Tuesday, June 20, 2006

Four Tips To Alleviate Your Child's Anxiety Over A Rite Of Passage

Rites of passage mark the passage of a person through the life cycle – our progress from birth to death. We often recognize the passage from one stage to another of our lives, from one role or social position to another – with formal ceremonies: birthday parties, weddings, baby showers, graduations and funerals. These ceremonies help us to understand our new roles in society. They can also help others learn to treat us in new ways after we experience certain rites of passage.

As you pass through your life cycle, you will experience three main phases in each rite of passage: separation, transition, and incorporation. Simply put, you are separated from your familiar environment during the separation phase and learning appropriate behavior for the new stage you are entering in the transition phase. The last phase, incorporation, takes place when the participant is formally admitted into the new role (marriage is a good example).

While the rights of passage for teens, young adults and adults are well established in most cultures, what of our young school aged children? There are many, many rites of passage in our lives. Some are considered to be more significant than others, but almost every day we live can bring about transitions.

For young children, their first right of passage may often be the move from Kindergarten to Grade 1. In most schools, this means a move from a half-day or alternating day program to a full-day.

Let’s meet Ryan:

Five-year old Ryan is in Kindergarten. For the past few weeks, his parents have been talking about the changes coming up in September. Mom has been telling Ryan that in September, he will be going to school for a full day like his older brother Andrew. Each time mom or dad mentions his new routine; Ryan expresses enthusiasm “I can’t wait to be like Andrew!”

As the end of the school year approaches, Ryan begins to have trouble waking to school. Formerly an engaged and enthusiastic child, he begins to say he doesn’t like school, that his teachers are mean to him and often makes up maladies in an attempt to stay home from school.

Ryan’s parents call the school and arrange to meet with the school councilor. Through discussions with Ryan, it is discovered that though he’s excited to be doing things like his older brother, he’s sad to be leaving his teacher, worried that he won’t like his new teacher and he’s not quite sure how he’s going find his new classroom. “I think I’m going to get lost,” he exclaims.

Though the school has a transition program in place, Ryan has not actively been participating in the program. He had broken his wrist wrestling with his brother in the spring and his follow up visits with the doctor conflicted with the school’s planned weekly visits to the new classroom. The school had planned a joint afternoon picnic and fitness day in the school yard but Ryan’s injury prevented him from participating.

The school assigned Ryan a buddy from the Grade 1 classroom. Each day during the morning break, Ryan would spend time with his buddy, touring the school so that Ryan felt more comfortable finding his way around. At home, Mom, Dad and his older brother begin to share more of their school experiences – telling stories about their days in Grade 1 and how they felt. Within a few days, Ryan began to feel more at ease and his morning episodes lessened and then ceased completely.

The school held a graduation ceremony for the his class as the final stage of their transition program. As Ryan posed for a picture with his teacher, he smiled at her and said “I’m going to miss you next year, Mrs. Jackson, but I know my way through the halls now and I can come visit you when I’m in Grade 1.”

If your child is exhibiting anxious behavior as the school year comes to a close, the following tips can help alleviate his anxiety and restore balance:

1) Staged Transition: Most schools have a planned transition program to help children adjust to their new classrooms and school routines. While most common between K and Grade 1, some schools practice the program at all age levels. Speak to your school principal if you are uncertain of your child’s school policies.

2) Share: Share stories of your school days and encourage older siblings to show your children that their anxieties are a normal part of growing older. Teach them to embrace the challenges of change rather than fearing them.

3) Awareness: Talk with your child at those times when they demonstrate behavior that is contrary to their usual behavior. Share your concerns with teachers and school officials if the behavior occurs over a long period of time. Professional intervention may be required in some cases and it is your right as a parent to ask that the school assist you in getting the help your child needs.

4) Celebrate: Rites of passage are formally celebrated in all cultures. Each ceremony is unique and meaningful. Help make the transition fun for your child by holding a graduation ceremony. If your child’s school does not host a ceremony at the Senior Kindergarten level, plan your own with family, friends and neighbors.

With proper planning and support, you can help plan a smooth transition for your child and end their school year on a positive note rather than having a summer marked by anxieties.

Dr. Charles Sophy, author of the "Keep 'Em Off My Couch" blog, provides real simple answers for solving life's biggest problems. He specializes in improving the mental health of children. To contact Dr. Sophy, visit his blog at http://drsophy.com.

Sunday, October 02, 2005

Avoiding Catastrophic Thinking


Avoiding Catastrophic Thinking

Provided by Psychology Today

There are things we can change about ourselves and things we cannot. Concentrate your energy on what is possible -- too much time has been wasted.

This is the age of psychotherapy and the age of self-improvement. Millions are struggling to change. We diet, we jog, we meditate. We adopt new modes of thought to counteract our depressions. We practice relaxation to curtail stress. We exercise to expand our memory and to quadruple our reading speed. We adopt draconian regimens to give up smoking. We come out of the closet or we try to become heterosexual. We seek to lose our taste for alcohol. We seek more meaning in life. We try to extend our life span.

Sometimes it works. But distressingly often, self-improvement and psychotherapy fail. The cost is enormous. We think we are worthless. We feel guilty and ashamed. We believe we have no willpower and that we are failures. We give up trying to change.

On the other hand, this is not only the age of self-improvement and therapy, but also the age of biological psychiatry. The human genome will be nearly mapped before the millennium is over. The brain systems underlying sex, hearing, memory, left-handedness, and sadness are now known. Psychoactive drugs quiet our fears, relieve our blues, bring us bliss, dampen our mania, and dissolve our delusions more effectively than we can on our own.

Our very personality -- our intelligence and musical talent, even our religiousness, our conscience (or its absence), our politics, and our exuberance -- turns out to be more the product of our genes than almost anyone would have believed a decade ago. The underlying message of the age of biological psychiatry is that our biology frequently makes changing, in spite of all our efforts, impossible.

But the view that all is genetic and biochemical and therefore unchangeable is also very often wrong. Many people surpass their IQs, fail to "respond" to drugs, make sweeping changes in their lives, live on when their cancer is "terminal," or defy the hormones and brain circuitry that "dictate" lust, femininity, or memory loss.

The ideologies of biological psychiatry and self-improvement are obviously colliding. Nevertheless, a resolution is apparent. There are some things about ourselves that can be changed, others that cannot, and some that can be changed only with extreme difficulty.

What can we succeed in changing about ourselves? What can we not? When can we overcome our biology? And when is our biology our destiny?

I want to provide an understanding of what you can and what you can't change about yourself so that you can concentrate your limited time and energy on what is possible. So much time has been wasted. So much needless frustration has been endured. So much of therapy, so much of child rearing, so much of self-improving, and even some of the great social movements in our century have come to nothing because they tried to change the unchangeable. Too often we have wrongly thought we were weak-willed failures, when the changes we wanted to make in ourselves were just not possible. But all this effort was necessary: Because there have been so many failures, we are now able to see the boundaries of the unchangeable; this in turn allows us to see clearly for the first time the boundaries of what is changeable.

With this knowledge, we can use our precious time to make the many rewarding changes that are possible. We can live with less self-reproach and less remorse. We can live with greater confidence. This knowledge is a new understanding of who we are and where we are going.


S.J. Rachman, one of the world's leading clinical researchers and one of the founders of behavior therapy, was on the phone. He was proposing that I be the "discussant" at a conference about panic disorder sponsored by the National Institute of Mental Health (NIMH).

"Why even bother, Jack?" I responded. "Everyone knows that panic is biological and that the only thing that works is drugs."

"Don't refuse so quickly, Marty. There is a breakthrough you haven't yet heard about."

Breakthrough was a word I had never heard Jack use before.

"What's the breakthrough?" I asked.

"If you come, you can find out."

So I went.

I had known about and seen panic patients for many years, and had read the literature with mounting excitement during the 1980's. I knew that panic disorder is a frightening condition that consists of recurrent attacks, each much worse than anything experienced before. Without prior warning, you feel as if you are going to die. Here is a typical case history:

The first time Celia had a panic attack, she was working at McDonald's. It was two days before her 20th birthday. As she was handing a customer a Big Mac, she had the worst experience of her life. The earth seemed to open up beneath her. Her heart began to pound, she felt smothered, and she was sure she was going to have a heart attack and die. After about 20 minutes of terror, the panic subsided. Trembling, she got in her car, raced home, and barely left the house for the next three months.

Since then, Celia has had about three attacks a month. She does not know when they are coming. She always thinks she is going to die.

Panic attacks are not subtle, and you need no quiz to find out if you or someone you love has them. As many as five percent of American adults probably do. The defining feature of the disorder is simple: recurrent awful attacks of panic that come out of the blue, last for a few minutes, and then subside. The attacks consist of chest pain, sweating, nausea, dizziness, choking, smothering, or trembling. They are accompanied by feelings of overwhelming dread and thoughts that you are having a heart attack, that you are losing control, or that you are going crazy.


There are four questions that bear on whether a mental problem is primarily "biological" as opposed to "psychological":

o Can is be induced biologically?

o Is it genetically heritable?

o Are specific brain functions involved?

o Does a drug relieve it?

Inducing panic. Panic attacks can be created by a biological agent. For example, patients who have a history of panic attacks are hooked up to an intravenous line. Sodium lactate, a chemical that normally produces rapid, shallow breathing and heart palpitations, is slowly infused into their bloodstream. Within a few minutes, about 60 to 90 percent of these patients have a panic attack. Normal control subjects with no history of panic rarely have attacks when infused with lactate.

Genetics of panic. There may be some heritability of panic. If one of two identical twins has panic attacks, 31 percent of the cotwins also have them. But if one of two fraternal twins has panic attacks, none of the cotwins are so afflicted.

Panic and the brain. The brains of people with panic disorders look somewhat unusual upon close scrutiny. Their neurochemistry shows abnormalities in the system that turns on, then dampens, fear. In addition, the PET scan (positron-emission tomography), a technique that looks at how much blood and oxygen different parts of the brain use, shows that patients who panic from the infusion of lactate have higher blood flow and oxygen use in relevant parts of their brain than patients who don't panic.

Drugs. Two kinds of drugs relieve panic: tricyclic antidepressants and the antianxiety drug Xanax, and both work better than placebos. Panic attacks are dampened, and sometimes even eliminated. General anxiety and depression also decrease.

Since these four questions had already been answered "yes" when Jack Rachman called, I thought the issue had already been settled. Panic disorder was simply a biological illness, a disease of the body that could be relieved only by drugs.

A few months later I was in Bethesda, Maryland, listening once again to the same four lines of biological evidence. An inconspicuous figure in a brown suit sat hunched over the table. At the first break, Jack introduced me to him -- David Clark, a young psychologist from Oxford. Soon after, Clark began his address.

"Consider, if you will, an alternative theory, a cognitive theory." He reminded all of us that almost all panickers believe that they are going to die during an attack. Most commonly, they believe that they are having heart attacks. Perhaps, Clark suggested, this is more than just a mere symptom. Perhaps it is the root cause. Panic may simply be the catastrophic misinterpretation of bodily sensations.

For example, when you panic your heart starts to race. You notice this, and you see it as a possible heart attack. This makes you very anxious, which means your heart pounds more. You now notice that your heart is really pounding. You are now sure it's a heart attack. This terrifies you, and you break into a sweat, feel nauseated, short of breath -- all symptoms of terror, but for you, they're confirmation of a heart attack. A full-blown panic attack is under way, and at the root of it is your misinterpretation of the symptoms of anxiety as symptoms of impending death.

I was listening closely now as Clark argued that an obvious sign of a disorder, easily dismissed as a symptom, is the disorder itself. If he was right, this was an historic occasion. All Clark had done so far, however, was to show that the four lines of evidence for a biological view of panic could fit equally well with a misinterpretation view. But Clark soon told us about a series of experiments he and his colleague Paul Salkovskis had done at Oxford.

First, they compared panic patients with patients who had other anxiety disorders and with normals. All the subjects read the following sentences aloud, but the last word was presented blurred. For example:


If I had palpitations, I could be excited



If I were breathless, I could be unfit


When the sentences were about bodily sensations, the panic patients, but no one else, saw the catastrophic endings fastest. This showed that panic patients possess the habit of thinking Clark had postulated.

Next, Clark and his colleagues asked if activating this habit with words would induce panic. All the subjects read a series of word pairs a aloud. When panic patients got to "breathless-suffocation" and "palpitations-dying," 75 percent suffered a full-blown panic attack right there in the laboratory. No normal people had panic attacks, no recovered panic patients (I'll tell you more in a moment about how they got better) had attacks, and only 17 percent of other anxious patients had attacks.

The final thing Clark told us was the "breakthrough" that Rachman had promised.

"We have developed and tested a rather novel therapy for panic," Clark continued in his understated, disarming way. He explained that if catastrophic misinterpretations of bodily sensation are the cause of a panic attack, then changing the tendency to misinterpret should cure the disorder. His new therapy was straightforward and brief:

Patients are told that panic results when they mistake normal symptoms of mounting anxiety for symptoms of heart attack, going crazy, or dying. Anxiety itself, they are informed, produces shortness of breath, chest pain, and sweating. Once they misinterpret these normal bodily sensations as an imminent heart attack, their symptoms become even more pronounced because the misinterpretation changes their anxiety into terror. A vicious circle culminates in a full-blown panic attack.

Patients are taught to reinterpret the symptoms realistically as mere anxiety symptoms. Then they are given practice right in the office, breathing rapidly into a paper bag. This causes a buildup of carbon dioxide and shortness of breath, mimicking the sensations that provoke a panic attack. The therapist points out that the symptoms the patient is experiencing -- shortness of breath and heart racing -- are harmless, simply the result of overbreathing, not a sign of a heart attack. The patient learns to interpret the symptoms correctly.

"This simple therapy appears to be a cure," Clark told us. "Ninety to 100 percent of the patients are panic free at the end of therapy. One year later, only one person had had another panic attack.'

This, indeed, was a breakthrough: a simple, brief psychotherapy with no side effects showing a 90-percent cure rate of a disorder that a decade ago was thought to be incurable. In a controlled study of 64 patients comparing cognitive therapy to drugs to relaxation to no treatment, Clark and his colleagues found that cognitive therapy is markedly better than drugs or relaxation, both of which are better than nothing. Such a high cure rate is unprecedented.

How does cognitive therapy for panic compare with drugs? It is more effective and less dangerous. Both the antidepressants and Xanax produce marked reduction in panic in most patients, but drugs must be taken forever; once the drug is stopped, panic rebounds to where it was before therapy began for perhaps half the patients. The drugs also sometimes have severe side effects, including drowsiness, lethargy, pregnancy complications, and addictions.

After this bombshell, my own "discussion" was an anticlimax. I did make one point that Clark took to heart. "Creating a cognitive therapy that works, even one that works as well as this apparently does, is not enough to show that the cause of panic is cognitive:" I was niggling. "The biological theory doesn't deny that some other therapy might work well on panic. It merely claims that panic is caused at the bottom by some biochemical problem."

Two years later, Clark carried out a crucial experiment that tested the biological theory against the cognitive theory. He gave the usual lactate infusion to 10 panic patients, and nine of them panicked. He did the same thing with another 10 patients, but added special instructions to allay the misinterpretation of the sensations. He simply told them: "Lactate is a natural bodily substance that produces sensations similar to exercise or alcohol. It is normal to experience intense sensations during infusion, but these do not indicate an adverse reaction." Only three out of the 10 panicked. This confirmed the theory crucially.

The therapy works very well, as it did for Celia, whose story has a happy ending. She first tried Xanax, which reduced the intensity and the frequency of her panic attacks. But she was too drowsy to work, and she was still having about one attack every six weeks. She was then referred to Audrey, a cognitive therapist who explained that Celia was misinterpreting her heart racing and shortness of breath as symptoms of a heart attack, that they were actually just symptoms of mounting anxiety, nothing more harmful. Audrey taught Celia progressive relaxation, and then she demonstrated the harmlessness of Celia's symptoms of overbreathing. Celia then relaxed in the presence of the symptoms and found that they gradually subsided. After several more practice sessions, therapy terminated. Celia has gone two years without another panic attack.


Attend to your tongue -- right now. What is it doing? Mine is swishing around near my lower right molars. It has just found a minute fragment of last night's popcorn (debris from Terminator 2). Like a dog at a bone, it is worrying the firmly wedged flake.

Attend to your hand--right now. What's it up to? My left hand is boring in on an itch it discovered under my earlobe.

Your tongue and your hands have, for the most part, a life of their own. You can bring them under voluntary control by consciously calling them out of their "default" mode to carry out your commands: "Pick up the phone" or "Stop picking that pimple." But most of the time they are on their own. They are seeking out small imperfections. They scan your entire mouth and skin surface, probing for anything going wrong. They are marvelous, nonstop grooming devices. They, not the more fashionable immune system, are your first line of defense against invaders.

Anxiety is your mental tongue. Its default mode is to search for what may be about to go wrong. It continually, and without your conscious consent, scans your life- - yes, even when you are asleep, in dreams and nightmares. It reviews your work, your love, your play -- until it finds an imperfection. When it finds one, it worries it. It tries to pull it out from its hiding place, where it is wedged inconspicuously under some rock. It will not let go. If the imperfection is threatening enough, anxiety calls your attention to it by making you uncomfortable. If you do not act, it yells more insistently -- disturbing your sleep and your appetite.

You can reduce daily, mild anxiety. You can numb it with alcohol, Valium, or marijuana. You can take the edge off with meditation or progressive relaxation. You can beat it down by becoming more conscious of the automatic thoughts of danger that trigger anxiety and then disputing them effectively.

But do not overlook what your anxiety is trying to do for you. In return for the pain it brings, it prevents larger ordeals by making you aware of their possibility and goading you into planning for and forestalling them. It may even help you avoid them altogether. Think of your anxiety as the "low oil" light flashing on the dashboard of your car. Disconnect it and you will be less distracted and more comfortable for a while. But this may cost you a burned-up engine. Our dysphoria, or bad feeling, should, some of the time, be tolerated, attended to, even cherished.


Some of our everyday anxiety, depression, and anger go beyond their useful function. Most adaptive traits fall along a normal spectrum of distribution, and the capacity for internal bad weather for everyone some of the time means that some of us may have terrible weather all of the time. In general, when the hurt is pointless and recurrent -- when, for example, anxiety insists we formulate a plan but no plan will work -- it is time to take action to relieve the hurt. There are three hallmarks indicating that anxiety has become a burden that wants relieving:

First, is it irrational?

We must calibrate our bad weather inside against the real weather outside. Is what you are anxious about out of proportion to the reality of the danger? Here are some examples that may help you answer this question. All of the following are not irrational:

o A fire fighter trying to smother a raging oil well burning in Kuwait repeatedly wakes up at four in the morning because of flaming terror dreams.

o A mother of three smells perfume on her husband's shirts and, consumed by jealousy, broods about his infidelity, reviewing the list of possible women over and over.

o A student who had failed two of his midterm exams finds, as finals approach, that he can't get to sleep for worrying. He has diarrhea most of the time.

The only good thing that can be said about such fears is that they are well-founded.

In contrast, all of the following are irrational, out of proportion to the danger:

o An elderly man, having been in a fender bender, broods about travel and will no longer take cars, trains, or airplanes.

o An eight-year-old child, his parents having been through an ugly divorce, wets his bed at night. He is haunted with visions of his bedroom ceiling collapsing on him.

o A housewife who has an MBA and who accumulated a decade of experience as a financial vice president before her twins were born is sure her job search will be fruitless. She delays preparing her resumes for a month.

The second hallmark of anxiety out of control is paralysis. Anxiety intends action: Plan, rehearse, look into shadows for lurking dangers, change your life. When anxiety becomes strong, it is unproductive; no problem-solving occurs. And when anxiety is extreme, it paralyzes you. Has your anxiety crossed this line? Some examples:

o A woman finds herself housebound because she fears that if she goes out, she will be bitten by a cat.

o A salesman broods about the next customer hanging up on him and makes no more cold calls.

o A writer, afraid of the next rejection slip, stops writing.


Everyday anxiety level is not a category to which psychologists have devoted a great deal of attention. Enough research has been done, however, for me to recommend two techniques that quite reliably lower everyday anxiety levels. Both techniques are cumulative, rather than one-shot fixes. They require 20 to 40 minutes a day of your valuable time.

The first is progressive relaxation, done once or, better, twice a day for at least 10 minutes. In this technique, you tighten and then turn off each of the major muscle groups of your body until you are wholly flaccid. It is not easy to be highly anxious when your body feels like Jell-O. More formally, relaxation engages a response system that competes with anxious arousal.

The second technique is regular meditation. Transcendental mediation (TM) is one useful, widely available version of this. You can ignore the cosmology in which it is packaged if you wish, and treat it simply as the beneficial technique it is. Twice a day for 20 minutes, in a quiet setting, you close your eyes and repeat a mantra (a syllable whose "sonic properties are known") to yourself. Meditation works by blocking thoughts that produce anxiety. It complements relaxation, which blocks the motor components of anxiety but leaves the anxious thoughts untouched.

Done regularly, meditation usually induces a peaceful state of mind. Anxiety at other times of the day wanes, and hyperarousal from bad events is dampened. Done religiously, TM probably works better than relaxation alone.

There's also a quick fix. The minor tranquilizers -- Valium, Dalmane, Librium, and their cousins -- relieve everyday anxiety. So does alcohol. The advantage of all these is that they work within minutes and require no discipline to use. Their disadvantages outweigh their advantages, however. The minor tranquilizers make you fuzzy and somewhat uncoordinated as they work (a not uncommon side effect is an automobile accident). Tranquilizers soon lose their effect when taken regularly, and they are habit-forming -- probably addictive. Alcohol, in addition, produces gross cognitive and motor disability in lockstep with its anxiety relief. Taken regularly over long periods, deadly damage to liver and brain ensue.

If you crave quick and temporary relief from acute anxiety, either alcohol or minor tranquilizers, taken in small amounts and only occasionally, will do the job. They are, however, a distant second best to progressive relaxation and meditation, which are each worth trying before you seek out psychotherapy. Unlike tranquilizers and alcohol, neither of these techniques is likely to do you any harm.

Weigh your everyday anxiety. It it is not intense, or if it is moderate and not irrational or paralyzing, act now to reduce it. In spite of its deep evolutionary roots, intense everyday anxiety is often changeable. Meditation and progressive relaxation practiced regularly can change it forever.


I have been watching my weight and restricting my intake -- except for an occasional binge like this -- since I was 20. I weighed about 175 pounds then, maybe 15 pounds over my official "ideal" weight. I weigh 199 pounds now, 30 years later, about 25 pounds over the ideal. I have tried about a dozen regimes -- fasting, the Beverly Hills Diet, no carbohydrates, Metrecal for lunch, 1,200 calories a day, low fat, no lunch, no starches, skipping every other dinner. I lost 10 or 15 pounds on each in about a month. The pounds always came back, though, and I have gained a net of about a pound a year -- inexorably.

This is the most consistent failure in my life. It's also a failure I can't just put out of mind, I have spent the last few years reading the scientific literature, not the parade of best-selling diet books or the flood of women's magazine articles on the latest way to slim down. The scientific findings look clear to me, but there is not yet a consenus. I am going to go out on a limb, because I see so many signs all pointing in one direction. What I have concluded will, I believe, soon be the consensus of the scientists. The conclusions surprise me. They will probably surprise you, too, and they may change your life.

Hear is what the picture looks like to me:

o Dieting doesn't work.

o Dieting may make overweight worse, not better.

o Dieting may be bad for health.

o Dieting may cause eating disorders--including bulimea and anorexia.


Are you above the ideal weight for your sex, height, and age? If so, you are "overweight." What does this really mean? Ideal weight is arrived at simply. Four million people, now dead, who were insured by the major American life-insurance companies, once weighed in and had their height measured. At what weight on average do people of a given height turn out to live longest? That weight is called ideal. Anything wrong with that?

You bet. The real use of a weight table, and the reason your doctor takes it seriously, is that an ideal weight implies that, on average, if you slim down to yours, you will live longer. This is the crucial claim. Lighter people indeed live longer, on average, than heavier people, but how much longer is hotly debated.

But the crucial claim is unsound because weight (at any given height) has a normal distribution, normal both in a statistical sense and in the biological sense. In the biological sense, couch potatoes who overeat and never exercise can legitimately be called overweight, but the buxom, "heavy-boned" slow people deemed overweight by the ideal table are at their natural and healthiest weight. If you are a 135-pound woman and 64 inches in height, for example, you are "overweight" by around 15 pounds. This means nothing more than that the average 140-pound, 64-inch-tall woman lives somewhat longer than the average 155-pound woman of your height. It does not follow that if you slim down to 125 pounds, you will stand any better chance of living longer.

In spite of the insouciance with which dieting advice is dispensed, no one has properly investigated the question of whether slimming down to "ideal" weight produces longer life. The proper study would compare the longevity of people who are at their ideal weight without dieting to people who achieve their ideal weight by dieting. Without this study the common medical advice to diet down to your ideal weight is simply unfounded.

This is not a quibble; there is evidence that dieting damages your health and that this damage may shorten your life.


The advice to diet down to your ideal weight to live longer is one myth of overweight. Here are some others:

o Overweight people overeat. Wrong. Nineteen out of 20 studies show that obese people consume no more calories each day than nonobese people. Telling a fat person that if she would change her eating habits and eat "normally" she would lose weight is a lie. To lose weight and stay there, she will need to eat excruciatingly less than a normal person, probably for the rest of her life.

o Overweight people have an overweight personality. Wrong. Extensive research on personality and fatness has proved little. Obese people do not differ in any major personality style from nonobese people.

o Physical inactivity is a major cause of obesity. Probably not. Fat people are indeed less active than thin people, but the inactivity is probably caused more by the fatness than the other way around.

o Overweight shows a lack of willpower. This is the granddaddy of all the myths. Fatness is seen as shameful because we hold people responsible for their weight. Being overweight equates with being a weak-willed slob. We believe this primarily because we have seen people decide to lose weight and do so in a matter of weeks.

But almost everyone returns to the old weight after shedding pounds. Your body has a natural weight that it defends vigorously against dieting. The more diets tried, the harder the body works to defeat the next diet. Weight is in large part genetic. All this gives the lie to the "weak-willed" interpretations of overweight. More accurately, dieting is the conscious will of the individual against a more vigilant opponent: the species' biological defense against starvation. The body can't tell the difference between self-imposed starvation and actual famine, so it defends its weight by refusing to release fat, by lowering its metabolism, and by demanding food. The harder the creature tries not to eat, the more vigorous the defenses become.


A concept that makes sense of your body's vigorous defense against weight loss is natural weight. When your body screams "I'm hungry," makes you lethargic, stores fat, craves sweets and renders them more delicious than ever, and makes you obsessed with food, what it is defending is your natural weight. It is signaling that you have dropped into a range it will not accept. Natural weight prevents you from gaining too much weight or losing too much. When you eat too much for too long, the opposite defenses are activated and make long-term weight gain difficult.

There is also a strong genetic contribution to your natural weight. Identical twins reared apart weigh almost the same throughout their lives. When identical twins are overfed, they gain weight and add fat in lockstep and in the same places. The fatness or thinness of adopted children resembles their biological parents--particularly their mother--very closely but does not at all resemble their adoptive parents. This suggests that you have a genetically given natural weight that your body wants to maintain.

The idea of natural weight may help cure the new disorder that is sweeping young America. Hundreds of thousands of young women have contracted it. It consists of bouts of binge eating and purging alternating with days of undereating. These young women are usually normal in weight or a bit on the thin side, but they are terrified of becoming fat. So they diet. They exercise. They take laxatives by the cup. They gorge. Then they vomit and take more laxatives. This malady is called bulimia nervosa (bulimia, for short).

Therapists are puzzled by bulimia, its causes, and treatment. Debate rages about whether it is an equivalent of depression, or an expression of a thwarted desire for control, or a symbolic rejection of the feminine role. Almost every psychotherapy has been tried. Antidepressants and other drugs have been administered with some effect but little success has been reported.

I don't think that bulimia is mysterious, and I think that it will be curable. I believe that bulimia is caused by dieting. The bulimic goes on a diet, and her body attempts to defend its natural weight. With repeated dieting, this defense becomes more vigorous. Her body is in massive revolt -- insistently demanding food, storing fat, craving sweets, and lowering metabolism. Periodically, these biological defenses will overcome her extraordinary willpower (and extraordinary it must be to even approach an ideal weight, say, 20 pounds lighter than her natural weight). She will then binge. Horrified by what this will do to her figure, she vomits and takes laxatives to purge calories. Thus, bulimia is a natural consequence of self-starvation to lose weight in the midst of abundant food.

The therapist's task is to get the patient to stop dieting and become comfortable with her natural weight. He should first convince the patient that her binge eating is caused by her body's reaction to her diet. Then he must confront her with a question: Which is more important, staying thin or getting rid of bulimia? By stopping the diet, he will tell her, she can get rid of the uncontrollable binge-purge cycle. Her body will now settle at her natural weight, and she need not worry that she will balloon beyond that point. For some patients, therapy will end there because they would rather be bulimic than "loathsomely fat." For these patients, the central issue -- ideal weight versus natural weight -- can now at least become the focus of therapy. For others, defying the social and sexual pressure to be thin will be possible, dieting will be abandoned, weight will be gained, and bulimia should end quickly.

These are the central moves of the cognitive-behavioral treatment of bulimia. There are more than a dozen outcome studies of this approach, and the results are good. There is about 60 percent reduction in binging and purging (about the same as with antidepressant drugs). But unlike drugs, there is little relapse after treatment. Attitudes toward weight and shape relax, and dieting withers.

Of course, the dieting theory cannot fully explain bulimia. Many people who diet don't become bulimic; some can avoid it because their natural weight is close to their ideal weight, and therefore the diet they adopt does not starve them. In addition, bulimics are often depressed, since binging-purging leads to self-loathing. Depression may worsen bulimia by making it easier to give in to temptation. Further, dieting may just be another symptom of bulimia, not a cause. Other factors aside, I can speculate that dieting below your natural weight is a necessary condition for bulimia, and that returning to your natural weight and accepting that weight will cure bulimia.


Being heavy carries some health risk. There is no definite answer to how much, because there is a swamp of inconsistent findings. But even if you could just wish pounds away, never to return, it is not certain you should. Being somewhat above your "ideal" weight may actually be your healthiest natural condition, best for your particular constitution and your particular metabolism. Of course you can diet, but the odds are overwhelming that most of the weight will return, and that you will have to diet again and again. From a health and mortality perspective, should you? There is, probably, a serious health risk from losing weight and regaining it.

In one study, more than five thousand men and women from Farmingham, Massachusetts, were observed for 32 years. People whose weight fluctuated over the years had 30 to 100 percent greater risk of death from heart disease than people whose weight was stable. When corrected for smoking, exercise, cholesterol level, and blood pressure, the findings became more convincing, suggesting that weight fluctuation (the primary cause of which is presumably dieting) may itself increase the risk of heart disease.

If this result is replicated, and if dieting is shown to be the primary cause of weight cycling, it will convince me that you should not diet to reduce your risk of heart disease.


Depression is yet another cost of dieting, because two root causes of depression are failure and helplessness. Dieting sets you up for failure. Because the goal of slimming down to your ideal weight pits your fallible willpower against untiring biological defenses, you will often fail. At first you will lose weight and feel pretty good about it. Any depression you had about your figure will disappear, Ultimately, however, you will probably not reach your goal; and then you will be dismayed as the pounds return. Every time you look in the mirror or vacillate over a white chocolate mousse, you will be reminded of your failure, which in turn brings depression.

On the other hand, if you are one of the fortunate few who can keep the weight from coming back, you will probably have to stay on an unsatisfying low-calorie diet for the rest of your life. A side effect of prolonged malnutrition is depression. Either way, you are more vulnerable to it.

If you scan the list of cultures that have a thin ideal for women, you will be struck by something fascinating. All thin-ideal cultures also have eating disorders. They also have roughly twice as much depression in women as in men. (Women diet twice as much as men. The best estimator is that 13 percent of adult men and 25 percent of adult women are now on a diet.) The cultures without the thin ideal have no eating disorders, and the amount of depression in women and men in these cultures is the same. This suggests that around the world, the thin ideal and dieting not only cause eating disorders, but they may also cause women to be more depressed than men.


I have been dieting off and on for 30 years because I want to be more attractive, healthier, and more in control. How do these goals stack up against the facts?

Attractiveness. If your attractiveness is a high-enough priority to convince you to diet, keep three drawbacks in mind. First, the attractiveness you gain will be temporary. All the weight you lose and maybe more will likely come back in a few years. This will depress you. Then you will have to lose it again and it will be harder the second time. Or you will have to resign yourself to being less attractive. Second, when women choose the silhouette figure they want to achieve, it turns out to be thinner than the silhouette that men label most attractive. Third, you may well become bulimic particularly if your natural weight is substantially more than your ideal weight. On balance, if short-term attractiveness is your overriding goal, diet. But be prepared for the costs.

Health. No one has ever shown that losing weight will increase my longevity. On balance, the health goal does not warrant dieting.

Control. For many people, getting to an ideal weight and staying there is just as biologically impossible as going with much less sleep. This fact tells me not to diet, and defuses my feeling of shame. My bottom line is clear: I am not going to diet anymore.


Clearly, we have not yet developed drugs or psychotherapies that can change all the problems, personality types, and patterns of behavior in adult life. But I believe that success and failure stem from something other than inadequate treatment. Rather, it stems from the depth of the problem.

We all have the experience of psychological states of different depths. For example, if you ask someone, out of the blue, to answer quickly, "Who are you?" they will usually tell you -- roughly in this order -- their name, their sex, their profession, whether they have children, and their religion or race. Underlying this is a continuum of depth from surface to soul -- with all manner of psychic material in between.

I believe that issues of the soul can barely be changed by psychotherapy or by drugs. Problems and behavior patterns somewhere between soul and surface can be changed somewhat. Surface problems can be changed easily, even cured. What is changeable, by therapy or drugs, I speculate, varies with the depth of the problem.

My theory says that it does not matter when problems, habits, and personality are acquired; their depth derives only from their biology, their evidence, and their power. Some childhood traits, for example, are deep and unchangeable but not because they were learned early and therefore have a privileged place.

Rather, those traits that resist change do so either because they are evolutionarily prepared or because they acquire great power by virtue of becoming the framework around which later learning crystallizes. In this way, the theory of depth carries the optimistic message that we are not prisoners of our past.

When you have understood this message, you will never look at your life in the same way again. Right now there are a number of things that you do not like about yourself and that you want to change: your short fuse, your waistline, your shyness, your drinking, your glumness. You have decided to change, but you do not know what you should work on first. Formerly you would have probably selected the one that hurts the most. Now you will also ask yourself which attempt is most likely to repay your efforts and which is most likely to lead to further frustration. Now you know your shyness and your anger are much more likely to change than your drinking, which you now know is more likely to change than your waistline.

Some of what does change is under your control, and some is not. You can best prepare yourself to change by learning as much as you can about what you can change and how to make those changes. Like all true education, learning about change is not easy; harder yet is surrendering some of our hopes. It is certainly not my purpose to destroy your optimism about change. But it is also not my purpose to assure everybody they can change in every way. My purpose is to instill a new, warranted optimism about the parts of your life you can change and so help you focus your limited time, money, and effort on making actual what is truly within your reach.

Life is a long period of change. What you have been able to change and what has resisted your highest resolve might seem chaotic to you: for some of what you are never changes no matter how hard you try, and other aspects change readily. My hope is that this essay has been the beginning of wisdom about the difference.

What Can We Change?

When we survey all the problems, personality types, patterns of behavior, and the weak influence of childhood on adult life, we see a puzzling array of how much change occurs. From the things that are easiest to those that are the most difficult, this rough array emerges:

Panic -- Curable

Specific Phobia -- Almost Curable

Sexual Dysfunctions -- Marked Relief

Social Phobia -- Moderate Relief

Agoraphobia -- Moderate Relief

Depression -- Moderate Relief

Sex Role Change -- Moderate

Obsessive-Compulsive Disorders - Mild Relief

Sexual Preferences Moderate, Mild Change

Anger Mild, Moderate Relief

Everyday Anxiety Mild Moderate Relief

Alcoholism Mild Relief

Overweight Temporary Change

Posttraumatic Stress Disorder (PTSD) Marginal Relief

Sexual Orientation Probably Unchangeable

Sexual Identity Unchangeable

Self-Analysis Questionnaire

Is your life dominated by anxiety? Read each statement and the mark the appropriate number to indicate how you generally feel. There are no right or wrong answers.

1. I am a steady person.

Almost never, Sometimes, Often, Almost always

4 3 2 1

2. I am satisfied with myself.

Almost never, Sometimes, Often , Almost always

4 3 2 1

3. I feel nervous and restless.

Almost never, Sometimes, Often, Almost always

1 2 3 4

4. I wish I could be as happy as others seem to be.

Almost never, Sometimes, Often, Almost always

1 2 3 4

5. I feel like a failure.

Almost never, Sometimes, Often , Almost always

1 2 3 4

6. I get in a state of tension and turmoil as I think over my

recent concerns and interests.

Almost never, Sometimes, Often, Almost always

1 2 3 4

7. I feel secure.

Almost never, Sometimes, Often, Almost always

4 3 2 1

8. I have self-confidence.

Almost never, Sometimes , Often, Almost always

4 3 2 1

9. I feel inadequate.

Almost never, Sometimes, Often, Almost always

1 2 3 4

10. I worry too much over something that does not matter.

Almost never, Sometimes, Often , Almost always

1 2 3 4

To score, simply add up the numbers under your answers. Notice that

some of the rows of numbers go up and others go down. The higher

your total, the more the trait of anxiety dominates your life. If

your score was:

10-11, you are in the lowest 10 percent of anxiety.

13-14, you are in the lowest quarter.

16-17, your anxiety level is about average.

19-20, Your anxiety level is around the 75th percentile.

22-24 (and you are male) your anxiety level is around the 90th


24-26 (and you are female) your anxiety level is around the

90th percentile.

25 (and you are male) your anxiety level is at the 95th


27 (and you are female) your anxiety level is at the 95th


Should you try to change your anxiety level? Here are my rules of thumb:

o If your score is at the 90th percentile or above, you can probably improve the quality of your life by lowering your general anxiety level -- regardless of paralysis and irrationality.

o If your score is at the 75th percentile or above, and you feel that anxiety is either paralyzing you or that it is unfounded, you should probably try to lower your general anxiety level.

o If your score is 18 or above, and you feel that anxiety is unfounded and paralyzing, you should probably try to lower your general anxiety level.

Excerpted from the book What You Can Change and What You Can't (Alfred A. Knopf) by Martin E. P. Seligman. Copyright (c), 1993 by Martin E. P. Seligman.

By: Martin Seligman
Originally published by Psychology Today:May/Jun 94
source from http://health.yahoo.com/centers/anxiety/1496





Provided by Psychology Today

The term agoraphobia is translated from Greek as "fear of the marketplace." Agoraphobia today describes severe and pervasive anxiety about being in situations from which escape might be difficult or embarrassing and/or from which help may not be available should a panic attack occur. This anxiety leads to the following behavior: 1) avoidance of these types of situations, i.e., being alone outside of the home, traveling in a car, bus, or airplane, being in a crowded area, or being on a bridge; 2) endurance of such situations under great stress, i.e., a panic attack may occur; or 3) requiring another person's company when in said situations. Agoraphobia typically accompanies a panic disorder although on rare occasions, it may also occur when criteria of a panic disorder are not fully met (Morrison, 1995). In panic disorder, panic attacks recur and the person develops an intense apprehension of having another attack. This fear - called anticipatory anxiety or fear of fear - can be present most of the time and seriously interfere with the person's life even when a panic attack is not in progress. In addition, the person may develop irrational fears called phobias, such as agoraphobia, about situations where a panic attack has occurred. If agoraphobia occurs with panic disorder, the onset is usually during the 20s, and women are affected more often than men.

Agoraphobia affects about a third of all people with panic disorder. Typically, people with agoraphobia restrict themselves to a "zone of safety" that may include only the home or the immediate neighborhood. Any movement beyond the edges of this zone creates mounting anxiety. As noted earlier, sometimes a person with agoraphobia is unable to leave home alone, but can travel if accompanied by a particular family member or friend. Even when they restrict themselves to "safe" situations, most people with agoraphobia continue to have panic attacks at least a few times a month.

People with agoraphobia can be seriously disabled by their condition. Some are unable to work, and they may need to rely heavily on other family members, who must do the shopping and run all the household errands, as well as accompany the affected person on rare excursions outside the "safety zone." People with this disorder may become house bound for years, with resulting impairment of social and interpersonal relationships. Thus the person with agoraphobia typically leads a life of extreme dependency as well as great discomfort.


Fear of being alone
Fear of losing control in a public place
Fear of being in places where escape might be difficult
Becoming house bound for prolonged periods
Feelings of detachment or estrangement from others
Feelings of helplessness
Dependence upon others
Feeling that the body is unreal
Feeling that the environment is unreal
Anxiety or panic attack (acute severe anxiety)
Unusual temper or agitation with trembling or twitching

Additional symptoms that may occur:

Lightheadedness, near Fainting
Excessive sweating
Skin flushing
Breathing difficulty
Chest pain
Heartbeat sensations
Nausea and vomiting
Numbness and tingling
Abdominal distress that occurs when upset
Confused or disordered thoughts
Intense fear of going crazy
Intense fear of dying

There may be a history of phobias, or the health care provider may receive a description of typical behaviors from family, friends, or the affected person. The pulse (heart rate) is often rapid, sweating is present, and the patient may have high blood pressure. A person may be described as having Agoraphobia if other mental disorders or medical conditions do not provide better explanation for the person's symptoms.

The etiology of most anxiety disorders, although not fully understood, has come into sharper focus in the last decade. In broad terms, the likelihood of developing anxiety involves a combination of life experiences, psychological traits, and/or genetic factors. The anxiety disorders are so heterogeneous that the relative roles of these factors are likely to differ. It is not clear why females have higher rates than males of most anxiety disorders, although some theories have suggested a role for the gonadal steroids. Other research on women's responses to stress also suggests that women experience a wider range of life events (e.g., those happening to friends) as stressful as compared with men who react to a more limited range of stressful events, specifically those affecting themselves or close family members.

The National Institute of Mental Health supports a sizable and multifaceted research program on panic disorder - its causes, diagnosis, treatment, and prevention. This research involves studies of panic disorder in human subjects and investigations of the biological basis for anxiety and related phenomena in animals. It is part of a massive effort to overcome the major mental disorders, an effort that started during the 1990s - the Decade of the Brain. Here is a description of some of the most important new research on panic disorder and its causes.

Genetics. Panic disorder runs in families. One study has shown that if one twin in a genetically identical pair has panic disorder, it is likely that the other twin will also. Fraternal, or non-identical twin pairs do not show this high degree of "concordance" with respect to panic disorder. Thus, it appears that some genetic factor, in combination with environment, may be responsible for vulnerability to this condition.

NIMH-supported scientists are studying families in which several individuals have panic disorder. The aim of these studies is to identify the specific gene or genes involved in the condition. Identification of these genes may lead to new approaches for diagnosing and treating panic disorder.

Brain and Biochemical Abnormalities. One line of evidence suggests that panic disorder may be associated with increased activity in the hippocampus and locus coeruleus, portions of the brain that monitor external and internal stimuli and control the brain's responses to them. Also, it has been shown that panic disorder patients have increased activity in a portion of the nervous system called the adrenergic system, which regulates such physiological functions as heart rate and body temperature. However, it is not clear whether these increases reflect the anxiety symptoms or whether they cause them.

Another group of studies suggests that people with panic disorder may have abnormalities in their benzodiazepine receptors, brain components that react with anxiety-reducing substances within the brain.

In conducting their research, scientists can use several different techniques to provoke panic attacks in people who have panic disorder. The best known method is intravenous administration of sodium lactate, the same chemical that normally builds up in the muscles during heavy exercise. Other substances that can trigger panic attacks in susceptible people include caffeine (generally 5 or more cups of coffee are required). Hyperventilation and breathing air with a higher-than-usual level of carbon dioxide can also trigger panic attacks in people with panic disorder.

Because these provocations generally do not trigger panic attacks in people who do not have panic disorder, scientists have inferred that individuals who have panic disorder are biologically different in some way from people who do not. However, it is also true that when the people prone to panic attacks are told in advance about the sensations these provocations will cause, they are much less likely to panic. This suggests that there is a strong psychological component, as well as a biological one, to panic disorder.

NIMH-supported investigators are examining specific parts of the brain and central nervous system to learn which ones play a role in panic disorder, and how they may interact to give rise to this condition. Other studies funded by the Institute are under way to determine what happens during "provoked" panic attacks, and to investigate the role of breathing irregularities in anxiety and panic attacks.

Animal Studies. Studies of anxiety in animals are providing NIMH-sponsored researchers with clues to the underlying causes of this phenomenon. One series of studies involves an inbred line of pointer dogs that exhibit extreme, abnormal fearfulness when approached by humans or startled by loud noises. In contrast with normal pointers, these nervous dogs have been found to react more strongly to caffeine and to have brain tissue that is richer in receptors for adenosine, a naturally occurring sedative that normally exerts a calming effect within the brain. Further study of these animals is expected to reveal how a genetic predisposition toward anxiety is expressed in the brain.

Other animal studies involve macaque monkeys. Some of these animals exhibit anxiety when challenged with an infusion of lactate, much like people with panic disorder. Other macaques do not exhibit this response. NIMH-supported scientists are attempting to determine how the brains of the responsive and non-responsive monkeys differ. This research should provide additional information on the causes of panic disorder.

In addition, research with rats is exploring the effect of various medications on the parts of the brain involved in anxiety. The aim is to develop a clearer picture of which components of the brain are responsible for anxiety, and to learn how their actions can be brought under better control.

Cognitive Factors. Scientists funded by NIMH are investigating the basic thought processes and emotions that come into play during a panic attack and those that contribute to the development and persistence of agoraphobia. The Institute also supports research evaluating the impact of various versions of cognitive-behavioral therapy to determine which variants of the procedure are effective for which people. The NIMH panic disorder research program will also explore the effects of interpersonal stress such as marital conflict on panic disorder with agoraphobia and determine if including spouses in the cognitive-behavioral treatment of the condition improves outcome.

The goal of treatment is to help the phobic person function effectively. The success of treatment usually depends upon the severity of the phobia. Systematic desensitization or graded real-life exposure, called "exposure therapy," is a behavioral technique used to treat phobias. It is based upon having the person relax, then imagine the components of the phobia, working from the least fearful to the most fearful. The individual will work with a therapist to develop coping strategies such as relaxation and breathing techniques et al. While "in vivo" or real-life exposure is ideal, imagined exposure is also an acceptable alternative in desensitization exercises. Treating agoraphobia with Exposure Therapy reduced anxiety and improved morale and quality of life with in 75% of cases.

Other types of therapy, such as cognitive therapy, assertiveness training, biofeedback, hypnosis, meditation, relaxation or couples therapy were found to be helpful for some patients. Cognitive-Behavioral Therapy is a combination of cognitive therapy, which can modify or eliminate thought patterns contributing to the patient's symptoms, and behavioral therapy, i.e., "in vivo" or real-life exposure therapy, which aims to help the patient change his or her behavior.

Treatment is complicated by the fact that often patients have difficulty getting to appointments because of their fears. To address this issue, some therapists will go to an agoraphobic patient's home to conduct the initial sessions. Often therapists take their patients on excursions to shopping malls and other places the patients have been avoiding. Or they may accompany their patients who are trying to overcome fear of driving a car.

The patient approaches a feared situation gradually, attempting to stay in spite of rising levels of anxiety. In this way the patient sees that as frightening as the feelings are, they are not dangerous, and they do pass. On each attempt, the patient faces as much fear as he or she can stand. Patients find that with this step-by-step approach, aided by encouragement and skilled advice from the therapist, they can gradually master their fears and enter situations that had seemed unapproachable.

Many therapists assign the patient "homework" to do between sessions. Sometimes patients spend only a few sessions in one-on-one contact with a therapist and continue to work on their own with the aid of a printed manual.

Often the patient will join a therapy group with others striving to overcome panic disorder or phobias, meeting with them weekly to discuss progress, exchange encouragement, and receive guidance from the therapist.

Cognitive-behavioral therapy generally requires at least 8 to 12 weeks. Some people may need a longer time in treatment to learn and implement the skills. This kind of therapy, which is reported to have a low relapse rate, is effective in eliminating panic attacks or reducing their frequency. It also reduces anticipatory anxiety and the avoidance of feared situations.

Treatment with Medications

In this treatment approach, which is also called pharmacotherapy, a prescription medication is used both to prevent panic attacks or reduce their frequency and severity, and to decrease the associated anticipatory anxiety. When patients find that their panic attacks are less frequent and severe, they are increasingly able to venture into situations that had been off-limits to them. In this way, they benefit from exposure to previously feared situations as well as from the medication.

The three groups of medications most commonly used are the tricyclic antidepressants, the high-potency benzodiazepines, and the monoamine oxidase inhibitors (MAOIs). Determination of which drug to use is based on considerations of safety, efficacy, and the personal needs and p Referencesof the patient. Some information about each of the classes of drugs follows.

The tricyclic antidepressants were the first medications shown to have a beneficial effect against panic disorder. Imipramine is the tricyclic most commonly used for this condition. When imipramine is prescribed, the patient usually starts with small daily doses that are increased every few days until an effective dosage is reached. The slow introduction of imipramine helps minimize side effects such as dry mouth, constipation, and blurred vision. People with panic disorder, who are inclined to be hypervigilant about physical sensations, often find these side effects disturbing at the outset. Side effects usually fade after the patient has been on the medication a few weeks.

It usually takes several weeks for imipramine to have a beneficial effect on panic disorder. Most patients treated with imipramine will be panic-free within a few weeks or months. Treatment generally lasts from 6 to 12 months. Treatment for a shorter period of time is possible, but there is substantial risk that when imipramine is stopped, panic attacks will recur. Extending the period of treatment to 6 months to a year may reduce this risk of a relapse. When the treatment period is complete, the dosage of imipramine is tapered over a period of several weeks.

The high-potency benzodiazepines are a class of medications that effectively reduce anxiety. Alprazolam, clonazepam, and lorazepam are medications that belong to this class. They take effect rapidly, have few bothersome side effects, and are well tolerated by the majority of patients. However, some patients, especially those who have had problems with alcohol or drug dependency, may become dependent on benzodiazepines.

Generally, the physician prescribing one of these drugs starts the patient on a low dose and gradually increases it until panic attacks cease. This procedure minimizes side effects.

Treatment with high-potency benzodiazepines is usually continued for 6 months to a year. One drawback of these medications is that patients may experience withdrawal symptoms - malaise, weakness, and other unpleasant effects - when the treatment is discontinued. Reducing the dose gradually generally minimizes these problems. There may also be a recurrence of panic attacks after the medication is withdrawn.

Of the MAOIs, a class of antidepressants which have been shown to be effective against panic disorder, phenelzine is the most commonly used. Treatment with phenelzine usually starts with a relatively low daily dosage that is increased gradually until panic attacks cease or the patient reaches a maximum dosage of about 100 milligrams a day.

Use of phenelzine or any other MAOI requires the patient to observe exacting dietary restrictions, because there are foods and prescription drugs and certain substances of abuse that can interact with the MAOI to cause a sudden, dangerous rise in blood pressure. All patients who are taking MAOIs should obtain their physician's guidance concerning dietary restrictions and should consult with their physician before using any over-the-counter or prescription medications.

As in the case of the high-potency benzodiazepines and imipramine, treatment with phenelzine or another MAOI generally lasts 6 months to a year. At the conclusion of the treatment period, the medication is gradually tapered.

Newly available antidepressants such as fluoxetine (one of a class of new agents called serotonin reuptake inhibitors) appear to be effective in selected cases of panic disorder. As with other anti-panic medications, it is important to start with very small doses and gradually increase the dosage.

Scientists supported by NIMH are seeking ways to improve drug treatment for panic disorder. Studies are underway to determine the optimal duration of treatment with medications, who they are most likely to help, and how to moderate problems associated with withdrawal.

Combination Treatments

Some patients with anxiety disorders may benefit from both psychotherapy and pharmacotherapy treatment modalities, either combined or used in sequence. The combined approach is said to offer rapid relief, high effectiveness, and a low relapse rate. Drawing from the experiences of depression researchers, it seems likely that such combinations are not uniformly necessary and are probably more cost-effective when reserved for patients with more complex, complicated, severe, or comorbid disorders. The benefits of multimodal therapies for anxiety need further study.Comparing medications and psychological treatments, and determining how well they work in combination, is the goal of several NIMH-supported studies. The largest of these is a 4-year clinical trial that will include 480 patients and involve four centers at the State University of New York at Albany, Cornell University, Hillside Hospital/Columbia University, and Yale University. This study is designed to determine how treatment with imipramine compares with a cognitive-behavioral approach, and whether combining the two yields benefits over either method alone.

Psychodynamic Treatment

This is a form of "talk therapy" in which the therapist and the patient, working together, seek to uncover emotional conflicts that may underlie the patient's problems. By talking about these conflicts and gaining a better understanding of them, the patient is helped to overcome the problems. Often, psychodynamic treatment focuses on events of the past and making the patient aware of the ramifications of long-buried problems.

Although psychodynamic approaches may help to relieve the stress that contributes to panic attacks, they do not seem to stop the attacks directly. In fact, there is no scientific evidence that this form of therapy by itself is effective in helping people to overcome panic disorder or agoraphobia. However, if a patient's panic disorder occurs along with some broader and pre-existing emotional disturbance, psychodynamic treatment may be a helpful addition to the overall treatment program.

By: Psychology Today Staff
Originally published by Psychology Today:20021010


Acute Stress Disorder


Acute Stress Disorder

Provided by Psychology Today

Acute Stress Disorder develops within one month after an individual experienced or saw an event that involved a threat or actual death, serious injury or another kind of physical violation to the individual or others AND responded to this event with strong feelings of fear, helplessness or horror. The diagnosis was established to identify those individuals who would eventually develop Post-Traumatic Stress Disorder. While this is a relatively new diagnosis, for years this condition was referred to as "shell shock" and though it stems from reactions of soldiers as far back as the U. S. Civil War in 1865, civilians may also suffer from it. More recently, ASD was brought to light as it became clear that for a short period, people might exhibit PTSD-like symptoms immediately after a trauma (Morrison, 1995).

"Trauma" has both a medical and a psychiatric definition. Medically, "trauma" refers to a serious or critical bodily injury, wound, or shock. This definition is often associated with trauma medicine practiced in emergency rooms and represents a popular view of the term. Psychiatrically, "trauma" has assumed a different meaning and refers to an experience that is emotionally painful, distressful, or shocking, which often results in lasting mental and physical effects.

Psychiatric trauma, or emotional harm, is essentially a normal response to an extreme event. It involves the creation of emotional memories about the distressful event that are stored in structures deep within the brain. In general, it is believed that the more direct the exposure to the traumatic event, the higher the risk for emotional harm. Thus in a school shooting, for example, the student who is injured probably will be most severely affected emotionally; and the student who sees a classmate shot, even killed, is likely to be more emotionally affected than the student who was in another part of the school when the violence occurred. But even second-hand exposure to violence can be traumatic. For this reason, all children and adolescents exposed to violence or a disaster, even if only through graphic media reports, should be watched for signs of emotional distress.

Symptoms persisting for a minimum of two days to up to 4 weeks within a month of the trauma.

A person may be described as having Acute Stress Disorder if other mental disorders or medical conditions do not provide better explanation for the person's symptoms. If symptoms persist after a month, the diagnosis becomes Post Traumatic Stress Disorder (Morrison, 1995).

Lack of emotional responsiveness, a sense of numbing, or detachment
A reduced sense of surroundings
A sense of not being real
Depersonalization or a sense of being dissociated from self
An inability to remember parts of the trauma, "dissociative amnesia"
Increased state of anxiety and "arousal" such as a difficulty staying awake or falling asleep
Have trouble experiencing pleasure
Repeatedly re-experiencing the event through recurring images and/or thoughts, dreams, illusions, flashbacks
Purposeful avoidance of exposure to thoughts, emotions, conversations, places or people that remind them of the trauma
Feelings of stress interfering with functioning; social and occupational skills are impaired affecting the patient's ability to function, pursue required tasks and seek treatment

When a fearful or threatening event is perceived, humans react innately to survive: they either are ready for battle or run away (hence the term "fight-or-flight response"). The nature of the acute stress response is all too familiar. Its hallmarks are an almost instantaneous surge in heart rate, blood pressure, sweating, breathing, and metabolism, and a tensing of muscles. Enhanced cardiac output and accelerated metabolism are essential for mobilizing fast action. This explanation is thought to be in part a cause for anxiety disorders. Yet over the past decade, the limitations of the acute stress response as a model for understanding anxiety have become more apparent. The first and most obvious limitation is that the acute stress response relates to arousal rather than anxiety. Anxiety differs from arousal in several ways. First, with anxiety, the concern about the stressor is out of proportion to the realistic threat. Second, anxiety is often associated with elaborate mental and behavioral activities designed to avoid the unpleasant symptoms of a full-blown anxiety or panic attack. Third, anxiety is usually longer lived than arousal. Fourth, anxiety can occur without exposure to an external stressor. Cognitive factors, especially the way people interpret or think about stressful events, play a critical role in the etiology of anxiety. A decisive factor is the individual's perception, which can intensify or dampen the response. One of the most salient negative cognitions in anxiety is the sense of uncontrollability. It is typified by a state of helplessness due to a perceived inability to predict, control, or obtain desired results. These are among the factors considered as causes of anxiety disorders such as Acute Stress Disorder.

The individual with acute stress disorder often will not seek treatment because their ability to mobilize and perform necessary tasks is affected. The severity of the disorder may be reduced if professional intervention is initiated soon after the trauma. Treatment involves a combination of medications and psychotherapy.


Psychotherapy involves talking with a trained mental health professional, such as a psychiatrist, psychologist, social worker, or counselor to learn how to deal with problems like anxiety disorders. Among the psychotherapy treatments that may be used are: Adlerian Therapy, Behavior Therapy, Existential Therapy, Gestalt Therapy, Person-Centered Therapy, Psychoanalytic Therapy, Rational-Emotive and Cognitive-Behavioral Therapy, Reality Therapy, Transactional Analysis.

Cognitive-Behavioral and Behavioral Therapy

Research has shown that a form of psychotherapy that is effective for several anxiety disorders, particularly panic disorder and social phobia, is cognitive-behavioral therapy (CBT). It has two components. The cognitive component helps people change thinking patterns that keep them from overcoming their fears. For example, a person with panic disorder might be helped to see that his or her panic attacks are not really heart attacks as previously feared; the tendency to put the worst possible interpretation on physical symptoms can be overcome. Similarly, a person with social phobia might be helped to overcome the belief that others are continually watching and harshly judging him or her.

The behavioral component of CBT seeks to change people's reactions to anxiety-provoking situations. A key element of this component is exposure, in which people confront the things they fear. An example would be a treatment approach called exposure and response prevention for people with OCD. If the person has a fear of dirt and germs, the therapist may encourage them to dirty their hands, then go a certain period of time without washing. The therapist helps the patient to cope with the resultant anxiety. Eventually, after this exercise has been repeated a number of times, anxiety will diminish. In another sort of exposure exercise, a person with social phobia may be encouraged to spend time in feared social situations without giving in to the temptation to flee. In some cases the individual with social phobia will be asked to deliberately make what appear to be slight social blunders and observe other people's reactions; if they are not as harsh as expected, the person's social anxiety may begin to fade. For a person with PTSD, exposure might consist of recalling the traumatic event in detail, as if in slow motion, and in effect re-experiencing it in a safe situation. If this is done carefully, with support from the therapist, it may be possible to defuse the anxiety associated with the memories. Another behavioral technique is to teach the patient deep breathing as an aid to relaxation and anxiety management.

Behavioral therapy alone, without a strong cognitive component, has long been used effectively to treat specific phobias. Here also, therapy involves exposure. The person is gradually exposed to the object or situation that is feared. At first, the exposure may be only through pictures or audiotapes. Later, if possible, the person actually confronts the feared object or situation. Often the therapist will accompany him or her to provide support and guidance.

If you undergo CBT or behavioral therapy, exposure will be carried out only when you are ready; it will be done gradually and only with your permission. You will work with the therapist to determine how much you can handle and at what pace you can proceed.

A major aim of CBT and behavioral therapy is to reduce anxiety by eliminating beliefs or behaviors that help to maintain the anxiety disorder. For example, avoidance of a feared object or situation prevents a person from learning that it is harmless. Similarly, performance of compulsive rituals in OCD gives some relief from anxiety and prevents the person from testing rational thoughts about danger, contamination, etc.

To be effective, CBT or behavioral therapy must be directed at the person's specific anxieties. An approach that is effective for a person with a specific phobia about dogs is not going to help a person with OCD who has intrusive thoughts of harming loved ones. Even for a single disorder, such as OCD, it is necessary to tailor the therapy to the person's particular concerns. CBT and behavioral therapy have no adverse side effects other than the temporary discomfort of increased anxiety, but the therapist must be well trained in the techniques of the treatment in order for it to work as desired. During treatment, the therapist probably will assign "homework"-specific problems that the patient will need to work on between sessions.

CBT or behavioral therapy generally lasts about 12 weeks. It may be conducted in a group, provided the people in the group have sufficiently similar problems. Group therapy is particularly effective for people with social phobia. There is some evidence that, after treatment is terminated, the beneficial effects of CBT last longer than those of medications for people with panic disorder; the same may be true for OCD, PTSD, and social phobia.

Medication may be combined with psychotherapy, and for many people this is the best approach to treatment. As stated earlier, it is important to give any treatment a fair trial. And if one approach doesn't work, the odds are that another one will, so don't give up.

If you have recovered from an anxiety disorder, and at a later date it recurs, don't consider yourself a "treatment failure." Recurrences can be treated effectively, just like an initial episode. In fact, the skills you learned in dealing with the initial episode can be helpful in coping with a setback.


Psychiatrists or other physicians can prescribe medications for anxiety disorders. These doctors often work closely with psychologists, social workers, or counselors who provide psychotherapy. Although medications won't cure an anxiety disorder, they can keep the symptoms under control and enable you to lead a normal, fulfilling life. The paragraph below gives a brief overview of medications. Continue reading for more in-depth information.

Anti-anxiety medications may be prescribed for short-term relief of mild to moderate cases of anxiety disorders. Beta-blockers (such as anti-anginals) are often prescribed for treatment of anxiety disorders but are not FDA approved for treatment of this disorder. Effective anti-anxiety medications include benzodiazepines, (ex. Xanax and Klonopin) although side effects for a small percentage of patients may include sleepiness, slight memory impairment and possible dependency on the medication (Nathan et al., 1999). Anti-depressants from the selective serotonin reuptake inhibitor (SSRI) family of drugs may be prescribed (ex. Paxil, Zoloft), as may anti-convulsant medications.

The major classes of medications used for various anxiety disorders are described in more detail below.


A number of medications that were originally approved for treatment of depression have been found to be effective for anxiety disorders. If your doctor prescribes an antidepressant, you will need to take it for several weeks before symptoms start to fade. So it is important not to get discouraged and stop taking these medications before they've had a chance to work.

Some of the newest antidepressants are called selective serotonin reuptake inhibitors, or SSRIs. These medications act in the brain on a chemical messenger called serotonin. SSRIs tend to have fewer side effects than older antidepressants. People do sometimes report feeling slightly nauseated or jittery when they first start taking SSRIs, but that usually disappears with time. Some people also experience sexual dysfunction when taking some of these medications. An adjustment in dosage or a switch to another SSRI will usually correct bothersome problems. It is important to discuss side effects with your doctor so that he or she will know when there is a need for a change in medication.

Fluoxetine, sertraline, fluvoxamine, paroxetine, and citalopram are among the SSRIs commonly prescribed for panic disorder, OCD, PTSD, and social phobia. SSRIs are often used to treat people who have panic disorder in combination with OCD, social phobia, or depression. Venlafaxine, a drug closely related to the SSRIs, is useful for treating GAD. Other newer antidepressants are under study in anxiety disorders, although one, bupropion, does not appear effective for these conditions. These medications are started at a low dose and gradually increased until they reach a therapeutic level.

Similarly, antidepressant medications called tricyclics are started at low doses and gradually increased. Tricyclics have been around longer than SSRIs and have been more widely studied for treating anxiety disorders. For anxiety disorders other than OCD, they are as effective as the SSRIs, but many physicians and patients prefer the newer drugs because the tricyclics sometimes cause dizziness, drowsiness, dry mouth, and weight gain. When these problems persist or are bothersome, a change in dosage or a switch in medications may be needed.

Tricyclics are useful in treating people with co-occurring anxiety disorders and depression. Clomipramine, the only antidepressant in its class prescribed for OCD, and imipramine, prescribed for panic disorder and GAD, are examples of tricyclics.

Monoamine oxidase inhibitors, or MAOIs, are the oldest class of antidepressant medications. The most commonly prescribed MAOI is phenelzine, which is helpful for people with panic disorder and social phobia. Tranylcypromine and isoprocarboxazid are also used to treat anxiety disorders. People who take MAOIs are put on a restrictive diet because these medications can interact with some foods and beverages, including cheese and red wine, which contain a chemical called tyramine. MAOIs also interact with some other medications, including SSRIs. Interactions between MAOIs and other substances can cause dangerous elevations in blood pressure or other potentially life-threatening reactions.

Anti-Anxiety Medications

High-potency benzodiazepines relieve symptoms quickly and have few side effects, although drowsiness can be a problem. Because people can develop a tolerance to them-and would have to continue increasing the dosage to get the same effect-benzodiazepines are generally prescribed for short periods of time. One exception is panic disorder, for which they may be used for 6 months to a year. People who have had problems with drug or alcohol abuse are not usually good candidates for these medications because they may become dependent on them.

Some people experience withdrawal symptoms when they stop taking benzodiazepines, although reducing the dosage gradu-ally can diminish those symptoms. In certain instances, the symptoms of anxiety can rebound after these medications are stopped. Potential problems with benzodiazepines have led some physicians to shy away from using them, or to use them in inadequate doses, even when they are of potential benefit to the patient. Benzodiazepines include clonazepam, which is used for social phobia and GAD; alprazolam, which is helpful for panic disorder and GAD; and lorazepam, which is also useful for panic disorder.

Buspirone, a member of a class of drugs called azipirones, is a newer anti-anxiety medication that is used to treat GAD. Possible side effects include dizziness, headaches, and nausea. Unlike the benzodiazepines, buspirone must be taken consistently for at least two weeks to achieve an anti-anxiety effect.

Other Medications

Beta-blockers, such as propanolol, are often used to treat heart conditions but have also been found to be helpful in certain anxiety disorders, particularly in social phobia. When a feared situation, such as giving an oral presentation, can be predicted in advance, your doctor may prescribe a beta-blocker that can be taken to keep your heart from pounding, your hands from shaking, and other physical symptoms from developing.

Taking Medications

Before taking medication for an anxiety disorder:

Ask your doctor to tell you about the effects and side effects of the drug he or she is prescribing.

Tell your doctor about any alternative therapies or over-the-counter medications you are using.

Ask your doctor when and how the medication will be stopped. Some drugs can't safely be stopped abruptly; they have to be tapered slowly under a physician's supervision.

Be aware that some medications are effective in anxiety disorders only as long as they are taken regularly, and symptoms may occur again when the medications are discontinued.

Work together with your doctor to determine the right dosage of the right medication to treat your anxiety disorder.

Alternative Therapy

Alternative approaches to treat acute stress disorder include acupuncture, and meditation, breathing exercises and yoga, which may be combined with psychotherapy. Homeopathic treatments and the use of herbal medicine may help the patient rebalance.

Strategies to Make Treatment More Effective

Many people with anxiety disorders benefit from joining a self-help group and sharing their problems and achievements with others. Talking with trusted friends or a trusted member of the clergy can also be very helpful, although not a substitute for mental health care. Participating in an Internet chat room may also be of value in sharing concerns and decreasing a sense of isolation, but any advice received should be viewed with caution.

The family is of great importance in the recovery of a person with an anxiety disorder. Ideally, the family should be supportive without helping to perpetuate the person's symptoms. If the family tends to trivialize the disorder or demand improvement without treatment, the affected person will suffer. You may wish to show this booklet to your family and enlist their help as educated allies in your fight against your anxiety disorder.

Stress management techniques and meditation may help you to calm yourself and enhance the effects of therapy, although there is as yet no scientific evidence to support the value of these "wellness" approaches to recovery from anxiety disorders. There is preliminary evidence that aerobic exercise may be of value, and it is known that caffeine, illicit drugs, and even some over-the-counter cold medications can aggravate the symptoms of an anxiety disorder. Check with your physician or pharmacist before taking any additional medicines.

By: Psychology Today Staff
Originally published by Psychology Today:20021010
source from http://health.yahoo.com/centers/anxiety/96410025


Anxiety Types & Causes


Anxiety Types & Causes
Listed below are links to information about different types of anxiety disorders as well as information about how different events or situations can trigger anxious feelings.
This information should not be used as a substitute for professional medical advice, examination, diagnosis or treatment. Always seek the advice of your physician or other qualified health professional before starting any new treatment or making any changes to existing treatment:

Acute Stress Disorder
Separation Anxiety
Generalized Anxiety Disorder
Obsessive-Compulsive Disorder
Panic Disorder
Post-Traumatic Stress Disorder
Social Phobia


Anxiety Test - Revised


Anxiety Test - Revised

30 questions, 10-15 min

Everybody worries or gets the odd case of butterflies in the stomach. But are you missing out on opportunity and happiness because of fears and worries? Is anxiety interfering with your life? While moderate anxiety can be limiting, severe anxiety can be crippling. Anxiety currently afflicts more than 20 million Americans, making it the most common mental illness in the US. Find out if you're too anxious with the Anxiety Test. It will determine whether you should consider seeking help, and to what degree.
Examine the following statements and indicate how often you feel that way. After finishing the Anxiety Test, you will receive a detailed, personalized interpretation of your score that includes diagrams, information on the test topic and tips.
Find out more about this test...

->> Take the Test!

Self Tests from Psychology Today

When Worry Takes Control


When Worry Takes Control

When Worry Takes Control

Provided by Psychology Today

Anxiety is part of the package of life. It's a natural byproduct of having a brain that is capable of such high-wire acts as considering the future. A little anxiety is good, even necessary, and a great motivator to get us to plan well and to perform ably.

Yet too much anxiety can be disabling. For millions of people, worry disrupts everyday life, restricting it to some degree or even overshadowing it entirely. An estimated 15 percent of Americans suffer from one or another of the anxiety disorders. These include generalized anxiety, specific phobias, obsessive-compulsive disorder and flat-out panic attacks. As a group, anxiety disorders constitute the most common disorder in the country.

How do you know whether you are worrying too much? When anxiety moves beyond an occasional wave of apprehension to become a constant and dominating force in your life, you need to take steps to curb anxiety.

Sometimes anxiety explodes in a panic attack, marked by a general feeling of terror. A person engulfed in a panic attack usually experiences a racing or pounding heart, sometimes even pain or heaviness in the chest. Breathing becomes difficult. The body trembles and hands turn clammy. The person may notice tingling in their hands and feet, sometimes in their arms and legs. They may start to feel light-headed.

Victims feel out of control of their body. Many feel like they are going crazy. Panic attacks are so frightening that sufferers wonder whether they will survive the episode.

At least 5 percent of American adults experience panic attacks. Often, the attacks come out of the blue, for no apparent reason. Or they can come on when a person is coping with extreme stress. Either way panic attacks can last for several minutes.

Other forms of anxiety are less dramatic but more widespread.

For some, other people are the cause of anxiety. Social anxiety creates in its sufferers the feeling that they are being watched and judged by others, even if rationally they know that this is not the case. In its milder forms, social anxiety can create extreme self-consciousness in the presence of others; but in its severe forms it can be debilitating, leading sufferers to avoid social situations altogether.

Another common form of worry is generalized anxiety disorder. Sufferers are filled with questions -- negative ones -- and dwell on endless "what if's" of a situation. They feel trapped in cycles of anxiety and worry.

General anxiety doesn't typically lead to panic attacks, but it can still be incapacitating. The endless worry saps energy, destroys interest in life and prompts frequent mood swings.

It's possible that some people are born with a temperament that inclines them to anxiety. Regardless of how anxiety develops, it's possible to control it.

"If anxiety is interfering with your work or personal life even though you tried to relax or do some stress management, at that point you should at least get a consultation by a health professional to see if there is an anxiety disorder," says Jerilyn Ross, M.A., director for the Ross Center for Anxiety and Related Disorders in Washington, D.C.

Treatment is tailored to the specific concerns that preoccupy each person. Nevertheless, there are some treatment techniques that are widely applied. Persons who are expert at treating anxiety often use a combination of approaches

? Cognitive Therapy Focuses on creating an understanding of the thought patterns that bring on worry. It helps anxiety suffers separate unrealistic from realistic thoughts.

? Behavior Therapy Focuses on taming anxiety through control of specific ways the body overreacts to worry. One common approach is to teach controlled breathing and the relaxing of muscles that constrict with worry. Both techniques lower heart rate and blood pressure.

?Relaxation Training Through a mixture of cognitive and behavior techniques, helps avert high anxiety. One approach is to think of a relaxing scene when anxiety levels start to rise.

?Desensitization Those who suffer phobias and obsessive-compulsive disorder are gradually and safely exposed to whatever is the source of their anxiety, until, over time, tolerance is built.

?Medication. Antidepressant and antianxiety medications are most effective in combination with psychotherapy.

By:Colin Allen
Originally published by Psychology Today:June 10, 2003