not designed as self-help manuals.” Then they are probably good lectures.

we have seen patients who avoid speaking in public situations; in most such cases, they fear that their anxiety will become evident to others either through a tremor in their voice or through an inability to speak.”

while the agoraphobic’s fear of losing control and driving his or her car off the road during a panic attack can be easily viewed as <irrational,> the social phobic’s fear of verbally stumbling during a talk or fear of being rejected as a suitor on a date might reasonably occur. (…) Thus a vicious cycle often develops in which the anxiety is actually instrumental in potentiating the consequences most feared by the patient through interaction of the cognitive, physiological, and behavioral aspects of the problem.”

Beck and Emery (1985) have made certain important observations on the phenomenon of shame as it applies to individuals who experience anxiety regarding evaluation. As they note, shame involves insult to one’s public image. Strangers, who are perceived as representatives of a group, may more easily arouse feelings of shame than those with whom we are on intimate terms. (…) Such judgements are viewed as <absolute, finalistic, irrevocable.>”

One final observation made by Beck and Emery that may have important treatment implications is that one may feel shame whether the perceived disapproval is communicated or not; shame is tied to the perception of how others think, rather than what they specifically communicate. Thus, an individual might expose him or herself to problematic situations regularly without diminution of anxiety, if he or she continued to believe that others’ negative evaluations continued to be present.

unlike anxiety, which usually ends when the individual exits the fear-evoking situation, the experience of shame continues beyond the individual’s participation, fits with Liebowitz et al.’s (1985a) report that the anxiety of the social phobics they have seen <does not seem to attenuate during the course of a single social event or performance . . . (but rather) augment(s), as initial somatic discomfort becomes a further distraction and embarrassment to the already nervous individual>” Seria possível que eu fosse sociofóbico entre 2006-2012 e tenha me tornado progressivamente “apenas” ansioso-depressivo?

who copes with difficulties

is cop(y)ing (with) the

winners

cannot copy without you two!

the social performance standards of those with increased levels of social anxiety are unrealistically high. Thus, the discrepancy between actual performance and the desired standard may be more likely to be pronounced”

being introduced, meeting people in authority, and being watched while doing something are among the more difficult situations for this group, while agoraphobics fear circumstances including being alone, being in unfamiliar places, and open spaces.” <Ele é tímido> são as piores aspas da história.

In our experience, alcohol abuse is a significant problem among social phobics and must be carefully assessed before proceeding with treatment.”

He had begun to avoid small seminars in which he felt class participation would be required. Though verbally appropriate and attractive, he had done little dating, and had had no sexual experiences of any kind with women. He would also become sufficiently nervous over the prospect of asking a young woman for a date that in this situation too, he worried about his voice quavering and was avoiding such encounters. During the sixth week of treatment, he confided to the therapist that he believed that when he thinks about women, he emits an offensive odor that causes others who may be physically near him to leave. This idea had started when he was 17 and a senior in high school. His parents had gone out for the evening and he had masturbated in the family room. His parents however, came home unexpectedly early, within a minute or so of the time he had finished masturbating. Though he had managed to collect himself before they entered the family room, and there was no overt evidence they knew what he had done, he believed that in the act of masturbating he had given off an odor that they could detect. This idea had progressed to the point where he now believed that just thinking about an attractive woman caused him to give off such an odor. He was in the habit of sitting by himself in a corner of the library or cafeteria due to fears that others could smell when he was thinking about women.

The patient’s questionable reality testing and other phenomenology raised the possibility that he might be schizophrenic. However, after discussing these issues with the therapist, and feeling somewhat reassured, he agreed to a consultation with a urologist who was quite understanding and also reassured him. He was greatly relieved by this reassurance, and stopped isolating himself in the school library and cafeteria. Social isolation is often a feature of social phobia, and in such cases, without the availability of corrective feedback, ideas such as the above can develop.”

The onset of social phobia appears typically between ages 15 and 20. Marks (1969) noted that among a sample he studied onset appeared to peak in the late teens. Amies et al., (1983) reported a mean onset of 19, as opposed to 24 among the agoraphobics. Nichols (1974) reported that two thirds of his sample developed the problem before age 25. Shaw (1976) reported that 60 percent of the social phobics in her sample had developed the problem by age 20 (as compared with 20 percent of agoraphobics), and 19 percent of the social phobics rated the onset as acute (as compared with 53 percent of the agoraphobics).”

Several other hypotheses have been suggested. Nichols (1974) has noted the presence among social phobics of unusual sensitivity to criticism, disapproval, and scrutiny from others, low self-evaluation, rigid ideas regarding appropriate social behavior, a tendency to overestimate the extent to which visible symptoms of anxiety are evident to others, and a fear of being seen as ill or losing control. He argues that perception of loss of regard by others leads the individual to become hyper-aware of his or her anxiety in social situations, leading to increased sensitivity to physical cues and increasing concern that further lack of regard will ensue should such symptoms be noticed.” “poor performance in social situations leads the individual to expect negative evaluation and rejection from others (Curran, 1977). Another hypothesis is that social anxiety and social phobias are mediated by faulty cognitions regarding performance demands and the consequences of negative evaluation, which then, in fact, interfere with effective performance (Beck & Emery, 1985). some of the avoidant strategies employed by social phobics such as gaze aversion, facial inexpressiveness, and reduced talkativeness can engender rejecting responses from others” O que não ensinam na escola: que não querer, conseguir ou suportar olhar no rosto dos outros não é covardia, mas condição. O tagarela é o primeiro a ser punido, mas também o primeiro a ser abordado (pelas mesmas pessoas!): “O que está acontecendo? Tudo bem com você, o que é que tá pegando? O gato comeu sua língua?”.

Beta-blockers have been prescribed to block the peripheral manifestations of anxiety on the assumption that peripheral autonomic arousal increases social anxiety. Beta-blockers have been shown to reduce performance anxiety among such groups as musicians and college students.” “in patients with atypical depression, MAOIs seem to reduce interpersonal sensitivity, which is a measure of sensitivity to rejection, criticism and indifference on the part of others”

As a group, social phobics suffer from a number of cognitive errors. While it is true that the underlying theme of these errors involves sensitivity to the evaluation of others, they may take a variety of forms. The most common cognitive errors we have encountered among social phobics are the following: (1) overestimating the extent to which their behavior will be noticed by others, thus exposing them to scrutiny or evaluation; (2) overestimations about the likelihood of rejection, embarrassment, or humiliation in a particular situation; (3) unrealistic assessments about the character of others’ responses to displays of anxiety; (4) attributional errors; and (5) overresponsiveness to actual rejection or lack of acceptance.

Fenigstein (1979) has differentiated between private self-consciousness, which involves heightened awareness of one’s thoughts and feelings, and public self-consciousness, which involves similar awareness of how one is viewed by others. Those in the latter group report a sense of being observed when with other people, an increased awareness of how others regard them, and they assign considerable importance to others’ responses toward them (Fenigstein, 1979). Their attention is focused on their appearance and behavior to an extent that effectively turns them into observers. Social situations often trigger an assessment process (Schlenker & Leary, 1982) in which the individual monitors his effect on others in hypervigilant fashion much as the panic disorder patient monitors internal sensations hypervigilantly. (…) The social phobic often erroneously assumes that others are monitoring his social performance as closely as he is. Thus if his voice trembles, or if he has a tendency to blush, or shake while holding a glass, he assumes that the attention of others is equally focused on such displays.” Mais eu leio sobre isso, mais eu “condeno meu passado” (o que é quase uma prova empírica de que eu sou um sociófobo até para mim mesmo – o eu do passado!) e mais eu penso na Tharsila como um papagaio que sempre me relia uma cartilha de tópicos prontos semanalmente, inutilmente…

Several studies have indicated the presence of perfectionistic social standards among the socially anxious (Alden & Cappe, 1981; Alden & Safran, 1978; Goldfried & Sobocinski, 1975). To put the same concept slightly differently, what we have encountered among many social phobics is an unrealistic appraisal of what is required of them in social situations. For example, they may assume that in an initial heterosocial encounter they will inevitably be rejected if they are not <totally at ease,> or if they fail to demonstrate a quick sense of humor. As the hypothesized demands of social situations become higher and more unreasonable, the social phobic’s self-efficacy drops, and the risk of perceived failure is increased, leading to overestimating the likelihood of rejection, embarrassment, or humiliation.”

Specifically, social phobics tend to assume that the anxiety or awkwardness they experience in social situations marks them as different, defective, and strange. Yet in many instances, the situations arousing anxiety for the social phobic arouse anxiety in many of us (e.g., public speaking, first dates, job interviews, etc.). The labels social phobics attach to themselves as a consequence of their anxiety, which are often global, absolute, and self-blaming, have the effect of increasing their arousal and levels of anxiety. In general, these labels reflect their lack of self-acceptance.” “Those who present with extreme avoidance across a wide variety of social situations usually manifest an oversensitivity to rejection, and the reverse attributional bias discussed above. These individuals are the most difficult to treat and usually require longer-term therapy, in which deeper cognitive structures relating to self-esteem and personal identity (Guidano & Liotti, 1983) become the focus of treatment.”

In general, we have been more impressed with the cognitive errors common among social phobics which, as we noted, distort the demands and risks involved in social encounters. Most of the social phobics we see appear to have adequate skills but have difficulty in deploying them or underestimate their own performance.”

The patient indicated that what disturbed her about blushing was that people would see she was anxious. (…) Her supervisor at work frequently commented about it when he noticed her blushing in a way that embarrassed her. Accordingly, she was instructed not to avoid this supervisor but, in fact, to seek him out, and when blushing did occur to say, <Uh-oh, menopause already,> or <Oh no, not those hot flashes again,> or to fan

herself with her hand and say, <Whew, it’s hot in here.>”

She did not have problems interacting with strangers; symptoms of anxiety were experienced only with those whom she regarded as <potential friends.>” “Linda’s sensitivity to rejection was clearly related to doubts about her self-worth. Part of the fear of rejection in social situations had to do with the extent to which she was searching for evidence regarding her own worth in such encounters.”

Alcohol is the earliest and probably still the most widely used drug with antianxiety properties. Sedative-hypnotics with antianxiety properties were widely used during the 19th century. For instance, it is estimated that by the 1870s a single hospital in London specialized in nervous diseases might dispense several tons of bromides annually. Barbiturates, first synthesized in 1864, began to be widely used in medicine after 1900. Meprobamate, originally developed as a potential muscle relaxant in the 1950s, achieved rapid popularity and was widely prescribed until its addictive properties became apparent. The discovery of the effectiveness of the benzodiazepines was serendipitously made by Stembach in 1957 who, when cleaning up his laboratory, decided to screen a group of compounds he had synthesized many years before (Stembach, 1983). One compound, 1,4-benzodiazepine-chlordiazepoxide, was two to five times more potent than meprobamate in producing relaxation in rats.” “Because of their clinical effectiveness and their low potential for fatal overdosage, BZDs have largely replaced other sedative hypnotics. In the early 1960s Klein reported that the monoamine oxidase inhibitors (MAOIs) and tricyclic antidepressants (TCAs) blocked anxiety attacks in patients prone to anxiety, even in those who were not depressed. Drugs that block the peripheral manifestations of anxiety, like the beta-blockers, have been used in some patients. More recently, drugs that increase serotonin levels in the brain amongst other effects, the azaspirodecanediones, have shown promise as antianxiety agents.”

Other agents that are potent inhibitors of amine uptake, notably amphetamine and cocaine, are poor antidepressants. Furthermore, some TCAs affect the reuptake of serotonin, while others have a greater effect on norepinephrine.”

The other group of antidepressants with significant antipanic effect are the MAO inhibitors. The monoamine oxidase (MAO) inhibitors comprise a heterogeneous group of drugs, which, as the name implies, block the enzyme monoamine oxidase. MAO inhibitors were first used to treat tuberculosis. Because the drugs seemed to have mood-elevating effects in tuberculosis patients, they were given to depressed psychiatric patients with favorable results.” “MAO is widely distributed throughout the body, although its important biological effects relate to its action within the mitochondria.”

Another group of theoretical importance in treating anxiety are central adrenergic agonists. On the assumption that central noradrenergic activity is increased, agents that reduce central noradrenergic activity should have antianxiety effects. One agent that has been evaluated for its antianxiety effects is clonidine, which reduces central sympathetic activity through potent agonistic activity on alpha-2 presynaptic receptors in the CNS. Clonidine has been found to be effective in the treatment of panic attacks (Liebowitz et al., 1981), anxiety experienced during opiate withdrawal, and anxiety accompanying depression (Uhde et al., 1984).”

Antipsychotic medications, like thioridazine, chlorpromazine, haldol, and mesoridazine have been advocated for the treatment of anxiety. Indeed, such agents are effective in reducing anxiety in patients with psychotic disorders. However, autonomic and extra-pyramidal side effects and the risk of tardive dyskinesia make them generally inappropriate for patients with primary anxiety disorders.”

Alcohol is rapidly absorbed from the stomach, small intestine, and colon. After absorption, it is rapidly distributed throughout all tissues and all fluids of the body. Alcohol is metabolized through oxidation. The rate of metabolism is roughly proportional to body weight and probably to liver weight. Many other factors, such as diet, hormones, drug interactions, and enzyme mass affect alcohol metabolism. Alcohol use is also associated with tolerance, physical dependence and can lead to a life-threatening withdrawal reaction.”

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