thatidn't develop xiy disorders.nces t end, xpts feel that a singl tn't plaianxiy disorders. xiy disorders.nces so my model, anthe model of most people involvedn abnoal psyology, shas to do with a multiplicity of factors. has to do with constitutional vulnelity, which is to say the kind of blogical, physiological, constuonal elements at the person is born with. the most important of these, i wod sa 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 constituonal. th is e factor, but th alo cnot cause adult aietyisder. that in mbination with, perhs, issues

that he to d with childho history-- early and later chdhood history-- issues that ve to dowi perst with childho history-- what srearchers refer to as adaptive style, the way ea onef usadapts ta- 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 wou be what we callife stss-- thstress going on at the time at figures in to t ultimate developmtof the p.

age 9, she remembers there were many arguments at the fily dier most centered arou 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 girl. she remembers being upset that she went upstrsgoing on anput a towel iner moule and scream, and shremembers inth because she kn that she couldn't scream out loud, that sheast allowed to scream, but she needed to ream. this later became verimportt as metaphorfor what the- the functionof theani- how it was serving to keep her frcreaming at her parents, at the people she neededo scre at, to kand her need to ng a good girl.parents,

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 father as crical. he was often argui and argumentative with the father, not doing whatthe father wa. there was a particularly angry period in his fr's life around this age of 5, anhifatherer died in a factorye.

as an adult, phil wastill ting to deal withis angry childhood feelgs. afid his aer killed hather, he was also afraid professor shulman believes phil's gas-checkingr was a soluon to an unconscious conflict. on one hand, it expressed his aggressive feelis, and on the oer hand, it stifled tm. 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 tele stomach ache.ian. i learned she was asleep and at 2 a.m., her husband me home, and they decided to ord. she ate the pizza at 2 a.m. d woke up and they decided to ord. with aorrible stomacache. typical of people with hypochondriis,

maria beeved 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-- she waraised 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 passivand ryeak. was someone 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 massive rebellion. she became very sexually active. she became involved as a rock groupie during the late sixties,

doing very--extremely frightening activities, sneaking outof the ho, reallypposing the father's iron hand. whenia decidedoutof the ho, toet married, her rebellion turn inward. she became hypochondriachal, preoccupied with her health and fears ofying. . shulman suggests that maria's dmac change related her upcong marriage. wh mar's disorder mostly had to do with s an attempt to disable hlf, just le the faer wasdwith a p, before adolescence and after, whilat theame , pressi her anger indirectly by withdrawing, to be not always clearwasth a p, pectiwhy a particularatientr, deveps a particular symptom 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 dagreementwi ths mia case, again was marriage, a maiage that shd significt coerns abo. inhe trd ce, a icularly angry conflt.a confl- son each case, the was a currenlife stress thatlso has toe figured in. it wld be too parochial to thi of any one of theseacto asons to consider the interplay hoseorder. beginninth the deathseriess of her mothe contributed to her chronianxiety. i was ose toy motherd, um... of her mothe

to mthat was--a lot of people might think it 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, 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 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 psychotherapies which us relearning t, changingehavr and automatic thought press. in thto challenge dna's us coautomatic thought that if she doesn't immediately pay bills inull, in thto challenge dna's usthconsequences wl be dire. u've been worrying about finances. are you worried about somethingspec? ything in parcular? i have lots of insurancesdue ght now. ything lots of insurances, um... 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 fiproblems, rrng dsn'tresolve the prlem. if you have we need to find alrnative ways to deal with your financial problems. we'rgoing to ve to get us to let go coro d find ways toet go. if youe a liteincome, what keeps you from paying part ofhe bill and saying, "you'll see the rest in september or october"? i don't like to recve bills i don't know why. it's probably from never having money as a child. does it trigger your worry, then, it triggers my worry receive immediately.the bills?

even if i had money, i would think, "i 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 pshotherapy to help clients learn new behaviors for anxiy-producing situations. here it used to help roger and for anxiy-producing tackle their fear ofeights. let your eyes focu to help don't t them wander. fos on what you see. pay attention focu to help to what they're doing. and that tends to come across i'm mor cy travelingly heights,

where there's a tall buiing ha, evenpen shopping malls with twor threorie that was--uh, is a real problem for me. there he is. heights, open spaces-- he's really having a very hard time. see him holding the railing? he'll come down. thk he'sall right, allen. 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 haveoted thesnscious conflicts,e-- and if one could make the unconscious conscious, if one could bring consciousness

these unconscious conflis, en the neurotic disong conswould diss. in this, uh... in this way, psychodynamic treatment is really based on insight-- the fact that what the analyst is trying to help the patit do is gain insight into his cdition, gain insight into his unconscio. en you are cld, you pusomething in the unconscious it is buried, and it stays intact. it stays t same way it went . it iit's only when we unbury somhing, that one can--then that thing, that memory, that fantasy,s, that idea can no longer be intact. in the real rld, it's almost always a combination of therapies that appropriate. in this scene, a combination of cognitive-bavioral a combination of therapies and psycdynamic psychotherapy isd with mary to work on hefeelings of anxiety

about being asked to drive alone. what would you to say aboupushinyou, asng 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 like i'm noready. can you say what y're feeling? "the way it makes me feel whenouush me..." yeah ma a nicstatement instead of a question. aryou going to push me... that's a question. into something i'm noadfor?. uhuh. and? how does i ma you fl? part of gdand of me bad because i el like i do need a push but i'm radand of me bad to g pusd.

how doou feel about thperson who shes? pardon me? how doou feel t e person gran.. who pues? "it makes me angrywhen youusme." but i want it. we're asng you to te chance make a dect atent about what you're feelin and see what happens. i think, out of alls the anxiety disords,. genelizeanxiety is one of the more diicult to treat, and especiallywith the. she's expericed anxiet 5o% of her life. i to you that the tingling of the 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 y doingyour g

anowinyour dily 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. it's nice to go t if we can get yorous under control, ur wries e going to see less excesve, and we'll be able to... ur wries actually, 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 on you d u don't want to do what they're asking. i want you to write that down fome. wel th. for the past four ars, laves chronic xiety with a varty of techques. ile gnitbehavioral psychotherapy has broughposive rests, lavee hafound the most relief roh medication. she's on xanax and has donextme well.

thquestion you always have to ask yourself t somee who is on one of tse medicatio is, ha they be on it long enough? and usually whate do is to ensure that they stay on e t e not erdosing themselves, if you start on "x" amount, you stay on " amountses. r the many years that you're on it. but periically, you have to review the case. i can ride an elevator,ened the 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. s worseen y try t it. it's best let was trying the feelg go away.g. i dn't do without it. right i'd be afraidto nota. i would be very afraid. return to the agoraobia clini in week two of their program to see the participants' progress. they made great strides innly twweeks. mary was now drivi alone, roger had crossed numerous bridges, and patrick drove alone to aantic city. althgh they weretpaniattac, and patrick drove alone tthere was improvemt. i got my license, and i drove twice. thsecond time, and pati had a pretty bad tthere nic attack,mt.

so two years ago, it i drove a couple weeks, and then i had paniattacks agn, 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, cursedyself. i just get mad at self d feel bad because i think i shouldn't be like this. i'm just like everyone else,fraid. 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 to be able to do tha and not have the paniattacks. patrick describes the symptoms he worked rough the way to atlantic city. going to atlant cit i i was mildly hyperventilati, and, umm...llow. i sort of talked myself out it. i practiced my breathing chniques and everying, and it went away quicker than it usually would. in that situation bere, i would have pulled over

but from coming here and learning wt 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 h then afterhile i'd sa "this gngea a eie my csses, prablywoyo tting the homework do there, i thinking that would... it's lik two differop, like i w a kid last week and adult this week i'm a t more aerve, go places alone easier. now there's a realood that i'll geto gto colge. while there similarities amg most psychotherapi,

the diffence 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 ke in mind. me of e anxiety medications reque very difficult withdrawals. me as matter of fact,ations some peoplhave noticed that withdwal from valium is as bad withdrawal me as mfrom heroinct,ations in terms of the experience of the person, that it's not is as bad withdrawal me to be taken casually.ons thdral isn't the only danger. the benzthe rule of thbre not . for mecation i don't usit if you don have to in pregnant women or nursing women in women of childbearing age because th don't always ow when they're pregnant, and those first week 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 quitsure, although there's no re evidce on the tabl that icausesdeformities. at's something want to aid. 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 d't keep taki those medications, u are virtually assured of relapsing. in addition tohat, it's very clear th som of the medications, the ones calledohat, minotranquilers-- the benzodiazepines particular, xanax, most commonly used thesdays-- actually interfe with o of the processes necessary getting over-- that is, permanent change--

the fear and the is da 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 illnes if y find at the intensity of theerson'behaviors, feelings, and thoughts are so great that they interfere with the dayday li,y d th can't wai- so that if ty'reuicidal or feel thathemight hurt thselves or somebody else-- then you start medication rightway. the second possibility is that once you've tried psychological 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

to u medication inrder to right the biologic wrgs in a person d prepare them to receive these psychological treatments that work so well well, it's nice to wake up d alive i'm glad tbe alive. it's like i was freed from ason. um. i feel that m noal, and that's the first timei've fl and that i wasn'azy and i wasn't insane in 28 ars, and it's aood feelin i've been give good coping sklsfreed. and undersnd the dynams of what'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 expin this. it's not a mystery anymore. i thk understand, to a large degree, what's happening, and that's 4 of the battle, is knowing what's ppening, being able to derstandt. 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 can. 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. cit's lika trsactionme from child to ult. before, it seemed like it was-- i was depending on others, and now i'm depending on myself. m not one. i'm with me. i don't know how to explain that. the fure? it looks goo 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 ever had. so i can see green trees now. i can hear the birds sing. i'm 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 nan institute, i. captions cight 11 alvin h. perlmutter

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