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How can you treat anxiety disorders, treating tinnitus caused by tmj - Plans Download

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This article provides a clinically relevant overview of issues related to social anxiety disorder (SAD), with particular emphasis on its diagnosis and treatment. Given the scope of the problem, its robust association with other forms of psychopathology, and the overwhelming human burden of this illness, clinicians should be proficient in detecting and diagnosing SAD, and should be knowledgeable about evidence-based treatment modalities. As the boundaries and core features of the syndrome were being discerned, behaviorally oriented clinicians were simultaneously laying the groundwork for both reliable measurement and behavioral and cognitive treatments of social anxiety-related difficulties. As a consequence of these key developments, the past 2 decades have been characterized by substantial progress in understanding the origins, nature, and treatment of SAD.
Research clearly suggests a largely chronic and unremitting course, which can last for decades if left untreated.
In virtually all major studies of representative community and clinical samples, SAD has shown elevated rates of comorbidity (both as a primary and secondary disorder). Thorough assessment of SAD and social anxiety symptoms is a key part of the treatment process.
The clinical interview typically serves as the point of departure in assessing for SAD and social-evaluative anxieties.
Identification of comorbid psychopathology is an especially important part of the diagnostic process, as people with co-occurring conditions pose a more significant treatment challenge. Another structured interview that focuses more precisely on the diagnosis of anxiety disorders is the Anxiety Disorders Interview Schedule for the DSM-IV (ADIS-IV).49 This interview is also administered by a clinical examiner in a semi-structured format, and identifies the presence of SAD, its generalized subtype, and the various other anxiety syndromes.
The Brief Fear of Negative Evaluation Scale (BFNE)52 is a useful 12-item self-report measure based on the original 30-item scale developed by Watson and Friend.13 Whereas the LSAS focuses on the dimensions of fear and avoidance in various social situations, the BFNE assesses the degree to which patients have core components of social-evaluative anxiety, including thoughts, expectations, and associated distress over possible negative social judgments and embarrassing behaviors.
Historically, treatments for social-evaluative anxieties and SAD have included both psychopharmacologic and psychotherapeutic strategies. Although pharmacotherapy of SAD was relatively neglected early on,18 recent years have witnessed a dramatic increase in progress of medication-based treatment. Several comprehensive narrative and quantitative reviews of the pharmacotherapy literature in SAD have been presented elsewhere.18,55-60 This article emphasizes fundamentally practical medication treatments that have received the greatest attention and been subjected to rigorous empirical investigation (typically through randomized, double-blinded, placebo-controlled clinical trials), and that are generally viewed by a consensus of the research community as first- or second-line treatments for SAD.
As a group, these studies have been characterized by some degree of methodological heterogeneity, such as varying research designs, number and nature of comparison conditions, sample composition, duration of acute treatment, medication dosage, and follow-up intervals. The MAOIs were one of the first groups of medications to receive intensive systematic evaluation in the treatment of SAD via controlled clinical trials.
Despite the proven effectiveness of the irreversible MAOIs in the treatment of SAD, and of phenelzine in particular, their use has been limited by an adverse side-effect profile, including the potential danger of hypertensive crisis if dietary restrictions on tyramine-rich foods are not carefully followed. SSRIs are also well tolerated and are highly efficacious for both depressive and other anxiety disorders, which are often comorbid with SAD. Given the preponderance of evidence in support of the SSRIs, at present these medications are widely accepted and strongly recommended as first-line treatments for SAD and its generalized subtype. Despite demonstrated efficacy in treating other anxiety disorders (eg, panic disorder, obsessive-compulsive disorder [OCD]), there is little existing data to support the efficacy of tricyclic antidepressants in the treatment of SAD. Interestingly, Jefferson114 points out that there has been a general reluctance among clinicians to utilize benzodiazepines, especially in longer-term treatment of SAD, despite evidence suggesting long-term effectiveness and safety of agents such as clonazepam. Generally speaking, β-adrenergic blockers (eg, propranolol) should be reserved for treating the prominent physiological arousal characteristic of discrete public performance situations. Recent interest in the use of novel anticonvulsants as antianxiety agents has prompted investigation of these medications in the treatment of generalized SAD.
SAD and social-evaluative anxiety states have been treated with a variety of behavioral, cognitive, and combined cognitive-behavioral therapies (CBT). Behavior therapies used for SAD have been relatively problem focused, addressing the most prominent features associated with the disorder. Physiological retraining, or applied relaxation, involves teaching patients to use breathing techniques and progressive muscle relaxation when anxiety-provoking social situations are encountered. Systematic exposure, either real or imagined, to a hierarchy of progressively more anxiety-provoking stimuli has been found to be a powerful component of treatment for several anxiety disorders. Individuals with SAD typically have persistent negative thoughts and maladaptive beliefs regarding how others perceive and evaluate them socially. The authors of this article use CBT treatment protocol in their clinic, which combines psychoeducation, cognitive therapy, and in-session systematic exposures to feared social situations using planned and structure role-play techniques. Briefly, individuals with SAD are educated about social anxiety in both its normal and pathological manifestations. Clients are taught to employ cognitive restructuring techniques, as discussed above, which help them to cope with anxiety experienced during in-session role-plays with the therapist. SAD has clearly evolved from a once neglected anxiety disorder to an increasingly recognized, highly prevalent, and impairing psychiatric condition with considerable public health significance. Despite high prevalence and negative consequences of anxiety disorders in later life, this area has received little research attention. Approximately half of older patients diagnosed with an anxiety disorder in primary care are prescribed an anxiolytic or antidepressant medication (Stanley et al., 2001). The purpose of this article is to provide a clinically relevant overview of some of the more substantive issues concerning the diagnosis and treatment of SAD.
The core fears center on behaving in a way or showing symptoms of anxious arousal (eg, blushing, sweating, trembling, stuttering, etc.) that would be humiliating or embarrassing (Criterion A). However, clinicians should be mindful of cultural variations in the presentation of SAD, or of social anxiety phenomena more generally.
One plausible hypothesis is that there may be a common underlying core trait of social anxiety, the expression of which varies as a function of cultural idioms.
Onsets later in life, after a peak between the second and third decades, are relatively rare and are more likely to be cases of SAD occurring secondarily to, or as sequellae of, another mental disorder (eg, depression, psychotic disorders, eating disorders).34 Though onset is characteristically early, individuals with SAD may not recognize the fears and anxieties they experience in social situations as legitimate emotional problems in need of treatment.
Clinical observations, focused interviewing, and the use of appropriate measures can help to facilitate accurate diagnosis and effective treatment planning. In this regard, clinicians should be particularly vigilant for the presence of other anxiety disorders, substance use or abuse, depressive symptoms, and possible suicidal ideation. The Structured Clinical Interview for DSM-IV (SCID-IV) is a comprehensive clinician-administered diagnostic interview, with both clinical and research versions available.48 It has been designed to be consistent with the classification of psychiatric diagnoses published in DSM-IV,24 and is organized into separate modules which evaluate classes of disorders (eg, psychotic, affective, anxiety, etc). However, it can also be time-consuming to administer, especially in more complex clinical presentations.
There are modules to detect common co-occurring disorders, (eg, affective, substance use, and somatoform disorders), as well.


However, a useful thread of continuity within the extant literature has been the relatively consistent use of specific outcome measures, namely the LSAS (as described above)50 and the Clinical Global Impressions–Improvement (CGI-I) rating scale. SSRIs are easily managed compared to other drug classes, and have therefore been investigated extensively in the treatment of SAD and its generalized subtype.
Moreover, only 2 months after drug discontinuation, most patients reported a return to baseline levels of social anxiety symptoms.
In fact, medications such as clonazepam possess a number of desirable qualities, including its established efficacy in treating SAD, relatively rapid onset of action, good tolerability, overdose safety, and dose flexibility.
Briefly reviewed are some methods employed to treat SAD via cognitive and behavioral therapies. Patients are taught to identify the earliest physiological cues of anxious arousal upon entering socially anxious situations, and then to counter these sensations via rapid deployment of learned anxiety reduction skills.
These disorders include panic disorder (eg, physical sensations), OCD (eg, perceived contaminants, intrusive thoughts) and posttraumatic stress disorder (eg, traumatic memories and associated environmental cues). These distorted cognitions generate significant anxiety and form the psychological core of the disorder. Patients are taught to treat each negative automatic thought as a hypothesis, much like a scientist, and to evaluate the available evidence via systematic logical analysis. This provides both in-session practice of cognitive restructuring skills and exposure to the distressing social situation, so that the patient can experience the process of habituation.
This approach provides a therapeutic context in which members of the group enact and replicate some of the problematic or anxiety-provoking social situations that individuals encounter in daily life. Studies by Kobak and colleagues86 and Clark and colleagues87 demonstrated that both combinations of active treatments and monotherapy are superior to placebo-controlled conditions. The distinguishing of a generalized subtype, which bears close resemblance to APD, has had important implications for assessment and treatment of SAD. A relatively small number of outcome investigations on late-life anxiety have focused on the impact of pharmacological and psychotherapeutic treatments. Benzodiazepines are the most commonly used anxiety management medication, followed by serotonergic antidepressants, buspirone (BuSpar), and venlafaxine (Effexor) (Mamdani et al., 2005).
All pharmacological interventions reviewed are approved treatment options for anxiety disorders.
Only three randomized controlled trials have investigated the efficacy of benzodiazepines for anxiety disorders in later life. Five pharmacotherapy studies of late-life anxiety disorders have tested antidepressant medications. The article begins with a brief account of the evolution of SAD from its early beginnings as an undifferentiated phobic disorder to its present status as an independent diagnosis, as detailed in the current Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-Revised (DSM-IV-TR).10 A discussion of the nature, core features, and phenomenology of SAD follows.
In contrast, early pharmacologic treatment approaches may have been somewhat hindered, as SAD had yet to be formally recognized as an autonomous syndrome requiring independent investigation. Exposure to these phobic situations consistently evokes an anxiety response, which in some cases may be in the form of a panic attack (Criterion B).
Individuals with SAD experience such incapacitating anxiety that it can actually have the untoward effect of undermining their public speaking performance, consequently reinforcing many of the fearful and maladaptive core beliefs driving the anxiety.
People with SAD often fear that their symptoms of anxiety, (eg, blushing, perspiration, trembling, or a quivering voice) will be noticeable to others.
A notable example of a culturally dependent manifestation of social anxiety is a condition known as taijin kyofusho, which has been reported in some Asian cultures including Japan and Korea, and is categorized as a culturally bound syndrome in the DSM-IV-TR.10 Whereas the primary focus of fear and anxiety in SAD is the prospect of embarrassing or humiliating oneself, in taijin kyofusho the individual is exquisitely sensitive to interpersonal relations, and may be preoccupied with concerns over doing something, or presenting oneself in a manner, that would be embarrassing or offensive to others in a social context (the offensive subtype).
The disorder appears to be slightly more prevalent in females, with a female to male ratio of 3:2. Several comprehensive reviews of the methodological issues and available assessment instruments for SAD have been presented elsewhere.45-47 The authors of this article provide a brief summary of strategies and tools that have been particularly useful in the assessment of SAD and social anxiety. Likewise, when these frequently co-occurring conditions are the presenting complaint, accompanying symptoms of social anxiety should be carefully probed for. The LSAS is both valid and reliable, and has become the standard primary outcome measure for social anxiety symptoms in clinical trials research.
The scale has been found to be reliable and valid in nonclinical samples, and was recently validated in a sample of clinically anxious individuals.53 The BFNE has also been found to be a sensitive measure of change over the course of treatment. Virtually all SSRIs, including citalopram,77-79 escitalopram,80-81 fluoxetine,82-88 fluvoxamine,89-91 paroxetine,92-98 paroxetine controlled release,99 and sertraline100-104 have been subjected to randomized, double-blind, placebo-controlled clinical trials, typically demonstrating superior treatment efficacy to placebo control conditions on primary efficacy parameters (Table 1). In contrast, the efficacy of the longer acting benzodiazepine, clonazepam, was tested in a 10-week, double-blind, placebo-controlled trial, revealing a treatment response rate of 78% compared to only 20% of patients receiving placebo.112 The effectiveness of clonazepam in treating SAD has also been supported by several open clinical trials, and has recently been examined in a placebo-controlled clinical trial as augmentation for partial and nonresponse to SSRI therapy. On the downside, however, there are several undesirable side effects such as sedation, impairment of coordination and cognition, and possible sexual dysfunction. The authors of this article focus on the CBT protocol developed by Heimberg and colleagues, which is currently being used in conjunction with pharmacotherapy in a collaborative research program between the Anxiety Disorders Clinic of New York State Psychiatric Institute and the Adult Anxiety Clinic of Temple University.
A rating of fear is established for each item in the hierarchy using the Subjective Units of Distress Scale, a 0–100 rating scale in which higher numbers indicate increasing levels of distress and anxiety. For example, patients can practice presentations or public speaking in front of the group, role-play social encounters with members of either sex, and receive constructive feedback from co-members. However, thus far there is little evidence suggesting superiority of the combined treatments over either individual treatment. Lifetime co-morbidities between social phobia and mood disorders in the U.S National Comorbidity Survey.
Social anxiety disorder and the risk of depression: a prospective community study of adolescents and young adults. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication.
The treatment of social failure: A comparison of anxiety-reduction and skills acquisition procedures on two social problems.
Relative effectiveness of rational restructuring and self-control desensitization in the reduction of interpersonal anxiety. The offensive subtype of Taijin-kyofu-sho in New York City: The phenomenology and treatment of a social anxiety disorder. Trends in the prevalence of social phobia in the United States: a synthetic cohort analysis of changes over four decades.
Current and lifetime comorbidity of the DSM-IV anxiety and mood disorders in a large clinical sample.


Social anxiety disorder and the risk of depression: A prospective community study of adolescents and young adults. Comorbidity of DSM-III-R major depressive disorder in the general population: results from the US National Comorbidity Survey.
Comorbidity of anxiety and depressive disorders: issues in conceptualization, assessment and treatment. The efficacy of selective serotonin reuptake inhibitors for social anxiety disorder (social phobia): A meta-analysis of randomized controlled trials. Symposium presented at the 25th Annual Meeting of the Anxiety Disorders Association of America. Psychopharmacological treatment of social phobia: clinical and biochemical effects of brofaromine, a selective MAO-A inhibitor.
Common changes in cerebral blood flow in patients with social phobia treated with citalopram or cognitive-behavioral therapy. Psychopharmacological treatment of social phobia; a double blind placebo controlled study with fluvoxamine. Fluvoxamine treatment of social phobia (social anxiety disorder): a double-blind, placebo-controlled study.
Fluvoxamine CR in the long-term treatment of social anxiety disorder: the 12- to 24-week extension phase of a multicentre, randomized, placebo-controlled trial.
Paroxetine treatment of generalized social phobia (social anxiety disorder): a randomized controlled trial.
A double-blind placebo-controlled trial of paroxetine in the management of social phobia (social anxiety disorder) in South Africa.
Efficacy of paroxetine for relapse prevention in social anxiety disorder: a 24-week study. A multicenter, randomized, double-blind, placebo-controlled trial of paroxetine in children and adolescents with social anxiety disorder. Randomised controlled general practice trial of sertraline, exposure therapy and combined treatment in generalised social phobia. Recent research has also examined the impact of psychotherapy, typically cognitive-behavioral therapy (CBT), for late-life anxiety.
Two of these studies included patients with panic disorder (PD), one included a mixed group of patients with GAD, PD or obsessive-compulsive disorder (OCD), and two included patients with GAD.
An overview of assessment and treatment via pharmacotherapy and cognitive-behavioral therapy, with a focus on practical clinical applications, is also presented. Issues concerning the assessment of SAD in the clinical and research settings are reviewed, and an overview of current empirically supported psychopharmacologic and psychotherapeutic treatments is provided. Equally problematic, the very nature of the core pathology in SAD, fear and avoidance of embarrassment and humiliation, leads to reduced treatment seeking.
Much like the SCID-IV, the ADIS-IV requires training and is more typically employed in clinical research settings and anxiety disorder specialty clinics. Equally important has been the demonstrated effectiveness of specific pharmacologic agents in treating SAD as well as the recent ascendance of biological psychiatry and psychopharmacology as a clinical specialization.
Whether MAOIs, SSRIs, or SNRIs used on a maintenance basis are helpful in patients who only suffer performance anxiety is not clear.
In the continued presence of the anxiety-provoking social stimulus, the central nervous system gradually habituates, so that the stimulus situation no longer has the capacity to evoke anxious arousal. The therapist and patient gradually work through the hierarchy beginning with situations that prompt moderate amounts of anxiety, and working up to more distressing situations as therapy progresses. However, benzodiazepines can lead to an increased risk of falls, and possibly increased cognitive decline, in older people (Paterniti et al., 2002).
The data from these trials suggest the utility of benzodiazepines for anxiety disorders in older adults. Finally, the article underscores the necessity of integrating biologically based and psychosocial therapies to maximize long-term treatment effectiveness of SAD.
For example, Schneier and colleagues24 have cogently argued for the recognition and study of a social anxiety spectrum, which would encompass clinical social phobic states, as well as subsyndromal manifestations, associated symptoms, behaviors, and underlying variations in temperament and personality traits, (eg, shyness, behavioral inhibition). There must also be prominent avoidance of the phobic performance or situation and, if not, it is typically endured with great anxiety or distress (Criterion D).
Thus, clinicians (especially those serving diverse populations) should be cognizant of this and other potential culturally variable expressions of social anxiety.
Total scores in the range of 30–60 are more typical of those with social anxiety in a specific circumstance, such as public speaking, eating in front of others, or other performance anxiety.
There is also greater abuse potential, discontinuation difficulties, adverse interactions with alcohol and other substances of abuse, and ineffectiveness for comorbid conditions, particularly depression.114 At present, there are no established guidelines suggesting the use of clonazepam over SSRIs as a first-line treatment for SAD.
However, they do seem to help the performance anxiety that is a component of generalized SAD.
Patients are trained to internalize and utilize this dialogue when working to challenge maladaptive anxiety-provoking thoughts on their own between sessions.
For example, panic attacks, but not necessarily DSM-diagnosable panic disorder, are common in chronic obstructive pulmonary disease (COPD). A follow-up investigation demonstrated improvement in anxiety symptoms in patients with PD using sertraline (Zoloft) (Sheikh et al., 2004). Among the advantages of a dimensional approach, Schneier and colleagues24 suggest that a social anxiety spectrum has utility in understanding the associations among SAD and diverse comorbid clinical syndromes, identifying underlying trait-like psychological constructs, and candidate neurobiological and neurochemical substrates.
Difficulties in these significant roles presumably lead to greater salience and recognition of personal functional impairment in men, and to subsequent treatment seeking. A sample with mixed anxiety disorders showed high response rates to fluvoxamine (Luvox) (Wylie et al., 2000).
Similarly, McNeil25 has proposed a continuum model of social anxiety and its disorders in which these anxieties and fears exist along a continuum, normally distributed in the general population.
Total scores of ≥90 occur in those patients with the generalized subtype of SAD experiencing very severe social anxiety and avoidance in a variety of situations.



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