December 2007
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Our First Classic Awards
For our first ratings, we have picked two books by outstanding clinical researchers. In our professional category, we selected Dr. David Barlow's Anxiety and Its Disorders. In the self-help category, we chose Dr. John March's Talking Back to OCD. |
David H. Barlow, Anxiety and Its Disorders:
The Nature and Treatment of Anxiety and Panic (2nd
edition). New York: Guilford, 2002.
This is an outstanding text. David Barlow is one of the foremost thinkers
in the world today on exactly this topic: the nature and treatment of the anxiety
disorders. This second edition includes contributions by Martin Antony,
Terence Keane, Gail Steketee and five other outstanding researchers and clinicians. Don't
bother with the book if you are looking for a treatment guide. This is
almost 700 pages of thorough analysis of the field. But what an analysis
it is! If you are a student of the work of anxiety disorders, then you
will want to educate yourself with this meticulous and comprehensive manuscript.
It moves from the nature of anxious apprehension and panic through the biology
and vulnerabilities of anxiety to the examination of each anxiety disorder and
its current treatment modalities. This will continue to be a classic in
the field. |
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John March, Talking
Back to OCD: The Program That Helps Kids and Teens Say "No
Way" -- and Parents Say "Way to Go". New
York: Guilford, 2006.
There's good news about recovery from childhood OCD, and it's called Talking
Back to OCD. Dr. March explains with clarity and compassion what parents
deserve to hear: they can make a difference in their children's lives. A highly
respected, innovative clinical researcher, he describes each component of recovery
in ways that both parents and children will understand and appreciate. Clinicians
will see this text as easily adapted into a well structured treatment protocol
for both children and adolescents. The usable stories, analogies and metaphors
are worth the investment, and there are far more gifts within. |
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Self-Help
Update:
Wanting Habituation
Let's define habituation as our body-&-mind's
ability to reduce its anxious reaction to a feared stimulus.
You create that change through exposure to the feared stimulus. The exposure that leads to habituation requires three elements: frequency, intensity and duration.
Frequency: You have to expose yourself to your feared situation often enough or you won't progress.
Intensity: When you practice, you need to get up to a moderate level of distress. Practicing while you try to keep yourself calm actually slows your progress.
Duration: According to research, practicing between 45 to 90 minutes seems to be the ideal amount of time.
These three components of habituation guide most behavioral homework assignments.
I think there is a fourth element missing: the spirit of wanting to experience what you need to experience. In anxiety treatment you will progress much more rapidly when you desire to have the habituation experience. Unless you are seeking and wanting frequency, intensity and duration as you go toward fear, then by default, you will be trying to do the opposite. At some level, you will be hoping that you don't get anxious, that the symptoms don't get very strong, and that the distress doesn't last very long.
But the logic of that approach doesn't hold up. If frequency, intensity and duration of exposure to distress and doubt are needed for me to get better, then I want to stumble upon, or purposely go toward, a situation which stimulates my anxiety. I want to do that often, and I want my distress to last, and I want the sensations to be strong. These elements create habituation, and habituation is my ticket out the door away from suffering.
Adopting this specific orientation can adjust your disposition toward the problem, help to guide your practice, and motivate you at the same time. I'll bet that it alters neurochemistry as well. How does that happen? In part, it is from the placebo effect. As an analogy, imagine someone you know is receiving chemotherapy for cancer treatment. It would be poor therapeutic form to go to each appointment dreading it, despite the fact that the side effects can truly be dreadful. Instead, they should see the chemotherapy as their friend, augmenting their body's natural ability to heal. That's good placebo.
The most important benefit of applying the skill of wanting is that it speeds healing by truncating the habituation process. I have noticed that clients learn rather quickly that if they invest in the stance of wanting, it returns to them the gift of a more rapid reduction in their anxiety. They gain insight sooner in the process, after fewer practices and after fewer minutes within each practice.
Here are the kinds of messages that you might convey in the moment:
"I want this feeling, I want it to last, I want it to be strong...because that's how I get better" or
"Whew! That's some strong anxiety right now. I'm really scared! And I'm glad I am practicing right now, because I want to get better."
When you apply this skill during practice, you may find that you actually have quite a hard time keeping your distress high (try as you might) or having it linger around for those 45 minutes. By paradoxically applying the orientation of wanting, you can have an 'aha' experience during practice that brings freedom from the fight.
Professional Update:
Medications during Pregnancy
An increasing amount of research is being conducted on the safety, risks and benefits of psychotropic medications during pregnancy. For the anxiety disorders, we tend to focus on two medication families: the benzodiazepines and the SSRIs/SNRIs.
The benzodiazepines are never to be used while attempting to become pregnant, during pregnancy or while breastfeeding.
Information available on the safety of antidepressant use during pregnancy is limited by the small size and the designs of most trials. However, there is growing evidence that taking serotonin reuptake inhibitors (SSRIs) and other related antidepressants during pregnancy carries an extra risk. For this reason, the American College of Obstetricians and Gynecologist (ACOG) recommends against their use during pregnancy unless it is absolutely required and no other options exist.
SSRIs have been found to cause "SSRI neonatal withdrawal syndrome" and "SSRI abstinence syndrome," as well as an increased risk for birth defects. About one out of three newborn infants exposed to antidepressants in the womb show signs of neonatal drug withdrawal, including tremors, gastrointestinal problems, muscle tensing, sleep disturbances, and high-pitched crying. Other complications from SSRIs or selective norepinephrine reuptake inhibitors (SNRIs) can include irritability, difficulty feeding, and rapid breathing. Studies have found that one particular SSRI, if used during the first trimester, may increase the risk of congenital cardiac malformations. In addition, for every 100 women taking an SSRI medication late in pregnancy, one may have a child with persistent pulmonary hypertension (PPHN).
At the same time, the symptoms of anxiety disorders and depression can have their own effects on the health of the mother and the fetus. The decision to use or not to use medication during pregnancy and during breast feeding is an important one.
Resources
Alwan S et al. Use of selective serotonin-reuptake inhibitors in pregnancy and the risk of birth defects. N Engl J Med 2007 Jun 28; 356:2684-92.
Bonari L et al. Risks of untreated depression during pregnancy. Can Fam Physician 2004 Jan; 50:37-9.
Chambers CD et al. Selective serotonin-reuptake inhibitors and risk of persistent pulmonary hypertension of the newborn. N Engl J Med 2006 Feb 9; 354:579-87.
Chung TK et al. Antepartum depressive symptomatology is associated with adverse obstetric and neonatal outcomes. Psychosom Med 2001 Sep/Oct; 63:830-4.
Cohen LS et al. Relapse of major depression during pregnancy in women who maintain or discontinue antidepressant treatment. [Erratum in: JAMA 2006 Jul 12; 296:170.] JAMA 2006 Feb 1; 295:499-507.
Einarson TR and Einarson A. Newer antidepressants in pregnancy and rates of major malformations: A meta-analysis of prospective comparative studies. Pharmacoepidemiol Drug Saf 2005 Dec; 14:823-7.
Greene MF. Teratogenicity of SSRIs: Serious concern or much ado about little? N Engl J Med 2007 Jun 28; 356:2732-3.
Hallberg P and Sjoblom V. The use of selective serotonin reuptake inhibitors during pregnancy and breast-feeding: A review and clinical aspects. J Clin Psychopharmacol 2005 Feb; 25:59-73.
Hemels ME et al. Antidepressant use during pregnancy and the rates of spontaneous abortions: A meta-analysis. Ann Pharmacother 2005 May; 39:803-9.
Louik C et al. First-trimester use of selective serotonin-reuptake inhibitors and the risk of birth defects. N Engl J Med 2007 Jun 28; 356:2675-83.
Newport DJ et al. Atypical antipsychotic administration during late pregnancy: Placental passage and obstetrical outcomes. Am J Psychiatry 2007 Aug; 164:1214.
Nulman I et al. Child development following exposure to tricyclic antidepressants or fluoxetine throughout fetal life: A prospective, controlled study. Am J Psychiatry 2002 Nov; 159:1889-95.
Orr ST et al. Maternal prenatal pregnancy-related anxiety and spontaneous preterm birth in Baltimore, Maryland. Psychosom Med 2007 Jul/Aug; 69:566.
Rubinow DR. Antidepressant treatment during pregnancy: Between Scylla and Charybdis. Am J Psychiatry 2006 Jun; 163:954-6.
Suri R et al. Effects of antenatal depression and antidepressant treatment on gestational age at birth and risk of preterm birth. Am J Psychiatry 2007 Aug; 164:1206.
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