Anxiety Disorders: University of California San Diego

Stein MB. · University of California at San Diego, 8939 Villa La Jolla Dr, Suite 200, La Jolla, CA 92037, USA. · J Clin Psychiatry. · Pubmed #19371502 No free full text.

Abstract: Generalized anxiety disorder (GAD) is a common illness with diagnostic criteria that have changed substantially over time. Symptoms of GAD overlap with those of major depressive disorder to such an extent that studying one disorder without studying the other may be impossible. Such an overlap, combined with potentially inappropriate diagnostic criteria for GAD, makes diagnosing and researching GAD challenging. Recent research into the genetics and neural circuitry of GAD may suggest solutions for the disorder's diagnostic controversies and point the way to productive future studies of etiology and pathophysiology.

Stahl SM, Felker A. · Department of Psychiatry, University of California-San Diego, La Jolla, CA, USA. · CNS Spectr. · Pubmed #18955941 links to  free full text

Abstract: Monoamine oxidase inhibitors (MAOIs) currently have a "bad rap" and are thus infrequently used in psychopharmacology, even by experienced clinicians. Misinformation about the dietary and drug interactions of MAOIs is widespread, whereas pragmatic tips for utilizing MAOIs to minimize risks and to maximize therapeutic actions are largely lacking in the contemporary literature. While clearly not first-line treatments, MAOIs, in the hands of experienced and well-informed clinicians, can be a powerful therapeutic intervention for patients with depression, panic disorder, and other anxiety disorders who have failed first-line treatments. This article focuses on the pharmacologic mechanisms of MAOIs, since an understanding of these mechanisms may provide a rationale to empower experts to expand their use of these agents. Discussed here are not only the mechanisms of therapeutic action of MAOIs, but also the mechanisms explaining their side effects, including hypertensive interactions with dietary tyramine (so-called "cheese reactions") and drug interactions that can lead to hypertensive reactions with some drugs and serotonin toxicities with others. This article also provides practical tips on how to use MAOIs, including debunking certain myths and giving specific guidance about which foods and drugs to avoid. Those with no previous interest in MAOIs may discover in this article a new "secret weapon" to add to their therapeutic armamentarium for patients who fail to respond to the better-known agents.

Saxena S. · Department of Psychiatry, University of California at San Diego, 8950 Villa La Jolla Village Drive, Suite C-207, San Diego, CA 92037, USA. · Curr Psychiatry Rep. · Pubmed #18627667 No free full text.

Abstract: Compulsive hoarding is a common and often disabling neuropsychiatric disorder. This article reviews the conceptualization, phenomenology, diagnosis, etiology, neurobiology, and treatment of compulsive hoarding. Compulsive hoarding is part of a discrete clinical syndrome that includes difficulty discarding, urges to save, excessive acquisition, indecisiveness, perfectionism, procrastination, disorganization, and avoidance. It was thought to be part of obsessive-compulsive disorder or obsessive-compulsive personality disorder, but recent evidence indicates that it should be classified as a separate disorder with its own diagnostic criteria. Compulsive hoarding is a genetically discrete, strongly heritable phenotype. Neuroimaging and neuropsychological studies are elucidating its neurobiology, implicating dysfunction of ventral and medial prefrontal cortical areas that mediate decision-making, attention, and emotional regulation. Effective treatments include pharmacotherapy and cognitive-behavioral therapy. More research will be required to determine the prevalence, etiology, and pathophysiology of compulsive hoarding and to develop better treatments.

Stein MB, Stein DJ. · Department of Psychiatry, University of California San Diego 92093-0855, USA. · Lancet. · Pubmed #18374843 No free full text.

Abstract: Our understanding of social anxiety disorder (also known as social phobia) has moved from rudimentary awareness that it is not merely shyness to a much more sophisticated appreciation of its prevalence, its chronic and pernicious nature, and its neurobiological underpinnings. Social anxiety disorder is the most common anxiety disorder; it has an early age of onset--by age 11 years in about 50% and by age 20 years in about 80% of individuals--and it is a risk factor for subsequent depressive illness and substance abuse. Functional neuroimaging studies point to increased activity in amygdala and insula in patients with social anxiety disorder, and genetic studies are increasingly focusing on this and other (eg, personality trait neuroticism) core phenotypes to identify risk loci. A range of effective cognitive behavioural and pharmacological treatments for children and adults now exists; the challenges lie in optimum integration and dissemination of these treatments, and learning how to help the 30-40% of patients for whom treatment does not work.

Kaye W. · University of California, San Diego, 8950 Villa La Jolla Drive, Suite C207, La Jolla, CA 92037, United States. · Physiol Behav. · Pubmed #18164737 links to  free full text

Abstract: Anorexia nervosa (AN) and bulimia nervosa (BN) are related disorders of unknown etiology that most commonly begin during adolescence in women. AN and BN have unique and puzzling symptoms, such as restricted eating or binge-purge behaviors, body image distortions, denial of emaciation, and resistance to treatment. These are often chronic and relapsing disorders, and AN has the highest death rate of any psychiatric disorder. The lack of understanding of the pathogenesis of this illness has hindered the development of effective interventions, particularly for AN. Individuals with AN and BN are consistently characterized by perfectionism, obsessive-compulsiveness, and dysphoric mood. Individuals with AN tend to have high constraint, constriction of affect and emotional expressiveness, ahendonia and asceticism, whereas individuals with BN tend to be more impulsive and sensation seeking. Such symptoms often begin in childhood, before the onset of an eating disorder, and persist after recovery, suggesting they are traits that create a vulnerability for developing an ED. There is growing acknowledgement that neurobiological vulnerabilities make a substantial contribution to the pathogenesis of AN and BN. Considerable evidence suggests that altered brain serotonin (5-HT) function contributes to dysregulation of appetite, mood, and impulse control in AN and BN. Brain imaging studies, using 5-HT specific ligands, show that disturbances of 5-HT function occur when people are ill, and persist after recovery from AN and BN. It is possible that a trait-related disturbance of 5-HT neuronal modulation predates the onset of AN and contributes to premorbid symptoms of anxiety, obsessionality, and inhibition. This dysphoric temperament may involve an inherent dysregulation of emotional and reward pathways which also mediate the hedonic aspects of feeding, thus making these individuals vulnerable to disturbed appetitive behaviors. Restricting food intake may become powerfully reinforcing because it provides a temporary respite from dysphoric mood. Several factors may act on these vulnerabilities to cause AN to start in adolescence. First, puberty-related female gonadal steroids or age-related changes may exacerbate 5-HT dysregulation. Second, stress and/or cultural and societal pressures may contribute by increasing anxious and obsessional temperament. Individuals with AN may discover that reduced dietary intake, by reducing plasma tryptophan availability, is a means by which they can modulate brain 5-HT functional activity and anxious mood. People with AN enter a vicious cycle which accounts for the chronicity of this disorder because caloric restriction results in a brief respite from dysphoric mood. However, malnutrition and weight loss, in turn, produce alterations in many neuropeptides and monoamine function, perhaps in the service of conserving energy, but which also exaggerates dysphoric mood. In summary, this article reviews findings in brain chemistry and neuroimaging that shed new light on understanding the psychopathology of these difficult and frustrating disorders.

Paulus MP. · Department of Psychiatry, University of California at San Diego, 8950 Villa La Jolla Drive, La Jolla, CA 92037-0985, USA. · Science. · Pubmed #17962553 links to  free full text

Abstract: Decision-making consists of selecting an action from a set of available options. This results in an outcome that changes the state of the decision-maker. Therefore, decision-making is part of a homeostatic process. Individuals with psychiatric disorders show altered decision-making. They select options that are either non-optimal or nonhomeostatic. These dysfunctional patterns of decision-making in individuals with psychiatric disorders may fundamentally relate to problems with homeostatic regulation. These may manifest themselves in (i) how the length of time between decisions and their outcomes influences subsequent decision-making, (ii) how gain and loss feedback are integrated to determine the optimal decision, (iii) how individuals adapt their decision strategies to match the specific context, or (iv) how seemingly maladaptive responses result from an attempt to establish an unstable homeostatic balance.

Meeks TW, Wetherell JL, Irwin MR, Redwine LS, Jeste DV. · Division of Geriatric Psychiatry, Department of Psychiatry, University of California, San Diego, USA. · J Clin Psychiatry. · Pubmed #17960959 No free full text.

Abstract: OBJECTIVE: We reviewed randomized controlled trials of complementary and alternative medicine (CAM) treatments for depression, anxiety, and sleep disturbance in nondemented older adults. DATA SOURCES: We searched PubMed (1966-September 2006) and PsycINFO (1984-September 2006) databases using combinations of terms including depression, anxiety, and sleep; older adult/elderly; randomized controlled trial; and a list of 56 terms related to CAM. STUDY SELECTION: Of the 855 studies identified by database searches, 29 met our inclusion criteria: sample size >or= 30, treatment duration >or= 2 weeks, and publication in English. Four additional articles from manual bibliography searches met inclusion criteria, totaling 33 studies. DATA EXTRACTION: We reviewed identified articles for methodological quality using a modified Scale for Assessing Scientific Quality of Investigations (SASQI). We categorized a study as positive if the CAM therapy proved significantly more effective than an inactive control (or as effective as active control) on at least 1 primary psychological outcome. Positive and negative studies were compared on the following characteristics: CAM treatment category, symptom(s) assessed, country where the study was conducted, sample size, treatment duration, and mean sample age. DATA SYNTHESIS: 67% of the 33 studies reviewed were positive. Positive studies had lower SASQI scores for methodology than negative studies. Mind-body and body-based therapies had somewhat higher rates of positive results than energy- or biologically-based therapies. CONCLUSIONS: Most studies had substantial methodological limitations. A few well-conducted studies suggested therapeutic potential for certain CAM interventions in older adults (e.g., mind-body interventions for sleep disturbances and acupressure for sleep and anxiety). More rigorous research is needed, and suggestions for future research are summarized.

Benazzi F. · Hecker Psychiatry Research Center, University of California at San Diego, San Diego, CA, USA. · Eur Psychiatry. · Pubmed #17764909 No free full text.

Abstract: OBJECTIVE: To review the diagnostic validity and utility of mixed depression, i.e. co-occurrence of depression and manic/hypomanic symptoms. METHODS: PubMed search of all English-language papers published between January 1966 and December 2006 using and cross-listing key words: bipolar disorder, mixed states, criteria, utility, validation, gender, temperament, depression-mixed states, mixed depression, depressive mixed state/s, dysphoric hypomania, mixed hypomania, mixed/dysphoric mania, agitated depression, anxiety disorders, neuroimaging, pathophysiology, and genetics. A manual review of paper reference lists was also conducted. RESULTS: By classic diagnostic validators, the diagnostic validity of categorically-defined mixed depression (i.e. at least 2-3 manic/hypomanic symptoms) is mainly supported by family history (the current strongest diagnostic validator). Its diagnostic utility is supported by treatment response (negative effects of antidepressants). A dimensionally-defined mixed depression is instead supported by a non-bi-modal distribution of its intradepression manic/hypomanic symptoms. DISCUSSION: Categorically-defined mixed depression may have some diagnostic validity (family history is the current strongest validator). Its diagnostic utility seems supported by treatment response.

Paulus MP, Stein MB. · Department of Psychiatry, University of California, San Diego (UCSD), 8950 Villa La Jolla Drive, Suite C-213, La Jolla, CA 92037, USA. · Neuropsychol Rev. · Pubmed #17436113 No free full text.

Abstract: In this review, we survey the state of the field of functional magnetic resonance imaging (fMRI) as it relates to drug discovery and drug development. We highlight the advantages and limitations of fMRI for this purpose and suggest ways to improve the use of fMRI for developing new therapeutics, with emphasis on treatments for anxiety disorders. Fundamentally, pharmacological studies with standard psychiatric treatments using standardized behavioral probes during fMRI will need to be carried out to determine characteristic brain signatures that could be used to predict whether novel compounds are likely to have specific therapeutic effects.

Ayers CR, Sorrell JT, Thorp SR, Wetherell JL. · University of California, San Diego, San Diego, CA 92093-0603, USA. · Psychol Aging. · Pubmed #17385978 No free full text.

Abstract: This project identified evidence-based psychotherapy treatments for anxiety disorders in older adults. The authors conducted a review of the geriatric anxiety treatment outcome literature by using specific coding criteria and identified 17 studies that met criteria for evidence-based treatments (EBTs). These studies reflected samples of adults with generalized anxiety disorder (GAD) or samples with mixed anxiety disorders or symptoms. Evidence was found for efficacy for 4 types of EBTs. Relaxation training, cognitive-behavioral therapy (CBT), and, to a lesser extent, supportive therapy and cognitive therapy have support for treating subjective anxiety symptoms and disorders. CBT for late-life GAD has garnered the most consistent support, and relaxation training represents an efficacious, relatively low-cost intervention. The authors provide a review of the strengths and limitations of this research literature, including a discussion of common assessment instruments. Continued investigation of EBTs is needed in clinical geriatric anxiety samples, given the small number of available studies. Future research should examine other therapy models and investigate the effects of psychotherapy on other anxiety disorders, such as phobias and posttraumatic stress disorder in older adults.

Stein MB. · Department of Psychiatry, University of California San Diego, La Jolla, CA 92037, USA. · J Clin Psychiatry. · Pubmed #17092189 No free full text.

Abstract: Social anxiety disorder (SAD) is among the most common mental disorders on a lifetime basis, ranging from 12% to 14%. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, categorizes SAD as either generalized (fear/avoidance of multiple social situations) or nongeneralized (fearing only a limited number of social situations), with some overlap between the 2 subtypes. Generalized SAD is associated with more comorbid mental disorders, greater functional impairment, and lower health-related quality of life. Half of SAD patients have onset by age 13 years and 90% by age 23 years; however, SAD is rarely diagnosed or treated by the pediatrician, highlighting the low awareness level of SAD and the need to increase attention among physicians. Social anxiety disorder is associated with an increased risk for depression and a more malignant course, characterized by increased likelihood of suicide attempts and greater disease chronicity. SAD has an adverse impact on outcomes in patients with other comorbid mental conditions such as bipolar disorder, eating disorders, and personality disorders.

Schuckit MA. · VA San Diego Healthcare System, San Diego, CA, USA. · Addiction. · Pubmed #16930163 No free full text.

Abstract: AIM: To review information relevant to the question of whether substance-induced mental disorders exist and their implications. DESIGN AND METHOD: This paper utilized a systematic review of manuscripts published in the English language since approximately 1970 dealing with comorbid psychiatric and substance use disorders. FINDINGS: The results of any specific study depended on the definitions of comorbidity, the methods of operationalizing diagnostic criteria, the interview and protocol invoked several additional methodological issues. The results generally support the conclusion that substance use mental disorders exist, especially regarding stimulant or cannabinoid-induced psychoses, substance-induced mood disorders, as well as substance-induced anxiety conditions. CONCLUSIONS: The material reviewed indicates that induced disorders are prevalent enough to contribute significantly to rates of comorbidity between substance use disorders and psychiatric conditions, and that their recognition has important treatment implications. The current literature review underscores the heterogeneous nature of comorbidity.

Hauger RL, Risbrough V, Brauns O, Dautzenberg FM. · San Diego VA Healthcare System, University of California San Diego, La Jolla, 929093-0603, USA. · CNS Neurol Disord Drug Targets. · Pubmed #16918397 links to  free full text

Abstract: Corticotropin-releasing factor (CRF) and the related urocortin peptides mediate behavioral, cognitive, autonomic, neuroendocrine and immunologic responses to aversive stimuli by activating CRF(1) or CRF(2) receptors in the central nervous system and anterior pituitary. Markers of hyperactive central CRF systems, including CRF hypersecretion and abnormal hypothalamic-pituitary-adrenal axis functioning, have been identified in subpopulations of patients with anxiety, stress and depressive disorders. Because CRF receptors are rapidly desensitized in the presence of high agonist concentrations, CRF hypersecretion alone may be insufficient to account for the enhanced CRF neurotransmission observed in these patients. Concomitant dysregulation of mechanisms stringently controlling magnitude and duration of CRF receptor signaling also may contribute to this phenomenon. While it is well established that the CRF(1) receptor mediates many anxiety- and depression-like behaviors as well as HPA axis stress responses, CRF(2) receptor functions are not well understood at present. One hypothesis holds that CRF(1) receptor activation initiates fear and anxiety-like responses, while CRF(2) receptor activation re-establishes homeostasis by counteracting the aversive effects of CRF(1) receptor signaling. An alternative hypothesis posits that CRF(1) and CRF(2) receptors contribute to opposite defensive modes, with CRF(1) receptors mediating active defensive responses triggered by escapable stressors, and CRF(2) receptors mediating anxiety- and depression-like responses induced by inescapable, uncontrollable stressors. CRF(1) receptor antagonists are being developed as novel treatments for affective and stress disorders. If it is confirmed that the CRF(2) receptor contributes importantly to anxiety and depression, the development of small molecule CRF(2) receptor antagonists would be therapeutically useful.

Risbrough VB, Stein MB. · Department of Psychiatry, University of California, San Diego, USA. · Horm Behav. · Pubmed #16870185 links to  free full text

Abstract: Anxiety disorders are a group of mental disorders that include generalized anxiety disorder (GAD), panic disorder, phobic disorders (e.g., specific phobias, agoraphobia, social phobia) and posttraumatic stress disorder (PTSD). Anxiety disorders are among the most common of all mental disorders and, when coupled with an awareness of the disability and reduced quality of life they convey, they must be recognized as a serious public health problem. Over 20 years of preclinical studies point to a role for the CRF system in anxiety and stress responses. Clinical studies have supported a model of CRF dysfunction in depression and more recently a potential contribution to specific anxiety disorders (i.e., panic disorder and PTSD). Much work remains in both the clinical and preclinical fields to inform models of CRF function and its contribution to anxiety. First, we will review the current findings of CRF and HPA axis abnormalities in anxiety disorders. Second, we will discuss startle reflex measures as a tool for translational research to determine the role of the CRF system in development and maintenance of clinical anxiety.

Paulus MP, Stein MB. · Department of Psychiatry, University of California, San Diego, La Jolla, California 92037, USA. · Biol Psychiatry. · Pubmed #16780813 No free full text.

Abstract: We propose a general hypothesis that integrates affective and cognitive processing with neuroanatomy to explain anxiety pronenes. The premise is that individuals who are prone to anxiety show an altered interoceptive prediction signal, i.e., manifest augmented detection of the difference between the observed and expected body state. As a consequence, the increased prediction signal of a prospective aversive body state triggers an increase in anxious affect, worrisome thoughts and other avoidance behaviors. The anterior insula is proposed to play a key role in this process. Further testing of this model--which should include investigation of genetic and environmental influences--may lead to the development of novel treatments that attenuate this altered interoceptive prediction signal in patients with anxiety disorders.

Wetherell JL, Lenze EJ, Stanley MA. · Department of Psychiatry, University of California San Diego, VA San Diego Healthcare System, 3350 La Jolla Village Drive (116B), San Diego, CA 92161, USA. · Psychiatr Clin North Am. · Pubmed #16325733 No free full text.

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Haroun N, Dunn L, Haroun A, Cadenhead KS. · University of California, San Diego, USA. · Schizophr Bull. · Pubmed #16207892 links to  free full text

Abstract: Over the last decade schizophrenia researchers have turned their attention to earlier identification in the prodromal period of illness. A greater understanding of both risk and protective factors can lead to improved prevention and treatment strategies in this vulnerable population. This research, however, has far-reaching ethical implications. One year follow-up data from 50 individuals who met established criteria for a prodromal state is used to illustrate ethical issues that directly affect clinicians and future research strategies. At 1-year follow-up, the psychotic transition rate was 13%, but it increased in subsequent years with smaller sample sizes. One-half developed an affective psychosis. The converted sample was older (p > 0.05) than the nonconverted sample and more likely to have a premorbid history of substance abuse, as well as higher clinical ratings on "subsyndromal" psychotic items (delusional thinking, suspiciousness, and thought disorder). Despite a lack of conversion, the nonconverted sample remained symptomatic and had a high rate of affective and anxiety disorders with evidence of functional disability. This conversion rate is relatively low compared to similar studies at 1 year. Specific risk factors were identified, but these findings need to be replicated in a larger cohort. By examining the rate of conversion and nonconversion in this sample as an example, we hope to contribute to the discussion of implications for clinical practice and the direction of future research in the schizophrenia prodrome. Finally, our data strengthen the evidence base available to inform the discussion of ethical issues relevant to this important research area.

Chavira DA, Stein MB. · Anxiety and Traumatic Stress Disorders Clinic, Department of Psychiatry, University of California San Diego, La Jolla, CA 92093-0985, USA. · Child Adolesc Psychiatr Clin N Am. · Pubmed #16171703 No free full text.

Abstract: Childhood social anxiety disorder is a condition of complex origins. Longitudinal studies of shyness and behavioral inhibition, and twin and family history studies, support a genetic component, but experiences such as family environment, parenting, and traumatic conditioning also are observed. Many children with significant shyness and behavioral inhibition do not develop social anxiety disorder, reinforcing the need for longitudinal studies exploring resiliency and risk factors that can be incorporated into diathesis stress models. Efficacy data regarding cognitive and behavioral therapies and pharmacotherapy are promising, and their effectiveness awaits further research. These studies will need to incorporate a multiplicity of perspectives to ensure the long-term sustainability of interventions for social anxiety disorder in children and adolescents.

Stahl SM, Grady MM, Moret C, Briley M. · Department of Psychiatry, University of California, San Diego, San Diego, CA, USA. · CNS Spectr. · Pubmed #16142213 links to  free full text

Abstract: The class of serotonin and norepinephrine reuptake inhibitors (SNRIs) now comprises three medications: venlafaxine, milnacipran, and duloxetine. These drugs block the reuptake of both serotonin (5-HT) and norepinephrine with differing selectivity. Whereas milnacipran blocks 5-HT and norepinephrine reuptake with equal affinity, duloxetine has a 10-fold selectivity for 5-HT and venlafaxine a 30-fold selectivity for 5-HT. All three SNRIs are efficacious in treating a variety of anxiety disorders. There is no evidence for major differences between SNRIs and SSRIs in their efficacy in treating anxiety disorders. In contrast to SSRIs, which are generally ineffective in treating chronic pain, all three SNRIs seem to be helpful in relieving chronic pain associated with and independent of depression. Tolerability of an SNRI at therapeutic doses varies within the class. Although no direct comparative data are available, venlafaxine seems to be the least well-tolerated, combining serotonergic adverse effects (nausea, sexual dysfunction, withdrawal problems) with a dose-dependent cardiovascular phenomenon, principally hypertension. Duloxetine and milnacipran appear better tolerated and essentially devoid of cardiovascular toxicity.

Jeste DV, Blazer DG, First M. · Department of Psychiatry, University of California, San Diego, California 92161, USA. · Biol Psychiatry. · Pubmed #16102544 No free full text.

Abstract: It is commonly thought and taught that most psychiatric disorders other than dementia are much less prevalent among the elderly than among younger adults. This perception is based on a relatively small number of published epidemiologic investigations of the incidence and prevalence of mental illnesses in elderly populations. Most of these studies have had a number of methodologic problems, including improper definitions and diagnostic criteria for older persons. A likely consequence of these misconceptions is that clinically significant and potentially treatable mental illnesses might be overlooked, misdiagnosed, and mistreated in elderly patients. Studies in community samples suggest that many older adults who experience clinically significant psychopathology do not fit easily into our existing nomenclature, and yet are disabled. There is a need to develop aging-appropriate diagnostic criteria for major psychiatric disorders. In this article, we discuss the potential causes of this diagnostic confusion. Four specific classes of disorders-mood (specifically depressive) disorders, schizophrenia (and related psychotic disorders), anxiety disorders, and substance use disorders-are discussed as examples. Finally, we suggest some future steps for clarifying this diagnostic confusion.

Wetherell JL, Sorrell JT, Thorp SR, Patterson TL. · University of California, San Diego, USA. · J Geriatr Psychiatry Neurol. · Pubmed #15911935 No free full text.

Abstract: The authors review the literature on psychological treatment for anxiety in older adults, focusing on randomized, controlled trials. Evidence exists for the efficacy of relaxation training for subjective anxiety symptoms and cognitive-behavioral therapy for generalized anxiety disorder and miscellaneous anxiety syndromes, including panic disorder. The authors also present the rationale for the CALM Study (Controlling Anxiety in Later-life Medical Patients), an ongoing randomized trial in which a modular psychotherapeutic intervention for anxiety in older primary care patients is compared with treatment as usual. Data are presented from 2 pilot patients in the CALM Study, and preliminary lessons are discussed.

Swartz R, Longwell P. · Department of Family and Preventive Medicine, University of California, San Diego, School of Medicine, La Jolla, California, USA. · Am Fam Physician. · Pubmed #15791890 links to  free full text

Abstract: Vertigo is the illusion of motion, usually rotational motion. As patients age, vertigo becomes an increasingly common presenting complaint. The most common causes of this condition are benign paroxysmal positional vertigo, acute vestibular neuronitis or labyrinthitis, Ménière's disease, migraine, and anxiety disorders. Less common causes include vertebrobasilar ischemia and retrocochlear tumors. The distinction between peripheral and central vertigo usually can be made clinically and guides management decisions. Most patients with vertigo do not require extensive diagnostic testing and can be treated in the primary care setting. Benign paroxysmal positional vertigo usually improves with a canalith repositioning procedure. Acute vestibular neuronitis or labyrinthitis improves with initial stabilizing measures and a vestibular suppressant medication, followed by vestibular rehabilitation exercises. Meniere's disease often responds to the combination of a low-salt diet and diuretics. Vertiginous migraine headaches generally improve with dietary changes, a tricyclic antidepressant, and a beta blocker or calcium channel blocker. Vertigo associated with anxiety usually responds to a selective serotonin reuptake inhibitor.

Akiskal HS. · VA Psychiatry Service (116A), International Mood Center, University of Caifornia, 3550 La Jolla Village Drive, San Diego, CA 92161, USA. · J Affect Disord. · Pubmed #15708407 No free full text.

Abstract: The depressive expressions of bipolar disorders have long been neglected. Current data, from both clinical and epidemiologic studies, indicate that such expressions far exceed the manic forms in both cross-section and during follow-up course. Thus, mania occurs in 1% of the population at large; bipolar depression afflicts at least 5 times more people. Much of the new literature on this subject has emphasized its high prevalence, morbidity, and mortality. There has been relatively less attention paid to the phenomenology of bipolar depression as it presents clinically. This special issue (volume 84/2-3, 2005) is devoted to a systematic data-based in-depth examination of the different clinical expressions of bipolar depression including, among others, retarded depression, agitated and/or activated depression, mood-labile depression, irritable-hostile depression, atypical depression, anxious depression, depressive mixed state, and resistant depression. Both bipolar I (BP-I), and the more prevalent yet relatively understudied bipolar II (BP-II), are covered. We trust that this extensive coverage of the "darker" side of bipolarity will set the stage for a much needed renaissance in its complex phenotypic expressions-and its delimitation from unipolar depression (UP). The phenomenology of BP-I depression ranges from depressive stupor to agitated psychosis, whereas UP depression expresses itself in psychic anxiety, and insomnia, as well as retardation. BP-II compared with UP is more likely to have atypical features, mood lability, hostility, activation, biographical instability, multiple anxiety comorbidities, suicidal tendencies, and to be rated as less "objectively" depressed. These findings are complex and do not fully agree with the conventional characterization of BP as retarded and UP as anxious and agitated. The inconsistency between the conventional and the phenomenology described herein is largely due to depressive mixed states, which tend to destabilize BP-II, and may account for the "contradictory" relationships of affect, sleep, drive, and psychomotor activity in mood disorders.

Shannahoff-Khalsa DS. · The Research Group for Mind-Body Dynamics, Institute for Nonlinear Science, Mail Code 0402, University of California, San Diego, 9500 Gilman Drive, La Jolla, California, 92093-0402 USA. · Integr Cancer Ther. · Pubmed #15695478 No free full text.

Abstract: The ancient system of Kundalini Yoga (KY) includes a vast array of meditation techniques. Some were discovered to be specific for treating psychiatric disorders and others are supposedly beneficial for treating cancers. To date, 2 clinical trials have been conducted for treating obsessive-compulsive disorder (OCD). The first was an open uncontrolled trial and the second a single-blinded randomized controlled trial (RCT) comparing a KY protocol against the Relaxation Response and Mindfulness Meditation (RRMM) techniques combined. Both trials showed efficacy on all psychological scales using the KY protocol; however, the RCT showed no efficacy on any scale with the RRMM control group. The KY protocol employed an OCD-specific meditation technique combined with other techniques that are individually specific for anxiety, low energy, fear, anger, meeting mental challenges, and turning negative thoughts into positive thoughts. In addition to OCD symptoms, other symptoms, including anxiety and depression, were also significantly reduced. Elements of the KY protocol other than the OCD-specific technique also may have applications for psycho-oncology patients and are described here. Two depression-specific KY techniques are described that also help combat mental fatigue and low energy. A 7-part protocol is described that would be used in KY practice to affect the full spectrum of emotions and distress that complicate a cancer diagnosis. In addition, there are KY techniques that practitioners have used in treating cancer. These techniques have not yet been subjected to formal clinical trials but are described here as potential adjunctive therapies. A case history demonstrating rapid onset of acute relief of intense fear in a terminal breast cancer patient using a KY technique specific for fear is presented. A second case history is reported for a surviving male diagnosed in 1988 with terminal prostate cancer who has used KY therapy long term as part of a self-directed integrative care approach.

Lang AJ. · University of California San Diego, and VA San Diego Healthcare System, San Diego, CA 92108, USA. · J Clin Psychiatry. · Pubmed #15384932 No free full text.

Abstract: Cognitive-behavioral therapy (CBT) can be successfully used to treat generalized anxiety disorder (GAD), with or without the inclusion of anxiolytics. The treatment of GAD using cognitive-behavioral techniques involves cognitive restructuring, relaxation, worry exposure, behavior modification, and problem solving. This article will review the principles used in CBT for the treatment of GAD and will discuss recent modifications of CBTs and how they may be employed. The simultaneous use of CBT and antidepressants will also be reviewed.