at the person is born with. the most important of these, i wod say, for anxiety disorders is that people are born with different tolerance levels for anxiety. some babies tolerate anxiety very, very wel some babies do not. it seems very clear that these kinds of differences are constitutional. that is e factor, but th alone cnot cause an adult aietyisorder. that in combination with, perhs, issues that have to do with childho history-- early and later chdhood history-- issues that have to do wi personalityevelopment-- at srearchers refer to chas adaptive style, the way ea one of us adapts to anxiety-- and also issues that have to do with current life stress. dr. shulman illustrates this multiplicity of factors with case histories of three differe anxiety-based disorders.

when dr. shulman took paula as a patient, she was about to marry a n out of h faith and was converting to his religion. her parents were very closed about such issues. paula guessed this wouldn't sit well with them. it didn't sit well with them. that would b what we call life stress-- thstress going on at the time that figures inm. to the ultimate developmt of the panic disorder. at age 9, she remembers there were many arguments at the fily dinner. most centered around her brother, who was three years younger than sheer. and was constantly in trouble in school. he was the bad son. she was always the good girl. she remembers being so upset that she went upstairsing on and put a towel in her mth

and scream, and she remembers doing this because she knew tt she couldn't scream out loud, that she wasallowed to scream, but she needed to scream. this later became very important as metaphor for what the panic disorder-- the function of t panicisorde- how it was serving to keep her fr screaming at her parents, the people she needed to scream at, to kand her need to ming a good girl.parents, phil is a 57-yeaold man with oessive-compulsive dirder. before going to work, phil had to check the gas 28 times to make sure it was really off. he knew how irrational this was, but it made him anxious not to check. phil also came into dr. shulman with a current life stressor, complaints of woening marital problems.

the traumatic experience in his life was when we was 5. his father and he constantly got into difficulties, even at that youngge. his father was constantly critical. he experienced his father as critical. he was often arguing and argumentative with the father, not doing what the father wanted. there was a particularly angry period in his fher's life around this age of 5, anhis fatherer died in a factory fire. as an adult, phil was still trying to deal with his angry childhood feelings. afid his aer killed h father, he was also afraid expressing anger at his fe might kill her. professor shulman believes phil's gas-checking was a solution to an unconscious conflict. on one hand, it exessed his aggressive feelings, and the oerand, itfledm.

maria is a 27-year-old woman with hypochondriasis-- intense anxiety that she's ill, even that she is dying. every physical symptom sends her running to her physian. one ght, she has i learned she was asleep and at 2 a.m., her husband came home, and they decided order. she ate the pizza at 2 a.m. aand woke upided order. with horrible stomach ache. typical of people with hypochondriasis, maria beeved it was stomach cancer, not the pizza, that caused her pain. in examining the causal factors in maria's anxiety disorder, . shulman loed both at her present stressor-- her recent marriage-- and at her childhood. she was raised in a very tradional italian home, the favored anthe rst child, and her father, o was seen as a very perful figure in the family--

the mother was seen as very passivand ry weak. was someone who pampered her as an exemand catered her.ure, this all changed at adolescence, when the father became very withdrawn and very critical of his daughter, particularly of her developing sexuality, and what maria did was a massive rebellion. she became very sexlly active. she became involved as a rock groupie during the late sixties, doing very--extremely frightening activities, sneaking out of the house constantly, really opposing the father's iron hand. when mia decided to get married, her rebellion turn inward. she became hypochondriachal, prccupied with her health and fears ofying. dr. shulman suggests that maria's dramatic change related her upcoming marriage. wh maria's disorder mostly had to do with was an attempt to disable hself,

to keep her connected with a powerful n, just like the father was befo adolescence a after, while at theame time, expressi hernger indirectly by withdrawing, by beingulnera by bng too fgile time, expressi hernger indirectly to be the partner that he was expecting he marriage. 's not always clear why a particular patient to bedevelops a particularwas expecsymptom pattern.. profr shulman sums up his poinof view th there are four contributing factors. in the first case, in paula's case, it was the upcoming marriage and conversion and the potential dagreement with the paren. in maria's case, ain it was marriage, a marriage that shd significant concerns about. in the third case, in phis case, it was a conflict-- a paicularly angry conflt.

so in each case, there was a currenlife stress thatlso has to be figured . it would be too parochial to think of any one of theseacto as being the reason for an anxiety disorder. ons to consider the interplay ofhoseors. for laverna series os beginninth the death of he the interplay ofhoseors. contributed torna series os her chronianxiety. i was ostoy mother,d, um... to mthat was--a lot of peopleos might think sounds funny, but th was my god on earth. losing her, i didn't really have anybody else that, um...really mattered, because she always talked to me about everything, d, um... oh, i was angry. i was angry at god. i couldn't understand why he didn't take my father

or somebody that i didn't love or something that wouldn't hurt me, and i cried a lot. i cried for about two years, every day, and that's when i first started getting anxiety and thinking that i was going crazy. there are basically three kinds of treatment for anxiety disorders-- one, medication. the antianxiety ugs most commonly prescribed are the benzodiazepines, with brand names like vali, librium, and xanax. these act to suppress the anxiety sympto, making the person feel calmer. two, psychodynamically-based psychotherapy, using insight to uncover unconscious conflicts. and three, cognitive-behavioral psychotherapies which us relearning techniques, changingehavior and automatic thought process. in thto challenge donna'sl us coautomatic thought

that if she doesn't immediatel pay bills inull, in thto challenge donna'sl usthe consequences will be dire. you've been worrying about finances. are you worried about somethingspec? anything in particular? i have lots of insurances due ght no lots of insurances, um... some things that i try to help my daughter with, even though she's college age. because i'm in a limited financial situation, it makes it rough for me. i'm a worrier. i know i'm going to have to pay them, and i know worrying isn't going to help, but it doesn't seem to stop me from worrying. we've talked about this before. worrying doesn't resolve a problem. if you have fincproblems, rrying doesn't resolve the problem. we need to find alrnative ways dl with your finaial problems. those things you can't control, we'rgoing to have to get you let go of

and find ways to let go. if you're a limiteincome, what keeps you from paying part ofhe bill and saying, "you'll see the rest in september or october"? i don't like to receive bills. i don't know why. it's probably from never having money as a child. does it trigger your worry, then, when you receive the bills? it triggers my worry immediately. even if i had money, i wod think, "i'm going to be in the streets." what will allow you to let go of it if the bill is unpd? are you in risk of losing your home? no. ok. what will allow me to stop worrying? is it the end of the world? no. ok. i just have to learn how to let go. now we turn to behavioral psychotherapy.

we saw eaier in our program, the agoraphoa clin uses behavioral psychotherapy to help clients learn new behaviors for anxiety-producing situations. here it is used to help roger and tale their fear ofeights. let your eyes focus. to help don'let them wander. focus on what you see. pay attention focus. to help to what they're doing. and that tends to come across i'm in mor cy traveling heights, where there's a tall buiing ha, evenpen shopping malls with twor three stor that was--uh, is a real problem for me. there he is. heights, open spaces-- he's reay having a very hard time. see him holding the railg? he'll come down. think he'sall right, allen. finally,e turn to classical psychodynamically-based psychotherapy. its goal is to get at experiences and conflicts

instilled in childhood d out ofhe patient's current awareness. in psychoanalytic forms of treatment, the basic assumption is that what needs to be done is a pern needto make-- if aerson has a neurotic disorder, th it's because they have unconscious conflicts-- primarily oted childhood experience-- t that they have thesconscious conflicts, and if o could make the unconscious conscious, if one could bring consciousness these unconscious conflis, en the neurotic disord would dissve. in this, uh... in this way, psychodynamic treatment is rlly based on insight-- the fact that what the analyst is trying to help the patient do is gain insight into his cdition, gain insight into his unconscious. wh you are a child, you pusomething in the unconscious it is buried, and it stays intact.

it stays t same way it went in. it iit's only when we unbury somhing, which one can do through psychoanalysis, that one can--then that thing, that memory, that fantasy, that idea can no longer be intact. in the real world, it's almost always a combination of therapies that's appropriate. in this scene, a combination of cognitive-bavioral and psycdynamic psychotherapy is ud with mary to work on her elings of anxiety about being asked to drive alone. what would you ke to say aboupushinyo asng you to it one more time? are these people for real? are they going to make me? say that to mepeople and allen.al? are yousegoing to me me go out in a car? i mean, when i'm not ready? i feel like i'm not ready.

can you say what y'rfeeling? "the way it makes me feel whenouush me." yeah ma a nice statement instead of a question. aryou going push me... that's a question. into something i'm not ready for? uh-huh. and? how does it make you feel? part of me good and part of me bad because i feel like i do need a push, but i'm raid to get pushed. how do you feel about the person who pushes? pardon me? how do you feel about the person who pushes? angry and... "it makes me angry when you push me." but i want it. we're asking you to take a chance. make a direct statement about what you're feeling and see what happens. maybe things have changed.

i think, out of all the anxiety disorders, generalizeanxiety is one of the more diicult to treat, and especiallywith the. geneshe's exriced anxiety of donn5o% of her life.ory.t, told you that the tingling othe feet, and i thought, "this is hyperventilation. these are why the symptoms are getting worse." we need to get your arousal down under control. i want you doi your breathing anslowinyour bodilyovemen i don't want you pacing.wn again. it's nice to go t for a wa, but i want you doing ur diaphragmat breathing. if we can getyourrl under control, ur worries e going to seem less excesve, and we'll be able to.. actually, we'lbeabl, but we can't do until the arousal's back down. what i want you to do

is monitor the times you feel someo is placing a demand on you u don't want to do what they're asking. i want you to write that down fome. we'll usth. for the past four years, laverne's chronic anxiety with a varpsychotherapyiques. wl has broughpositive results, laverne hafound the most relief through mecation. she's on xanax and has do extremeell. the question you always have to ask yourself out someone who is on one of these medications is, ha they been on it long enough? and usually whate do is to ensure that they stay on an adequate doge t are not erdosing themselves, and most peoe do stay on stable doses. if you start on "x" amount, you stay on "x" amount

for the many years that you're on it. but periodically, you have to review the cas i'm not frightened of anythg. i can ride an elevator, the subway. i don't think of any of those things anymore. it just calms--it makes-- it keepse calm. i don't get anxious or anything, uh...but if i do, then i'll take the medication, or i'll talk to myself and tell myself that this is something that happens and to let it pass. at one time, i was trying to stop the feeling. it's best to letn y try top. the feeling go away. i dn'to without it. right d be afraid to notake it. i would very afraid. return to the agoraphobia clini

in week two of their program to see the participants' progress. they made great strides in only twweeks. mary was now driving alone, roger had crossed numerous bridges, and paick drove one to aanticity. although they weret paniattack free, and paick drove one tthere was improvement. i got my license, and drove ice. the second time, i had a pretty bad nic attack, so two years ago, it i drove a couple weeks, and then i had panic attacks again, so then i haven't driven till now. yesterday, on one of her driving assignments, mary had and survived a panic attack. it was scary. i didn't think i could keep driving, but i did. linda was with you then? no. i was alone. so where were you when you saw you were having an attack

on city line what did you say to yourself to keep yourself going? i got mad at myself, cursed myself. i just get mad at myself and feel bad because i think i shouldn't be like this. i'm just like everyone else, afraid. and i get mad at myself, and that would give me more courage, and i'd be able to keep going on. there are some bridges, some roads-- one in particular, a high bridge-- that i have not crossed by myself, with anybodysure in the c driving for six or seven years probably, and yesterday i had probably a total of 14 or 15 passes across those two bridges. it felt great to be able to do that

and not have the panic attacks. patrick describes the symptoms he worked rough on the way to atlantic city. going to atlant cit i ticed my brehing was getting shallow. i was mildly hyperventilating, and, umm... i sort of talked myself out it. i practiced my breathing techniques and everying, and it went away quicker than it usually would. in that situation bere, i would have pulled over, but fr coming here and learning what i learned and knowing what i know fr h but fr coming here and i was able to handle it. as he surveys a nearby college mpus, patrick fantasizes about his futu life as a student. thit wouea tt scary but i would adjustt. you'd say, "thi har th afterhile, i'd sa

"this geasier a eie my csses," d probat tting e homework do there i thinking that would... it's lik two different op, like i was a k last week and adult this ek i'm a t more assertive, go places alone easier. now there's a reald ho that i'll geto g college. while therare similaries among most psychotherapi, the difference between using psychological treatments and medication is signicant. when to use ese two forms of treatment d n remains a difficult and often sensitive issue. some of thantianxiety meditions are dictive-- very important to keep in mind. some of e anxiety medications reque very difficult very impwithdrawals.ep in mind. as a matter of fact,

some people have noticed thatithdrawal from valium is as bad as withdrawal from heroin in terms of the experience of the person, is that it's nothdrawal to be taken casually. thdrawal isn't the only danger. the benzodiazepines we're not sure about in pregnancy. the rule of thb for medication is, don't use it if you don't have to in pregnant women or nursing women in women of childbearing age because they don't always know when they're pregnant, and those first eks that they don't know is really when the baby is being shaped. some of the side effects, not of the benzodiazepine group, but of some of the other groups, are sedation, cognitive impairment. and they're not quite sure, although there's no re evidence on the table, that it causesdeformiti. that's something we want to avoid. this is the reason why i so strongly believe in psychological treatment.

there's also bn great advances in medication treatment of anxiety and of panic, t ifou don't keep taking those medications, u are virtually assured of relapsing. in additn to that, it's very clear th some of the medications, the ones calledthat, minor tranilers-- the benzodiazepines in particular, xanax, most commonlysed the days-- actually interferes with o of the processes necessary for getting over-- that is, permanent change-- the fear, and there is data to support that. we certainly see it clinically allhe tim once you've made diagnosis and the person is prepared for treatment, yodiscuss the options. when you think medication is legitimate is the same as you would in non-anxiety-related illnesses. if you find that the intensity of the person's behaviors, feelings, and thoughts

are so great that they interfere with the dayo-day life, and they can't wait-- so that if they're suicidal or feel that they might hurt thselves or somebody ee-- then you start medication right away. the second possibility is that once you've tried psychological or nonpharmacalogic treatments and they have not worked or the benefit is not 1oo%, it's possible to go ahead and to use medications. the last possibility is that you plan ahead of time to use medication in order to right the biologic wrongs in a person and prepare them to receive these psychological treatments that work so well. well, it's nice to wake up and be alive. i'm glad tbe alive. it's like i was freed from a prison. um...

i feel that m noal, and that's the first time i've felt that i'm normal and that i wasn't azy and i wasn't insane in 28 years, and it's a good feeling. it's like being freed. i've been given good coping skls and understand the dynamics of what's going on undernth the surface, and we've learned a lot of lower-level information about our childhood. in particular, i've gotten in touch with some things in my past that explain this. it's not a mystery anymore. i think i understand, to a large degree, what's happening, and that's 4 of the battle, is knowing what's ppening, being able to unrstandt. didn't knoas much about it that i do now, and now i know i'm not goincrazy. i know i'm not going to diand i. i told somebody that i was trying catch--

trying to go-- catch up on a lifetime in two weeks. it sort of see that way. it's just weird. it's like a transaction from child to ult. before, it seemed like it was-- i was depending on others, and now i'm depending on myself. i'm not alone. i'm with me. i don't know how to explain that. the fure? it looks good. it's going to be good. it can't get any worse. i know that because those days were the darkest days that i've ev had. so i can see green trees now. i can hear the birds sing. i'm not just going through the motions anymore. i'll know how to handle things from now on, so i know the future is real good. no problems there.

captioning performed by the national captioning institute, inc. captions copyright 1991 alvin h. perlmter

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