The latest pharmaceutical strategies for treating anxiety and depression are thoughtfully reviewed in the Anxiety Toolbox Program. As a medical doctor treating patients with these conditions on a daily basis, I have developed a system of determining which medications are most likely to be successful in the shortest time with the least chance of side effects. Many factors go into this decision process, and the Anxiety Toolbox Program will help you understand the rationale behind the choice of a medication for any given symptom or diagnosis. Even the medical treatment of complex situations involving multiple diagnoses and complaints in a single individual will make sense to you. If you are considering your medical treatment options with your physician, you will fully understand how medication works and how you can facilitate the process of finding the best choice for initial medical intervention.
Because my homepage emphasizes the self-help aspects of the Anxiety Toolbox Program rather than its value in evaluating medical treatment options, I felt the readers browsing this site might assume that I am a Ph.D. rather than an M.D. who treats the majority of my patient population suffering from clinically significant anxiety and/or depression disorders with pharmacueticals. I particularly enjoy the challenge of patients who have been refractory to previous medical treatment regimens. I am often able to find a better fit and success rate through the protocols and paradigms explained in the download.

This week I got an e-mail from Tony Gill, a student at Johns Hopkins who is working with the National Institute of Mental Health to research the effectiveness of therapies for treating phobias. He had read “Phobias and How to Overcome Them; Understanding and Beating Your Fears,” and this had led him to the Anxiety Toolbox Program. Here is the meat of the e-mail;

“I am writing an article on specialized phobias and while researching I came across your book, “Phobias and How to Overcome Them.” I would like to ask you a few questions on DIY [”Do-It-Yourself”]ways to overcome specific phobias. All of the behavioral researchers I have interviewed at the National Institute of Mental Health seem to be of the mind that professional therapy and medication are the only sure way to overcome phobias, while your book seems to say otherwise. Could you offer an alternative perspective?…What do you gauge the success rate to be for people who follow your Anxiety Toolbox Program? Rough percentages are okay.”

Here’s my answer:

“Thanks for your inquiry about specific phobias. Although it is thought that some specific phobias, like the fear of spiders and needle/injection phobias may have an inherited component, most probably result from traumatic experiences either in childhood or young adulthood. My wife’s fear of birds came after watching Alfred Hitchcock’s “The Birds,” for instance. These patients do well with desensitization and cognitive behavioral therapy. Those with underlying anxiety disorders, like OCD, will often need medical treatment to get well. All these forms of therapy and various methods to determine a rational medical regimen are discussed in the Anxiety Toolbox Program.

On the other hand, I have been impressed by how many of my adult patients aquire specific phobias, like a fear of bridges, tunnels, or airplane travel. In all of these cases, I can find a direct link between a recent increase in overall stress and anxiety (divorce, new job, health problems) and the development of these specific phobias. In addition, if the patient starts getting panic attacks, they may develop an even more debilitating condition called agoraphobia. In this case, they may not even be able to leave their house without getting ill from anxiety symptoms. These are people who never had anxiety or phobias growing up.

Luckily, the answer for them may be easier than medication or extensive therapy. Understanding the root causes of stress and how to build a life that is resistant to anxiety can be accomplished with a variety of “tools” in the Anxiety Toolbox Program. These include attitudinal changes we accomplish after examining our expectations, values, and priorities. In addition, our program teaches methods of deep breathing, meditation, assertiveness training, stress and anger management, exercise, diet, sleep hygeine, progressive relaxation, spiritual perspectives, and many mind-body and body-mind tools that have been used in different cultures for centuries. When the patient incorporates these tools into their daily life, their acquired specific phobias often resolve spontaneously as the overall stress levels drop and the nervous system calms down. For some, time off work and medical intervention is really helpful. This allows them to acheive some level of stability on which to build a framework of emotional strength.

The success rate of the Anxiety Toolbox Program depends very much on the person who do downloads it and the type of phobia they are dealing with. In my practice, the Anxiety Toolbox Program success rate is very high for phobias arising from underlying stress and anxiety disorders. I would guess around 90%. This is because these patients are given additional encouragement, support, medical treatment, time off work through state disability programs, family counselling, and so on. I would say my success with agoraphobia is 100% in the practice environment.

On the other hand, people usually don’t come to a doctor for a non-debilitating specific phobia, like a fear of spiders or heights or dogs; they just avoid them. These types of phobias require a committment to regular and increasingly intense exposure to the feared stimlulus. If done with a therapist or a virtual reality program, success is very high. My program describes in detail how a graded desensitization program can be individually designed and implemented, but suggests that it be done with the help of a trained therapist for a higher success rate. The feedback we have had from patients who have read and worked through our self-help program has been overwhelmingly positive. However, it could be that just as many people did not find benefit and did not bother to let us know. In this case, there is no way for us to follow up, as we have a policy against contacting our clients for reasons of privacy. In any case, I think our program gives an immense sence of relief and overall understanding of the human emotional system to any reader. This then serves as a positive starting point for moving forward with confidence with a self-directed program or a program devised by a professional therapist.

It is interesting to note that a study out of Sweden found that Internet-based cognitive behavioral programs were even more successful than standard one-on-one sessions with a therapist. The overall conclusion of the study was that more Internet-based programs should be made available for those who can’t afford therapy, as many insurance companies don’t cover it. I feel that the Internet programs are more successful because they give a large amount of information all at once, rather than doling it out over months or years of weekly sessions. I don’t believe the classical assumption that psychiatric patients must be gently hand-held step-by-step. The danger that they will get worse and reject the therapeutic process is real. I feel intensive up-front intervention as is provided in our download is the best strategy.”

Yesterday, Teen People Magazine called to ask if I could help with an article about phobias they are writing for the September 2006 issue. They had read “Phobias and How to Overcome Them; Understanding and Beating Your Fears,” and wanted to know how I would rank the top ten phobias.

All phobias are exaggerated fear responses. The symptoms you might feel during a phobic reaction are common to all phobias because they are caused by activation of the same sympathetic nervous system. When the sympathetic nervous system is activated, you may feel fast heartbeats, chills, sweats, hot flashes, shortness of breath, nausea, abdominal pain, faintness, dizziness, tremors, choking sensations, chest discomfort, numbness and tingling, thoughts of doom or death, or feelings of unreality or being detached from yourself.

Phobias are broadly divided into three types; social phobia (also called social anxiety), specific or “simple” phobias, and agoraphobia. At least 13% of Americans experience one or more of these anxiety conditions in their lifetime. Taken together, phobic disorders are the most common forms of psychiatric illness, more prevalent than depression disorders or substance abuse.

Here is my response for the ten most common phobias:

1.Arachnophobia

The fear of spiders has been reported in up to 50% of women and 10% of men. There is some evidence that we might even inherit this phobia from our parents. Another theory is that we may fear spiders because we are wired to see them as a potential threat, just like horses seem to have an instinctual fear of snakes. Or we may learn to fear spiders from someone else like our parents. I don’t believe in the theory of association when it comes to spider phobia. This theory says that some unrelated frightening experience happens at the same time we just happen to notice a spider, and we then link or “associate” the spider to the experience of fear from then on. Many people try to cure themselves of this fear through a desensitization program offered by many zoos. Exposure to spiders is gradually increased, from looking at pictures, to finally touching spiders and letting them crawl on you. (Sounds like “Fear Factor”!) According to some experts, arachnophobia is really a fear of the unknown. The best form of self-help is to learn about spiders and to know that they are essentially innocent and most are harmless. Related to the fear of spiders are many other phobias directed at insects and animals.

2. Social Phobia

Although it is less common than spider phobia, social phobia can cause a lot more heartbreak and dysfunction. Those who suffer from social phobia are more likely to overuse alcohol, stay unmarried and live with their parents into midlife, and never reach their potential when it comes to career goals. They are also more likely to develop eating disorders like anorexia and bulimia. Social phobia is the fear of being scrutinized, judged, or criticized by other people. Social phobics tend to avoid parties or other social situations involving interaction with other people, especially if they have to meet new people. There are two types of social phobia, generalized and nongeneralized. People with the nongeneralized form are afraid of specific situations like speaking in public, eating in public, or performance situations. They can lead otherwise normal lives by avoiding these situations. The generalized form is more disruptive because it interferes with a healthy social life and can eventually lead to loneliness and isolation. These people fear the scrutiny of others and worry that they will be embarrassed or humiliated in front of others. They are often hypersensitive to rejection, which may be partly related to an imbalance in brain neurochemicals known as serotonin and dopamine. The initial cause of social phobia may be a traumatic social experience while growing up, like throwing up in class. Current thought points to an interaction between biological, genetic, personality factors, and environmental events. Approximately 5.3 million American adults ages 18 to 54, or about 3.7 percent of people in this age group in a given year, have social phobia. Social phobia typically begins in childhood or adolescence.

3. Aerophobia

People who fear flying in airplanes generally fear losing control of their emotions and having a panic attack in front of other passengers. They realize it would be difficult to escape if an anxiety attack were to occur. Less frequently, people fear that turbulence will cause the plane to fall apart, or worry about others seeing them go to the toilet. Others feel a claustrophobic fear of small, enclosed spaces. Less than 40% actually worry about a fatal plane crash, and these people are most likely to benefit from “fear of flying” courses.

4. Agoraphobia

Agoraphobia is the irrational fear of having panicky symptoms in a situation where escape may be difficult. The agoraphobic fears that the anxiety attack will lead to humiliation, incapacitation, or some catastrophe, such as a stroke, heart attack, loss of sanity, or even death. They develop avoidance behaviors, staying away from buildings, bridges, airplanes, tunnels—anywhere that would be difficult to escape from if they where to have an attack. In severe cases, people are too scared to leave home. Evidence suggests that 5% percent of the population suffers from agoraphobia at some point in their life. Those with agoraphobia are more likely to commit suicide than any other phobic disorder, especially if complicated by frequent panic attacks.

5. Claustrophobia

This is the fear of being trapped in small, confined spaces. The sense of restriction of movement can cause psychological and physical symptoms. For some, just sitting in the middle of a row at the cinema becomes a big ordeal. They may get dizzy, feel nauseated, collapse and faint from hyperventilation, or lose bladder or bowel control. Sometimes though, just the presence of a trusted friend can provide reassurance.

6. Acrophobia

The fear of heights may cause people to panic at the thought of being in a high-rise building or a glass elevator. They will sometimes have reoccurring nightmares about falling off cliffs and may experience being pulled towards the edge of sheer drops.
The good news is acrophobia is highly treatable with desensitization, or “exposure therapy”, either real or using virtual reality programs to gradually lessen the fear.

7. Emetophobia

Emetophobia is the fear of vomit or vomiting. Sufferers fear being sick in public and people watching them in the act of throwing up. For many it’s the fear of being out of control that’s so terrifying. People with this phobia usually develop elaborate avoidance strategies to make sure they don’t get sick. They’ll avoid foods that might cause an upset stomach, eating only bland items like crackers and bread, and rarely eating out or having leftovers. Many emetophobic women will avoid pregnancy due to the risks of “morning sickness”. Interestingly, some therapists recommend watching vomit videos. There’s a debate whether they actually work, but it can’t be a very pleasant form of therapy.

8. Carcinophobia

People with a cancer phobia usually worry about getting cancer themselves and obsess over every bodily experience, believing it to be sign of cancer. Others may worry about coming into contact with someone who has cancer, thinking they might catch it, even though their rational mind realizes that it is not a communicable disease. If they do think they have come into contact with someone with cancer, they may loose their appetite and feel the need to wash repeatedly. Unfortunately one of the most common symptoms of this type of anxiety is a headache, which is then often interpreted as a brain tumor.

9. Brontophobia

The fear of thunderstorms usually starts in childhood after experiencing a scary storm, especially if the child sees dread in the faces of the adults around them! Brontophobes may obsessively watch weather reports most of the day, or fear the start of summer and electrical storms. Others have to run to the toilet to hide or take the day off work if they believe a storm is on the way.

10.Necrophobia

This is a death phobia. Some fear dying, others fear bereavement, and still others fear being buried or cremated alive. Sadly many people with necrophobia spend so much time worrying about death that they forget to live life joyfully while they can.

Although not quite making the top ten, Blood-Injection-Injury type phobias deserves an honorable mention. These are so common that nearly everyone has personally experienced or knows someone who faints in the doctor’s office at the site of a needle, or goes into shock seeing their own blood or injury.

Also, the above top ten list is for the United States. It would be different in another population. For Instance, in Iceland, based on a 1993 study by the US National Institute of Mental Health, the top ten list would look like this: 1. Acrophobia 2. Claustrophobia 3. Agoraphobia 4. Social Phobia 5. Amaxophobia (Taking Public Transportation) 6. Glossophobia (Public Speaking) 7. Monophobia (Being Alone) 8. Entomorphobia (Insects) 9. Brontophobia 10. Aquaphobia (Being in water). Maybe they don’t have too many spiders up there…

Remember, most phobias can be successfully treated with cognitive behavioral therapy or the many lifestyle or alternative strategies that are available. However, some cases of agoraphobia, panic attacks, and more severe social anxiety problems should be treated medically first to stabilize the situation. Most general/family doctors or a psychiatrist can prescribe the correct treatment for you until your emotions are under control. You can learn more about all your options by visiting www.anxietytoolbox.com.

I often say that my patients are my greatest teachers. This week I was reminded how sensitive our psychological balance can be. It seems that many people experience a day-to-day, even minute-by-minute fluctuation in their sense of emotional well-being. Often, a small intervention in the form of rhythmic exercise, deep breathing, taking a neurotransmitter-enhancing supplement, talking with a friend, or some special activity will allow us to quickly regain emotional control and perspective.

I use the analogy of looking at a coin on edge. With a very slight movement, you will view only one side of the coin, either all heads or all tails. Brain chemistry is often like this; a gentle nudge through the use of any number of techniqes can change our point of view from mostly negative to largely hopeful and optimistic.

One patient told me she felt a physical “rush” sensation in her brain as her depressed mood elevated in response to strong sunlight. Another, who has Bipolar II disorder, explained that he smoked cigarrettes because they give him a controlled level of hypomania (mild mania), causing him to feel especially sociable, energetic, and productive. I’m sure Starbucks has figured out that a certain (large) segment of the population gets an emotional rush from caffeine. No doubt, food is the most commonly used substance for self-treating anxiety and depression, with alcohol close behind.

As a physician, I try to help my patients gain insight into what they are doing and why. There is always a reason for our choice of self-medication. We find through trial and error what works for us. While there is probably no serious health risk from sunlight (if you wear sunglasses and sunscreen) or coffee (as far as we know)—but food, cigarettes, and alcohol may lead to more problems than they help aleviate.

Recognizing that some very simple and quickly learned strategies work well for flipping the emotional balance switch from the despondent and apprehensive to the unlifted and confident, the Anxiety Toolbox Program teaches and explains dozens of healthy and time-tested ideas for you to try and perhaps incorporate into a daily routine. Many of our patients have learned how to be in complete control of their emotions with one or more of these techniques. Let us know what works for you!

The survivors of Hurricane Katrina are vulnerable to more severe emotional health problems due to the unique characteristics of this particular disaster and the way it was handled. Since our nation has never before exerienced such a devastating natural domestic disaster—more traumatic in many ways than 9-11 or the Oklahoma City bombing—mental health experts agree that the emotional toll will be hard to predict.

Unlike 911 or Oklahoma City, Katrina did not confine her wrath to a discrete geographical area. In addition, the devestating blows came in stages; just when you thought it couldn’t get any worse, it did. There was actually a cascade of disaters—the hurricane, followed by the flood, followed by violence, lawlessness, and anarchy, followed by rains, more flooding and collapsing levies, followed by a breakdown in law enforcement and the relief efforts, and culminating in the horrendous conditions in the relocation areas.

The best way for people to begin recovering from traumatic stress is to provide strong social support by reuniting them with friends, family, and familiar surroundings. In the case of Katrina survivors, most experienced a complete fragmentation of their lives and support systems. Many were displaced to places they had no prior connection with. There was no concerted effort to bring families back together.

Many survivors are expected to develop Post-Traumatic Stress Disorder (PTSD), although the symptoms of this anxiety disorder will often take over a month to surface. I believe that initial anxiety and depression reactions will be common and that both medical treatment and psychotherapy should be considered. For instance, a sleep medication or anti-anxiety medication with some supportive listening or cognitive-behavioral therapy might be very helpful in preventing the development of a full-blown anxiety disorder if started early-on.

This Holiday season, I hope we will all remember those who have lost so much. It could have happened to any of us. I worry that, like with the clumsy relief efforts, we will offer these victims too little, too late.

Depression (mood) disorders are covered thoroughly in the Anxiety Toolbox Program. We did this because anxiety and depression are, at times, inextricably connected. They can also exist independently of one-another. Understanding this dynamic is essential in creating a successful medical and psychotherapeutic treatment program. For instance, here is the list of disorders that are covered in this program:

Anxiety Disorders:
* Generalized Anxiety Disorder (GAD)
* Posttraumatic Stress Disorder (PTSD)
* Acute Stress Disorder
* Panic Disorder
* Agoraphobia
* Obsessive Compulsive Disorder (OCD)
* Specific Phobia
* Social Phobia
* Body Dysmorphic Disorder
* Anorexia and Bulimia

Depression (Mood) Disorders:
* Dysthymic Disorder
* Seasonal Affective Disorder (SAD)
* Major Depressive Disorder
* Grief Response
* Hypomania and Mania
* Bipolar I and Bipolar II Disorders

Other Disorders:
* Substance Abuse
* Attention Deficit Disorder
* Personality Disorders
* Oppositional Defiant Disorder

In short, we look at all the overlapping diagnostic possibilities in the Comprehensive Anxiety Sceening Tool (CAST) test, not just anxiety disorders. And our analysis of the medical and alternative strategies for treating depression is just as complete as our information on anxiety. Our goal is to get you well and back to full functionality as quickly as possible! One download includes everything you will need.

Being the father of a “terrible two-year-old” son recently led me to discover a helpful strategy to reduce the stress and turmoil of daily life: Live by the rules!

Of course, you have to make the rules first. Unless, of course, you are a toddler; then “dada” makes the rules for you! Whenever my son asks “Why do I have to sit in my car seat?” “Why are we stopping at the red light?” or “Why do we have to pay for this toy?” I answer simply, “Because it’s the law. And if you don’t obey the law, the police will come and take you to jail.”

He knows the concept of jail because his pet Yorkshire terrier is often sentenced to an hour in the doggie cage for peeing in the house. And he has been led to believe that the police will promptly and efficiently enforce all the laws. So the other day when he was throwing a fit over going to bed at his bedtime, I said, “Jacob, you need to go to bed now.” “It’s the law?” he asked with reverence and sincere concern. “No, it’s more like a rule,” I said. “It’s dada’s rule for Jacob so that you will be healthy and ready for school without…Yeah, it’s the law, now get to bed.”

Then it hit me as I saw him shuffle off to bed with acceptance and resignation: How much happier and anxiety-free we would be if we obediently accepted and followed good and reasonable laws? Why not make ourselves a list of laws to keep us on the straight and narrow and help us avoid making the same mistakes over and over? Here are a few laws that came to mind:

Law 1: I will not date someone who has no job.
Law 2: I will get a job.
Law 3: I won’t self-medicate with food or alcohol when I’m nervous.
Law 4: I will not use anger in communicating with my employees, children or spouse.
Law 5: I will not feel sorry for myself.
Law 6: I will not blame others for my problems.

You could pass dozens of laws a day if you really sat down and thought about it!

The next morning, Jacob looked pensively as he watched me eat my cereal. After awhile he said, “Dada makes the laws for Jacob.” “Yes,” I said, “That’s my job as your father; to make the laws to help you and protect you.” “And mama makes the laws for dada.” he added matter-of-factly.

“Well…uh…yes, how right you are” I slowly replied as an impish grin spread across his face.

Today, people will reflect on many things that deserve gratitude; their families, a decent job, a place to live, and food to eat will be among the top ten. I will be thankful for emotional health, and hope to never take it for granted. No matter our level of education, genetics, or financial security, emotional health is something that can be stripped away from us at any time. Although all of us experience some level of uncontrolled anxiety during our life, up to 50% of Americans will go through a period of a pathologic, or “clinical” anxiety, depression, or phobic disorder.

It may start insidiously with a Lemony Snicket-like series of unfortunate events, or arise from unabated stress over an extended period of time. Gradually, what started as transient insomnia or an occasional chest palpitation may blossom into a full-blown, unpredictable panic condition. Or an anxiety disorder may stike with no warning “out of the blue.” A patient of mine with no previous history of anxiety problems recently found himself paralyzed by fears and phobias on a trip to Italy with his family.

We can never know for certain when or if our lives will suddenly experience a factor that finds a chink in our illusion of emotional strength and security. And those who believe this could never happen to them will be the least prepared to handle it.

On Thanksgiving, lets remember that emotional health is what allows us to nurture and support our families and to hold down a regular job. It can determine whether we are dependent on others or able to provide for ourselves. And emotional health is absolutely necessary to be a truly supportive spouse, attentive parent, helpful co-worker, successful student, or consistent friend.

Health, especially emotional health, is our most precious gift and useful attribute. And with thankfulness should come the recognition that we carry some responsibility for protecting and promoting our own emotional well-being.

Well, its the time of year again that days get shorter, depressing nights longer, the season more stressful, and our vulnerability to anxiety increases (especially after we see our Visa bill!). Stanford is presently doing a study on light therapy in the elderly to see whether it can help cognitive abilities, improve mood, and promote healthy immune system functioning.

Many studies have shown an improvement in seasonal affective disorder, which is classified as a form of depression, with full sprectrum light therapy. Outdoor light on a clear, brisk winter morning ranges between 50,000 to 100,000 lux (a measure of energy). In contrast, indoor lighting runs between 2,000 to 10,000 lux. To set out brain’s internal clock in the pineal gland, light energy levels over 50,000 lux are needed. Full-spectrum light devices are widely available and are able to achieve these high energy outputs.

The successful release of our internal sleep and waking hormones and the production of positive, healthy brain chemistry relies on this circadian rhythm. In the Anxiety Toolbox Program, we give information and helpful links to find the right full-spectrum light for your situation. Ideally, one to two hours on exposure first thing in the morning is the key to counteracting the winter blahs and blues.

While it is true that anxiety is a common symptom of depression, it is also true that depression can arise from a pre-existing anxiety disorder, such as OCD, Panic Disorder, Social Phobia or PTSD. Becoming depressed about our anxiety or getting anxious about how difficult our lives have become with untreated depression are more the norm than the exception.

Understanding when we have crossed over into clinical depression, therefore, is a key factor in reducing our vulnerability to anxiety. “You can’t fix what you don’t own,” as Dr. Phil would say. Knowing when you are dipping into a depressive state and quickly seeking professional support and guidance will greatly reduce your suffering, not to mention that of your children, spouse, and family.

The simple check list below will help you recognize depression when you feel it. It was designed by the folks at the National Institute of Mental Health and is available at http://www.nimh.nih.gov/publicat/depression.cfm#ptdep3 :

____ Persistent sad, anxious, or “empty” mood

____ Feeling of hopelessness, pessimism

____ Feeling of guilt, worthlessness, helplessness

____ Loss of interest or pleasure in previously enjoyed hobbies, activities, or sex

____ Fatigue, decreased energy, being “slowed down”

____ Difficulty concentrating, remembering, making decisions

____ Insomnia, early morning awakening, or oversleeping

____ Appetite and/or weight loss or overeating and weight gain

____ Thoughts of death or suicide; suicide attempts

____ Restlessness, irritability

____ Persistent physical symptoms that do not respond to treatment, such as headaches, digestive disorders, and chronic pain

If you checked any of the above, you may carry the diagnosis of depression. The Anxiety Toolbox Program is designed to help you further categorize your condition as dysthymia, seasonal affective disorder, unipolar, or bipolar depression. In fact, the short and long-term solutions for anxiety and depression disorders and nearly identical and are thoroughly covered in the Anxiety Toolbox.