Natural Ways to Treat Panic Attack

Panic Away Ebook

The Panic Away system is a completely natural approach to eliminating 100% of anxiety and panic attacks in a short time. This Program has been developed by Joe Barry, a former sufferer of all too frequent panic attacks that recovered himself from those attacks and since then has been working to help other people get out of it too. The Panic Away Techniques Can Be Used Anywhere Various anxiety sufferers try therapy to get rid of the panic attacks and anxiety, but find not so good result from it, and it will be uncomfortable. There are other techniques, but they may be very embarrassing to utilize in public. Overall, the Panic Away an e-book is worth to read. It is not a potion, pill or any magic formula. This program addresses actual science and speaks to folks in all situations. The information that is contained in this an e-book provides sufferers the confidence that they can tackle the problems. These include panic attacks and anxiety that comes during driving, air travel or during interviews. Various users also stand behind this technique, assuring those with panic attacks that this ebook is a system that really works. Read more here...

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Anxiety and Obsessive Compulsive Disorder Syndromes

Anxiety is an extremely common occurrence that affects everyone at some time and is characterized by an unpleasant and unjustified sense of fear that is usually associated with autonomic symptoms including hypervigilance, palpitations, sweating, lightheadedness, hyperventilation, diarrhea, and urinary frequency as well as fatigue and insomnia. Anxiety is thought to be mediated through the limbic system, particularly the cingulate gyrus and the septal-hippocampal pathway, as well as the frontal and temporal cortex. The term anxiety disorder is used to denote significant distress and dysfunction resulting from anxiety, including panic attacks and anxiety with specific phobias. Chronic, moderately severe anxiety tends to run in families and may be associated with other anxiety disorders or depression. The differential diagnosis of anxiety states includes other psychiatric conditions such as anxious depression as well as schizophrenia, which may present as a panic attack with disordered...

Primary Anxiety Disorders

Pediatric patients may present with a history of preexisting anxiety disorder or develop an anxiety disorder after a medical illness is diagnosed. Because anxiety disorders often present with physical symptoms, particularly complex diagnostic issues can be gener ated in children and adolescents with comorbid medical conditions that may also be associated with somatic symptoms. The psychological symptoms of anxiety are routinely associated with physical signs of autonomic activity (e.g., palpitations, shortness of breath, tremulousness, flushing, faintness, dizziness, chest pain, dry mouth, muscle tension). The most common somatic symptoms reported by children and adolescents with DSM-IV-TR anxiety disorders (i.e., social, separation, and generalized anxiety disorders) were as follows restlessness (74 ), stomachaches (70 ), blushing (51 ), palpitations (48 ), muscle tension (45 ), sweating (45 ), and trembling shaking (43 ) (Ginsburg et al. 2006). Several subtypes of anxiety disorders...

Anxiety Disorder as a Psychological Reaction to Physical Illness

In this section, we discuss the DSM-IV-TR diagnostic categories that conceptualize the nature of the anxiety as a specific psychological reaction or response to the child's physical illness (see center column of Figure 7-1). A child's adjustment to an illness diagnosis and the medical procedures that are intended to help treat the illness can fluctuate over time and can significantly impact his or her experience of anxiety symptoms. Included are discussions of adjustment disorder, which is commonly seen

Substance Induced Anxiety Disorder

Anxiety may be induced by a variety of substances or medications, either as a direct effect of a substance or as a withdrawal reaction (see Table 7-7). Corticosteroids, anticholinergic medications, beta-adrenergic agonists, and asthma medications are all potential causes of anxiety, particularly if the medication has recently been started or the dosage has changed (see Table 7-8). Table 7-9 serves as a reference for how anxiety disorders relate to the specific DSM-IV-TR specifiers of substance dependence, abuse, intoxication, withdrawal, and intoxication delirium for specific classes of substances.

Studies of Cerebral Metabolism and Blood Flow in Anxiety Disorders

A dysfunctional cortico-striato-thalamo-cortical circuitry may play an important role in this disorder (Rauch and Baxter, 1998 Rauch et al., 1998). According to this model, the primary pathology afflicts subcortical structures (striatum thalamus), which leads to inefficient gating and results in hyperactivity within the orbito-frontal cortex and also within the anterior cingu-late cortex. Compulsions are conceptualized as repetitive behaviors that are ultimately performed in order to recruit the inefficient striatum to achieve thalamic gating and hence to neutralize the unwanted thoughts and anxiety. PET and SPECT studies have consistently indicated that patients with OCD exhibit increased regional brain activity within orbitofrontal and anterior cingulate cortex, in comparison with normal control subjects (Baxter et al., 1988 Machlin et al., 1991 Nordahl et al., 1989 Rubin et al., 1992 Swedo et al., 1992). Observed differences in regional activity...

Generalised anxiety disorder GAD

GAD is characterised by excessive anxiety and worry occurring on more days than not for a period of at least six months (APA, 2000). The person finds it difficult to control this worry and is distressed by it and, as a consequence, is compromised in their daily functioning. Lewis and Rosenberg (1990) report that TBI patients often experience anxiety of a generalised and free-floating type consisting of persistent tension, worry and fearfulness, which is experienced in an intense and overwhelming way but without much comprehension due to their inability to understand or adapt to these external and internal stimuli. GAD in the TBI-affected patient is also frequently associated with depression (Jorge, Robinson, Starkstein et al., 1993) with comorbidity rates ranging from 33 to 65 (Stavrakaki & Vargo, 1986). For example, Jorge, Robinson, Starkstein et al. (1993) studied a mixed TBI sample, all of whom were diagnosed with GAD (n 7) and also met the criteria for major depression. Merskey...

Prevalence and incidence of secondary anxiety disorders including demographic and psychiatric correlates

Anxiety disorders are common in patients with TBI and range in frequency from 11 to 70 (Klonoff, 1971 Lewis, 1942). In their review of 12 studies conducted between 1942 and 1990, Epstein and Ursano (1994) noted that in a total sample of 1,199 subjects, most of whom had featured only minor head injuries, 29 of postinjury subjects featured anxiety disorders. Deb, Lyons, Koutzoukis, Ali et al. (1999) followed up 196 patients who were admitted to the hospital between July 1, 1994 and June 30, 1995 with a traumatic brain injury. Each of these patients had a period a loss of consciousness, radiological evidence of brain assault, or a GCS of less than 15. Of the 120 patients interviewed between the ages of 18 and 64, 26 (21.7 ) had an International Classification of Diseases (ICD)-10 diagnosis of psychiatric illness. Of this group, 17 patients (14 ) had diagnoses of anxiety disorder including 11 (9 ) with panic disorder, 3 (2.5 ) with generalised anxiety disorder, 1 (0.8 ) with phobic...

A note on anxiety and its relationship with fear

The relationship between the emotion of fear and the experience of anxiety creates considerable debate within the psychology literature. For example, DSM-IV (APA, 1994) proposes that the term anxiety denotes apprehension, tension or uneasiness that stems from the anticipation of danger, which may be internal or external (p. 392), a definition that could, we suggest, just as readily apply to fear. One possible difference, it is argued (e.g., Ohman, 1993), between anxiety and fear is that the former lacks a recognisable external source of threat. However, an alternative analysis has been proposed by, among others Epstein (1972), that external stimuli are insufficient to distinguish fear and anxiety. Epstein submits that fear is related to action (particularly escape and avoidance) in a way that anxiety is not. Anxiety, he suggests, is what happens when fear-related action (namely flight) is blocked or thwarted. In other words, anxiety is unresolved fear or, as Ohman (1993) has...

Disordered Fear And Anxiety

Fear and anxiety can become disordered in a variety of ways. We can experience excessive fear to relatively harmless objects or we can develop beliefs that certain things are threatening or harmful when they are not. In other situations fear or anxiety can seem appropriate but overgeneralised such as in post-traumatic reactions or chronic worry. The challenge for any theory that seeks to explain both fear order and fear disorder is to account for the varieties of abnormal fear without making them seem like discrete pathological entities. Balancing this challenge is the need to integrate new ideas with the existing literature on disordered fear that is centred around the so-called anxiety disorders. In this second half of the chapter we have elected to use the anxiety disorder categories to organise our discussion of fear disorder. We must emphasise, however, that the use of such categories by no means reflects a belief on our part that anxiety disorders are qualitatively different...

Cognitive theoretical approaches to panic disorder

Psychological approaches to understanding panic disorder have revolved around the idea that the panic is in some way a fear of fear (Goldstein & Chambless, 1978). That is, people panic because they are threatened by the presence or potential presence of fear-related phenomenal states. There are a number of variations of the fear of fear hypothesis Pavlovian interoceptive conditioning (Bouton, Mineka, & Barlow, 2001 Goldstein & Chambless, 1978 Razran, 1961 Seligman, 1988 Wolpe & Rowan, 1988) catastrophic misinterpretation of bodily sensations (Clark, 1986, 1996) and anxiety sensitivity (McNally, 1990 Taylor, 1999). In this section we will concentrate on the work of Clark because this is the main cognitive account of panic disorder however, we shall also discuss some of the research on anxiety sensitivity where relevant.

Anxiety sensitivity research in panic

An additional factor that has been put forward to try to explain individual differences in the vulnerability to panic is anxiety sensitivity. The research on anxiety sensitivity revolves around the issue that not everybody is equally likely to misinterpret bodily sensations as catastrophic (see Taylor, 1999, for a review). The central thesis of much of this work is the suggestion that a set of pre-existing beliefs about the harmfulness of certain bodily sensations predisposes individuals to misinterpret those sensations in a catastrophic manner, thus leading to panic experiences. This has been termed the Anxiety Sensitivity Hypothesis (Reiss & McNally, 1985). A considerable body of research has focused on the establishment of a measure of anxiety sensitivity the Anxiety Sensitivity Index (ASI Reiss, Peterson, Gursky, & McNally, 1986). This is a self-report measure of fear of fear and has been shown to be distinct from trait anxiety (e.g., McNally & Lorenz, 1987) the latter...

Competition Social Fraudulence And Anxiety

As with depression, the history of modern anxiety parallels the shift of location of the self from the group to the individual.6 The rise of the powerful individual provided the basis for the current cultural strategy of competitive individualism, which in turn has shaped the new forms of anxiety experienced by moderns. The exceptionally intense competitive arrangements that exist in many segments of modern society have the effect of emphasizing technique and outcome. Individual participants often experience so much competitive anxiety that they disengage their private imagination in favor of situational pragmatics. Some people with strong creative inclinations experience frustration as they compromise this aspect of themselves in order to maximize the likelihood of competitive success.7 If the rewards are high, they are often able to persist in their compromise, but smaller payoffs frequently fail to mask their discontent. Research on the emotional consequences of competition shows...

Generalised Anxiety And Worry

Generalised anxiety problems involve excessive worry about several lifestyle domains such as health, finances, relationships, and so on. Such worrying usually takes up most of the individual's time and becomes highly disabling, both for the individuals concerned and for their partners, friends, and families. This so-called pathological worry is associated with a number of physiological somatic symptoms of fear or anxiety, although, for diagnostic purposes, it is not usually regarded as including among its domains of concern the sorts of stimuli that are associated with the other so-called anxiety disorders (for example, a specific aetiological trauma as in PTSD, the phobic object in phobias, etc.). Such generalised worry has been labelled generalised anxiety disorder (GAD) in psychiatric classification systems such as the DSM-IV (APA, 1994). There are a variety of nosological issues involved in the conceptualisation of GAD. These concern first, the relationship between GAD, a...

Defining The Syndrome Of Panic Disorder

The syndrome now called panic disorder was first described in the medical literature in 1895, by Sigmund Freud (1895a), under the term anxiety neurosis. His description differed from the currently accepted one in Diagnostic and Statistical Manual of Mental Disorders (DSM IV-TR) (APA, 2000), in that he included features of the illness other than panic attacks, including general irritability, anxious expectation, rudimentary anxiety attacks (which bear a similarity to our current conceptualization of limited symptom attacks), vertigo, phobias and agoraphobia, nausea and other gastrointestinal symptoms, and paresthesias. In the DSM IV-TR description of panic disorder, recurrent and unexpected panic attacks are the central feature, along with persistent anxiety about having another attack or the consequences of the attacks, or a change in behavior in reaction to the attacks. Panic attacks are carefully defined with regard to time (abrupt development, reaching a peak within 10 min,...

Course Of Panic Disorder

Panic disorder has been generally found to have a chronic, recurring course (Pollack and Otto, 1997 Pollack and Marzol, 2000 Faravelli et al., 1995). There is often a persistence of subthreshold symptoms even in the absence of a DSM IV-TR diagnos-able disorder. In a naturalistic, 5-year study following 99 patients with panic disorder without any psychiatric comorbidity (Faravelli et al., 1995), even transitory full remission was achieved by only 37.5 percent of patients, while full remission, sustained at 5 years only, occurred for 12 percent. Seventy-three percent of patients in this study experienced some improvement, but only 41 percent of those were still well at 5-year follow-up. On the other hand, many treatment outcome studies, particularly of cognitive-behavioral therapy, cite high rates of remission (Craske et al., 1991 Clark et al., 1994 Fava et al., 1995). It was the varying definitions of remission of panic disorder, ranging from a narrower view in which elimination of...

Basic Models Of The Etiology Of Panic Disorder Neurophysiological Models

Several lines of evidence suggest a neurophysiological basis for panic disorder, including genetic studies. The illness's medication responsiveness (discussed in the treatment section below) has been interpreted to imply a neurophysiological etiology. Evidence for a genetic basis for panic disorder has also been derived from studies of twins that demonstrate a higher rate of concordance for panic in monozygotic than dizygotic twins (Torgersen, 1983, Kendler et al., 1993 Skre et al., 1993). Neurophysiological models of the etiology of panic disorder have developed primarily from animal models of brain functioning and studies of substances that provoke panic. The interpretation of these data by different theorists in developing models for panic will be described below. Neuroimaging studies are expected to be an increasingly important source of data. and heart rate), and periaqueductal gray region (defensive behaviors). In fact, data from animal models suggest that stimulation of the...

Psychodynamic Model of Panic Disorder

In the psychodynamic model of panic disorder, anxiety symptoms are believed to be triggered by unconscious fantasies and impulses that are experienced by the individual as unacceptable, and threaten to break through into consciousness. The anxiety also represents the failure of defense mechanisms to adequately protect against the emergence of these wishes in undisguised form. In addition, the physical symptoms of panic, as well as many other aspects of life, are a result of compromise formations (Freud, 1895b) between wishes that are unacceptable and defenses against these very wishes. As described below, unconscious fears of loss, separation, and conflicts about autonomy are important elements underlying panic attacks. Angry fantasies triggered by fantasies of being controlled by others, or unprotected by loved ones, represent an additional threat to attachment that can trigger panic. Panic attacks in part represent partial expressions of these wishes by easing the danger of...

Treatment Of Panic Disorder

Medications, including tricyclic antidepressants, selective serotonin reuptake inhibitors, monoamine oxidase inhibitors, and benzodiazepines, as well as cognitive-behavioral therapy (CBT) have demonstrated efficacy for treatment of panic disorder in multiple double-blind, placebo-controlled studies. Common concerns have also surfaced in some of these studies (Nagy et al., 1989 Noyes et al., 1989 1991 Pollack et al., 1993 Barlow et al., 2000). Because of the narrower definition of panic disorder that was used prior to 1994 (Shear and Maser, 1994), very few panic studies to date have assessed broader quality of life aspects of treatment response. Many patients have persistent, though frequently less intense, symptoms that may cause persistent morbidity and functional impairment following completion of treatment (Nagy et al., 1989 Noyes et al., 1991 Pollack et al., 1993). For example, in the most recent large-scale, multicenter, highly controlled outcome study of patients with panic...

Psychodynamic Psychotherapy for Panic Disorder

Systematic study of psychodynamic treatments for panic disorder is in its infancy. As described above, a significant minority of patients fail to respond to the more extensively empirically tested treatments, and many patients experience residual symptoms after pharmacological and cognitive-behavior treatments (Nagy et al., 1989 Noyes et al., 1989, 1991 Pollack et al., 1993 Barlow et al., 2000). Thus, attention to psychodynamic issues may potentially provide further improvement for some patients. Milrod and Shear (1991) found 35 cases in the literature with DSM-III-R panic disorder who were successfully treated with psychodynamic psychotherapy or psychoanalysis alone. Since then, other successful psychodynamic treatments for patients with panic disorder have been reported (Milrod, 1995 Stern, 1995 Renik, 1995 Busch et al., 1996 Milrod et al., 1996). Clinical reports cannot substitute for controlled clinical trials. Nonetheless, these reports suggest...

Longterm Outcome Of Treatment Trials For Panic Disorder

Patients with panic disorder are a highly symptomatic, help-seeking group who tend toward recurrent exacerbations of symptoms (Pollack and Otto 1997 Pollack and Marzol, 2000 Faravelli et al., 1995). It is therefore important to gauge not only the effectiveness of treatments over the short term but to ascertain their effectiveness over longer follow-up intervals. Useful data with regard to long-term outcome, however, has been limited thus far in the literature. In a review of follow-up studies to date, Milrod et al. (1996) found that most did not monitor concurrent nonstudy treatments (e.g., untracked medication use in CBT studies or ongoing psychotherapies in medication studies) either during study treatment or during follow-up intervals. The authors concluded that there was limited evidence that patients responding to short-term treatments maintained their gains if they did not receive further treatment. Bakker et al. (1998) conducted a meta-analysis of studies that had information...

Xanax Valium and Other Sedatives

An important class of drugs that are among the most widely prescribed in the world is the benzodiazepines. This is a general chemical name for drugs that share certain chemical structures and properties. Trade names of drugs in this class include Xanax, Klonopin, Valium, and Ativan. They are used as sedatives and as sleep inducers or hypnotics. As sedatives, they reduce anxiety and have a calming effect as sleep inducers, they cause drowsiness that facilitates the onset of sleep. Each drug can be used as a sedative and as a sleep inducer, the only difference being the dose that is used. Sleep induction requires a higher dose than is required for calming. These drugs are relatively safe in overdose situations and have replaced older drugs such as the barbiturates. Sometimes these drugs are used before various diagnostic or surgical procedures to produce both calming and amnesia. motor functions, amnesia, and accidents. When taken during the day for anxiety, the dose is important...

Anxiety as a Disabling Disease

Anxiety disorders cause substantial disability in mental and role functioning. The degree of disability was shown in the Medical Outcomes Study, in which the health related quality of life of patients with panic disorder was compared to patients with other chronic medical illnesses (hypertension, diabetes, heart disease, arthritis, chronic lung problems) as well as other psychiatric disorders (major depression) (Sherbourne et al., 1996). Patients with panic disorder had levels of role functioning that were substantially lower than patients with other major medical illnesses but were higher or comparable to patients with depression. In contrast, physical functioning and self-perception of current health in panic patients were similar to that of patients with hypertension and the general population (Sherbourne et al., 1996).

Panic Disorder Definition

The key feature of panic disorder in DSM-III is the occurrence of three or more panic attacks within a three week period. These attacks cannot be precipitated only by exposure to a feared situation, cannot be due to a physical disorder, and must be accompanied by at least four of the following symptoms dyspnea, palpitations, chest pain, smothering or choking, dizziness, feelings of unreality, paresthesias, hot and cold flashes, sweating, faintness, trembling or shaking (APA, 1980). In DSM-III-R, the definition was revised to require four attacks in four weeks or one or more attacks followed by a persistent fear of having another attack. In DSM-III-R, the list of potential symptoms was revised to include nausea or abdominal distress and to exclude depersonalization or derealization (APA, 1987). More important, DSM-III-R changed the diagnostic hierarchy so that panic disorder could be diagnosed as a primary disorder with or without agoraphobia and dropped the category of agoraphobia...

Generalized Anxiety Disorder Definition

The DSM-III criteria for generalized anxiety disorder (GAD) require the presence of unrealistic or excessive anxiety and worry, accompanied by symptoms from three of four categories (1) motor tension, (2) autonomic hyperactivity, (3) vigilance and scanning, and (4) apprehensive expectation. The anxious mood must continue for at least a month, and the diagnosis is not made if phobias, panic disorder, or obsessive - compulsive disorder are present, or if the disturbance is due to another physical or mental disorder, such as hyperthyroidism, major depression, or schizophrenia (APA, 1980). By this definition, generalized anxiety disorder is treated primarily as a residual category after the exclusion of the other major anxiety disorders. DSM-III-R narrowed the definition further by requiring a minimum of six symptoms and a duration of six months (APA 1987).

Common Childhood Anxiety Disorders

Everyone, including teenagers and younger children, experiences passing bouts of anxiety. In contrast, those whose day-to-day routines are disrupted by long periods of anxiety lasting for days and even weeks probably suffer from an anxiety disorder. Examples of fears that can escalate and become disabling include fear of leaving the house, fear of interacting with other people, fear of contamination, an inability to concentrate on a task, an unreasonable fear of becoming fat, and a generalized feeling of anxiety that makes one's life basically dysfunctional. More than three quarters of young adults who have psychiatric disorders were first diagnosed between the ages of 11 and 18 years. The comorbidity of an anxiety disorder with depression and substance abuse during adolescence predicts a greater likelihood of any one or all three of these conditions continuing into adulthood. One half of adults with a mental disorder had symptoms that began before the age of 14.

Separation Anxiety Disorder

Many children experience separation anxiety between 18 months and 3 years, when it is normal to feel some anxiety when a parent leaves the room or goes out of sight. It's also common for a child to cry when first being left at daycare or preschool. If a child is older and unable to leave a family member or takes longer to calm down after separation than other children, then the problem could be a separation anxiety disorder. Other symptoms include refusing to go to school, camp, or a sleepover. This disorder is most common in kids ages 7 to 9 and affects about 4 percent of children.

Review of the Brain Substrates of FEAR and Anxiety

The experiences of fear and anxiety reflect the actions of complex, poorly understood emotional systems of the brain, for which no common neural denominator no generally accepted mechanistic explanation yet exists. In order to make sense of how these substrates are functionally organized, we must currently simplify to a substantial extent. In any event, the capacity of organisms to respond effectively to threats to survival was such an important evolutionary issue that it was not simply left to individual learning. As already noted, the study of the evolved neurochemistries of these mechanisms provides an optimal strategy for yielding new, clinically useful information. downward through the anterior and medial hypothalamus to the periaqueductal gray (PAG) of the midbrain and adjacent tegmental fields. Henceforth, this neural trajectory will be called the FEAR system, to distinguish it from other, less well-understood, negative affective systems, including those that precipitate panic...

Treatment of Anxiety Disorders

When treating children with anxiety disorders, therapists often use exposure therapy, also called exposure response therapy or ERT. This approach, used individually or in groups of people dealing with anxiety, gradually exposes a person to the thing she fears. This can be, for example, the use of a public bathroom or any social encounter until her fears lessen. Role playing within exposure therapy groups allows participants to act out and conquer the situations they fear. Outcome data from the use of exposure therapy for anxiety disorders is strongly positive. This is encouraging in that this form of therapy can be effective without the use of medication even with young children.

Treatment Of Anxiety In Clinical Practice Symptoms of Anxiety

The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) of the American Psychiatric Association (1994) includes eight major types of anxiety disorders, most of which have been summarized in previous chapters, including PTSD (Chapter 11), panic attacks (Chapter 12), obsessive-compulsive disorders (Chapter 13), and various acute stress reactions (Chapter 4). Here we will be primarily concerned with generalized anxiety disorders, but the coverage is also relevant for specific phobias, including social phobias and agoraphobia. The most common clinical symptom of all these disorders is excessive worry and sustained feelings of mental anguish. Among the common symptoms of generalized anxiety there are a variety of psychological disturbances, such as uncontrollable apprehensive expectations, jumpiness, and a tendency for excessive vigilance and fidgeting. The accompanying autonomic symptoms commonly include gastrointestinal irritability, diarrhea, and frequent urination, as well...

Varieties of Anxiety Systems in the Brain

Of course, the neuronal complexities that we face as we seek a definitive understanding of anxiety within the mammalian brain remain vast. Surely, several forms of trepidation are elaborated by distinct emotional systems of the brain, and meaningful functional differentiations have been identified in a single complex brain zone such as the amygdala (Killcross et al., 1997). As briefly noted earlier, a discrete separation distress PANIC system runs from the BNST and preoptic areas, through dorsomedial regions of the thalamus, down to the mesencephalic PAG (Panksepp et al., 1988). How any of the postulated anxiety or PANIC systems actually contribute to panic attacks remains a controversial issue (Chapter 12). Clinically, an early differentiation between brain systems that contribute to panic attacks and those that generate anticipatory anxiety was based on the observation that first-generation BZ antianxiety agents (e.g., chlordiazepoxide and diazepam) were not as effective for...

Anxiety A New Dimension in Apprehension

But what if there is no action or danger to tackle When these symptoms are not connected to an identifiable threat or last longer than is warranted, then it's called an anxiety disorder. Your fight-or-flight response is geared to go at the wrong time. There are several recognized anxiety disorders, including > Panic Disorders. Sudden onset of extreme fear without reason. > Obsessive-Compulsive Disorder. Persistent, irrational thoughts or repetitive behavior. > Post-Traumatic Stress. Prolonged anxiety after a traumatic event. > Generalized or Free-Floating Anxiety.

Anxiety and Depression

And Anxiety Disorders Anxiety Anxiety, Major Depression, and Medical Illnesses Panic Disorder Interaction of Depression and Anxiety Continuation of Treatment in Anxiety Disorders Interaction of Depression, Anxiety, and Medical Illness Diagnosis and Screening of Mood and Anxiety Disorders Diagnosis of Anxiety Disorders

Interaction of Depression and Anxiety

Major depression and anxiety are often found together, and each illness complicates the course and outcome of the other. Studies have consistently shown that anxiety disorders are the most frequently occurring comorbid disorder with major depression, with 50 to 60 of major depressed patients with both illnesses (Zimmerman et al., 2002). Anxiety can lead to depression in almost 60 of patients, whereas depression leads to anxiety in only 15 of patients (Mineka et al., 1998). Not surprisingly, the more severe anxiety disorders are more likely to lead to subsequent depression that is, panic disorder, agoraphobia, OCD, PTSD and GAD more frequently lead to depression compared to either social phobia or simple phobia. In addition, patients with both illnesses often have increased severity of symptoms, increased frequency of episodes (either mood or anxiety episodes), poorer response to treatment, higher suicide rates, a more chronic course, and overall poorer prognosis. Treatment is...

Interaction of Depression Anxiety and Medical Illness

A complex and reciprocal relationship exists between medical illnesses and comorbid anxiety and depressive disorders. Medical illnesses are associated with higher prevalence rates of anxiety and depression, and anxiety and depression are associated with higher rates of comorbid medical illnesses. Studies of patients with diabetes, cancer, stroke, myocardial infarction, HIV-related illness, and Parkinson's disease have higher rates of depression compared to patients without such illnesses (Katon, 2003 a). Common medical disorders seen in primary care settings have high comorbidity with anxiety disorders as well. Cardiovascular disease is associated with a 1.5 times greater risk of both GAD and panic disorder (Goodwin et al., 2008). Patients with back pain or arthritis are almost twice as likely to have panic attacks or GAD (McWilliams et al., 2004), whereas patients with asthma (pediatric or adult) may have a 30 increased likelihood of anxiety disorders (Katon et al., 2004). The...

Diagnosis of Anxiety Disorders

The essential feature of generalized anxiety disorder is excessive anxiety and worry about a number of events or activities, occurring most days over 6 months. Patients have difficulty controlling the worry, report subjective distress, and may experience difficulties in social or occupational functioning. The intensity, duration, or frequency of the worry is out of proportion to the actual likelihood or impact of the feared event. Patients must have at least three associated physical symptoms, including restlessness, irritability, muscle tension, disturbed sleep, fatigability, and difficulty concentrating. The list of associated symptoms can be thought of as symptoms of inner tension (restlessness or edginess, irritability, muscle tension) and symptoms associated with the fatiguing effects of chronic anxiety (fatigue, concentration difficulties, sleep disturbance) (Box 47-3). Panic attacks, a collection of distressing physical, cognitive, and emotional symptoms, may occur in a variety...

Screening Tools for Anxiety Disorders

At present, screening tools for anxiety disorders have been developed to recognize anxiety as a broad syndrome, examining somatic symptoms (racing heart, lightheadedness) or cognitive symptoms (tendency to worry, intensity of worry). Other tools have been used to screen for single, distinct disorders, such as phobias or panic disorder. To date, no clear screening tool or symptom-severity measure has emerged for use in primary care settings, although newer instruments may be useful for primary care physicians. The Generalized Anxiety Disorder 7 (GAD-7) scale was developed and validated Box 47-3 Diagnostic Criteria for Generalized Anxiety Disorder Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities. B. The anxiety and worry are associated with three (or more) of the following six symptoms C. The focus of the anxiety and worry is not confined to features of an Axis I disorder, e.g., the anxiety...

Management and Treatment of Major Depression and Anxiety Disorders

The key objective in treating depressive and anxiety disorders is remission of all symptoms. Studies in the treatment of major depression have consistently shown that lack of remission is associated with higher relapse rates, more severe subsequent depressions, shorter duration between episodes, continued impairment in work settings and social relationships, increased all-cause mortality, and increased risk of suicide (Judd et al., 2000). Initiation of treatment should include education about the expected temporal course of improvement importance of regular eating, activity, social interaction, and sleep medication selection follow-up schedule and safety management if symptoms worsen or suicidal ideation is evident (Box 47-7). Box 47-7 Initiation of Treatment for Major Depression and Anxiety Disorders

Generalized Anxiety Disorder

Initiation if doses are high (see Table 47-2). Patients with anxiety disorders are typically more sensitive to antidepres-sant side effects (see Table 47-4), and thus starting at lower doses and titrating slowly will likely yield better results. The TCAs, also effective agents for treating GAD, have been relegated to second-line treatment because of side effects (e.g., anticholinergic, sedative, orthostatic) and potential lethality in overdose. Imipramine has the strongest data to support its use in GAD (Kapczinski et al., 2003). Although used effectively in the treatment of anxiety disorders, monoamine oxidase inhibitors (MAOIs) have significant side effects (risk for hypertensive crisis, potential lethal interactions with other medications) and likely do not have a role in primary care and should be reserved for psychiatric practice. Mirtazapine has shown some efficacy in open-label trials (Gambi et al., 2005) but needs further study in RCTs to be considered a first-line agent in...

Continuation of Treatment in Anxiety Disorders

Treatment for anxiety disorders should be continued for 6 months to a year a more definitive time frame is not yet clear. Results from long-term RCTs of antidepressants in anxiety disorders indicate that maintenance treatment significantly reduces the risk of relapse, whatever the disorder (Thuile et al., 2009). Decisions on length of treatment are generally made on a case-by-case basis, taking into account the risk benefit ratio of treatment versus no treatment. If the decision is to discontinue treatment, the medication should be tapered at a rate that takes into account its pharmacokinetics and whether the patient experiences withdrawal symptoms (see Box 47-9).

Anxiety Claustrophobia

Three to five percent of patients have been reported to terminate their MRI study due to anxiety or claustrophobia.35 45 Claustrophobia is particularly high in patients requiring brain MRI, as well as those with neurological diseases and those who have had previous scans.45 Of those patients remaining awake for MRI, 12-14 will require some form of sedation to tolerate the procedure.45 Non-pharmacological techniques, such as patient counselling, presence of a companion and the prone position can be explored before embarking on sedation. It is particularly important to provide patients with information about the sensations that will be experienced as providing patients with procedural information alone has been shown to be particularly anxiety provoking.46

Anxiety Disorders

Anxiety is an ubiquitous human emotion. Its expression can range from a normal reaction to an acutely threatening stimulus to an anxiety attack with multiple physical sensations and fear of impending doom in response to an unknown stimulus. There are two properties that underlie the definitions of anxiety. It is generally unpleasant and future-oriented. It is distinguished from fear in that it either has no discernible source of danger or the emotion is disproportionate to the fear stimulus. Lader (1972) defines pathologic anxiety by subjective assessment of the individual patient that the symptoms are more frequent, more severe, or more persistent than those to which he or she is accustomed to or is able to tolerate.

Magnitude of Anxiety Disorders

Table 3 presents the rates of anxiety disorders in children and adolescents in community surveys which applied either DSM-III-R or DSM-IV criteria (Anderson et al., 1987 Bird et al., 1988 Bowen et al., 1990 Canals et al., 1995, 1997 Cohen et al., 1993 Costello et al., 1996, 1988a, b Feehan et al., 1993 Fergusson et al., 1993a Kashani et al., 1987a Kessler et al., 1994 Lewinsohn et al., 1993 Magee et al., 1996 McGee et al., 1990 Newman et al., 1996 Pine et al., 1998 Reinherz et al., 1993a Simonoff et al., 1997 Velez et al., 1989 Verhulst et al., 1985 Whitaker et al., 1990 Wittchen et al 1994 1998). Similar to community studies of adults, anxiety disorders are the most common disorder in the general population. However, there is a wide range in prevalence rates according to the specific anxiety subtypes as well as according to the study methodology. In general, approximately 20 of youth suffer from one of the anxiety disorders, and half as many have impairment in functioning resulting...

Phenomenology and nosology of the secondary anxiety disorders

Anxiety consists of apprehension, tension, and undue concerns about a perceived danger. It is usually accompanied by signs associated with the activation of the sympathetic nervous system and is described as free-floating anxiety when there is no conscious recognition of the specific threat. Anxiety is regarded as the chief characteristic of all of the neurotic disorders, and can be differentiated from normal or adaptive fear in that (1) it is not related to a perceived realistic threat or at least is out of keeping in degree with the level of threat that such an object or event actually would pose (2) it results from some form of intrapsychic conflict and (3) it is not relieved by the amelioration of the objective situation. Spielberger (Spielberger, Lushene, & McAdoo, 1977) divided anxiety into two distinct forms trait anxiety and state anxiety. State anxiety is that level of anxiety that all individuals experience from time to time in response to a real or perceived threat. This...

Overlap Between Mood And Anxiety Disorders

Although this review considered the magnitude and risk factors for anxiety and depression independently, there is compelling evidence from prospective longitudinal studies, family studies, twin studies, and treatment studies that anxiety and depression have a common diathesis. There are now several reviews of comorbidity of anxiety and depression in youth that provide a comprehensive summary of the evidence for comorbidity as well as of the possible sources of comorbidity (Caron and Rutter, 1991 Angold et al., 1999). Their evaluation of methodologic issues, criterial overlap, common criteria, shared versus independent genetic and familial influences, and stability of course concluded that there is a common underlying genetic diathesis between anxiety and depression in general, but that there are also specific genetic and environmental factors that mold susceptibility to fear and anxiety. Table 4 presents the risk factors for anxiety and depression divided by their unique associations...

Social Anxiety Skills Deficit

The Shyness & Social Anxiety Workbook Proven Techniques for Overcoming Your Fears. Oakland, CA New Harbinger Publishers. Dayhoff, S. (2000). Diagonally Parked in a Parallel Universe Working Through Social Anxiety. Placitas, NM Effectiveness-Plus Publications.

Definitions and Assessment of the Anxiety Disorders

In this chapter, we consider the anxiety disorders as defined by the DSM-IV criteria including panic, phobias, and general anxiety. The major subtypes of anxiety include panic disorder (with or without agoraphobia), specific phobia, social phobia, and generalized anxiety disorder (GAD). Although obsessive -compulsive disorder and post-traumatic stress disorder are also included as anxiety disorders in the DSM-IV, they will not be included here due to differences in their prevalence rates and correlates. There are two additional subtypes of anxiety that are specific to youth separation anxiety disorder and overanxious disorder. The DSM-IV did not include the category of overanxious disorder because of the purportedly substantial degree of overlap with GAD. However, as described below, there is emerging evidence that overanxious disorder does indeed provide coverage of anxiety disorder in youth who do not meet criteria for GAD. Despite the biologic underpinnings of anxiety, there are no...

Lesion location and mechanism of secondary anxiety disorders

Grafman, Vance, Weingartner, Salazar, and Amin (1986) conducted a study of 52 veterans who suffered penetrating missile wounds that caused damage to the orbito-frontal cortex during the Vietnam War. Grafman et al. found that the patients with left-sided or bilateral wounds showed no differences in mood states when compared with the control participants. However, patients who had right-sided orbitofrontal lesions initially manifested anger that later gave way to panic, lassitude, general anxiety, and edginess. As a result Grafman et al. contended that the right orbitofron-tal cortex plays a critical role in the regulation of anxiety states. Specification of the site and side of lesions and their contribution to the development of psychiatric state must be interpreted with the utmost caution. This matter is addressed in more detail in the discussion of the mood disorders in chapter 5. The effects of brain injury and their implication to the emergence of anxiety disorders was reviewed by...

Anxiety Disorder Due to a General Medical condition

Many medical conditions may result in symptoms of anxiety, and the consultant should consider this possibility if the history is not typical for a primary anxiety disorder or if anxiety symptoms are resistant to treatment (see Table 7-5). Medical etiologies are also more likely when physical symptoms of anxiety, such as shortness of breath, tachycardia, or tremor, are more marked. Anxiety that is secondary to a medical condition should be differentiated from co-morbid anxiety or anxiety that is a reaction to the underlying medical illness. Table 7-6 lists some of the more common medical conditions that may result in symptoms of anxiety. With respect to anxiety disorders due to medical conditions, the mental health consultant needs to appreciate that all patients facing a physical illness and its treatment will experience noncategorical effects of anxiety. From this perspective, children and their families are seen as experiencing stress as a result of being ill and not because of...

Anxiety

A comprehensive review of anxiety disorders may be found in Chapter 40. Anxiety is a state of fearfulness, apprehension, worry, emotional discomfort, or Anxiety is closely related to fear, but fear has an identified cause or source of worry (e.g., fear of death). Fear may be more responsive to counseling than an anxiety state that the patient cannot attribute to a particular fearful stimulus. Anxiety disorders are the most prevalent class of mental disorders overall, so it is not surprising that anxiety is a common cause of distress at life's end.14 In addition to anxiety disorders, a variety of conditions can cause, mimic, or exacerbate anxiety15,16 Delirium, particularly in its early stages, can easily be confused with anxiety. Significant anxiety is present in the majority of patients with advanced lung disease and is closely related to periods of oxygen desaturation. Medication side effects, especially akathisia from older antipsychotics and antiemetics (including and especially...

Poststroke Anxiety

Among adult patients, anxiety disorders are common after experiencing a stroke, with prevalence estimates of 25 -30 (Carson et al. 2005), and often include generalized anxiety or PTSD symptoms, including intrusive revisiting of the event, as well as increased somatic preoccupation. Poststroke anxiety is typically associated with right-hemisphere lesions, whereas symptoms of depression are correlated with left-hemisphere lesions (Epstein and Hicks 2005). Although 10 of children with sickle cell disease experience a stroke before age 20, placing them at greater risk for neurocognitive difficulties (Helps et al. 2003 Lemanek et al. 2003), little is known about pediatric poststroke symptoms of anxiety. A dysregulation of affect, including symptoms of anxiety, has been reported for both adults and children who experience lesions in the limbic cerebellum (vermis and fastigial nucleus) that can result from stroke or other conditions (Schmah-mann et al. 2007).

Role of Anxiety

Fust as Freud had revised his theory of instincts in 1920 and his model of the mind in 1923, so too he revised his theory of the genesis of anxiety and its pivotal role in psychic conflict in his 1926 monograph The Problem of Anxiety Freud 1926). Freud's first theory explaining the genesis of anxiety was that anxiety was the product of the transformation of dammed up sexual energy, in other words, a product of sexual frustration. Although he never fully abandoned this view, in 1926 he added a second, more important, explanation an individual developed anxiety in response to the perception of a developing danger situation. He called this signal anxiety ' in response to which the ego mobilized its defensive operations. Here Freud set out his series of the typical danger situations for the developing child loss of the object, loss of the penis (castration), and loss of the superego's love (moral or social anxiety, fear of punishment) (Freud 1926). The genesis and role of anxiety in...

Panic disorder

Panic disorder is characterised by the presence of recurrent, unexpected panic attacks followed by at least one month of persistent concern about having an attack (APA, 2000). In a comparison of agitated versus nonagitated patients following traumatic brain injury, Levin and Grossman (1978) noted that patients who experienced screaming, combativeness, and other signs of sympathetic arousal in the acute confusional phase following the brain injury tended to display significantly higher levels of anxiety, depression, and thought disturbance after stabilization or improvement in orientation. The symptoms did not appear to be related to the side of the injury but correlated with acute aphasic symptoms and the appearance of auditory or visual hallucinations (Epstein & Ursano, 1994). Schuetznow and Wiercisiewski (1999) report a single case of panic disorder featuring anxiety symptoms regarding health, and fear of suffering a heart attack following TBI. Again, panic is a relatively...

The New Anxiety

Although depression seems to have superseded anxiety as the defining emotional state of the modern age, mental health professionals are aware that we still live in a so-called Age of Anxiety. Modernity, however, has given rise to several new sources of anxiety that are less tangible and less controllable than the anxiety determinants of earlier times. Regrettably, attempts to understand anxiety in historical and cultural contexts are often overshadowed by explanations that emphasize the biological and physiological processes and the apparent universality of anxiety. But even though most human beings have the potential to experience anxiety, there exists extensive cross-cultural variation with regard to the general magnitude of anxiety, as well as the prevalence of anxiety disorders. Indeed, there have been some striking observations made on this subject in different cultures. In a study of 2,360 Yoruba Aboriginals of Australia, not a single case of overt anxiety was found.1 No...

Relief from anxiety

Surgical patients have a high incidence of anxiety and there is a significant inverse relationship between anxiety and smoothness of induction of anaesthesia. Relief from anxiety is accomplished most effectively by non-pharmacological means, which may be termed psychotherapy. This is effected at the preoperative visit by establishment of rapport, explanation of events which occur in the perioperative period and reassurance regarding the patient's anxieties and fears. There is good evidence that this approach has a significant calming effect. In some patients, reassurance and explanation may be insufficient to allay anxiety. In these patients, it is appropriate to offer anxiolytic medication the benzodiazepine drugs are the most effective for this purpose.

Stranger Anxiety

Stranger anxiety is an important and sometimes misunderstood event in the normal emotional development of all babies. Some psychologists have called it eight-month anxiety because it reaches a peak at about that age. I think of it as five-month anxiety because I saw it at that age in many babies not all in my pediatric office. The characteristics of stranger anxiety in the doctor's office after the age of a year is quite different from what I've been describing at five or ten months. This is an indication of how rapidly a child is changing in his emotional makeup at this period. Now when the doctor comes close, the one-year-old immediately tries to clamber to his feet and into his mother's arms as she stands beside the examining table. He tries to push himself and his mother away from the table. At the same time he sets up a noisy, angry crying. He buries his face in his mother's shoulder but every once in a while he looks There is nothing abnormal about the usual amount of stranger...

Social Anxiety

Up to 3 percent of children and adolescents have social anxiety disorder, also called social phobia. This cluster of fears about being negatively judged or Social anxiety often overlaps with general anxiety disorder (GAD). Generalized anxiety is believed to affect up to 6 percent of children and manifests as chronic or exaggerated worry and unjustified anticipation of disasters. GAD often includes physical symptoms such as nausea and headaches. Research shows that although more girls are affected by depression in middle childhood and early adolescence, school-age boys more commonly have an anxiety disorder.

Buspirone to Paxil

Even though there are many candidates in the wings to succeed BZs, the only major items that have reached the market are buspirone (Buspar) and selective serotonin reuptake inhibitors (SSRIs) such as paroxetine (Paxil), which have distinct profiles of action (Eison and Temple, 1986 Goddard et al., 1999). The therapeutic effect of these agents appears to be based on the ability of the serotonin 5-hydroxytryptamine (5-HT) systems to modulate anxiety (Handley, 1995). Buspirone has the relatively selective effect of stimulating 5-HT1A receptors, which are concentrated on serotonin cell bodies. At this site, buspirone reduces serotonin neuronal activity, and hence it acutely diminishes serotonin release in higher brain areas, which can lead to long-term up-regulation of postsynaptic serotonin receptors. Although some investigators believe that buspirone alleviates anxiety by reducing 5-HT activity, the benefits may also be due to a compensatory functional elevation of brain serotonin...

FEARAnxiety Systems

For an extensive discussion of this emotional system, see Chapter 16. Here we will focus on specific neuropeptide modulators. Of all emotional systems, probably more neuropeptides have been implicated in the facilitation of fear and anxiety than any other emotional tendency. They include, most prominently, CRH, neuropeptideY (NPY), CCK, alpha-melanocyte stimulating hormone adrenocorticotropic hormone (a-MSH ACTH), diazepam-binding inhibitor (DBI), but also several others, and thus several neuropeptide systems have been considered as primary molecular targets in the treatment of anxiety (Kent et al., 2002). The CRH antagonists are silent in many anxiety tests but are anxiolytic when animals are being stressed (Holsboer, 2001a,b). This suggests that CRH is released upon demand, supporting the general idea that neuropeptides are released only in case of increased neural activation (Hokfelt et al., 2000). This should facilitate their use as prophylactic compounds with limited side...

Anxiety Checklist

Anxiety affects most people from their teenage years to middle age, but others are affected at different times in their lives. Often people self-medicate with alcohol or recreational drugs to help them feel better. If you have any questions after looking over the following list, make an appointment with your health provider to discuss your feelings. During an ordinary activity, your heart pounds and you hyperventilate, sweat, and tremble. You may think it's a heart attack, but it's a panic disorder that afflicts about 35 percent of Americans each year. No one is sure why these attacks occur. They typically begin between the ages of 15 and 25. During an ordinary activity, your heart pounds and you hyperventilate, sweat, and tremble. You may think it's a heart attack, but it's a panic disorder that afflicts about 35 percent of Americans each year. No one is sure why these attacks occur. They typically begin between the ages of 15 and 25. Joan was a 39-year-old professional who had...

Four Developmental Subphases in the Mature

Interestingly, recent research has shown - albeit on laboratory rats - that lifelong intermittent environmental enrichment since infancy prevents the decline of recognition memory, reduces anxious behavior in a novel environment, and increases the number of newly generated neurons within the hippocampus during aging. Obviously, a mouse is not a man, but nevertheless the species share many biological characteristics, making the generalization quite feasible.

Should I or My Child Receive Sedative Medication Before Surgery

Anxiety is a normal reaction to anticipated surgery and anesthesia. The vast majority of patients scheduled for surgery will express anxieties about anesthesia. More than half the patients in one study expressed anxiety that they might awake during surgery others expressed concern about pain after surgery some were concerned they might not wake up others feared nausea and vomiting.1 Whatever the reasons for your own anxiety, the adverse physiological and psychological consequences of stress and anxiety are well known. Anxiety can activate the fight-or-flight reaction, mediated by the sympathetic nervous system. Activation of the sympathetic nervous system results in adrenaline secretion by the adrenal glands, increased heart rate, increased blood pressure, increased anxiety, and often a sense of doom. In the healthy adult or child, this reaction may not be life threatening, but it can be quite unpleasant, and there are consequences stemming from untreated anxiety. More than half the...

Evidence Based Practice

Given the time constraints typically encountered by primary care physicians and the expertise required to use behavioral interventions effectively, the physician should be aware of behavioral health providers in the community in order to make effective and timely referrals. The evidence base for effective behavioral interventions in numerous psychiatric and psychosocial problems, as well as medical problems, continues to expand (e.g., mood and anxiety disorders, trauma victims). Highly effective treatments are underused when physicians underrefer to mental health professionals with specialized training and overrely on the use of psychotropic medicines alone. Unfortunately, even when guidelines are available that physicians could follow themselves, resistance to change impedes their implementation (Torrey et al., 2001). Negative emotions such as anger, anxiety, and depression are associated with poor health (SOR B Salovey et al., 2000).

Stefan G Hofmann And Joel Weinberger

Managed health care has further polarized these two groups, which has led to heated debates around the report by the APA Division 12 (Society of Clinical Psychology) Task Force on Promotion and Dissemination of Psychological Procedures. In an effort to identify problems in the dissemination of psychological interventions, this Task Force constructed a list of efficacious treatments (empirically supported treatments) for various mental disorders, including anxiety, depression, substance use problems, and personality disorder (e.g., Chambless & Hollon, 1998). In an effort to offer an alternative to the recommendations of this Task Force, Division 29 (Division of Psychotherapy) of the APA formed its own Task Force on Empirically Supported Therapy Relationships with the objective to identify effective elements of the therapy relationship (empirically supported relationships, ESR) and to determine effective means of tailoring them to the individual patient (e.g., Norcross, 2002). The...

Ultrapositivistic Psychopharmacology Era 1970present

Other molecules (e.g., the tricyclic imipramine) were soon discovered to be effective in treating depressive disorders and eventually panic attacks (Klein and Rabkin, Various benzodiazepine antianxiety agents came into use in the 1960s, directly developed from preclinical animal studies that initially observed sedation and antiaggressive effects with chlordizepoxide (Librium). At this same time, the even earlier preclinical and clinical work on lithium by John Cade (1949) in Australia was gradually crafted into a treatment for manic-depressive disorders by Mogens Schou (1992) in Denmark. Most of the successes of biological psychiatry have arisen from our ability to manipulate just a few neurochemical systems (Fig. 1.1). This is now understandable. There exist a limited number of state-control neurochemical systems that arise from discrete brainstem nuclei and ramify widely in the brain, affecting many mind functions in fairly predictable ways catecholamines such as norepinephrine (NE)...

My daughter doesnt hug me anymore and she doesnt like it when I hug her Whats happening

The cows seemed to relax when the side panels of the chute were pressed against their bodies. After experiencing a panic attack one day, Grandin put her body into the machine and had her aunt adjust the side panels so that they squeezed her body. She experienced a wave of relaxation that she had never felt before. After this, she constructed her own human squeeze machine.9

Associated Neurological Findings

The motor examination may reveal several signs relevant to the assessment of mood and thought. Any abnormality such as a hemiparesis indicates an organic disorder. The finding of myoclonus or asterixis generally indicates a metabolic or toxic disorder and occurs only rarely with focal lesions. Tremor at rest is seen with neuroleptic drug use or Parkinson's disease, and these should be considered. Rigidity and akinesia should also be assessed they may accompany catatonia, neuroleptic use, or any parkinsonian syndrome. Catatonic akinesia may include waxy flexibility and abnormal sustained postures including one limb being stretched out for extended periods. Adventitious movements such as chorea may be seen and usually indicate tardive dyskinesia following chronic exposure to dopamine-blocking drugs. Alternative explanations include dyskinesias in the presence of psychosis in Pd, Huntington's disease, Sydenham's chorea, or systemic lupus erythematosus....

Affective Disorder Syndromes

The differential diagnosis of depression includes primary psychiatric syndromes other than major depression such as behaviors associated with schizophrenia, generalized anxiety disorder, and obsessive-compulsive neuroses. Medical and neurological disorders either associated with or mimicking depression include malignancy, infections, medications (steroids, reserpine, levodopa, benzodiazepines, propranolol, anticholinesterases), endocrinological dysfunction (Cushing's disease, hypothyroidism, apathetic hyperthyroidism, diabetes), pernicious anemia, and electrolyte and nutritional disorders (inappropriate secretion of antidiuretic hormone, hyponatremia, hypokalemia, hypercalcemia). Depression is also associated with multiple sclerosis, Parkinson's disease, head trauma, stroke (particularly of the left frontal lobe), and Huntington's disease. Interictal changes in temporal lobe epilepsy may mimic depression, particularly with right-sided epileptic foci. Patients with diencephalic and...

Psychotic Syndromes

Newer agents including clozapine, risperidone, and olanzapine may also be used. Anxiety and Obsessive-Compulsive Disorder Syndromes In patients with chronic mild or moderately severe anxiety, benzodiazepines, used sparingly for a few weeks to several months, can be helpful. When chronic treatment is necessary, buspirone, tricyclic antidepressants, and MAO inhibitors may be utilized in selected patients, particularly those with concomitant depression. Beta-blockers may also be useful in certain cases. Referral to a neuropsychologist or psychotherapist for training in self-reliance and relaxation techniques including biofeedback, meditation, and self-hypnosis should also be considered. The treatment of obsessive compulsive disorders should involve both pharmacological and psychological measures. Medications can significantly reduce the symptoms in over 50 percent of patients. Clomipramine is generally considered the drug of first choice, but other drugs with serotonergic properties such...

What is the difference between and the relationship of the socalled normal emotions and the emotional disorders

An answer to this final question lies at the heart of what we are hoping to achieve in this book. The majority of extant theories are concerned with explaining so-called normal emotions (see the current chapter and Chapter 3) or else present an analysis of a specific emotional disorder such as depression or generalised anxiety disorder (see

The Aggressive Patient

However, if allowed to have their way, they may be quite pleasant. Frequently, aggressive patients have intense dependency needs that they cannot consciously handle. These patients mask the primary problem by becoming aggressive and hostile to disguise their anxiety and feelings of inadequacy and inferiority. Aggressive patients are difficult to interview. The interviewer must try carefully to avoid areas provoking anxiety early in the interview. Once a rapport is established, the interviewer may attempt to delve into the deeper areas. In general, aggressive patients refuse any type of psychotherapy.

Understanding patients explanations

Alternative explanations for specific symptoms may be developed through discussion. Prompting the patients may be necessary, but the more the patients are able to provide their own alternative explanations the more likely they are to accept them. Anxiety symptoms are frequently misunderstood e.g. the thought that 'my boss is controlling my mind' can arise from the giddiness associated with hyperventilation, or I'm being shocked from paraesthiae.

Exercise Induced Asthma

Psychiatric Conditions Antidepressants and Anxiolytics Primary care physicians commonly treat patients with depression and anxiety, and athletes with these conditions compete at all skill levels. However, very little research exists studying the interaction of medications for these conditions and exercise. In a study of patients with major depressive disorder, decreases in isokinetic quadriceps and hamstring strength were shown to improve significantly after 3 months of treatment with a selective serotonin reuptake inhibitor.31 However, selective serotonin reuptake inhibitors have also been linked with significant weight gain after 6 to 12 months of use32 and possible episodes of heat-related illness and hyponatremia.33,34 In a small trial of patients, use of loprazolam, a benzodiazepine that can be used for anxiety, did not affect hand-eye coordination, 30-m sprint time, VO2max, or time to exhaustion. However, use of loprazolam was associated with prolonged reaction time and a...

Is the Disorder Familial

Relationship between the disorder used to select cases and the disorders that were screened from controls (Kendler, 1990). For example, we know that alcoholism and anxiety disorders both run in families. Consider a family study of alcoholism that screens control, but not alcoholic, probands for anxiety disorders. Since anxiety is familial, the rates of anxiety among relatives of controls will be decreased by the screening process. In contrast, the rates in relatives of alcoholics will not be decreased. Thus, anxiety disorders will be more prevalent among the relatives of alcoholics due to the choice of control group. Other studies have shown that the accuracy of family history assessments varies by diagnosis. Thompson et al. (1982) found that sensitivities for major depression and alcoholism were much higher than for generalized anxiety, drug abuse, phobic disorder, and depressive personality. Moreover, diagnoses based on spouse or offspring reports were more sensitive than those...

Stresses of Physical Illness

Medical distress is a common problem among youngsters that has been associated with behavior management and adherence problems. In the pediat-ric patient population, prevalence estimates for medical anxiety are as high as 7 , and estimates of behavior management problems range from 9 to 11 (Van Horn et al. 2001). Overt emotional and behavioral distress often reflects children's efforts to avoid frightening and unpleasant situations and serves as a protective response to an external threat (Van Horn et al. 2001). Such reactions can range from verbal expressions of discomfort to resistance, physical protest, and refusal to cooperate. Fear and behavioral distress can interfere with the delivery of safe, efficient care for these children (Van Horn et al. 2001). Negative medical experiences also increase the likelihood of behavioral distress during subsequent health care encounters (Siegel and Smith 1989). Assessing coping is complicated by the fact that different people involved in a...

The Patient with Posttraumatic Stress Disorder

Many trauma-related disorders have been recognized and include brief reactive psychosis, multiple personality disorder, dissociative fugue, dissociative amnesia, conversion disorder, depersonalization disorder, dream anxiety disorder, summarization disorder, borderline personality disorder, and antisocial personality disorder. Many other trauma-related disorders have been postulated. These disorders and the trauma that may precede them are indicated as follows Dream anxiety disorder any major life stress, depression, substance abuse, or substance withdrawal Patients who are Holocaust survivors may have many psychosomatic complaints commonly related to the gastrointestinal tract. Chest pain, often relieved by belching, may be related to frequent air swallowing. These patients experience vivid dreams and nightmares. They are suspicious and do not trust people readily because they suffered so much in the past. The interviewer must be especially kind and understanding. The majority of the...

Effectiveness of Early Detection and Intervention

Screening with PSA and DRE can detect prostate cancer in its early stages, but it is not clear whether early detection improves health outcomes. Screening may result in several potential harms, including frequent false-positive results, biopsies, and anxiety. Treatment side effects may include erectile dysfunction, urinary incontinence, and bowel dysfunction. Treatment of all cases detected by screening is likely to result in many interventions for men who would never have experienced symptoms from their cancers (Harris et al., 2001).

Clinician Patient Relationship

It is important to determine patients' oral habits before beginning treatment. Smoking and parafunction can influence the success of implant therapy. Special care should be given to apprehensive and anxious patients. Generally, pretreatment apprehension is a result of the faulty information that the patients gathered from other sources. The dental staff's attitude toward the patient is also a natural concern the staff should communicate with the patient in quiet, reassuring tones, addressing the patient by name while avoiding inappropriate personal terms.

Long Term Adaptation to

Currently, information is limited regarding the types of adjustment and psychiatric problems that are experienced by chronically ill children, but available research suggests that these children primarily have internalizing syndromes (R.J. Thompson et al. 1990). In a population of children with cystic fibrosis, 37 of those who received psychiatric diagnoses were diagnosed with an anxiety disorder, 23 with oppositional defiant disorder, 14 with enuresis, 12 with conduct disorder, and 2 with a depressive disorder (R.J. Thompson et al. 1990). The issue of whether these indicators of psychosocial functioning change over time is complicated. Although there is reason to suspect that changes in illness severity and illness status over time might influence adjustment, research suggests that psychiatric problems, when they are present in chronically ill children, persist over time. One study found that nearly two-thirds of children with chronic physical illnesses who had been classified as...

The Patient with AIDS

Patients with AIDS are fearful for their lives and of being stigmatized as a member of an undesirable group. The fear and misunderstanding common in high-risk groups result in delays in medical treatment. Denial is the important factor in most of these patients. The patient may have an intense fear of physicians, nurses, students, and paramedical personnel, who may have strong emotions related to this disease and its risk groups. The patient's fear is paralleled by the anxiety of the hospital workers who have to treat an individual with this disease. Their fear of contracting the disease, even by casual contact, is formidable. These fears are also present among the patient's friends and family, who often banish the patient from all activities. The patient may have been fired from a job because the employer is afraid of catching the disease. There is an unsympathetic rejection of patients with AIDS. They suffer emotional turmoil, which contributes to intense anxiety, hostility, and...

A Fear System in the Brain

Several distinct systems for anxious trepidation may exist in the brain. One FEAR circuit that courses parallel to the RAGE circuit has been extensively studied. When artificially aroused, this circuit promotes freezing and hiding at low levels of arousal and flight during more intense arousal. We can be confident that other animals experience negative affect when this circuit is aroused, since they avoid environmental contexts in which such brain stimulation has been experienced in the past. Humans stimulated at homologous brain sites are commonly engulfed by intense anxiety. If it turns out to be that there is much less variability across species in the subcortical FEAR systems of the brain that helps generate anxiety than in the cognitive structures that regulate such feelings, then it follows that the study of the FEAR system in animals constitutes an excellent strategy for coming to terms with the affective nature of fear in humans. This system as well as other variants of...

Separation Distress PANIC and Social Bonding Affiliative Love Systems of the Brain

One of the most distinct outputs of this care-soliciting system, quite easy to study in animal models, is crying or emission of separation calls when socially separated from caretakers. Based on the possibility that precipitous arousal of this circuitry, which courses between the PAG and more rostral brain areas (preoptic, septal, bed-nucleus of the stria terminalis, and anterior cingulate cortex) via medial thalamic corridors, may contribute to panic attacks, this system was originally designated the PANIC system (Panksepp, 1982). This and several other working hypotheses await empirical evaluation (Chapter 12).

The Five Control Schedules

Schedule III Drugs Paregoric, methyprylon (Noludar) anabolic steroids, codeine and hydrocodone with aspirin or Tylenol, and some barbiturates have an abuse potential less than Schedules I and II drugs and currently have an accepted medical use in the United States. Abuse of these drugs may lead to moderate or low physical dependence and or high psychological dependence. Schedule IV Drugs Chloral hydrate (Noctec), ethchlorvynol (Placidyl), flu-razepam (Dalmane), pentazocine (Talwin), chlordiazepoxide (Librium), propoxyphene (Darvon), and diethylpropion (Tenuate), Equanil, Valium and Xanax have low abuse potential compared with Schedule III drugs and currently have an accepted medical use in the United States. Abuse of these drugs may lead to limited physical dependence and or psychological dependence. Schedule V Drugs Narcotic-atropine mixtures (Lomotil) and codeine mixtures (less than 200 mg) have a low potential for abuse relative to Schedule IV drugs and have a currently accepted...

Selection as Solution Selecting Variability Levels Habitual variability levels

Importantly, while skills remain malleable (repertories can be expanded and performance perfected over time), habitual levels do not. Pressure to regain a habitual level arises from the discomfort of either anxiety or boredom the former when variability requirements are too high the latter, when they are too low. If boredom or anxiety motivates an individual to regain a habitual level, then variability shifts due to changed contingencies should be - and are - transitory. For example,

The Psychosomatic Patient

There are many ways of dealing with psychosomatic patients. First, identify the disorder Do not miss the possible diagnosis of an affective or anxiety disorder. Treatment of somatization is directed toward teaching the patient to cope with the psychological problems. Be aware that somatization operates unconsciously the patient really is suffering. Above all, the patient should never be told that his or her problem is ''in your head.'' Anxiety, fear, and depression are the main psychological problems associated with psychosomatic illness. The list of associated common symptoms and illnesses is long and includes chest pain, headaches, peptic ulcer disease, ulcerative colitis, irritable bowel syndrome, nausea, vomiting, anorexia nervosa, urticaria, tachycardia, hypertension, asthma, migraine, muscle tension syndromes, obesity, rashes, and dizziness. Answers to an open-ended question such as ''What's been happening in your life '' often provide insight into the problems.

Contracting With Clients

W's negotiating position with his employer would benefit from having a forensic psychiatric evaluation. Mr. H explains that he does not want Dr. M to address causation of Mr. H's anxiety, but only to document the existence of an anxiety disorder for purposes of invoking the protection of the Americans with Disabilities Act. Mr. H proposes that Dr. M perform the evaluation, write a report, and suggest reasonable accommodations. Mr. H offers to pay Dr. M half of a prenegotiated flat fee-for-service rate when Dr. M delivers the report, and the other half of the fee at the successful conclusion of the case. Assuming he has the appropriate training and expertise to undertake such an evaluation, should Dr. M agree to these conditions

Segregated Limbic Cortical Pathways

In a comparison to transient memory-script-induced sadness and anxiety in healthy subjects (Liotti et al., 2000a), it was found that the regions involved in emotion generation and suppression (neocortex) are distinct for sadness versus anxiety, with dorsal cortical regions right dorsolateral BA9 and inferior parietal cortex BA40 more involved in the control expression of sadness, and ventral regions, particularly the inferior temporal cortex and parahippocampal gyri, more involved in the control expression of anxiety (Fig. 2.9). This hypothesized model fits with reports of (1) prefrontal and inferior parietal abnormalities in clinical depression, but not with inferior temporal and parahippocam-pal ones (Bench et al., 1992 Mayberg, 1997) (2) prominent inferior and middle temporal but not inferior parietal deactivations in anxiety patients with PTSD (i.e., Bremner et al., 1999) and most strikingly, (3) consistent findings of right parahippocampal Anxiety Figure 2.9. Segregated...

Emotional Regulatory Network

The primary structures in the circuitry for emotional regulation include the orbital and ventromedial prefrontal cortex (BA 12), regions of the DLPFC, and the amygdala, hippocampus, and anterior cingulate. Other interconnected structures implicated in aspects of emotion, affective style, and the maintenance, amplification, and attenuation of an emotion include the hypothalamus, insular cortex, and ventral striatum. This system also suppresses negative emotions such as anger and impulsive aggression, partly through seroton-ergic neuromodulation.363 Antidepressant and antianxiety medications act on the system through such modulation.

Hidden or Masked Communication and Patients Expectations

Although the average person has a symptom about every 6 days, he or she visits a physician only once every 4 months. Some people visit a physician much more frequently than others for the same symptom. The group who visits more frequently tends to have a higher level of anxiety, fear, grief, or frustration. It is the physician's responsibility to search for, identify, and treat organic disease if it is present, but in about one half of cases, none will be found. It is equally important to identify the reason for these visits the basis for the heightened concern or increased anxiety. A person may see a minor symptom as a potential catastrophe if she or he thinks it may be a sign of cancer similar to that causing a parent's death. Is the patient really there just for a blood pressure check, or because of concern about the condition of his or her coronary arteries since a friend recently had an acute myocardial infarction If the physician deals only with the symptoms, the real concerns...

Modernity Unnatural Compromise And Asocial Freedom

Sometimes, when cultures suddenly come into contact, one culture is overwhelmed and thrown out of equilibrium. Much of the actual research examining the relationship between modernization and mental health has focused on the issue of culture change. One consistent finding has been that rapid culture change from a non-Western to a Western orientation raises the level of mental illness. A cultural disintegration model would explain the escalating rates of psychopathology in terms of the affected culture's diminished capacity to accommodate the essential needs of its members. A similar type of interpretation could be made with regard to the research that has found strong correlations between modernization and specific types of mental disturbances, such as depression, psychosomatic disorders, anxiety disorders, and alcoholism.18

The neurological neuropsychological behavioural and emotional consequences of TBI

Neuropsychiatrie illness is a common concomitant of TBI (Jorge, 2005). Fann and colleagues (2004) compared the frequency of psychiatric diagnoses in 939 TBI patients and 2817 controls. The presence of any psychiatric diagnosis in the first year following the TBI was 49 in the moderate to severe group, 34 following an MTBI, and 18 in the controls. In patients without a prior diagnosis of psychiatric disorder, the adjusted relative risk for psychiatric illness in the first 6 months following a moderate to severe TBI was 4.0 (95 CI, 2.4-6.8). Following an MTBI it was 2.8 (95 CI, 2.1-3.7) in comparison to the noninjured controls. For those patients with a psychiatric diagnosis prior to the injury, the adjusted relative risk in the first six months postinjury was 2.1 (95 CI 1.3-3.3) for moderate to severe TBI and 1.6 (95 CI, 1.2-2.0) for MTBI. Prior psychiatric illness proved to be a significant predictor of psychiatric morbidity post TBI, and these problems tended to persist for these...

Comorbidity The Depression Bulimia Link

More examples of comorbidity are shown in the following statistics 71 of bulimic women have some kind of anxiety disorder and of those, 59 have social phobia. About one-third have a kind of seasonal affective disorder in which eating disorder symptoms increase in severity in the winter (Pearlstein, 2002). An interesting study has shown that bulimic symptoms seem to be relieved by simple light therapy (Mark Moran, Light Therapy Lessens Bulimics' Binging and Purging, WebMD Medical News, April 6, 2001).

What psychological factors are important in the management of chronic pain

Several psychological systems are potentially at work in the patient with chronic spinal pain. These include the traditional Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) categories, cognitive-behavioral factors, and character traits. In one functional restoration program, 59 of patients with chronic back pain had active psychopathology, which included major depression in 45 , substance abuse disorder in 19 , and anxiety disorder in 17 . Although there were psychological illnesses present before the spinal pain began, most of the disorders developed after the spinal injury. Cognitive-behavioral factors commonly observed include fear, fear-avoidant behavior, and poor coping abilities.

Depression and Physical Symptom Perception

Although fewer studies have focused on pediatric than adult populations, similar associations have been described for children and adolescents (Apley 1967 Campo et al. 2002). In a cross-sectional study, Konijnenberg et al. (2006) examined psychiatric morbidity in children with medically unexplained chronic pain and pediatricians' abilities to identify psychological factors that might contribute to chronic pain symptoms using clinical judgment or a screening tool. In the study of 134 chronic pain patients ages 8-18 presenting in a university-based outpatient clinic, psychiatric morbidity was found in 60 , with 40 meeting criteria for an anxiety disorder and 35 for depressive disorders. The investigators found that clinical judgment and the screening tool were equally effective for identifying psychiatric disorders and allowing for interventions (Konijnenberg et al. 2006).

Initial case formulation

A very basic cognitive formulation links a person's mood and behaviour to the way that he or she interprets or thinks about an event. Using this simple model we can understand that a person who believes that hearing voices is a sign of madness and impending incarceration is likely to feel anxious, and may hide away as a result. This would contrast with a person believing the experience of hearing voices means that he has special powers who may feel quite elated and may want to spread the word of his newly found gift. Physiological Poor sleep anxiety unable to concentrate.

The Benzodiazepine Site Of Gabaa Receptors

GABAA receptors are transmembrane proteins that are assembled from subunits into a pentameric structure forming an ion-channel through which the influx of chloride ions is regulated. In addition to the binding site for the endogenous agonist GABA, the GABAA receptors have binding sites for compounds that allosterically modify the chloride channel gating of GABA. The most well-known class of such compounds is the BZDs and the binding site for this class of compounds has been named the BZD site. The pharmacological effects of the BZDs (anxiolytic, anticonvulsant, muscle relaxant, and sedative-hypnotic) make them the most important GABAA receptor-modulating drugs in clinical use.

Psychological Reactions to Illness

Anxiety is a common psychological reaction to the stress of a major physical illness. Patients with genetic biological vulnerabilities to develop anxiety symptoms are likely to have more intense reactions to diagnosis and treatment of a physical illness, although these same conditions can induce disabling anxiety in patients with no prior history of anxiety. Multiple psychological sources of anxiety should be considered during evaluation (Epstein and Hicks 2005 Goldberg and Posner 2000). In Table 7-1, we highlight the primary psychological sources of anxiety associated with pediatric physical illness, along with important factors that should be considered.

What Leads To Disordered Personality

The promise of measuring dimensions of personality disorder symptoms leads to the possibility of linking those measures to physiological substrates. As succinctly stated by Jang and Vernon (2001) The definition of the phenotype remains the most important prerequisite for successful genetic studies (p. 177). In other words, investigators can most easily link protein expression mechanisms to phenotypes that are internally coherent, distinct from other phenotypes, and stable across measurement attempts. Because some personality traits show desirable psychometric qualities of validity and reliability and describe key features of personality disorders, they may provide ideal endophenotypes for linkage to genetic and intermediate physiological mechanisms (Jang and Vernon, 2001). Investigations of the relationship between genetic polymorphisms and personality traits provide fertile ground for inquiry. For instance, mice genetically engineered to lack serotonin 1a receptors show increased...

Gastrointestinal Disorders

Studies of patients with inflammatory bowel disease suggest that they may be more vulnerable than healthy comparison adolescents to developing psychiatric disorders, including symptoms of anxiety and depression (Hommel 2008 Mackner and Cran-dall 2006 Mackner et al. 2006). Anxiety symptoms can occur in the context of any treatment with a cor-ticosteroid. Evidence is mixed regarding whether patients' inflammatory bowel disease relapses are related to times of increased stress in adults (Creed and Olden 2005), and less is known about the role of stress in inflammatory bowel disease symptom exacerbation in pediatric patients (Mackner et al. 2006). structural, infectious, inflammatory, or biochemical etiology) have been found to have elevated levels of anxiety that, although similar to anxiety levels reported by children with organic gastrointestinal diagnoses, are significantly higher than those of healthy children (Banez and Cunningham 2003 Scharff 1997 Walker et al. 1993). Patients with...

Traumatic Brain Injury and Postconcussive Syndrome

Adult patients who have sustained traumatic brain injury have an increased prevalence of anxiety disorders, including generalized anxiety disorder, panic disorder, obsessive-compulsive disorder, and phobias (Fann et al. 2005). Among pediatric patients, a study examining the onset of obsessions and compulsions within 1 year of severe traumatic brain injury found these symptoms to be common (29.2 of the sample) and associated with the co-occurrence of DSM-III-R anxiety disorders (Grados et al. 2008). In a separate study examining the impact of mild, moderate, and severe childhood traumatic brain injury, Barker-Collo (2007) reported rates of emotional behavioral symptoms that were within normal limits across groups, with the moderate traumatic brain injury group having the highest levels of somatic and anxious-depressed symptoms. Although these symptoms may be transient, some patients develop more sustained symptoms. Notably, adult patients with traumatic brain injury have been found to...

Concluding Comments

Anxiety is a particularly common experience in the medical setting for pediatric patients and their family members. When assessing and treating pediatric anxiety in these settings, the clinician needs to consider the context in which the symptoms present and the environment in which symptoms are maintained due to the strong degree of overlap between symptoms of anxiety and certain medical disorders. Anxiety symptoms may be present as part of a primary or preexisting psychological disorder, as a psychological reaction to a physical illness, or as the result of an organic etiology. In addition to the more familiar DSM-IV-TR-based anxiety disorders, medical traumatic stress has emerged as a relatively common set of symptoms. Medical conditions such as cancer, gastrointestinal disorders, heart disease, hormone-secreting tumors, stroke, pulmonary disease, seizure disorders, transplantation, traumatic brain injury, and thyroid disease may be associated with anxiety symptoms for pediatric...

How To Win Your War Against Anxiety Disorders

How To Win Your War Against Anxiety Disorders

Tips And Tricks For Relieving Anxiety... Fast Everyone feels anxious sometimes. Whether work is getting to us or we're simply having hard time managing all that we have to do, we can feel overwhelmed and worried that we might not be able to manage it all. When these feelings hit, we don't have to suffer. By taking some simple steps, you can begin to create a calmer attitude, one that not only helps you feel better, but one that allows you the chance to make better decisions about what you need to do next.

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