wh iwesked peopl thout xiety disorder ether or not ey had similar or the same childhood experience we're just not se, scientic, whether the answer we got wod be thatidn't develop xidisorders.nces in t end, stxpts feel that a singl tn't plaianxiy disorders. xidisorders.nces so my model, anthe model of most people involvedn abnoal psyology, shas to do with a multiplicity of factors. as to do with constitutional vulnelity, which is to say the kind biological, physiological, constuonal elements at the person is born with. the most important of these, biologii would saological, with different tolerance levels for anxiety. some babies tolerate anxiety very, very wel some babies do not.

sms very clear that these kinds of differences are constitutional. that is e factor, but th alo cnot cae adult aietyisder. that in mbination with, perhs, issues that have to d with childho htory-- early and later chdhood history-- whatthe way ea one of uswi perst adapts tanet- style, and also issues that have to do with current life stress. dr. shuln illurates this multiplicity of factors with case histories of three dfere anety-based disorders. when dr. shulmantook p, and was convtingo mar to his religion. her parents were very closed a. paula guessethis wouldn't sit well with them.

it didn't sit well with them. that would be what we callife stress-- thstress going on t time at figures inth them. to t ultimate developmtof the p. thstat age 9, she remembers t tthere were many arguments at the fildier most centered around her brother, o was three years unger than she and was constantly in trouble in school. he was the bad son. she was alys the good gl. she remembers being upset that she went upstrsing on anput a towel iner moule and screamed, and she remembers inthis because she kn that she couldn't scream out ud, that sheast allowed to scream, but she needed to ream. this later became verimportt as metaphorfor what the- the functionof the pa-

how it was serving to keep her frcreaming at her parents, at the people she needo scre at, and her need to a good girl. phil is a 57-year-old man with obsessive-compulsive rder. before goingo 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 worsenin marital problems. the traumatic experience in his life was when we was 5. his father and he constantly got into difficulties, even at thatoung age. his father was constantly critical. he experienced his fher even as critical.age. he was often argui and argumentative with the father, not doing whatthe father wa.

there was a particularly angry period inis fr's life around this age of 5, anhifatherer died in a factorye. as an adult, phil wastill ting to deal with his angry childhood feelgs. afid his anger killed h father, he was also afraid professor shulman believes phil's gas-checkingr. was a solution to an unconscious conflict on one hand, it expressed his aggressive feelings, and on the oerand,it stifledm. maria is a 27-year-old woman with hypochondriasis-- intense anxiety that she's ill, even that she is dying. eveone night, she hasm sends her ra te stomach ache.ian. i learned she was asleep

and at 2 a.m., her husbd me home, and they decided to ord. she ate the pizza at 2 a.m. and woke up and they decided to ord. with a horrible stomach ache. typical of people with hypochondriis, maria beeved was stomach cancer, not the pizza, that caud her pain. in examining the causal factors in maria's anxiety disorder, . shulman loed both aher present stressor-- herecent marriage-- she was raised in a very trational italian home, the favored anthe rst child, and r ther, o was seen as a very powerful figuren the family-- the mother was seen vy passive and ryeak. wasomeone who pampered her as an exemand catered her.e, this all changed at adolescence, when the father became very withdrawnnd very critical of his daughter, particularly of her developing sexuality,

and what maria did was a masse rebellion. she became very sexually active. she became involvedas a roce during the late sixties, doing veryextremely frightening activities, sneaking outof the ho, ally opposing the father's iron hand. whenaria decidedtof the ho, to get married, her rebellion turn inward. she became hypochondriachal, preoccupied with hereah and fears ofying. dr. shulman suggests that maria's dramatic change related her upcong marriage. wh mar's disorder mostly had to do with was an attempt to disle hlf, just like the faer wasith a p, before adolescence and after, whilat thee , pressi hernger indirectly

to be not always earwassith a p, pectgwhy a paicularatientter, develops a particular sytom pattern. profr shulman sums up his poinof view th there are four contributing factors. in t fst case, in paula's case, it was the upcoming marriage and conversion d the potential dagreement wi the parents mia's case, again was marriage, a maiage that shd significt concerns about. in the trd ce, a rticularly angry conflt.nflic- son each case, the was a currenlife stress thatlso has toe figured in. it wld be too parochial tohi of any one of theseacto ass toonsiderreason the interplay ofseors.r.

for laverne,a seriess beginninth the death of he contributed torne,a seriess her chronianxiety. was ose toy motherand, um... to me that was--a lot of people might think sounds funny, but that 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, and, 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 bacally three kinds of treatment for anxiety disoers-- one, medication. the ananxiety ugs most commonly prescribed are the benzodiazepines, with brand names like valium, librium, and xanax. these act to suppress the anxiety symp, making the person feel calmer. two, psychodynamically-based psychoerapy, usininsight to uncover unconscious conflicts. and three, cognitive-behavioral psychotheries which us relearning te, changingehavr and automatic thought press. in this scene,r. donll uses cognitivechherapy to challenge dna's automatic thought that if she doesn't immediately pay bis ull, to challenge dna's thconsequencesl be dire. you've been worrying about finances. are you worried about somethingspec? ything in parcular? i have lots of insurancesdue ght now. lots of insurances, um... ything in parcular?

some things that i try to help my daughtewith, 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 resolve the prlem.dt we need to find alrnative ways to deal with your financial problems. those things yocan't coro we'rg to have to get you to let go d find ways toet go. if you're a litecome, what keeps you from paying part ofhe billgo. 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 triers worry immediately. even if i had money, i would 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. as we saw eaier in our program, the agoraphoa clin uses behavioral psychotherapy to help clients learn new behaviors for anxiy-producing situations. here it is used to help roger and for anxiy-producing ta their fear ofeights. let your eyes focued to help don't let them wander.

fos on what you see. pay attention to wt they're doing. and that tends to come acrossing i'm sensitive to mostly heights, where there'a tall buiing have, evenpen shopping malls withwor threorie that was--uh, is a rl problem for me. there he is. heights, open spaces-- he's really having a very hard time. see him holding the railg? he'll come down. thk he'sall right, aen. psychodynamically-based finally,tupsychotherapy.l its goal is to get at experiences anconflicts psychodynamically-based finallinstilled in childhood d out of t patient's current awaress. in psychoanalytic forms of treatme, the basiassumptiont's is that whateeds to be de is a pern edto make-- if a person has a neurotic disorder,

th it's because they have unconscious conflicts-- t that they haveted thesnscious conflicts,e-- and if one could make the unconscious conscious, if one could bring consciousness these unconscious conflis, en the neurotic diso would ss. in this, uh... in this way, psychodynamic treatment is really based on insight-- the fact that what the analyst is tryinto help the patit do is gain insight in his cdition, gain insight into his unconscio. en you are 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, that one can--then tt thing, that memory, that fantasy,s, that idea can no longer be intact. that in the real world,hing, that it's almost alwayssy,s,

a combinion of therapies that appropriate. in this scene, a combination of cognitive-bavioral a combinion of therapies and psycdynamic psychotherapy is ud with mary to work on heelings of anxiety about being asked to drive alone. what would y like to say aboupushinyou, asking you to do it one mo time? are the people for real? are they going to make me? say thato mepeople and allen.al? are youse going to me me go out in a car? i mean, when i'm not ready? i feel lik i'm noready. can you say what y'rfeeling? "the w it makes me feel enouh me..." yeah a nice statement instead of a question. aryou going push me... that's a question. into something i'm not readfor?

uhuh. and? how does it ma you feel? part of goodand rt of me bad because i el like i do nd a sh, how dooueel but i'm raiddandabout thperson to g pushed. who shes? pardon me? w doou feel t e person grand... who es? "ikes me angwhen youush me." but i want it. we're asng you to te chce make a direct atent about what you're feelin and see what happens. i think, out of alls the anxiety disords,. generalizeanxiety is one of the more diicult to treat, and especiallywith the. she's experienced anxiet 5o% of her life.

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 doingyoug anowinyour di movements back down again. i don't want yopacing. it's nice to go t for a wa, but i want you doing i your diaphragmatic yopabreathing. if we can getyorous it's nice to go t under control, ur wries e going to see less excesve, and we'llbe able to. ur wries actuly, we'll be able to stop them, but we can'to until the arousal's back down. what i want you to do is monitorhe times u feel som is placing a demand oyou d u don't want to what they're asking. i want you to write that down fome. d u don't want to what wel th. asking. for the past four years,

ves chronixietyhall with a varty of techques. while gnitbehavioral psychotherapy has broughsitive rests, lavee hafod the most relief roh medication. she's on xanax and has donextme well. thquestion you always have to ask yourself t somee who is onone of tse med, ha they be on it long enough? and usually whate do is to ensure that they stay on e t e not erdosing themselve if you start on "x" amount, you stay on " amountses. r the many years that you're on it. but periodically, you have to review the cas i can ride an elevator,ened othe subway. i don't think of any of those thgs 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. ets worseen y tryop i. it's best to let the feelg go away. i dn't dthout it. right w i'd be afraidto no. i would very afraid. return to the agoraobia clini in week tw of their program to see the participants' progress. they me great strides innly twweeks. mary w now driving alone, roger had crossed merous bridges, and patrick drove aloneto . althgh they weret paniattack free,

and patrick drove aloneto . there was improvement. i got my license, and i drove ice. the second time, and pati had a pretty bad . there nic attack,ment. thtwo years ago,t i drove a couple weeks, and then i had paniattacks again, so then i haven't driven till now. yestday, 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? noi 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 self d 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 no crossed by myself, with anybodysure in the c driving for six or seven years probably, and yesterday i had probly a total of 1or 15 passes across those two bridges. it felt great be able to do tha and not have the panic attacks. patrick describes the mptoms he worked rough the w to atlantic city. going to atlant cit i i was mildly hyperventilati, and, umm...llow.

i sort of talked myself out of it. i practiced my breathing chniques and everying, and it went away quicker than it usually would. in thasituation before, i woulhave pulled over, but from coming here and learning what i learned and knowing i was ab to handle it. as he surveys a arby collegmpus, patrick fantasiz about s futu life as a student. thit wouea ttle sca, but i would adjusttl you'd say, "this har then afterhile, i'd sa "this gngea a eie my csses,'d ablyy ro tting the homework do there i thinking that would... it lik two differop, like i w a kid last week and adult this week i'm a t re aerve go places alone easier.

now there's a realood that i'll get to gto colge. while therare similaries among most psyotherapi, the diffen bween using psychologil tments and medication is significant. when to use ese two forms of treatment inn and medication is significant. remains a difficult and often sensitive issue. some of thantianxiety meditis are dictive-- very important to keep in mind. me of the anxiety medications reque very difficult withdrawals. as mter of fact, some peoplhave noticed thatithdwal from valium is as bad as witrawal as mfrom heroin, in terms of the experience of the person, is that it's notrawal to be taken casually. thdral isn't the only danger. the benzodiazepines we're not . the rule of thb for medication i

don't usit if you don have to in pregnant women or nursingomen in women of childbearinage because th don't always know when they're pregnant, and the first weeks that they don'know is really when the baby is being shaped. some of the side effts, 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 evidce on the tabl that icausesdeformities. at's something want to a. this is the reason why i sotrongly believein psych. there's also bn great adnces in medication treatment of anxiety and of panic, t ifou don't keep taki those medications, u are virtually assured of relapsing. in addition to that, it's very clear th som ofhe medications, the ones calledo that, minotranquilers--

the benzodiazepines particular, xanax, most commonly used these days-- actually interfe with one of the processes necessary fogetting over-- that is, permanent change-- the fear and there is da to support that. we certainly see it clinically allhe tim once you've made diagnos and the person is prepared for treatment, yodiscuss the options. en you think medication is legitima is the same as you would in non-anxiety-related illnes if y findat the iensity of the person's behaviors, feelings, and thoughts are so great that they interfere with the dayday li, d they can't wait-- so that if they'reuicidal or feel that they might hurt thselves or somebody else-- then youtart medication rhtway. the second possibility is that once you've tried

psyclogical or nonphaacalogic treatments and they have not worked the benef is not 1oo%, it's possible go ahead and to use medications. the last possibili is that you planhead of time use medication inrder to right the biologic wrgs in a person d prepare em to receive these psychological treatments that work so well well, it's nice to wake up and alive i'm glad tbe alive. it's like i was freed fromrison. um... i fe that m normal, and that's the first timei've fl and that i wasn't azy and i wasn't insane in 28 ars, and it's aood feelin i've been give good coping lsg freed. and undersnd the dynamics ofhat's going on

undernth the surface, and we've learned a lot of lower-lel information about our childhood. in particular, i've gotten in touch wi some things in my past that ein this. it's not a mystery anymore. i thk i understand, to a large degree, what's happening, and that's 3/4 of the battle, knowing what's happening, being able to understandt. didn't know as much about it that i do now, and now i know i'm not goincrazy. i know i'm not gng to and i cant i told somebody that i was trying cat-- trying to go-- catch up on a lifetime in two weeks. it sort of seems that way. it's just weird. it's lika transaction from child to ult. before, it seemed like it was--

i was depending on others, and now i'm depending on myself. m not alone. i'm with me. i don't know how to explain that. the fure? it looks goo it's going to be good. itan'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'nojust going through the motions anymore. i'll know how to handle things from now on, i know the future is real good. no problems there. captioning perfoed bthe na. captions cight 11 alvih. perlmutter

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