Acute and delayed effects of alprazolam on flight phobics during exposure

A dataset of daily ambulatory psychological and physiological recording for emotion research

To better understand the psychological and physiological basis of human emotion, increasing interest has been drawn towards ambulatory recordings of emotion-related data beyond the laboratories. By employing smartphones-based ambulatory assessment and wrist-worn physiological recording devices, the Daily Ambulatory Psychological and Physiological recording for Emotion Research (DAPPER) dataset provides momentary self-reports and physiological data of people's emotional experiences in their daily life. The dataset consists of ambulatory psychological recordings from 142 participants and physiological recordings from 88 of them over five days. Both the experience sampling method (ESM) and the day reconstruction method (DRM) were employed to have a comprehensive description of the participants' daily emotional experiences. Heart rate, galvanic skin response, and three-axis acceleration were recorded during the day time. By including multiple types of physiological and self-report data at a scale of five days with 100+ participants, the present dataset is expected to promote emotion researches in real-life, daily settings.

Considering Needle Phobia among Adult Patients During Mass COVID-19 Vaccinations

As mass vaccination is underway to combat the COVID-19 pandemic and achieve herd immunity, healthcare professionals need to recognize the fear and phobia of needles among their patients. Approximately 11.5 to 66 million U.S. adults may suffer from this condition. This population often avoids seeking medical care including vaccinations. The exact number of people suffering from this phobia is unknown, and the potential years of life lost in the American health care system cannot be estimated accurately. The resistance to vaccinations among this population may delay achieving herd immunity to end this current pandemic. An overview of needle phobia, vaccinations, and current treatments are explored. The use of telemedicine could prove critical for reaching this population as well as those who are hesitant about vaccinations. Providing education to healthcare providers to identify and manage these patients during the pandemic is necessary.

Absence of definitive scientific evidence that benzodiazepines could hinder the efficacy of exposure-based interventions in adults with anxiety or posttraumatic stress disorders: A systematic review of randomized clinical trials

BACKGROUND AND OBJECTIVES

Exposure-based interventions (EBIs) are the first-line treatment for anxiety disorders and posttraumatic stress disorder. Although common, the association between EBIs and benzodiazepines is controversial. Therefore, we systematically reviewed the literature to evaluate if benzodiazepines could undermine the efficacy of EBIs in treating these disorders.

METHODS

We conducted a systematic review aiming for randomized clinical trials (RCTs) in ISI Web of Science, Scopus, PubMed/MEDLINE, and PsycINFO databases. We scrutinized the reference list of selected papers and other systematic reviews. Finally, we evaluated the methodological quality and the scientific evidence of the studies.

RESULTS

We screened 1,529 studies and included 12 RCTs in this review (all showing some concerns or high risk of bias). Benzodiazepines did not impact the efficacy of EBIs in nine studies at posttreatment, improved efficacy in two, and reduced it in one. In the follow-up, benzodiazepines (after its discontinuation) did not impact the efficacy in six studies and reduced it in five. The scientific level of evidence achieved was B for both phases.

CONCLUSIONS

Until now there is no definitive evidence that benzodiazepines could hinder the EBIs' efficacy for treating posttraumatic stress disorder and anxiety disorders.

Benzodiazepines I: Upping the Care on Downers: The Evidence of Risks, Benefits and Alternatives

Benzodiazepines are some of the most commonly prescribed medications in the world. These sedative-hypnotics can provide rapid relief for symptoms like anxiety and insomnia, but are also linked to a variety of adverse effects (whether used long-term, short-term, or as needed). Many patients take benzodiazepines long-term without ever receiving evidence-based first-line treatments (e.g., psychotherapy, relaxation techniques, sleep hygiene education, serotonergic agents). This review discusses the risks and benefits of, and alternatives to benzodiazepines. We discuss evidence-based indications and contraindications, and the theoretical biopsychosocial bases for effectiveness, ineffectiveness and harm. Potential adverse effects and drug-drug interactions are summarized. Finally, both fast-acting/acute and delayed-action/chronic alternative treatments for anxiety and/or insomnia are discussed. Response to treatment-whether benzodiazepines, other pharmacological agents, or psychotherapy-should be determined based on functional recovery and not merely sedation.

The Combination of Long-term Ketamine and Extinction Training Contributes to Fear Erasure by Bdnf Methylation

A combination of antidepressant drugs and psychotherapy exhibits more promising efficacy in treating fear disorders than either treatment alone, but underlying mechanisms of such treatments remain largely unknown. Here we investigated the role of DNA methylation of the brain-derived neurotrophic factor (Bdnf) gene in the therapeutic effects of ketamine in combination with extinction training in a mouse model of post-traumatic stress disorder (PTSD) induced by inescapable electric foot shocks (IFS). Male mice received ketamine for 22 consecutive days starting 1 h after the IFS (long-term ketamine treatment) or 2 h prior to the extinction training on days 15 and 16 after the IFS (short-term ketamine treatment). The Open Field (OF) and Elevated Plus Maze (EPM) tests were conducted on days 18 and 20. The spontaneous recovery and fear renewal tests were performed on day 23. Mice, subjected to IFS, exhibited anxiety-like behavior and fear relapse, accompanied by the increased levels of DNA methyltransferases, hyper-methylation of Bdnf gene, and decreased BDNF mRNA expression in the medial prefrontal cortex (mPFC) and hippocampus (HIP). Long-term treatment with ketamine combined with extinction training alleviated the IFS-induced abnormalities. These results suggest that long-term ketamine treatment in combination with extinction training may ameliorate fear relapse in the murine model of PTSD, at least in part, by normalizing DNA methylation of Bdnf gene.

Prevention and Intervention Strategies to Alleviate Preoperative Anxiety in Children

Preoperative anxiety (anxiety regarding impending surgical experience) in children is a common phenomenon that has been associated with a number of negative behaviors during the surgery experience (e.g., agitation, crying, spontaneous urination, and the need for physical restraint during anesthetic induction). Preoperative anxiety has also been associated with the display of a number of maladaptive behaviors postsurgery, including postoperative pain, sleeping disturbances, parent-child conflict, and separation anxiety. For these reasons, researchers have sought out interventions to treat or prevent childhood preoperative anxiety and possibly decrease the development of negative behaviors postsurgery. Such interventions include sedative premedication, parental presence during anesthetic induction, behavioral preparation programs, music therapy, and acupuncture. The present article reviews the existing research on the various modes of intervention for preoperative anxiety in children. Clinical implications and future directions are discussed.

Psychological Distress and Physiological Reactivity During In Vivo Exposure in People With Aviophobia

OBJECTIVES

Exposure is regarded to be a crucial component of therapies for phobias. According to emotional processing theory, the success of exposure therapy is predicted by activation of subjective and physiological fear responses and their within-session habituation and between-session adaptation. This study tested this prediction for aviophobia.

METHODS

Seventy-nine participants following a highly standardized treatment program for aviophobia provided self-reported and physiological (heart rate, respiratory sinus arrhythmia and pre-ejection period) measurements of fear activation, within-session habituation, and between-session adaptation during exposure to flight-related stimuli, a flight simulator, and during two real flights. Multiple regression analyses were conducted to examine whether these measurements predicted therapy outcome up to 3 years after finishing therapy, including number of flights flown in this period.

RESULTS

Both subjective and physiological arousal measurements indicated strong fear activation and large within-session habituation and between-session adaptation during exposure. Flight anxiety measures showed large improvements up to 3 years after treatment (η between 0.72 and 0.91). Lower self-reported anxiety during flight exposure was associated with lower flight anxiety after exposure (R = 0.15) and more flights flown (R = 0.14). Within-flight habituation or between-session adaptation of self-reported anxiety had no relationship with treatment outcome. Within-flight habituation of HR reactivity (R = 0.10) and respiratory sinus arrhythmia reactivity (R = 0.11) was associated with lower flight anxiety directly after the flight, but not on flight anxiety 3 years after finishing therapy or on long-term flying behavior.

CONCLUSIONS

The results provide only weak support for emotional processing theory. Low self-reported anxiety during in vivo flight exposure was the best predictor of successful long-term therapy outcome.

Pharmacology of cognitive enhancers for exposure-based therapy of fear, anxiety and trauma-related disorders

Pathological fear and anxiety are highly debilitating and, despite considerable advances in psychotherapy and pharmacotherapy they remain insufficiently treated in many patients with PTSD, phobias, panic and other anxiety disorders. Increasing preclinical and clinical evidence indicates that pharmacological treatments including cognitive enhancers, when given as adjuncts to psychotherapeutic approaches [cognitive behavioral therapy including extinction-based exposure therapy] enhance treatment efficacy, while using anxiolytics such as benzodiazepines as adjuncts can undermine long-term treatment success. The purpose of this review is to outline the literature showing how pharmacological interventions targeting neurotransmitter systems including serotonin, dopamine, noradrenaline, histamine, glutamate, GABA, cannabinoids, neuropeptides (oxytocin, neuropeptides Y and S, opioids) and other targets (neurotrophins BDNF and FGF2, glucocorticoids, L-type-calcium channels, epigenetic modifications) as well as their downstream signaling pathways, can augment fear extinction and strengthen extinction memory persistently in preclinical models. Particularly promising approaches are discussed in regard to their effects on specific aspects of fear extinction namely, acquisition, consolidation and retrieval, including long-term protection from return of fear (relapse) phenomena like spontaneous recovery, reinstatement and renewal of fear. We also highlight the promising translational value of the preclinial research and the clinical potential of targeting certain neurochemical systems with, for example d-cycloserine, yohimbine, cortisol, and L-DOPA. The current body of research reveals important new insights into the neurobiology and neurochemistry of fear extinction and holds significant promise for pharmacologically-augmented psychotherapy as an improved approach to treat trauma and anxiety-related disorders in a more efficient and persistent way promoting enhanced symptom remission and recovery.

Anxiety sensitivity moderates the relationship of changes in physiological arousal with flight anxiety during in vivo exposure therapy

Physiological sensations and discomfort constitute the major symptoms reported by aviophobics. Anxiety sensitivity (AS) seems to moderate the relationship between self-reported somatic sensations and flight anxiety, and AS has been identified as a vulnerability factor for flight phobia. In this study we examined whether AS moderates the effects of somatic sensations and autonomic nervous system reactivity on flight anxiety induced by real flight. In fifty aviophobics participating in Cognitive Behaviour Group Therapy (CBGT), flight anxiety, somatic sensations and autonomic nervous system reactivity were assessed during a guided return flight. Results indicate that physiological reactivity interacted with AS. Changes in heart rate and parasympathetic activity were more strongly associated with changes in reported flight anxiety for high AS participants, and less for participants low on AS. Results did not indicate a moderating effect of AS on the relationship between self-reported somatic sensations and flight anxiety. Our results suggest that therapy for flight phobia might benefit from addressing the physical effect of anxiety, by means of cognitive restructuring and exposure to interoceptive stimuli, particularly in aviophobics high in AS.

Virtual reality exposure therapy and hypnosis for flying phobia in a treatment-resistant patient: a case report

Flying phobia is a problem that affects a significant portion of the population. There are a number of therapeutic approaches but no one is universally accepted as the gold standard. One therapy is hypnosis. A recent addition to the armamentarium is virtual reality exposure (VRE) therapy. Both therapies are short-term and compare favorably to in vivo desensitization. Heretofore a combination of both approaches has not been reported. This article presents a case of a 50-year phobia to flying that was refractory to traditional methods including pharmacotherapy, systematic desensitization, and cognitive behavioral therapy but was successfully treated using VRE therapy and hypnosis as the primary modalities. This treatment was supplemented by other approaches. The rationale for this multimodal therapy and possible mechanisms involved are discussed.

The psychology of fear of flying (part II): a critical evaluation of current perspectives on approaches to treatment

This is the second of a two part review which critically evaluates research published in disparate sources into the psychological treatment of fear of flying. Part I established fear of flying as a complex heterogeneous clinical phenomenon. This paper discusses the way in which evidence from clinical trials translates to best practice in treating fear of flying. Published research on psychological interventions uses terminology which bears a close resemblance to cognitive behavioural therapy. It is, however, questionable whether some treatment approaches reflect the implementation of the cognitive behavioural model as it is described in the wider literature on the treatment of anxiety disorders. This review evaluates a synthesis of published research which considers fear of flying and related anxiety disorders with the aim of deriving best practice. It concludes that the most effective psychological interventions will be those based on an accurate functional assessment of an individual and their social context relevant to fear of flying and not merely a set of standard and invariant protocols. Most published research has been carried out on participants who self refer or volunteer for treatment and it is probable that this is a biased clinical group which may distort reported efficacy and treatment outcomes. It concludes by highlighting directions for future research and the development of psychological treatments for fear of flying.

Physiological reactivity to phobic stimuli in people with fear of flying

OBJECTIVE

The nature of the relationship between physiological and subjective responses in phobic subjects remains unclear. Phobics have been thought to be characterized by a heightened physiological response (physiological perspective) or by a heightened perception of a normal physiological response (psychological perspective).

METHOD

In this study, we examined subjective measures of anxiety, heart rate (HR), and cardiac autonomic responses to flight-related stimuli in 127 people who applied for fear-of-flying therapy at a specialized treatment center and in 36 controls without aviophobia.

RESULTS

In keeping with the psychological perspective, we found a large increase in subjective distress (eta(2)=.43) during exposure to flight-related stimuli in the phobics and no change in subjective distress in the controls, whereas the physiological responses of both groups were indiscriminate. However, in keeping with the physiological perspective, we found that, within the group of phobics, increases in subjective fear during exposure were moderately strong coupled to HR (r =.208, P=.022) and cardiac vagal (r =.199, P=.028) reactivity. In contrast to predictions by the psychological perspective, anxiety sensitivity did not modulate this coupling.

CONCLUSION

We conclude that subjective fear responses and autonomic responses are only loosely coupled during mildly threatening exposure to flight-related stimuli. More ecologically valid exposure to phobic stimuli may be needed to test the predictions from the physiological and psychological perspectives.

Enhancing exposure therapy for anxiety disorders with glucocorticoids: from basic mechanisms of emotional learning to clinical applications

Current neurophysiological and psychological accounts view exposure therapy as the clinical analog of extinction learning that results in persistent modifications of the fear memory involved in the pathogenesis, symptomatology, and maintenance of anxiety disorders. Evidence from studies in animals and humans indicate that glucocorticoids have the potential to facilitate the processes that underlie extinction learning during exposure therapy. Particularly, glucocorticoids can restrict retrieval of previous aversive learning episodes and enhance consolidation of memory traces relating to non-fearful responding in feared situations. Thus, glucocorticoid treatment especially in combination with exposure therapy might be a promising approach to optimize treatment of anxiety disorders. This review examines the processes involved in aversive conditioning, fear learning and fear extinction, and how glucocorticoids might enhance restructuring of fear memories during therapy.

Emotions beyond the laboratory: theoretical fundaments, study design, and analytic strategies for advanced ambulatory assessment

Questionnaire and interview assessment can provide reliable data on attitudes and self-perceptions on emotion, and experimental laboratory assessment can examine functional relations between stimuli and reactions under controlled conditions. On the other hand, ambulatory assessment is less constrained and provides naturalistic data on emotion in daily life, with the potential to (1) assure external validity of laboratory findings, (2) provide normative data on prevalence, quality and intensity of real-life emotion and associated processes, (3) characterize previously unidentified emotional phenomena, and (4) model real-life stimuli for representative laboratory research design. Technological innovations now allow for detailed ambulatory study of emotion across domains of subjective experience, overt behavior and physiology. However, methodological challenges abound that may compromise attempts to characterize biobehavioral aspects of emotion in the real world. For example, emotional effects can be masked by social engagement, mental and physical workloads, as well as by food intake and circadian and quasi-random variation in metabolic activity. The complexity of data streams and multitude of factors that influence them require a high degree of context specification for meaningful data interpretation. We consider possible solutions to typical and often overlooked issues related to ambulatory emotion research, including aspects of study design decisions, recording devices and channels, electronic diary implementation, and data analysis.

Specific phobias

Exposure based treatments in which patients are systematically confronted with their feared objects of situations are highly effective in the treatment of specific phobias and produce stable improvement both in reported fear and behavioral avoidance. Exposure in reality is more effective in most cases than exposure in sensu. For situations that are difficult to realize, exposure in virtual environments has become increasingly valuable. Exposure in vivo is clearly superior to pharmacotherapy, although cognitive enhancers have been successfully used recently to increase the effect of exposure therapy. The induction of relaxation is not a necessary precondition for exposure therapy. Rather the current mechanisms of change focus on extinction learning as being the central mechanism both on a cognitive level namely that the feared object is no longer associated with severely threatening consequence but also on an affective level, meaning that feared cue is no longer capable to activate the fear circuit in the brain. Accordingly future diagnostic categorizations of phobic disorders in the DSM-V should rather focus on the pattern of the fear response that needs to be changed than on the eliciting cues or situations that are avoided.

Does oral alprazolam affect ventilation? A randomised, double-blind, placebo-controlled trial

The respiratory effects of benzodiazepines have been controversial. This investigation aimed to study the effects of oral alprazolam on ventilation. In a randomised, double-blind cross-over protocol, 20 healthy men ingested 1 mg of alprazolam or placebo in random order, 1 week apart. Ventilation was unobtrusively monitored by inductance plethysmography along with end-tidal PCO(2) and pulse oximetry 60-160 min after drug intake. Subjects were encouraged to keep their eyes open. Mean +/- SD minute ventilation 120 min after alprazolam and placebo was similar (6.21 +/- 0.71 vs 6.41 +/- 1.12 L/min, P = NS). End-tidal PCO(2) and oxygen saturation did also not differ between treatments. However, coefficients of variation of minute ventilation after alprazolam exceeded those after placebo (43 +/- 23% vs 31 +/- 13%, P < 0.05). More encouragements to keep the eyes open were required after alprazolam than after placebo (5.2 +/- 5.7 vs 1.3 +/- 2.3 calls, P < 0.05). In a multiple regression analysis, higher coefficients of variation of minute ventilation after alprazolam were related to a greater number of calls. Oral alprazolam in a mildly sedative dose has no clinically relevant effect on ventilation in healthy, awake men. The increased variability of ventilation on alprazolam seems related to vigilance fluctuations rather than to a direct drug effect on ventilation.

Comorbid anxiety in bipolar disorder alters treatment and prognosis

Mood disorders in general, and bipolar disorder in particular, are unique among the psychiatric conditions in that they are associated with extraordinarily high rates of comorbidity with a multitude of psychiatric and medical conditions. Among all the potential comorbidities, co-occurring anxiety disorders stand out due to their very high prevalence. Outcome in bipolar illness is worse in the presence of a comorbid anxiety disorder. The coexistence of an anxiety disorder presents a particularly difficult challenge in the treatment of bipolar illness since antidepressants, the mainstay of pharmacologic treatments for anxiety, may adversely alter the course of manic-depression. Identification of anxiety disorders in bipolar patients is important. The treatment plan needs to balance the potential benefit and harm of antidepressant administration.

Combining alprazolam with systematic desensitization therapy for dental injection phobia

To determine whether a benzodiazepine facilitates systematic desensitization, 144 subjects with dental injection phobia received systematic desensitization in combination with placebo or one of two doses of alprazolam (0.5mg or 0.75mg). Systematic desensitization therapy included computer-controlled presentation of digitized video segments followed by in vivo exposure segments, culminating in an actual dental injection. Subjects advanced to the next hierarchy segment when low anxiety was reported during a segment. Alprazolam and placebo groups progressed at the same rate. The 0.75mg group had elevated heart rates while watching video segments compared with placebo. In a subsequent behavioral avoidance test (during which subjects were randomized to a new drug condition), there was no indication that state-dependent learning had occurred. Dental fear was reduced similarly in all groups for 1 year after study completion. No advantage was found to combining alprazolam with systematic desensitization for dental injection phobia.

Anxiolytic therapy with alprazolam increases muscle sympathetic activity in patients with panic disorders

Anxiolytic therapy with the benzodiazepine alprazolam is an established therapy in patients with panic disorder. Normally, panic-like anxiety and its concomitant physical symptoms quickly disappear under such treatment. Therefore we investigated whether there is a difference in sympathetic nervous system in patients with panic disorder compared to healthy controls. Three groups of subjects were included: ten patients with panic disorder, who received alprazolam and 20 healthy control subjects who were given either alprazolam (n=10) or matching placebo (n=10). Muscle sympathetic nerve activity (MSNA) and heart rate did not differ at baseline but significantly increased both in patients and healthy controls after intake of alprazolam (1 mg). However, in both groups both MSNA and heart rate were significantly elevated when compared to both baseline and the placebo control group. This study demonstrates (1) that anxiolytic therapy with alprazolam increases muscle sympathetic nerve activity and heart rate not only in patients with panic disorder but also in healthy controls and (2) that a significant difference in sympathetic nervous system activity between patients and controls, at baseline and during the therapy with alprazolam could not be demonstrated.

Treatment of specific phobia in adults

This is a comprehensive review of treatment studies in specific phobia. Acute and long-term efficacy studies of in vivo exposure, virtual reality, cognitive therapy and other treatments from 1960 to 2005 were retrieved from computer search engines. Although specific phobia is a chronic illness and animal extinction studies suggest that relapse is a common phenomenon, little is known about long-term outcome. Treatment gains are generally maintained for one year, but longer follow-up studies are needed to better understand and prevent relapse. Acutely, the treatments are not equally effective among the phobia subtypes. Most phobias respond robustly to in vivo exposure, but it is associated with high dropout rates and low treatment acceptance. Response to systematic desensitization is more moderate. A few studies suggest that virtual reality may be effective in flying and height phobia, but this needs to be substantiated by more controlled trials. Cognitive therapy is most helpful in claustrophobia, and blood-injury phobia is uniquely responsive to applied tension. The limited data on medication have not been promising with the exception of adjunctive D-clycoserine. Despite the acute benefits of in vivo exposure, greater attention should be paid to improve treatment acceptance and retention, and additional controlled studies of more acceptable treatments are needed.

Mechanisms of virtual reality exposure therapy: the role of the behavioral activation and behavioral inhibition systems

J. A. Gray's (1975) theory distinguishes between two motivational systems, which he refers to as the behavioral activation system (BAS) and the behavioral inhibition system (BIS). D. C. Fowles (1980) has shown that heart rate responses reflect activity of the BAS, and electrodermal responses reflect activity of the BIS. Both BAS and BIS are reliably activated during in-vivo exposure to fearful situations (F. H. Wilhelm & W. T. Roth, 1998). However, due to the constraints imposed by virtual reality (VR), we hypothesized that VR exposure to fearful situations would activate the BIS alone. To test this hypothesis, a VR free-standing elevator simulation was presented to participants selected for high and low fear of heights. As predicted, the high-anxious group strongly responded electrodermally (effect size d = 1.53), but showed only minimal HR elevations during exposure (d = 0.12), and little other cardiovascular or respiratory changes. The low-anxious control group showed little electrodermal and HR reactivity (d = 0.28 and 0.12). A comparison with data from a previous study demonstrated that this pattern was in stark contrast to the large electrodermal and cardiovascular response observed during situational in-vivo exposure outside the laboratory. We conclude that the BIS, but not BAS, is selectively activated during VR exposure, causing discordance between self-report and commonly used physiological measures of anxiety. Results are discussed within the framework of E. B. Foa & M. J. Kozak's (1986) emotional processing theory of fear modification, suggesting different mechanisms underlying VR and in-vivo exposure treatments.

Effects of transdermal nicotine during imaginal exposure to anxiety and smoking cues in college smokers

In a 2 (patch) x 2 (smoking) x 2 (anxiety) mixed design, 52 undergraduate smokers randomly received a nicotine (21 mg) or placebo patch. After a 4-hr nicotine absorption/deprivation period, participants imagined several scenarios varying in cue content: (a) anxiety plus smoking, (b) anxiety, (c) smoking, and (d) neutral. Although smoking urge increased in both the nicotine and placebo conditions after the absorption/deprivation period, those who received the placebo reported significantly greater urge. During the cue reactivity trials, a significant Patch x Smoking x Anxiety interaction effect was observed for urge. However, participants who received nicotine still experienced moderate urges, indicating that nicotine did not attenuate cue-elicited urge. Transdermal nicotine did not diminish anxiety during the absorption/deprivation period or in response to the cues.

Pharmacotherapy for performance anxiety disorders: Occasionally useful but typically contraindicated

Pharmacotherapy is an effective part of treatment for most anxiety disorders, but not for specific phobia or performance anxiety. In them it is contraindicated, because it interferes with the effectiveness of exposure therapies and the extinction of fear responses. Interference with exposure-extinction is a drug side effect that should rarely if ever be tolerated in treating them. This article reviews the many indications for pharmacotherapy in treating most anxiety disorders and contrasts its usefulness in treatment of anxiety disorders with its relatively rare usefulness in treating specific phobias and performance anxiety. In both the latter disorders, benzodiazepines interfere with exposure and generally are best avoided, although temporary use, with safeguards, can sometimes be helpful for a specific phobia. The recent discovery that D-cycloserine (DCS) facilitates exposure and the extinction of anxiety offers promise that it could in the future be usefully and broadly employed to catalyze and enhance exposure therapies.

Clinical pharmacology, clinical efficacy, and behavioral toxicity of alprazolam: a review of the literature

Alprazolam is a benzodiazepine derivative that is currently used in the treatment of generalized anxiety, panic attacks with or without agoraphobia, and depression. Alprazolam has a fast onset of symptom relief (within the first week); it is unlikely to produce dependency or abuse. No tolerance to its therapeutic effect has been reported. At discontinuation of alprazolam treatment, withdrawal and rebound symptoms are common. Hence, alprazolam discontinuation must be tapered. An exhaustive review of the literature showed that alprazolam is significantly superior to placebo, and is at least equally effective in the relief of symptoms as tricyclic antidepressants (TCAs), such as imipramine. However, although alprazolam and imipramine are significantly more effective than placebo in the treatment of panic attacks, Selective Serotonin Reuptake Inhibitors (SSRIs) appear to be superior to either of the two drugs. Therefore, alprazolam is recommended as a second line treatment option, when SSRIs are not effective or well tolerated. In addition to its therapeutic effects, alprazolam produces adverse effects, such as drowsiness and sedation. Since alprazolam is widely used, many clinical studies investigated its cognitive and psychomotor effects. It is evident from these studies that alprazolam may impair performance in a variety of skills in healthy volunteers as well as in patients. Since the majority of alprazolam users are outpatients, this behavioral impairment limits the safe use of alprazolam in patients routinely engaged in potentially dangerous daily activities, such as driving a car.

The lifeShirt. An advanced system for ambulatory measurement of respiratory and cardiac function

An accurate ambulatory breathing monitor is needed to observe acute respiratory changes in patients with medical or psychological disorders outside the clinic (e.g., hyperventilation during panic or apneas during sleep). Significant limitations of existing monitors are size, troublesome operation, and difficulty holding chest and abdomen bands in place during 24-hour recordings. Recently, a garment has been developed with embedded inductive plethysmography sensors for continuous ambulatory monitoring of respiration, heart activity, inductive cardiography, motility, postural changes, and other functions. The signals are displayed and stored on a handheld computer (Visor), and then analyzed offline, extracting more than 40 clinical parameters relating to cardiorespiratory function (e.g., heart rate, respiratory sinus arrhythmia, tidal volume, stroke volume, pre-ejection period, apnea-hypopnea index, thoraco-abdominal coordination, sighing). The device also serves as an electronic diary of symptoms, moods, and activities. This advanced system may open a new era in ambulatory monitoring for clinical practice and scientific research.

Effects of benzodiazepines on explicit memory in a paediatric surgery setting

RATIONALE

Many laboratory-based studies indicate that benzodiazepines impair explicit memory performance, increase sedation, and impair attention.

OBJECTIVES

The present study was designed to extend prior lab-based findings to an applied setting in which the amnestic effects of benzodiazepines may be beneficial for users. In addition, the study extended the previous adult-focused research by examining the cognitive effects of benzodiazepines in children.

METHODS

The present study examined the use of a specific benzodiazepine (midazolam) as a premedicant among 40 children aged 4-6 years old having ear tube (myringotomy) surgery, who were randomly assigned to receive midazolam or placebo.

RESULTS

Consistent with previous studies, the results indicated that midazolam causes significant amnesia on a cued recall task. In addition, free recall for post-drug events were also impaired by midazolam relative to placebo, indicating that benzodiazepine-induced amnesia occurs even for highly salient information.

CONCLUSIONS

Overall, it appears that benzodiazepines do impair memory in a pediatric population. This amnesia was not secondary to the inattention and sedation also caused by midazolam administration. The theoretical and clinical implications of these findings are discussed, as are potential future studies.

Anticipatory anxiety in moderately to highly-anxious oral surgery patients as a screening model for anxiolytics: evaluation of alprazolam

Alprazolam, a benzodiazepine anxiolytic, was evaluated in anxious patients prior to oral surgery. This population represents a possible acute screening model for novel anxiolytic agents. Healthy subjects, preselected for a moderate to high degree of dental anxiety based upon Corah's Dental Anxiety Scale, were enrolled in a three-arm parallel design study and randomly assigned to receive double-blind placebo (N=15), alprazolam 0.25 mg (N=16) or alprazolam 1 mg (N=16). Subjective self-reported anxiety was rated using the State Anxiety Inventory and visual analog scales. Objective measures included galvanic skin conductance, heart rate variability, blood pressure, pulse rate, and respiration. At 90 minutes after dosing, there were statistically significant (p<0.05) reductions compared with placebo in subjective anxiety and skin conductance mean level for the alprazolam-treated subjects. Changes from pre-dose (mean +/- SEM) at 90 minutes in the placebo, alprazolam 0.25 mg, and alprazolam 1 mg groups were -4.73 +/- 2.79, -13.75 +/- 2.49, and -12.81 +/- 2.32 for the State Anxiety Inventory and 5.44 +/- 6.71, -31.88 +/- 5.88, and -32.34 +/- 5.32 mm for analog anxiety scores. Corresponding skin conductance mean level at 100 minutes in the three groups (respectively) changed 0.64 +/- 0.24, -0.53 +/- 0.21, -0.71 +/- 0.22 microSiemens. The 0.25 mg and 1 mg dosages of alprazolam were not differentiated. Changes in heart rate variability, blood pressure, pulse rate, and respiration did not reflect subjective anxiety. Overall, the oral surgery anticipation anxiety model was found to be a sensitive test for benzodiazepine anxiolytic activity and may represent a potential screening model for evaluation of investigational agents.

Virtual reality exposure therapy for the treatment of fear of flying: a controlled investigation

Forty-five participants who refused to fly during a screening test and who also met Diagnostic and Statistical Manual of Mental Disorders criteria for specific phobia, agoraphobia, or panic disorder with agoraphobia were randomly assigned to 5 sessions of either virtual reality exposure (VRE) or attention-placebo group treatment (GT). At posttreatment, 65% of VRE participants and 57% of GT participants flew during a test flight. Both groups showed significant improvement following treatment on standardized self-report measures of flight anxiety, with a better outcome for the VRE group on 4 of 5 of these measures. At 6-month follow-up, however, most group differences had disappeared; VRE resulted in a better outcome on only 1 of 5 standardized flight anxiety measures.

The somatic symptom paradox in DSM-IV anxiety disorders: suggestions for a clinical focus in psychophysiology

Although DSM-IV criteria for anxiety disorders include physiological symptoms, these symptoms are evaluated exclusively by verbal report. The current review explores the background for this paradox and tries to demonstrate on theoretical and empirical grounds how it could be resolved, providing new insights about the role of psychophysiological measures in the clinic. The three-systems approach to evaluating anxiety argues that somatic measures as well as verbal and behavioral ones are indispensable. However, the low concordance between these domains of measurement impugns their reliability and validity. We argue that concordance can be improved by examining the relationship of variables less global than anxiety and by restriction to specific anxiety disorders. For example, recent evidence from our and other laboratories indicate a prominent role of self-reported and physiologically measured breathing irregularities in panic disorder. Nonetheless, even within a diagnosis, anxiety patients vary radically in which somatic variables are deviant. Thus, in clinical practice, individual profiles of psychological and physiological anxiety responses may be essential to indicate distinct therapeutic approaches and ways of tracking improvement. Laboratory provocations specific to certain anxiety disorders and advances in ambulatory monitoring vastly expand the scope of self-report and physiological measurement and will likely contribute to a refined assessment of anxiety disorders.

Phobia-relevant illusory correlations: the role of phobic responsivity

The authors investigated the role of phobic responsivity in the generation of phobia-relevant illusory correlations. As a means of disentangling the contributions of prior fear and elicited fear responses, half of a group of phobic women received 1 mg alprazolam (n = 21), and half received a placebo (n = 22). A group of nonfearful women (n = 24) was included to control for prior fear per se. Participants were exposed to slides of spiders, weapons, and flowers that were randomly paired with a shock, a siren, or nothing. Postexperimental covariation estimates and on-line outcome expectancies were assessed. Irrespective of both prior and elicited fear, participants postexperimentally overassociated spiders and shock. Yet, only women with spider phobia displayed a persisting fear-confirming expectancy bias. This bias was similar for the placebo and alprazolam groups. Thus, the bias appeared to be due to preexisting phobogenic beliefs, whereas phobic responsivity played a negligible role.

Comparison between one-session psychological treatment and benzodiazepine in dental phobia

To compare the effects of a single session of psychological treatment and acute administration of benzodiazepine, 50 dental phobic patients were allocated either to psychological treatment, benzodiazepine, or no treatment for anxiety. Psychological treatment consisted of stress management training and imaginal exposure to phobic stimuli with homework assignments. Benzodiazepine was administered 30 min before dental treatment. Both treatment conditions led to less anxiety during dental surgery than did the control condition. Phobic patients in the benzodiazepine condition showed a relapse after dental treatment, whereas those in the psychological treatment condition showed further improvement until the follow-up 2 months later. Of the latter group, 70% continued dental treatment; only 20% and 10% returned in the benzodiazepine and control conditions, respectively.

Clinical characteristics of flight phobia

Sixty-six subjects with severe fear of flying were recruited by advertisement and compared to 21 controls without flying fears. Subjects were interviewed and given several questionnaires to determine DSM-III-R diagnoses, history of flying, and development and course of flying phobia. Our phobic sample had a mean age of 46 and was 89% female. Diagnostically, 27% met criteria for current Panic Disorder with Agoraphobia, and 17% criteria for that diagnosis in the past. These two groups were more concerned with internal or social anxiety stimuli during flight than the group who had never had panic attacks but met criteria for Simple Phobia (flying). All three groups were equally concerned about external dangers. Traumatic flight events were common in phobics and controls, but phobics reported reacting to these events more strongly. Our results suggest a vulnerability-stress model with several vulnerability factors, including cognitive ones. Treatment implications are discussed.