Self-Help & Professional Update:
Benzodiazepines versus SSRIs in the Learning Process

At the recent ADAA national conference, I had the opportunity to hear Extinguishing Anxiety co-author Dr. Catherine M. Pittman talk on anxiety and the brain.  She spoke about how medications fit into this picture. There are three questions to ask about medications:

• How do they affect the anxiety response?
• How do they affect the exposure process? (Meaning how do they affect the amygdala’s learning?
• How do they affect cognitive interventions? (Meaning how do they affect the cortex’s learning?)

Based on the principle that you need to “activate to generate” new circuitry, here’s what she said:

The SSRIs, such as Zoloft (sertraline), Lexapro (escitalopram oxalate), & Prozac (fluoxetine)

• While they have little immediate effect on the anxiety response, they eventually stimulate neurons to modify the circuits
• It’s possible that they can facilitate activation and new learning

The Benzodiazepines, such as Valium (diazepam), Xanax (alprazolam), & Klonopin (clonazepam)

• Decrease anxiety immediately
• However, they reduce the amygdala’s ability to respond. If they reduce activation, they will tend to preserve the current state of the circuitry
• Therefore, they will impair new learning during exposure treatment

Professional Update:
My Opinions about the DSM-V and Anxiety Disorders

A tremendous group effort, involving 100’s of mental health experts, is in its final stages: the DSM-V is scheduled for release in 2013. This is a major revision that began 11 years ago, and I congratulate all of the contributing international experts for their investment of time, dedication, and cooperation.  Not all decisions have been made, and I have passed along my opinions.  Here they are, briefly:

• We should make this a living document, like Wikipedia. DSM IV was released in 1994. That means there will be a 19-year gap between revisions. Far, far too long.
• I like the naturalistic approach of this new edition. To carve nature by its joints.
• Don't pull of OCD out of the anxiety disorders and into OC spectrum disorders. The spectrum disorders are more complex than OCD.
• Hypochondriasis should be added to the OCD spectrum disorders. While it’s currently within the somatoform disorders, the treatment fits an OCD model.  Let’s start matching diagnostic categories with treatment protocols.
• Move hoarding out of the OCD subtypes and into the OC spectrum disorders. It’s complex in a similar fashion.
• There will be a new rating system to identify the severity of the disorder.  While this is absolutely helpful, I hope, with the struggle to get insurance company approval for continued treatment, therapists don’t end up rating the severity higher than appropriate in order to be reimbursed for their continued services. Then this whole dimension will be wasted.
• This is a strong push to include comorbidity and to blend aspects of several disorders.  I hope this will allow future clinical research to use less exclusions. That way the research subjects will more closely match who we see in our practices.
• There is also a new dimension to indicate "the level of anxiety and avoidance."  We should include other safety behaviors within this dimension as well, like the degree of separation anxiety.
• Adding other distinctions would be helpful clinically. For instance, age of onset for panic disorder. If onset is 46 years old, how does that influence treatment versus when age of onset is 19 years old?
• I hope they will toughen up the "lack of insight" category.  With so many patients, lack of insight really boarders on delusions. Think of those with hoarding, body dysmorphic disorder, or even OCD in general.  “I'm keeping this 3 year old carton of eggs in case I need them in the future."  “I need a fourth plastic surgery on my (originally fine looking, by objective standards) nose, because it’s deformed.” “I need to replace that glass in the cupboard or my sons will develop cancer.” Are these examples of only “poor insight?”

Book Update:
The Procrastinator's Guide to Getting Things Done

The Procrastinator's Guide to Getting Things Done, by Monica Ramirez Basco, (178 pages, paperback), New York: Guilford Press, 2010.

Do you hold off to the last minute on those less-than-pleasant tasks? Are you typically off by 50% on your that-won’t-take-long-I’ve-got-time estimates? Think you are a capital-P Procrastinator for life? With this guide you’ll get the quick-and-easy shortcuts around all your excuses. Then you’ll gain the tools to find your personal stall tactics and the repair kit to fix them. When you’re done, get ready for your reward: efficient productivity and more time for fun.

Table of Contents

1. Why Do I Procrastinate?
2. Shortcuts to Help You Get Started
3. What Are You Afraid Of?
4. Are You Disorganized?
5. Moving from Self-Doubt to Self-Confidence
6. Procrastination in Relationships
7. All-or-Nothing Workers
8. Pleasure Seekers
9. This Is Just How I Roll!

Book Update:
Extinguishing Anxiety: Whole Brain Strategies to Relieve Fear and Stress

Extinguishing Anxiety: Whole Brain Strategies to Relieve Fear and Stress, by Catherine M. Pittman and Elizabeth Karle, (248 pages, paperback), South Bend, IN: Foliadeux Press, 2009.

This is a casually written and quite readable self-help book that gives the simple neurological underpinnings of anxiety and the fear response.  Most of it revolves around the amygdala, the body’s alarm system: understanding its processes and getting out of its way so it can learn what is truly dangerous and what is no longer a threat.

Occasionally our 2nd floor smoke detector will fire off if a guest lingers too long in the steamy shower. It confuses steam with smoke. That’s like some people’s genetically inherited amygdala: it’s hypersensitive, and can more easily give false positives.  Other people experience threatening events (like a car accident or a panic attack) that create a conditioned alarm within the amygdala.  Regardless of the contributing causes, if the amygdala is setting off false alarms, you need to help it learn to settle down.  This is where the authors successfully establish the rationale for exposure treatment.  You repeatedly present the trigger that sets off the alarm without presenting the negative event.  The amygdala learns to settle down.  But here’s the catch: you still have to have fear, because “you have to activate to generate." This means you have to activate circuits associated with the amygdala to generate new connections. You gotta be anxious to get over anxiety.  Don’t you hate that!  Except that it works.  Short term pain for long term gain. They built the book around this unifying theory, and it’s quite convincing.  Nice work!