Anxiety and Panic Attacks

Anxiety-and-Panic-Attacks-6-Christian-Jonathan-Haverkampf-psychotherapy-series

Anxiety and Panic Attacks

Christian Jonathan Haverkampf, M.D.

Abstract – Anxieties can cause incredible suffering, especially in combination with panic attacks, which are usually a short-lived but more intense form of anxiety. At the foundation is often a subconscious, or sometimes partially conscious, feeling that something in life is ‘out of sync’. Anxiety is often triggered by interpersonal difficulties, such as relationship breakups or human problems at the work place. The less one has a good sense of oneself, one’s values, interests and needs, the more difficult interactions and communication with others can become, the lower is one’s resilience in conflicts and situations of divergent interests. All this can induce and maintain anxiety. While a predisposition for anxiety has been shown on the molecular biological and the epidemiological level, it usually is triggered and maintained by conflicts on the inside or the outside. Psychotherapy has been shown to be very effective in treating anxiety disorder and panic attacks.

Keywords: anxiety, panic attacks, psychotherapy

Table of Contents

Anxiety Disorders. 3

Biology. 4

Panic Attack. 4

Invisibility. 5

Lack of Communication. 5

Loss of Control 5

The Need for Control 5

A Signal of Change. 6

Fear of Imminent Death: Somatic (Body) Reaction. 6

Certainty and Security. 6

Meaningful Relationships. 7

Values and Interests. 8

Inner Conflicts. 8

Self-Talk. 9

Three Steps. 9

Happiness. 10

References. 11

Anxiety Disorders

Anxiety is an unpleasant feeling that is often accompanied by tension, nervousness and a restlessness to escape from it. It is a dread of uncertainty about the immediate future, but can also be about the more distant one. Communication Anxiety is an unpleasant feeling that is often accompanied by tension, nervousness and restlessness to escape from it. It is a dread of uncertainty about the immediate future, but can also be about the more distant one. Communication plays, as in most mental health conditions, a vital role (Haverkampf, 2010b). The more connected one feels with others and oneself in a meaningful way, the lower the levels of anxiety usually are (Haverkampf, 2017c) As communication reduces uncertainty, better and more meaningful interactions with oneself and others regularly reduce anxiety.Anxiety is an unpleasant feeling that is often accompanied by tension, nervousness and a restlessness to escape from it. It is a dread of uncertainty about the immediate future, but can also be about the more distant one. Communication plays, as in most mental heal

Anxiety disorders are a group of mental disorders characterised by feelings of anxiety and fear. (APA, 2013) It is a worry about the uncertainty about the nature and occurrence of future events and fear is a reaction to a specified current event. These feelings may cause physical symptoms, such as a fast heart rate and shakiness. There are a number of anxiety disorders:

generalised anxiety disorder

specific phobia

social anxiety disorder,

separation anxiety disorder,

agoraphobia,

panic disorder, and

selective mutism.

An individual may be diagnosed with more than one anxiety disorder. It is important to remember that in psychiatry diagnoses are mostly bundle of symptoms dating back to a time when little was known about the underlying causes, the etilogy of a condition. Over time, the diagnostic systems will change as our understanding of these underlying causes develops further, biologically and psychologically (Haverkampf, 2018b). For now it is important to note that all forms of anxiety have certain common communication and information constellation patterns. Anxiety is often a signal that something is ‘out of sync’.

The epigenetic factors of anxiety are usually placed within the realms of

Biology,

Psychology, and

Social systems / Economics,

but it takes all three too varying degress to result in anxiety.

Biology

Anxiety is a behavioural state, which occurs in response to signals of danger. On the physiological level these signals initiate activation of the hypothalamus-pituitary-adrenal (HPA) axis (Boyce & Ellis, 2005) and secretion of adrenal steroids called stress hormones, which are present in almost every vertebrate cell (Korte, 2001) This leads to increased heart rate, deeper breathing, vigilance, decrease in feeding, and exploration of environment (Cannon, 1916). The genes that code for stress hormones are highly conserved across diverse species: primates, rodents, reptiles, and amphibians (Lovejoy & Balment, 1999; Lovejoy & Jahan, 2006). Neuroevolutionary studies have shown that anxiety is an adaptive response that has been conserved during evolution (Nesse, 1998; Stein & Bouwer, 1997).

Individuals can have a genetic predisposition towards anxiety, which means they are more likely to suffer from an anxiety than someone who does not have this predisposition given the same amount of stress or other internal psychological or external factors. The amygdala, for example, is believed to play a key role in assigning emotional significance to specific sensory input, and conditions such as anxiety, autism, stress, and phobias are thought to be linked to its abnormal function. Growing evidence has also implicated the amygdala in mediation of the stress-dampening properties of alcohol. There have been reports that decreased phosphorylation of cAMP responsive element–binding protein (CREB) resulted in decreased neuropeptide Y (NPY) expression in the central amygdala of alcohol-preferring rats, causing high anxiety-like behaviour (Wand, 2005). Alcohol intake by these animals was shown to increase PKA-dependent CREB phosphorylation and thereby NPY expression, subsequently ameliorating anxiety-like behaviour. Thus, a CREB-dependent mechanism may underlie high anxiety-like and excessive alcohol-drinking behaviour.

Panic Attack

The first panic attack can occur as from nowhere and the sudden sense of imminent death or literally going crazy usually comes as an enormous and sudden shock. In many cases, it has five stages:

An ominous feeling of an imminent panic attack. A heightened sense of self-consciousness with beginning hyperventilation and other symptoms.

  • The sense that there is no way to avert the full-blown panic attack.
  • The panic attack with hyperventilation, heart palpitations, the sense of imminent doom and/or death.
  • Alternations in the intensity of the panic attack, leading to a decline after about ten minutes.
  • A post-panic phase in which there is a sense of exhaustion and sometimes elation that it is over.

Since the first panic attack often occurs in adolescence or young adulthood, the individual might not know what a panic attack is. In older people, panic attacks often lead to visits to the hospital emergency admission.

Invisibility

A feature of many anxieties and panic attacks is that they go largely unnoticed by the environment. Anxieties and panic attacks can lead to the inability to leave the house and interfere with almost every sphere of life, professional, social, and one’s relationships. When anxiety reaches into all areas of life and no longer seems specific to certain situations and locations, we call it ‘generalised’. It is then the pure form of a disturbing feeling that no longer is attached to specific object, but ‘floats freely’.

Loneliness has been demonstrated to be strongly associated with anxiety over social skills, for both male and female undergraduates and for a variety of social relationships. Both factors were related significantly but independently to loneliness, with anxiety having a larger effect size. (Solano & Koester, 1989) Communication as a basic information process plays a strong role in anxiety. (Haverkampf, 2012, 2017b)

Lack of Communication

When people identify and talk about their emotions, they usually become more manageable to the individual. This also applies to anxiety. The more one can talk about the anxiety and the underlying emotions, the less the anxiety will feel uncertain and unpredictable, which helps break through the vicious cycle of feeling anxious about feeling anxious. Any form of communication can potentially break through the vicious cycle. Psychotherapy, however, can deliver results faster and more reliably, because of the focus of the interaction and the training of the therapist.

Loss of Control

Anxiety and Panic Attacks are often a result of a perceived loss of control in an area one feels is relevant to oneself, emotionally and otherwise. Often patients mention the sense of loss of control. This may be linked to emotions from past experiences which have not been resolved or current stress situations which have led to feelings of entrapment in a hopeless situation with out a way out. At the core is the sense that one is not strong enough to bring about a change, which is often a result of losing the sense of efficacy in the world. Since communication is how humans interact with the world, the loss of control is ultimately due to the faith in the own abilities to communicate with oneself and the world. (Haverkampf, 2010c, 2010a, 2017a, 2018a)

The Need for Control

The more one perceives being in a situation where one cannot pursue the own needs, values and aspirations, the higher is usually the sense of loss of control. If there is also a perceived lack of strength and ability to bring about a change, the loss of control will only be increased. Frequently, when there is an underlying depression or unresolved negative past experiences, the own sense of efficacy will be lowered, which can then lead to an aversion of change and a persistent feeling of being trapped.

On the other side, a greater sense of stable factors in oneself and the world can lower anxiety. Such factors may include a good and stable sense of self, basic values, fundamental needs and wants, several personality traits, character attributes, one’s memory of facts and thoughts, a sense for one’s body, and a number of other factors. Once one learns to explore and reflect on oneself and the world around, the need for control lessens because one sees more regularity and structure and learns to experience excitement rather than anxiety when looking at oneself and the world.

A Signal of Change

Since anxiety is a sign that something is ‘out of sync’, it also signals a necessity for change. This does not necessarily require a change in job or relationship partner, but often it does mean that a modification of existing relationships or situations can be beneficial. When things seem to be out of sync, the world becomes less certain and predictable. Anxiety is not a fear of something specific, but of uncertainty itself. It springs from a realisation that something is out of sync, and usually this something refers to interpersonal relationships. People may be fearful of objects, but the latter are unlikely to cause anxiety.

Anticipatory processes are a general feature of the mind that includes responses to both real and imagined (neurotic) appraisals of a situation. (Wong, 1998) This has originally been described by Freud as signal anxiety, whose general concept has been confirmed in research. From a communication perspective, anything that helps in making the information of emotional conflicts available to consciousness is valuable. This can help the individual to reduce the emotional conflicts, primarily through communicating with the environment and with oneself.

Fear of Imminent Death: Somatic (Body) Reaction

Panic attacks often trigger thoughts of an imminent death, such as not being able to breathe anymore or a heart attack. They frequently go along with bodily ‘fear’ reactions, such as heart palpitations and dizziness. In general, there is a general sense of a loss of control over one’s body and even one’s mind, which further worsens the panic attack. Often panic attacks start in adolescence and young adulthood and frequently they are triggered by relationship events and social situations. But if they remain untreated, they can spread out and become ‘generalised’. They can reach a point where they even occur when someone is at home lying in back or after waking up at night. In the extreme, this can lead to a situation in which a patient is not only house but also bed bound.

Certainty and Security

Under the surface of the symptoms of anxiety and panic attacks there often a perceived deficit of certainty and security in one’s life. As babies and small children learn to rely on their interactions with others, especially primary caretakers, to meet their needs, they build up a sense of safety regarding the world around them and a secure sense of self. As we figure out the ‘rules of daily life’ as children we learn to be reasonably in the world. Things might still be unpredictable at times, but in a caring and supportive environment, unpredicted events, whether good or bad, are seen as a fact of life that one might not be able to control, but that one cope with. In an environment where individuals are less able to deal with such events, a greater sense of uncertainty and a greater susceptibility to anxiety develops, especially if there are also biological factors present. It ultimately comes down not to the actual level of control one has over external and internal events, such as the functions of the own body, but the perceived need for it. Yielding control can be quite effective in regaining control over life in a more general sense.

Sanderson and co-workers tested in a study the notion that a sense of control can mitigate anxiety and panic attacks caused by the inhalation of 5.5% carbon dioxide (CO2)—enriched air. (Sanderson, Rapee, & Barlow, 1989) Twenty patients with panic disorder inhaled a mixture of 5.5% CO2-enriched air for 15 minutes. All patients were instructed that illumination of a light directly in front of them would signal that they could decrease the amount of CO2 that they were receiving, if desired, by turning a dial attached to their chair. For ten patients, the light was illuminated during the entire administration of CO2. For the remaining ten patients, the light was never illuminated. In fact, all patients experienced the full CO2 mixture, and the dial was ineffective. When compared with patients who believed they had control, patients who believed they could not control the CO2 administration (1) reported a greater number of DSM-III—revised panic attack symptoms, (2) rated the symptoms as more intense, (3) reported greater subjective anxiety, (4) reported a greater number of catastrophic cognitions, (5) reported a greater resemblance of the overall inhalation experience to a naturally occurring panic attack, and (6) were significantly more likely to report panic attacks. (Sanderson et al., 1989) Thus it seems that the subjective amount of control a patient has over the level of anxiety influences the experienced anxiety. Clinically, it is often observed that if a patient carries a relatively fast acting anxiolytic in their pockets, the additional sense of control can reduce the occurrence of panic attacks. It is often the anxiety about becoming anxious or suffering a panic attack which is the most debilitating feature of more pronounced anxiety and panic attacks.

Society has developed several ways to deal with anxiety and reduce uncertainty. Many human endeavours aim to provide a greater sense of safety. Laws and scientific progress deal with both, uncertainty in people and uncertainty in the natural world. However, in generalised anxiety and panic attacks, it is less a certainty in the outside world than in the inside world which individuals with anxiety strive for, and it is here that psychotherapy often takes its starting point.

Meaningful Relationships

A message is meaningful if it has a degree of novelty and can bring about a change in the person receiving the message. Relationships are meaningful if there is mutual understanding and empathy, but also if there is an exchange of information that benefits both over the long-run. For someone suffering from anxiety it may not be easy to communicate to an extent that could help against the anxiety, which can prolong the latter. Reducing perceived dangers from participating in interactions with others can be achieved by shifting the focus away from the own person, making other people’s comments not about the own person and realising it is OK to say ‘no’. This can be quite easily resolved through the communication work in the therapeutic session by developing awareness for these patterns, reflecting on them and working out modifications or replacing them with other patterns in a playful and experimental way.

Meaningful relationships with other and with oneself help to counteract anxiety because the individual feels a higher degree of efficacy in the world and with respect to oneself. Meaningful communication reconnects the individual with others, but it also aids in self-regulation and gives the individual a greater sense of being effective in taking care of oneself through the interactions with others.

Values and Interests

The other important element is finding not only the strength in oneself but also the direction to proceed in the life. Often there are many paths that can be taken, which confuses people and causes anxiety. Without a sense of one’s trues values, interests and aspirations it is more difficult to make the relevant decisions in life that lead to greater happiness. If one’s sense for one’s own values and fundamental interests and aspirations is compromised because of losses of connection with the rational and emotional self, stress, anxiety and burnout can ensue. It is like running in place without getting anywhere, while having a strong desire to get somewhere.

True values, part biology, part social learning from other human beings, means a fundamental belief that acting according to these values and interests and attaining one’s aspiration will really mean happiness in the long run. In anxiety, these values and fundamental interests are out of sync with our lives.

Inner Conflicts

Anxiety is caused by inner conflicts, which in the cognitive behavioural therapy tradition are assumed to be conscious or ‘near-conscious’, while the psychodynamic or psychoanalytic psychotherapy traditions see most of it in the domain of the unconscious. This largely explains the differences in treatment times between the two approaches, but on a theoretical level both can complement each other quite well. Fundamentally the causes are difficulties in communicating one’s underlying needs and wishes in a way that subjectively strengthens rather than weakens a relationship out of a fear of further loss. This also makes the internal conflicts persist. Our communication with the people in our lives has an impact on how we talk to ourselves, because they provide crucial feedback to us. When our social interactions become meaningless, our sense of shaping our world in a way that makes us feel secure and happy suffers.

Effective mental functioning requires that cognition be protected from emotional conflict due to interference by task-irrelevant emotionally salient stimuli. The neural mechanisms by which the brain detects and resolves emotional conflict are still largely unknown, however. Using functional magnetic resonance imaging (fMRI), Etkin et al found that activity in the amygdala and dorsomedial and dorsolateral prefrontal cortices reflects the amount of emotional conflict. By contrast, the resolution of emotional conflict is associated with activation of the rostral anterior cingulate cortex. Activation of the rostral cingulate is was accompanied by a simultaneous and correlated reduction of amygdalar activity. These data suggested that emotional conflict is resolved through top-down inhibition of amygdalar activity by the rostral cingulate cortex. (Etkin, Egner, Peraza, Kandel, & Hirsch, 2006). Interestingly, the amygdala also plays a significant role in the triggering and maintenance of anxiety.

Resolving emotional conflicts is thus an important technique to lower anxiety. Often, one may not be aware of these emotional conflicts. Particularly in stress or burnout situations, the focus is on survival in a job, a relationship or everyday life rather than on self-exploration and connecting emotionally with oneself. The therapeutic interaction can be helpful to provide the space and the sense of safety to explore and reconnect emotionally. While at first this can increase the anxiety level, within weeks of consistent work the anxiety levels often drop dramatically, even before concrete external adjustments can be made in life.

Self-Talk

When I refer to ‘talking to oneself’ I do not mean literally talking to oneself in the street but bouncing back and forth thoughts in one’s head, observing one’s thought process and reflecting on it. This requires the exchange of highly complex information in even more complex webs of networks of nerve cells in the brain. Since our brain is a highly complex network of ever smaller networks of nerve cells it allows the brain to process information in parallel. This is the reason why we can ‘listen’ to our own thoughts. Brain cells are in contact with other brain cells and they can alter the properties of their own connections depending on the information they transmit. Medication can alter certain types of transmissions in this system, but if we want to be more specific, we have to expose ourselves to meaningful information which the brain can use to refigure itself. This is essentially what psychotherapy does. As many empirical studies have shown, psychotherapy can bring about changes in connectivity and activation of the brain, which in turn can have a lasting effect on certain conditions, such as anxieties and panic attacks.

Three Steps

The first step is to become aware of situations that trigger anxieties and panic attacks, such as relationship problems or work-related stress. But these problems might not always be obvious, and they might not even explain the anxiety. Problems in a relationship or shyness in social situations are normally not the ultimate explanation for anxiety or panic attacks. We need to analyse in the specific case why losing a relationship causes such threatening fears as anxieties or panic attacks suggest. Sometimes it is worthwhile taking a look into one’s past and reconstruct how an individual dealt with his or her environment as a child or adolescent and how the environment dealt with the individual. At other times, it may be important to ‘dissect’ the thought patterns in the here and now and to try to find out what they could mean. “If I leave the house I might have to figure out what I really want to do in life. “If this relationship breaks up I might have to figure out what I need and what I want, who I am, who I want to be with …” and so on. This step is about better understanding one’s needs, values and aspirations, and thus oneself.

The second step is to determine if the current approach, such as avoidance or negation, is the best strategy. It always never is. But this does not mean that one has to radically alter one’s current lifestyle or social life, though in special cases it might. The actual life we have starts in our head, so it is first and foremost about determining the questions that matter to oneself and how to approach them. This is actually easier than most people think, because it is not so much about having certain answers but about learning how to think and communicate in novel ways. Change usually means widening one’s mental repertoire, not narrowing it. The more effective tools are in our toolbox and the more meaningful information we have access to, the better will be our answers and decisions.

The third step is to act according to this novel information. This might sound like a tall order in the face of fears, anxieties and panic attacks, but once someone reaches this stage, the hurdles are often diminished or gone altogether. The fears usually disappear during the first and the second step. The reason is that we are usually more afraid of an uncertain ill-defined event than a certain defined event. When you are facing a threatening event, the uncertainty about an unlikely ill-defined outcome can be more painful than the certainty about a certain well-defined event. The certainty of death does not disturb people nearly as much as not knowing how they will die.

Happiness

The goal is not absolute certainty in life but the attainment of happiness. Anxiety does not necessarily mean a shift in the balance between happiness and writing a meaningful story for one’s life, rather, it often is a wake-up call for us to re-evaluate who we are and what we really want in life to make us happier.

Most people want to lead lives which feel true to themselves for the simple reason that they believe it will make them happy. The only certainty that really helps against anxiety is the certainty that one follows one’s own path. To help a patient reach this path and follow it with confidence is an important objective of psychotherapy and counselling.


Dr. Jonathan Haverkampf, M.D. MLA (Harvard) LL.M. trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. He also has advanced degrees in management and law. The author can be reached by email at jonathanhaverkampf@gmail.com or on the websites www.jonathanhaverkampf.ie and www.jonathanhaverkampf.com.

References

APA (Ed.). (2013). Diagnostic and statistical manual of mental disorders. Am Psychiatric Assoc.

Boyce, W. T., & Ellis, B. J. (2005). Biological sensitivity to context: I. An evolutionary–developmental theory of the origins and functions of stress reactivity. Development and Psychopathology, 17(2), 271–301.

Cannon, W. B. (1916). Bodily changes in pain, hunger, fear, and rage: An account of recent researches into the function of emotional excitement. D. Appleton.

Etkin, A., Egner, T., Peraza, D. M., Kandel, E. R., & Hirsch, J. (2006). Resolving emotional conflict: a role for the rostral anterior cingulate cortex in modulating activity in the amygdala. Neuron, 51(6), 871–882.

Haverkampf, C. J. (2010a). A Primer on Interpersonal Communication (3rd ed.). Dublin: Psychiatry Psychotherapy Communication Publishing Ltd.

Haverkampf, C. J. (2010b). Communication and Therapy (3rd ed.). Retrieved from http://www.jonathanhaverkampf.com

Haverkampf, C. J. (2010c). Creativity and Communication (3rd ed.). Dublin: Psychiatry Psychotherapy Communication Publishing Ltd.

Haverkampf, C. J. (2012). A Case of Severe Anxiety. J Psychiatry Psychotherapy Communication, 1(2), 35–40.

Haverkampf, C. J. (2017a). Communication-Focused Therapy (CFT) (2nd ed.). Dublin: Psychiatry Psychotherapy Communication Publishing Ltd.

Haverkampf, C. J. (2017b). Communication-Focused Therapy (CFT) for Anxiety and Panic Attacks. J Psychiatry Psychotherapy Communication, 6(4), 91–95.

Haverkampf, C. J. (2017c). Treatment-Resistant Borderline Personality Disorder. J Psychiatry Psychotherapy Communication, 6(3), 68–89. Retrieved from http://borderline-treatment.com/wp-content/uploads/2019/01/Haverkampf-CJ-Treatment-Resistant-Borderline-Personality-Disorder-J-Psychiatry-Psychotherapy-Communication-2017-Sept-30-63-68-89.pdf

Haverkampf, C. J. (2018a). Communication-Focused Therapy (CFT) – Specific Diagnoses (Vol II) (2nd ed.). Dublin: Psychiatry Psychotherapy Communication Publishing Ltd.

Haverkampf, C. J. (2018b). Psychiatric Medication and Psychotherapy (1st ed.). Psychiatry Psychotherapy Communication Publishing Ltd.

Korte, S. M. (2001). Corticosteroids in relation to fear, anxiety and psychopathology. Neuroscience & Biobehavioral Reviews, 25(2), 117–142.

Lovejoy, D. A., & Balment, R. J. (1999). Evolution and physiology of the corticotropin-releasing factor (CRF) family of neuropeptides in vertebrates. General and Comparative Endocrinology, 115(1), 1–22.

Lovejoy, D. A., & Jahan, S. (2006). Phylogeny of the corticotropin-releasing factor family of peptides in the metazoa. General and Comparative Endocrinology, 146(1), 1–8.

Nesse, R. (1998). Emotional disorders in evolutionary perspective. Psychology and Psychotherapy: Theory, Research and Practice, 71(4), 397–415.

Sanderson, W. C., Rapee, R. M., & Barlow, D. H. (1989). The influence of an illusion of control on panic attacks induced via inhalation of 5.5% carbon dioxide-enriched air. Archives of General Psychiatry, 46(2), 157–162.

Solano, C. H., & Koester, N. H. (1989). Loneliness and communication problems: Subjective anxiety or objective skills? Personality and Social Psychology Bulletin, 15(1), 126–133.

Stein, D. J., & Bouwer, C. (1997). A neuro-evolutionary approach to the anxiety disorders. Journal of Anxiety Disorders, 11(4), 409–429.

Wand, G. (2005). The anxious amygdala: CREB signaling and predisposition to anxiety and alcoholism. The Journal of Clinical Investigation, 115(10), 2697–2699.

Wong, P. S. (1998). Anxiety, signal anxiety, and unconscious anticipation: neuroscientific evidence for an unconscious signal function in humans. Journal of the American Psychoanalytic Association, 47(3), 817–841.

This article is solely a basis for academic discussion and no medical advice can be given in this article, nor should anything herein be construed as advice. Always consult a professional if you believe you might suffer from a physical or mental health condition. Neither author nor publisher can assume any responsibility for using the information herein.

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The Fear of Living (1)

The-Fear-of-Living-1-Christian-Jonathan-Haverkampf-life-improvement-series-new

The Fear of Living

Christian Jonathan Haverkampf, M.D.

Fear of death is widespread, but the fear of living can often be more impairing in daily life. Many mental health symptoms derive from an anxiousness, fear or apprehension about living in line with one’s needs, values and aspirations. Not engaging with life can lead to an unfilled life and several mental health issues. Engaging with life means communicating with others and oneself effectively.

Keywords: fear of living, communication, psychotherapy

Table of Contents

Introduction. 5

Control and Perspective. 6

Communication Fears and Barriers. 6

Understanding Fear. 7

Overgeneralization. 8

Fear and cognitive abilities. 8

Learning. 9

Anxiety. 9

Social Networks. 9

Connectedness, Social Networking Sites (SNSs) and the Fear of Missing Out (FOMO) 10

Extinction. 10

Flexibility. 10

Memory. 11

Learning. 11

Empathy and Fear. 11

Stress. 11

Fear and Society. 12

You and I 12

Example: Initiating Communication with a Romantic Interest. 13

The Fear of Being Single, Scarcity and ‘Settling for Less’ 13

Proactive Behaviours in Men. 13

Fear of Rejection. 14

Early Communication. 15

Attachment. 15

The Power of Connectedness. 16

Self-Statements. 16

Technology and Communication. 17

Information about Oneself 18

Anxiety vs Behaviours. 20

Misattribution. 20

Fearing the Fear. 21

Fear of Change. 21

Reasonable vs Unreasonable Fears. 21

Neurobiology. 21

The Fear Network. 22

Serotonin. 22

Oxytocin. 23

The Amygdala. 23

Fear without the Amygdala?. 23

Fast Pathways. 24

The Microbiome. 24

Inferior Frontal Gyrus. 24

Learning. 24

Reversal 25

Neuronal coordination. 25

Memory. 26

The Thalamus. 26

Fear vs Anxiety: Information. 27

Extinction. 27

Change. 28

The Cortical Neural Network. 28

Anxiety. 29

Biological Approaches. 29

Memory. 29

C-Cycloserine. 29

MDMA. 30

Other Approaches. 30

Change. 30

Change from Within. 30

Change Without. 31

Psychological Approaches. 31

CBT: Fear of Flying. 31

Virtual Exposure. 31

Fear of Flying (FOF) 32

Systematic Desentization. 32

Expressive Therapy. 32

Cognitive Processing Therapy (CPT) 32

Thoughts and Emotions. 32

Meaningfulness. 33

Communication and Fear. 33

Patterns and Communication Structures. 34

Questions. 34

Building the Motivation to Overcome One’s Fears. 34

Information Overload. 34

Relevance. 35

Selecting Information. 35

The Right Question. 35

Values and Basic Interests. 35

Generalisation. 36

General Questions. 36

Communication to Counter Fear. 36

References. 37

Introduction

Many are aware of the fear of death, but the fear of living can often be more impairing in daily life. Fear can be an adaptive emotion that helps defend against potential danger. However, the overgeneralization of fear to harmless stimuli or situations is a burden to daily life and characteristic of posttraumatic stress disorder and other anxiety disorders. (Dunsmoor & Paz, 2015)

Many mental health symptoms to derive from an anxiousness, fear or apprehension about living in line with one’s needs, values and aspirations. Life can be complicated and scary, but not engaging with it can lead to an unfilled life and various mental health issues. One of the pillars of life is the exchange of information, whether this occurs in a single cell organism or the human body. The communication between cells and within cells ensures survival. Once it ceases, death results. Communication also occurs among living organisms, including people. Engaging with life means communicating with others and oneself effectively.

The first important step is to identify what is the aim of a fear one is experiencing. In many cases, this may be life itself or just allowing oneself to be happy. Facing one’s fears means acting. They are a hindrance to interactions with oneself and the world, and overcoming them can increase happiness, satisfaction and contentment in the long run. Unhelpful fears are those that do not offer protection and interfere with life. The fear of interacting and connecting with oneself and others can be the most life impairing one.

Emotions are usually valuable signals, but internal events unrelated to the current situation can trigger fear. Emotional messages, such as fear, are at the most basic information that is assembled and communicated internally. (Haverkampf, 2018a) Foa and Kozak contended that emotions are represented by information structures in memory, and anxiety occurs when an information structure that serves as a program to escape or avoid danger is activated. (Foa & Kozak, 1986) Fear of communication, the flow of information, is probably the widest-reaching and most debilitating fear because any new information to which the brain is exposed can activate it.

The information flows leading to the emergence of fear follow the basic rules of communication, while there are certain structures in the brain which play a more pronounced role in fear. The amygdala has many efferent projections and represents a central fear system involved in both the expression and the acquisition of conditioned and unconditioned fear. (Davis, 1997) Lesions of the amygdala block innate or conditioned fear, as well as various measures of attention, and local infusions of drugs into the amygdala have anxiolytic effects in several behavioural tests.  From a biological standpoint, fear is a very important emotion. It helps you respond appropriately to threatening situations that could harm you. This response is generated by stimulation of the amygdala, followed by the hypothalamus. This is why some people with brain damage affecting their amygdala do not always respond appropriately to dangerous scenarios. When the amygdala stimulates the hypothalamus, it initiates the fight-or-flight response. The hypothalamus sends signals to the adrenal glands to produce hormones, such as adrenaline and cortisol.

Control and Perspective

Having a sense of control makes people feel more secure in life. However, the amount of influence one has is a matter of perspective. Fear and anger have opposite effects on risk perception. Whereas fearful people express pessimistic risk estimates and risk-averse choices, angry people show optimistic risk estimates and risk-seeking choices. Appraisals of certainty and control seem to moderate and (in the case of control) mediate the emotion effects. (Lerner & Keltner, 2001) This does not mean going through life taking senseless risks and being angry, but to be open to and keep an eye on the options life has to offer. Following the own path feels at least more in control and less fearful than just running around in circles.

Important in overcoming fear is to assess the level of control that a given situation requires. Often, fear is a result of an increased perceived need for control to stay ‘safe’. Feeling less in control usually happens when the internal compass of needs, values and aspirations gets lost. One can recover it by thinking of what one needs to feel happy and content. In communication-focused therapy, one way to address this is to look at the primary parameters, the needs, values and aspirations of the individual. (Haverkampf, 2018f) Quite often, patients find out that they were searching for that basic sense of security in something external, such as relationships or material goods, that were not the highest priorities on their needs and value lists. So, rather than feeling safer, they often felt less safe when acquiring them.

Communication Fears and Barriers

People build barriers when they are afraid. The problem with this is that information can reduce fears, and any restrictions on the free flow of meaningful information will make it even harder to lessen fears, leading into a vicious cycle. Connectedness with oneself and with others reduces anxiety, but it may require changing unhelpful and counterproductive communication patterns which interfere with effective communication within oneself and with others (Haverkampf, 2018b, 2019a)

Internal communication, the one we have with ourselves, and external communication, the one we have with others, are closely linked, and often reflections of each other. In the area of dating communicatioon, for example, results of one study showed that relatively shy emerging adults had more internalizing problems (e.g., anxious, depressed, low self-perceptions in multiple domains), engaged in fewer externalizing behaviours (e.g., less frequent drinking), and experienced poorer relationship quality with parents, best friends, and romantic partners than did their non-shy peers. (Nelson et al., 2008)

Understanding Fear

When faced with threat, the survival of an organism is contingent upon the selection of appropriate active or passive behavioural responses. Freezing is an evolutionarily conserved passive fear response, for example. The central amygdala (CEA) is a forebrain structure vital for the acquisition and expression of conditioned fear responses, and the role of specific neuronal sub-populations of the CEA in freezing behaviour is well-established. Fadok and colleagues showed that active and passive fear responses are mediated by distinct and mutually inhibitory CEA neurons. Cells expressing corticotropin-releasing factor mediate conditioned flight, and activation of somatostatin-positive neurons initiates passive freezing behaviour. (Fadok et al., 2017) The selection of appropriate behavioural responses to threat seems to be based on competitive interactions between inhibitory signals on each other from these cell groups.

Since our reality is built from the information in our brain, an emotion can be as real as a rock. A fear of life can perfuse everything that we associate with life, including the things that may be important or of special value to us. Taking the first step to go out there and actively participate in life, whether in work or in one’s personal life, can inspire fear. Quite often apprehensiveness with connectedness in one realm can spill into the other one, and vice versa. While fears can be quite specific, such as a fear of insects, a fear of a more colourful and enjoyable life can modify everyday behaviours and thoughts considerably.

Understanding the fear signals and the information they contain provide important insight, which  can bring about change that reduces the fear. An emotion is an ‘e-motion’ because it is supposed to move something, because it needs to bring about change. Identifying the information behind, or underlying, an emotion required identifying and reflecting on the emotion, but in communication oriented therapies, for example, it can become a useful habit. (Haverkampf, 2010c, 2017d, 2017b, 2018c) The effect of fears and anxiety, and whether they can lead to positive adjustments and changes, depends on how one reads them, how one extracts and distils the signals contained in them. Often, the fear of being fearful prevents the resolution of fear. In this situation a focus on changes in internal and external communication patterns can lead to the needed information to resolve the fear in a better way than merely confronting an emotion. The author has described many techniques in this regard elsewhere (Haverkampf, 2017a, 2018c).

Overgeneralization

A fear of living is different from simply a generalised anxiety disorder because of its all-pervasiveness, affecting also one’s perspective and approach to life, often without even being aware of it. The overgeneralization of fear is maladaptive and can be observed also in conditions such as PTSD. A generalisation of fear can happen quite quickly and within few steps. Asok and colleagues examined how male and female mice generalize contextual fear at 3 weeks after conditioning. The test order of training and generalization contexts appeared to be critical determinants of the generalization and context discrimination. (This was particularly true for female mice, while tactile elements that were present during fear conditioning were more salient for male mice.) (Asok et al., 2019)

Fear and cognitive abilities

Fear of physical injury includes matters that are perceived by human beings that depend on reality testing, abstraction ability, and capacity for self-preservation. (Blackman, 2018). Treating people who are afraid of physical injury involves helping them to understand the realities of life and to acknowledge their reality perceptions of danger. In cases where the reality of the danger is miniscule or non-existent but reality testing is adequate and abstraction ability good, insight-directed work can help people understand the contributions to their fears of physical injury from various stages of development where they experienced difficulty.

PTSD

It may sometimes be hard to understand why horrible man-made atrocities and natural disasters happen in the world. As a first step, we may have to accept that they do, which can be helpful in trying to prevent them. When someone has experienced trauma, often the fear of communicating with oneself and others increases. Overall, engaging with and in life becomes more difficult. One usually withdraws from the world but dissociates from oneself at the same time. The end result can be a feeling of numbness and disconnectedness from oneself and others. It also shakes the sense of security in the world and within oneself because rules that underlie the predictability and normalcy of everyday life have been shattered and broken.  Soldiers who witnessed atrocities in combat or rape victims are brought to and beyond the edge of normal human experience, perpetrated by other human beings where the basic parameters of what it means to be human seemingly no longer apply.

It is now generally believed that PTSD is due at least in part to a learning process in which formerly neutral stimuli are paired with extremely aversive events. This may be something as mundane as a spoon, if this was the last thing one used before the Tsunami hit the bar, or in a rape situation the pattern on a carpet. This is a classic example of Pavlovian fear conditioning, particularly if it happens repeatedly. Even though it may seem that the fear is focused on specific objects or situations, it is important to remember that trauma by its very definition affects the overall sense of feeling safe within the world and oneself. Reshaping communication-patterns, new meaningful information and a greater connectedness with oneself and others are all helpful in overcoming trauma (Haverkampf, 2016)

Learning

Learning by conditioning is a key ability of animals and humans for acquiring novel behaviour necessary for survival in a changing environment. Aberrant conditioning has been considered a crucial factor in the aetiology and maintenance of various types of fear. We learn throughout our entire life, which brings about change, which can cause anxiety. Once we realize how close anxiety and excitement lie together, it can help to establish a deeper feeling and connection with life. While fear can be helpful in the moment, we need to overcome int over time when we face a similar situation again. Below a sea of anxiety there is really the bright light of a love for life and connectedness with the universe.

Anxiety

Anxiety begets more fears. The learning of fear seems to be facilitated in patients suffering from anxiety. In a meta-study by Duits and colleagues, results demonstrated increased fear responses to conditioned safety cues in anxiety patients compared to controls during acquisition. In contrast, during extinction, patients show stronger fear responses to the safety cues and a trend toward increased differentiation between the safety and danger cues compared to controls. (Duits et al., 2015) A fear of life is thus greater when there is a background anxiety. But as mentioned above, it depends on how the feeling of anxiety is interpreted. If the feeling of anxiety is interpreted as excitement in the sense of investigating how the world works, fear in general will be lower (Haverkampf, 2017g, 2018e).

Social Networks

Our social network are the outcomes of our communication patterns and interactions with other people. Social networking sites are especially attractive for adolescents, but it has also been shown that these users can suffer from negative psychological consequences when using these sites excessively. Particularly, the fear of missing out has becomes a major problem. Since information about the outside world and the inside world is processed in the same brain in often the same centres, it is easy to understand that virtual networks can seem very real. While it is still possible to use the virtual nature of social networks to ease into dating, it may be the case that over time the virtual world becomes the new real world.

At the same time, it is important to remember that the need to communicate is a basic biological requirement of life, and that the fear of missing out is connected with this basic need. The main problem is that if meaningful sources of information cannot be identified effectively, the person may look to plug into communication networks, including social networks, merely for the sake of connecting, rather than really benefiting from it. As mentioned before, fear can be reduced by meaningful information (Haverkampf, 2018e), but that requires the skills and insight to identify sources of meaningful information.

Connectedness, Social Networking Sites (SNSs) and the Fear of Missing Out (FOMO)

In an online survey of over a thousand social media users between 16 and 18 years old, it was found that both the fear of missing out and social networking intensity mediate the link between psychopathology and negative consequences of using social networking sites via mobile devices, but by different mechanisms. Additionally, for girls, feeling depressed seemed to trigger higher SNS involvement, while for boys, anxiety triggered higher SNS involvement. (Oberst, Wegmann, Stodt, Brand, & Chamarro, 2017) In another study by Blackwell and colleagues that investigated whether extraversion, neuroticism, attachment style, and fear of missing out were predictors of social media use and addiction, 207 participants completed a brief survey measuring levels of extraversion, neuroticism, attachment styles, and FOMO. Younger age, neuroticism, and fear of missing out predicted social media use. However, only fear of missing out predicted social media addiction. Attachment anxiety and avoidance predicted social media addiction, but this relationship was no longer significant after the addition of FOMO. (Blackwell, Leaman, Tramposch, Osborne, & Liss, 2017) In a study by Elhai and colleagues, smartphone use was most correlated with anxiety, need for touch and FOMO. Problematic smartphone use was associated with FOMO, depression (inversely), anxiety, and need for touch. Frequency of use was associated with need for touch, and (inversely) with depressive symptoms. Interestingly, emotional suppression also mediated the association between problematic smartphone use and anxiety. (Elhai, Levine, Dvorak, & Hall, 2016) This is another example for the tight link between external and internal connectedness (Haverkampf, 2010a).

Extinction

The goal of any therapeutic approach to fear, or to managing fear in life generally, is to manage fear. While this should not mean extinguishing all fear, as this is an important informational signal for survival, but to be able to reduce or extinguish the fear which is interfering with life in unhelpful ways. In fear extinction, the positive experience of an omitted aversive event drives the reduction of fear responses and the formation of long-term extinction memories. Dopamine emerges as key neurobiological mediator of these related processes. (Kalisch, Gerlicher, & Duvarci, 2019) Exposure therapy is a form of cognitive intervention that specifically changes the expectancy of harm. (Hofmann, 2008)

Extinction is possible even without exposure to the feared situation or location in real life. A number of studies have shown that exposure to virtual stimuli works as well. Investigators have, for example, shown that VRT was successful in reducing the fear of the public speaking. (North, North, & Coble, 2015) In other words, the information is again what is important and the way in which it is communicated.

Flexibility

Fear can be highly adaptive in promoting survival, yet it can also be detrimental when it persists long after a threat has passed. Flexibility of the fear response may be most advantageous during adolescence when animals are prone to explore novel, potentially threatening environments. Two opposing adolescent fear-related behaviours—diminished extinction of cued fear and suppressed expression of contextual fear—may serve this purpose, but the neural basis underlying these changes is unknown.

Memory

Memory is a store of information available for retrieval by the individual. As meaningful information can reduce fear, the ability to store it, can have a lasting effect of reducing or mitigating fear. Fear memory is formed in the hippocampus (contextual conditioning and inhibitory avoidance), in the basolateral amygdala (inhibitory avoidance), and in the lateral amygdala (conditioning to a tone).

The circuitry involves, in addition, the pre- and infralimbic ventromedial prefrontal cortex, the central amygdala subnuclei, and the dentate gyrus. Fear learning models, notably inhibitory avoidance, have also been very useful for the analysis of the biochemical mechanisms of memory consolidation as a whole. These studies have capitalized on in vitro observations on long-term potentiation and other kinds of plasticity. The effect of a very large number of drugs on fear learning has been intensively studied, often as a prelude to the investigation of effects on anxiety.

Learning

Fear memory was thoroughly investigated mostly using two classical conditioning procedures (contextual fear conditioning and fear conditioning to a tone) and one instrumental procedure (one-trial inhibitory avoidance).

Empathy and Fear

The relationship between empathy, a connective signal, and fear, a potentially disconnective signal, is interesting. Olsson and colleagues investigated how social (vicarious) fear learning is affected by empathic appraisals by asking participants to either enhance or decrease their empathic responses to another individual (the demonstrator), who received electric shocks paired with a predictive conditioned stimulus. A third group of participants received no appraisal instructions and responded naturally to the demonstrator. During a later test, participants who had enhanced their empathy evinced the strongest vicarious fear learning as measured by skin conductance responses to the conditioned stimulus in the absence of the demonstrator. Moreover, this effect was augmented in observers high in trait empathy. Their results suggest that a demonstrator’s expression can serve as a “social” unconditioned stimulus (US), similar to a personally experienced US in Pavlovian fear conditioning, and that learning from a social US depends on both empathic appraisals and the observers’ stable traits. (Olsson et al., 2016)

Stress

Stress has a critical role in the development and expression of many psychiatric disorders and is a defining feature of posttraumatic stress disorder (PTSD). Stress also limits the efficacy of behavioural therapies aimed at limiting pathological fear, such as exposure therapy. Here we examine emerging evidence that stress impairs recovery from trauma by impairing fear extinction, a form of learning thought to underlie the suppression of trauma-related fear memories. We describe the major structural and functional abnormalities in brain regions that are particularly vulnerable to stress, including the amygdala, prefrontal cortex, and hippocampus, which may underlie stress-induced impairments in extinction. We also discuss some of the stress-induced neurochemical and molecular alterations in these brain regions that are associated with extinction deficits, and the potential for targeting these changes to prevent or reverse impaired extinction. A better understanding of the neurobiological basis of stress effects on extinction promises to yield novel approaches to improving therapeutic outcomes for PTSD and other anxiety and trauma-related disorders. (Maren & Holmes, 2016)

Fear and Society

Society is built on communication links, which are not entirely flexible. Since fear and anxiety are both lower the more meaningful information there is, their level depends on how messages are formed and can be transmitted within a community. More rapid and efficient communication networks can make more meaningful information from more sources more easily and quickly available, but their effectiveness in the end depends on how information streams are selected and the individual’s ability to choose information sources most efficiently and beneficially. Messages of fear can reduce openness and put a narrower focus on the sources and the content of these messages. Tannenbaum and colleagues have studied fear appeals in a comprehensive meta-analysis investigating their effectiveness for influencing attitudes, intentions, and behaviours. Results showed that fear appeals were effective at positively influencing attitude, intentions, and behaviours, that there were very few circumstances under which they were not effective, and that there were no identified circumstances under which they backfired and lead to undesirable outcomes. (Tannenbaum et al., 2015) Group messages can even give rise to irrational or illogical fears, which then have the potential to become entrenched. Research results imply that there is a fear of the feminine in men, which prevents them from infringing on prescribed gender boundaries. This may also take the form of the use of psychological defences to distance from thoughts and behaviours perceived as not masculine. (Kierski & Blazina, 2009)

You and I

Shyness is a form of social anxiety that has been characterized as anxious preoccupation with the self in the presence of others. Some researchers argue that a necessary precondition for experiencing the state emotion of shyness is public self-consciousness—that is, awareness of the self as a social object. Although the importance of self-processes in the experience of shyness has been generally recognized, the role of the self has not been fully explicated in this regard. This chapter reviews previous researches on shyness as well as some recent data with particular emphasis on the discrepancy between self and other perception of social behaviour. An overview of the concept of shyness is presented and its emergence in the psychological literature as a descriptive and theoretical construct is discussed. The research is analysed which focuses on shyness including the rate of its occurrence, internal, and behavioural correlates. The data linking dispositional shyness to limited and problematic social networks is also reviewed in the chapter. (Jones & Briggs, 1984)

Perspective is important, because one cannot read another person’s thoughts. One often decodes information from oneself and from other’s differently, which depends on the assumptions one makes about how another person processes information (Haverkampf, 2018a).  In one study, participants who indicated that they were more likely than a potential partner to be inhibited from making an initiative by a fear of rejection, attributed a potential partner’s inaction to a lack of interest in developing a relationship with them. Individuals spontaneously perceive a potential partner’s inaction as reflective of disinterest more so than they perceive their own inaction in these terms. Participants’ divergent perceptions of their own vs their potential partner’s underlying feelings stemmed from the biased interpretation of inaction. (Vorauer & Ratner, 1996)

Example: Initiating Communication with a Romantic Interest

Making romantic connections is a very basic, yet powerful need. Evolutionary requirements for the survival of the species come into play, which may explain why the mating process involves communication nuances on so many levels. It is biologically serious business, and fears in this domain can impact significantly on the quality of the life of the individual. On the other hand, there is hardly any domain of communication which has as much to do with how one communicates with oneself, self-image, confidence, self-esteem, and one’s place in the world overall. Mating communication thus serves as a good example to investigate the fear of living in general.

The Fear of Being Single, Scarcity and ‘Settling for Less’

Spielmann and colleagues in a cross-sectional study found that those with stronger fear of being single reported greater longing for their ex‐partners. The fear of being single seemed to increase after a breakup, regardless of who initiated the breakup. Longing for an ex‐partner and attempts to renew the relationship were greater on days with stronger fear of being single. The fear of being single increased longing and renewal attempts over time, but longing and renewal attempts did not influence fear of being single. (Spielmann, MacDonald, Joel, & Impett, 2016)

In another study by the same authors, the fear of being single predicted (Spielmann et al., 2013)

  • settling for less in ongoing relationships

interest in less responsive and less attractive dating targets being less selective in expressing romantic interest but did not predict the other’s romantic interest.

Proactive Behaviours in Men

In a study by Kraeger and colleagues on American online dating data, the authors found that men and women tend to send messages to the most socially desirable alters in the dating market regardless of their own desirability levels. They also found that male initiators connect with more desirable partners than men who wait to be contacted, but female initiators connect with equally desirable partners as women who wait to be contacted. Female‐initiated contacts are also more than twice as likely as male‐initiated contacts to result in a connection, but women send four times fewer messages than men. (Kreager, Cavanagh, Yen, & Yu, 2014)

Fear of Rejection

Fisman and colleagues studied dating behavior using data from a Speed Dating experiment where we generate random matching of subjects and create random variation in the number of potential partners. Our design allows us to directly observe individual decisions rather than just final matches. Women put greater weight on the intelligence and the race of partner, while men respond more to physical attractiveness. Moreover, men do not value women’s intelligence or ambition when it exceeds their own. Also, we find that women exhibit a preference for men who grew up in affluent neighborhoods. Finally, male selectivity is invariant to group size, while female selectivity is strongly increasing in group size. (Fisman, Iyengar, Kamenica, & Simonson, 2006)

Using technology to eliminate a fear of rejection offers a powerful incentive for a powerful emotion. One invention, for example, uses the knowledge one has with certain people or companies of interest, and discloses a member’s intention to advance relation to the other only when the other also wants to advance it, and only when certain criteria or expectations predefined by the members are met. (“US20090006120A1 – Social and/or Business Relations Icebreaker: the use of communication hardware and/or software to safely communicate desires to further advance relations without the fear of being rejected and/or unnecessarily revealing information and/or intentions. – Google Patents,” n.d.)

It is also important to consider that rejection may have an important role to play. In a study using online dating data, couple similarities were more likely to result from relationship termination, i.e. nonreciprocity, than initial homophilous preferences. (Kreager et al., 2014)

Online dating sites try to lower the fear of rejection by collecting and comparing data to lessen the risk of rejection. In one case, the computer program takes advantage of existing contact lists such as those on social networking sites, instant messaging programs, or cell phones. It allows the user to characterize each contact on the basis of the user’s level of interest in that contact as a date. The program keeps these rankings secret until two users indicate an interest in each other that surpasses a certain threshold. The users are then notified of the mutual interest. (“US9934297B2 – Method of facilitating contact between mutually interested people – Google Patents,” n.d.) This may help lesten the risk of rejection, but by not exposing individuals to rejection, it may actually worsen it when it happens. On the other hand, computer-assisted matchmaking makes it possible to screen more information in a smaller amount of time. So, thereby it may enhance the engagement with the romantic aspect of life, even though it may lower the risk of rejection.

Perceiving Reality

Fears can distort how we perceive reality. They change how information is decoded and translated into meaning or how one perceives the communication process. Work on communication patterns in interpersonal and internal contexts in CFT can reverse this distortion (Haverkampf, 2017a). Vorauer and colleagues demonstrated in their studies that fears of rejection prompt individuals to exhibit a signal amplification bias, whereby they perceive that their overtures communicate more romantic interest to potential partners than is actually the case. The link between rejection anxieties and the bias was evident regardless of whether feats of rejection were assessed in terms of chronic attachment anxiety or were induced by reflection on a previous rejection experience. Mediation analyses suggested that the bias stems in part from an expected-augmenting process, whereby persons with strong fears of rejection incorrectly assume that the recipient of their overtures will take their inhibitions into account when interpreting their behavior. Implications for understanding the link between attachment anxiety and loneliness and for designing social skills interventions are discussed. (Vorauer, Cameron, Holmes, & Pearce, 2003)

Human emotions serve adaptive functions. A study by Teich and colleagues proposed that mating anxiety helps solve the adaptive problem of the costliness of being rejected by a potential mate. To accomplish this, the mating anxiety mechanism was hypothesized to estimate the likelihood of rejection by a potential mate by calculating the discrepancy between their respective levels of desirability (Mate Value Discrepancy) in terms of social attractiveness and social / financial resources. Hierarchical Linear Modeling was used to test the predictions about mate value discrepancy (MVD) and likelihood of rejection (LR) on Anxiety. MVD had a highly significant effect on Anxiety and on LR. LR had a significant effect on Anxiety as predicted, but did not mediate the effect of MVD on Anxiety. A gender differences in anxiety were found in the effect of profile status/resources on anxiety, but not for other profile or participant characteristics as expected. men having greater anxiety than women. (Telch et al., n.d.)

Early Communication

This study examined the relationship between perceived dysfunctional family-of-origin rules and intimacy in single young adult dating relationships. A sample of 754 single, Caucasian-American young adults completed measures of perceived dysfunctional family-of-origin rules and emotional, intellectual, and sexual intimacy in dating relationships. When controlling for the effects of gender and age, results showed that perceived dysfunctional family-of-origin rules had a negative impact on the perceived expression and experience of these three kinds of intimacy in dating relationships. Implications for relationship therapy are discussed. (Larson, Peterson, Heath, & Birch, 2000)

Attachment

Attachment anxiety predicts dating outcomes that goes beyond other factors, including attractiveness. In a study by McClure and colleagues, anxious participants at speed-dating were motivated by loneliness. They were unpopular and unselective; they missed fewer opportunities but made more failed attempts. Anxious men made fewer matches than non-anxious men, whereas anxious women were buffered by having a response bias toward saying “yes” to potential partners. (McClure, Lydon, Baccus, & Baldwin, 2010)

Electronic intrusion (EI) is the use of social media to intrude into the privacy of a dating partner, monitor a partner’s whereabouts and activities, and pressure a partner for constant contact. A survey study of 703 high school girls and boys by Reed and colleagues found that higher levels of attachment anxiety were associated with more frequent perpetration of EI for both girls and boys. Therefore, especially for anxiously attached teens, social media may create a “cycle of anxiety” in which social media serve as both a trigger for relationship anxiety and a tool for partner surveillance in an attempt to alleviate anxiety. (Reed, Tolman, Ward, & Safyer, 2016)

This prospective study (N = 90) investigated the early formation of romantic relationships within an attachment‐theoretical framework. Specifically, it tested whether general attachment to romantic partners was predictive of single individuals’ progressing from not dating to dating and from not dating or casual dating to a committed and exclusive relationship when simultaneously considering desire for starting a committed relationship, prior dating involvement, and self‐perceived physical attractiveness. Attachment avoidance, but not anxiety, was predictive of not entering into committed dating relationships even with rival predictors included. The transition from not dating to casual or committed dating was mainly predicted by prior dating success with some support for a potential additional role of the desire to form a committed relationship. (Schindler, Fagundes, & Murdock, 2010)

The Power of Connectedness

The effect of communication connectedness goes beyond any immediate direct effects. La Greca and colleagues found in their study found that adolescents with fewer other-sex friends and those with less positive and more negative interactions with their best friends reported high levels of dating anxiety. They concluded that adolescents’ social relationships have the potential to support or interfere with the development of successful romantic relationships. (La Greca & Mackey, 2007) In a study by Himadi and colleagues, low-daters showed greatermdifficulties in same-sex friendship interactions and were less well-adjusted on the Eysenck Personality Inventory (EPI) than more relaxed frequent daters. However, these differences were not observed in women. (Himadi, Arkowitz, Hinton, & Perl, 1980)

Self-Statements

Results in a study by Glass and colleagues indicated that participants trained in cognitive self-statement modification showed significantly better performance in role-play situations for which they were not trained, made significantly more phone calls, and made a significantly better impression on the women than subjects in other groups. These effects were generally maintained at follow-up, and the cognitive self-statement groups’ performance on the role-play measures improved from posttreatment to follow-up. (Glass, Gottman, & Shmurak, 1976) Women with breast cancer or a genetic susceptibility to developing this disease report a myriad of dating concerns. In a study by Shaw and colleagues, six areas of concern were identified: Feeling unattractive due to treatment side effects; perceiving limited dating partners available; determining how, when and what to disclose; fear of cancer recurrence and reduced life expectancy; apprehension about entering into a new sexual relationship; and dating urgency and not wanting to ‘waste time’ on partners without long-term potential. (Shaw, Sherman, & Fitness, 2015)

Technology and Communication

Anxiety associated with dating appears to occur for a variety of reasons, such as (a) the desire to establish heterosocial relationships; (b) the social importance and status associated with dating; (c) the fact that dating is a social skill that emerges relatively late in development (Hansen, Christopher, & Nangle, 1992)

Technology can help overcome inhibitions, particularly in men. A survey of the users of an online computer-mediated matchmaking service by Scharlott and Christ found that (Scharlott & Christ, 1995)

  • Men generally contacted women more than vice versa, but a substantial minority of the women contacted a great number of men.
  • Users who scored higher on a shyness scale were much more likely than less shy users to say they were using the system to find romance or sex
  • Women who rated their own appearance as average were less likely to be contacted by men than those who rated their appearance as above average
  • There was no significant difference between appearance groups concerning the likelihood of starting a romantic or sexual relationship.
  • Intrinsic aspects of the computer-mediated matchmaking system helped some users overcome relationship-initiation barriers rooted in sex role, shyness, and appearance inhibitions.

In a study by Gatter and Hodkinson, no differences were found in motivations, suggesting that people may use both Online Dating Agencies and Tinder for similar reasons. There were no differences in self-esteem or sociability between the groups. Users of both Tinder and Online Dating Agencies did not appear to differ from the general population. (Gatter & Hodkinson, 2016) However, in a study by Zlot and colleagues, users of Internet-dating applications showed higher scores on a sex addiction scale. (Zlot, Goldstein, Cohen, & Weinstein, 2018)

“People-nearby applications” (PNAs) are a form of ubiquitous computing that connect users based on their physical location data. One example is Grindr, a popular PNA that facilitates connections among gay and bisexual men. A factor analysis by Van De Wiele and Tong revealed six uses and gratifications: social inclusion, sex, friendship, entertainment, romantic relationships, and location-based search. (Van De Wiele & Tong, 2014)

Dinh and colleagues examined the mate preferences and communication patterns of male and female users of the online dating site eHarmony over the past decade to identify how attitudes and behaviors have changed over the past decade. (Dinh, Gildersleve, & Yasseri, 2018) Some of the findings were that

  • women are more selective and restrict their potential mating pool more than men do
  • smoking level, ethnicity, and drinking level were the most important match criteria for both men and women overall
  • income was the second least important criterion to women, religion being the least
  • women on average do consider income in a potential match more important than men do, but the importance of this trait has decreased significantly over time
  • women are still more restrictive overall in their preference for age than men are
  • In larger group sizes, male selectivity is unchanged (about one in two), while females become significantly more selective, choosing a little more than a third of their partners
  • physical attractiveness does not have a linear relationship with communication rate; communication rates may also be determined by expectations about who will respond
  • women’s communication rates seem to me more dependent on their looks than for men
  • an indication, at least, that individuals have an awareness, if weak, of their own desirability
  • correlations between attractiveness and selectivity
  • being younger and athletic and having more photos increases likelihood of receiving messages in online dating, as does being romantic and altruistic.

However, apart from some very general pointers, much may also depend on the dating platform. As people’s motives for joining a virtual mating space may be different, so will also be the chances of finding what one is looking for. Some sites are also making the sending of certain signals that one is interested more costly or restrict their number. This could help to create a more even playing field and reduce the problem that sending messages to a large number of people is a strategy for several men. In the case of Bumble, for example, only women can make the first move by sending the first message. This may solve some problems, but also turn away those who want the man to take the first step, whether male or female, and preselect a certain profile.

Information about Oneself

The experience of the self is equivalent to the experience of information flows within oneself and with the outside world (Haverkampf, 2012, 2017f). Feeling alive means perceiving more information flows. Information about the self is information about these information flows, which are unique to the individual but happen within the information flows in the world shared with others.

Social anxiety is linked to the communication of information about the self. Social anxiety appears to arise from people’s concerns about the impressions others are forming of them. Social anxiety occurs when people are motivated to create a desired impression on audiences but doubt they will do so (Schlenker & Leary, 1985). High social anxiety, in turn, is associated with qualitative and quantitative changes in how people communicate (Schlenker & Leary, 1985).

Attempting to create the desired impression, but low expectations of achieving this, produces negative affect, physical or psychological withdrawal from the situation, and self-preoccupation with one’s limitations. The heightened social anxiety impedes optimally effective self-monitoring and control. A protective self-presentational style, in which the focus is on avoiding blatant failures rather than achieving significant successes, is engaged. The result can include (Schlenker & Leary, 1985):

  • less interactions with others,
  • the avoidance of topics that might reveal one’s ignorance (e.g. factual matters),
  • minimal disclosure of information about the self,
  • cautious self-descriptions that are less positive and less likely to assert unique qualities that draw attention to the self, and
  • a passive yet pleasant interaction style that avoids disagreement (e.g. reflective listening, agreeing with others, smiling).

The consequence is a vicious cycle in which less engagement with life leads to even greater isolation. Once one begins to focus and connect with oneself, this cycle can be broken. Practically, this can be achieved by working on the communication patterns one uses with oneself and others. The authors has described several techniques and the theoretical underpinnings elsewhere (Haverkampf, 2017a, 2018d). Improved communication patterns support a more active participation in life and foster the feeling of greater self-efficacy, self-actualization, more fulfilment, satisfaction and a greater quality of life in general (Haverkampf, 2017e).

Projection

Usually, one uses the information one has about oneself to conjecture how one appears to others. Projection is when we use our own thoughts to estimate what others are thinking, when we see others as copies of ourselves without realising it. The problem is that when we are critical of ourselves we will think others are critical of us or when we feel incompetent we think that others see us as incompetent. If we constantly feel a need to evaluate or control ourselves, we feel that others are constantly evaluating us as well, even in areas that may not be visible to another. It has been argued from a self-presentational view that the fear of being socially evaluated is pivotal to dispositional shyness.  In a study by Asendorpf, compared with the group lower in shyness, the shy subjects (Asendorpf, 1987)

  • recalled more fear of social evaluation (including fear of positive evaluation) but did not more often report other kinds of fear,
  • had more negatively biased thoughts about the impression made on their partner but not more impression-related thoughts in general, and
  • showed more negatively biased reactions to the positive feedback of their partner.

Findings further suggested that evaluative situations also arouse fears of having to evaluate others. (Asendorpf, 1987) The problem with a constant need for evaluation is that we cannot measure something that is still unfolding, one’s journey in life. Something that may not make sense yet could be a blessing later on. The only thing we can do is live life in alignment with the basic parameters, the needs, values and aspirations, which should spring from well-informed insight (Haverkampf, 2018f).  This approach is particularly helpful when one experiences anxiety and fears, and the author has described several techniques from a CFT perspective (Haverkampf, 2017c)

Socially anxious or shy individuals may use their anxiety symptoms as a strategy to control attributions made about their performances in social-evaluative settings. In a study by Snyder and colleagues the results supported the following for males but not for females  (Snyder, Smith, Augelli, & Ingram, 1985):

  • trait-socially anxious or shy Ss would report more symptoms of social anxiety in an evaluative setting in which anxiety or shyness could serve as an excuse for poor performance than would Ss in (a) an evaluative setting in which shyness was precluded as an excuse or (b) a nonevaluative setting
  • this self-protective pattern of symptom reporting would not occur for Ss who were not trait-socially anxious because these Ss would not commonly use such symptoms as a self-handicapping strategy

Anxiety vs Behaviours

From a communication perspective, it is important to remember that it is ultimately about meaningful information. Since information flows on the inside inform us of moods and anxiety, for example, communication patterns in the external world have also as an aim to gain or to give information. There are important conceptual distinctions between of reticence, shyness, communication apprehension, and unwillingness to communicate and other constructs. Some of these terms refer to subjective, affective responses, and comprise specific instances of the umbrella construct of social anxiety. Others refer to patterns of overt, social‐communicative behaviours. (LEARY, 1983) But all of them affect how information is being communicated and whether a message ultimately arrives as intended.

In any pursuit in life, not just dating, better ways of communicating and working with information are frequently key in being successful. Work on communication patterns in Communication-Focussed Therapy (CFT) helps to make communication with oneself and the world more effective (Haverkampf, 2010b, 2017a, 2019b)

Misattribution

Schachter and Singer postulated in the 1960s that physical arousal played a primary role in emotions. The arousal was hypothesized to be the same for a wide variety of emotions, so physical arousal alone could not be responsible for emotional responses. The arousal must be identified to feel a specific emotion. An experimental design based upon an explication of Schachter’s theory of emotion demonstrated that fear reduction through induced misattribution of the physiological concomitants of fear could be accomplished. A test situation was utilized in which reduced fear would be reflected by test subjects’ willingness to work on a puzzle which would gain them monetary reward while leaving unsolved a puzzle which could allow them to avoid impending electrical shock. (Ross, Rodin, & Zimbardo, 1969)

Fearing the Fear

Fear can inhibit communication, which happens to be the instrument to resolve it. The reason for this may be to conserve resources for more automatic problems of fight or flight. In today’s world, however, more complex ways of reacting to fear are required, and new sources of information to be able to do so have to be tapped. An important strategy to counter fear is thus to communicate nonetheless. An adjustment and change in communication patterns can make this easier and less fear inducing. On the inside, more effective and gentler ways of connecting with oneself are helpful. Towards the outside, adjusting communication patterns, more questioning and reflecting, and more openness can make it easier to get the information one needs, while reducing the fear and anxiety.

In the case of kidney transplantation, prolongation of life involves not only adding time to the length of life, but it also involves the matter of the quality and worthwhileness of the life that is thus prolonged (Beard, 1969).

Fear of Change

Often, people are afraid of connecting with themselves and others because they fear the changes which can be brought on by the additional information, the impact it can have on their lives. In the case of anxiety and OCD, the ability to distinguish between a mere thought and reality is often reduced, which leads to more anxiety in a world which seems more uncertain and unpredictable. Breaking down fears is thus made easier when one is able to take a step back and identify the type and source of communicated messages, while also trying to determine the meaning in them relative to oneself.

Reasonable vs Unreasonable Fears

Our mind may tell us that a fear of tall buildings is unnecessary, but our emotions tell us otherwise. Some of these fears may be linked with experiences from one’s own past, others with innate programs in our brain. Emotions have an evolutionary function to guarantee our survival by providing simple signals to induce action or stop an action. However, the brain circuits leading to fear, for example, are partly hardwired for specific information. A fear of heights on top of a tall building makes sense, because tall buildings have only been around for a fraction of human history. In earlier times, standing close to a precipice on a tall cliff or mountain was indeed a dangerous affair.

Neurobiology

Tremendous progress has been made in basic neuroscience in recent decades. One area that has been especially successful is research on how the brain detects and responds to threats. Such studies have demonstrated comparable patterns of brain-behaviour relationships underlying threat processing across a range of mammalian species, including humans. This would seem to be an ideal body of information for advancing our understanding of disorders in which altered threat processing is a key factor, namely, fear and anxiety disorders. But research on threat processing has not led to significant improvements in clinical practice. The authors propose that in order to take advantage of this progress for clinical gain, a conceptual reframing is needed. Key to this conceptual change is recognition of a distinction between circuits underlying two classes of responses elicited by threats:

  • behavioral responses and accompanying physiological changes in the brain and body and
  • conscious feeling states reflected in self-reports of fear and anxiety.

This distinction leads to a “two systems” view of fear and anxiety. The authors argue that failure to recognize and consistently emphasize this distinction has impeded progress in understanding fear and anxiety disorders and hindered attempts to develop more effective pharmaceutical and psychological treatments. The two-system view suggests a new way forward. (LeDoux & Pine, 2016) Fear conditioning and extinction learning in animals often serve as simple models of fear acquisition and exposure therapy of anxiety disorders in humans.

The Fear Network

Fear is mediated by a brain-wide distributed network involving long-range projection pathways and local connectivity. The disinhibitory microcircuit is a common motif in the basolateral amygdala (BLA), central amygdala and the prelimbic region of the medial prefrontal cortex, and is instrumental in fear acquisition and expression. (Tovote, Fadok, & Lüthi, 2015) Stress promotes a shift from a hippocampus-dependent, ‘cognitive’ memory system to a dorsal striatum-dependent, ‘habitual’ memory system, which also plays an important part in fear-related disorders. Importantly, glucocorticoids have similar effects on memory processes in both cognitive and habitual forms of memory. (de Quervain, Schwabe, & Roozendaal, 2017) There is overlap of neuronal circuits that mediate negative and positive valence in areas such as the VTA. Understanding the interplay between these circuits is of vital importance for understanding adaptive behavioural states. (Tovote et al., 2015)

Serotonin

Brain serotonin system dysfunction is implicated in exaggerated fear responses triggering various anxiety-, stress-, and trauma-related disorders. Waider and colleagues investigated the impact of constitutively inactivated serotonin synthesis on context-dependent fear learning and extinction using mice, which are completely devoid of serotonin synthesis in the  brain. The mice displayed accelerated fear memory formation and increased locomotor responses to foot shock. Furthermore, recall of context-dependent fear memory was increased. The behavioural responses were associated with increased c-Fos expression in the dorsal hippocampus. The hippocampus controls contextual representation of fear-related behavioural responses and c-fos expression indicates neuronal activity. It also showed resistance to foot shock-induced impairment of hippocampal long-term potentiation. (Waider et al., 2019)

Oxytocin

Brain areas supporting the formation romantic attachment are those rich in oxytocin (OT) receptors (Acevedo et al., 2011), underscoring the potential role of OT in romantic bonding. (Schneiderman, Zagoory-Sharon, Leckman, & Feldman, 2012)  OT is a nonapeptide hormone associated with affiliative bonding in mammals (Insel et al., 1997) that is known to mediate social behaviour, pair-bonding, and parental attachment across a variety of species (Carter, 1998). Specifically, OT has been shown to play a critical role in the regulation of pair-bond formation in monogamous mammals (Ross and Young, 2009). It has been repeatedly shown that the Mating-induced release of OT reverses social fear in mice (Grossmann, Sommer, Menon, & Neumann, 2017)

The Amygdala

Conditions such as anxiety, autism, depression, post-traumatic stress disorder, and phobias are suspected of being linked to abnormal functioning of the amygdala, owing to damage, developmental problems, or neurotransmitter imbalance. The amygdala is a key brain region that is critically involved in the processing and expression of anxiety and fear-related signals. It is an almond-shape set of neurons located deep in the brain’s medial temporal lobe and forms part of the limbic system. The amygdala has been shown to play key roles in the processing of emotions. In humans and other animals, this subcortical brain structure is linked to both fear responses and pleasure. Its size is also positively correlated with aggressive behaviour across species. In humans, it is the most sexually-dimorphic brain structure, and shrinks by more than 30% in males upon castration.

Fear without the Amygdala?

The amygdala’s role appears to extend to both recognition and recall of fearful facial expressions. Bilateral amygdala damage in humans compromises the recognition of fear in facial expressions while leaving intact recognition of face identity (Adolphs et al., 1994). This impairment appears to result from an insensitivity to the intensity of fear expressed by faces. The amygdala seems to be required to link visual representations of facial expressions, on the one hand, with representations that constitute the concept of fear, on the other. Adolphs and colleagues reported of patient “S.M.” who lost her left and right amygdalae to disease. Initial testing suggested that S.M.’s most defining symptom was an inability to recognize fear in other people’s facial expressions. (R Adolphs, Tranel, Damasio, & Damasio, 1995; Barrett, 2018) Returning to the patient ten years later, Adolphs and colleagues showed that her impairment stems from an inability to make normal use of information from the eye region of faces when judging emotions, a defect they traced to a lack of spontaneous fixations on the eyes during free viewing of faces. Although the patient failed to look normally at the eye region in all facial expressions, her selective impairment in recognizing fear was explained by the investigators by the fact that the eyes are the most important feature for identifying this emotion. Her recognition of fearful faces became entirely normal when she was instructed explicitly to look at the eyes. (Ralph Adolphs et al., 2005)

Fast Pathways

A fast, subcortical and phylogenetically old pathway to the amygdala is thought to have evolved to enable rapid detection of threat, which could also explain nonconscious emotional responses. Mendez-Bertolo and colleagues recorded human intracranial electrophysiological data and found fast amygdala responses, beginning 74-ms post-stimulus onset, to fearful facial expressions, which had considerably shorter latency than fear responses that were observed in the visual cortex. They were limited to low spatial frequency components of fearful faces and were not evoked by photographs of arousing scenes. (Méndez-Bértolo et al., 2016)

The Microbiome

There are at least as many bacterial cells as human cells in the body, of which many are in the intestinal tract. They are commonly called the microbiome in their entirety. They seem to influence brain development, activity and behaviour. A growing number of preclinical and human studies have implicated the microbiome–gut–brain in regulating anxiety and stress-related responses. Hoban and colleagues demonstrated in their study that the presence of the host microbiome is crucial for the appropriate behavioural response during amygdala-dependent memory retention. (Hoban et al., 2018)

Inferior Frontal Gyrus

There appears to be a link between cerebral correlates of cognitive processing in the inferior frontal gyrus and emotional processing in the amygdalae – insulae – anterior cingulate cortex axis during symptom improvement across time in panic disorder with agoraphobia. In a randomized, controlled, multicentre clinical trial Kircher and colleagues studied medication-free patients with panic disorder with agoraphobia who were treated with 12 sessions of manualized CBT. Patients’ functional MRIs compared to those of control subjects revealed reduced activation for the conditioned response in the left inferior frontal gyrus. This activation reduction was correlated with reduction in agoraphobic symptoms. Patients compared to control subjects also demonstrated increased connectivity between the IFG and the amygdalae – insulae – anterior cingulate cortex axis across time. (Kircher et al., 2013)

Learning

The link between specific stimuli and fear responses is often learned. Input specificity is a fundamental property of long-term potentiation (LTP). (Maren, 2017) Kim and Cho showed that fear conditioning is mediated by synapse-specific LTP in the amygdala, allowing animals to discriminate stimuli that predict threat from those that do not. (Kim and Cho, 2017) In rats, brief electrical stimulation of the infralimbic cortex has been shown to reduce conditioned freezing during recall of extinction memory. This finding has been translated to humans with magnetic resonance imaging–navigated transcranial magnetic stimulation (TMS). (Raij et al., 2018)

Reversal

Learning mechanisms can also explain how the link between specific stimuli and a fear response can be attenuated and eliminated. Learning-related changes of synaptic connections in the cortex seem to be at least partially reversed after unlearning. Lai and colleagues examined in their study the impact of auditory-cued fear conditioning and extinction on the remodelling of synaptic connections in the living mouse auditory cortex. They found that fear conditioning leads to cue-specific formation of new postsynaptic dendritic spines, whereas fear extinction preferentially eliminates these new spines in a cue-specific manner. (Lai, Adler, & Gan, 2018)

Neuronal coordination

Coordination dynamics provides a unifying framework for understanding the neurophysiological mechanisms underlying the integration and segregation of cortical areas in large-scale networks. A goal of coordination dynamics is to identify the key variables of coordination (defined as a functional and/or task-dependent ordering among context-sensitive interacting components) and their dynamics (rules that govern the stability and change of coordination patterns), and the nonlinear coupling among components that gives rise to them. In the context of cognitive neuroscience, the aim of coordination dynamics is to understand the functional interactions within and between different areas of the brain in relation to cognitive task performance. (Bressler & Kelso, 2016)

Precise spike timing through the coordination and synchronization of neuronal assemblies is an efficient and flexible coding mechanism for sensory and cognitive processing. In cortical and subcortical areas, the formation of cell assemblies critically depends on neuronal oscillations, which can precisely control the timing of spiking activity. Fear behaviour relies on the activation of distributed structures, among which the dorsal medial prefrontal cortex (dmPFC) is known to be critical for fear memory expression.

The results of a study by Dejean and colleagues identified a novel phase-specific coding mechanism, which dynamically regulates the development of dmPFC assemblies to control the precise timing of fear responses. Fear behaviour relies on the activation of distributed structures, among which the dmPFC is known to be critical for fear memory expression. In the dmPFC, the phasic activation of neurons to threat-predicting cues, a spike-rate coding mechanism, correlates with conditioned fear responses and supports the discrimination between aversive and neutral stimuli. However, this mechanism does not account for freezing observed outside stimuli presentations, and the contribution of a general spike-time coding mechanism for freezing in the dmPFC remains to be established. They used a combination of single-unit and local field potential recordings along with optogenetic manipulations to show that, in the dmPFC, expression of conditioned fear is causally related to the organization of neurons into functional assemblies. During fear behaviour, the development of 4 Hz oscillations coincides with the activation of assemblies nested in the ascending phase of the oscillation. The selective optogenetic inhibition of dmPFC neurons during the ascending or descending phases of this oscillation blocks and promotes conditioned fear responses, respectively. (Dejean et al., 2016)

Memory

Strong aversive memories lie at the core of several fear-related disorders. Therefore, the memory-modulating properties of glucocorticoids have become of considerable translational interest. (de Quervain et al., 2017) Evidence indicates that the effects of glucocorticoids on both the consolidation and the retrieval of memory depend on interactions with the endocannabinoid system, which may open novel therapeutic avenues. (de Quervain et al., 2017) The evidence that genetic and epigenetic variations in the glucocorticoid system are related to traumatic memory, as well as to post-traumatic stress disorder (PTSD) risk and treatment, adds to the understanding of individual risk and resilience factors for PTSD. (de Quervain et al., 2017) Collections of cells called engrams are thought to represent memories. Although there has been progress in identifying and manipulating single engrams, little is known about how multiple engrams interact to influence memory. In lateral amygdala (LA), neurons with increased excitability during training outcompete their neighbours for allocation to an engram. Rashid and colleagues examined whether competition based on neuronal excitability also governs the interaction between engrams. Mice received two distinct fear conditioning events separated by different intervals. LA neuron excitability was optogenetically manipulated and revealed a transient competitive process that integrates memories for events occurring closely in time (coallocating overlapping populations of neurons to both engrams) and separates memories for events occurring at distal times (disallocating nonoverlapping populations to each engram). (Rashid et al., 2016)

The Thalamus

The prelimbic prefrontal cortex, which is necessary for fear retrieval sends dense projections to the paraventricular nucleus of the thalamus (PVT). Do-Monte and colleagues showed that the PVT may act as a crucial thalamic node recruited into cortico-amygdalar networks for retrieval and maintenance of long-term fear memories by demonstrating that the dorsal midline thalamus of rats is required for the retrieval of auditory conditioned fear at late (days), but not early (hours) time points after learning. (Do-Monte, Quiñones-Laracuente, & Quirk, 2015)

Shift in Retrieval Circuits

Do-Monte also showed that there may be a shift in the retrieval circuits along the time axis. The PVT showed increased c-Fos expression, indicating neuronal activity, only at late time points, indicating that the PVT is gradually recruited for fear retrieval. Retrieval at late time points activated prelimbic prefrontal cortex neurons projecting to the PVT and silencing of these projections impaired retrieval at late time points. In contrast, silencing of prelimbic prefrontal cortex inputs to the basolateral amygdala impaired retrieval at early time points. Retrieval at late time points also activated PVT neurons projecting to the central nucleus of the amygdala, and silencing these projections at late time points induced a persistent attenuation of fear. (Do-Monte et al., 2015)

Fear vs Anxiety: Information

A fear of living is really a combination of both, a concrete fear of a very broad concept and an anxiety associated with uncertainty and strong emotions. It is unclear to what extent a small dose of them can push or pull us forward on our journey. But it is quite clear that they can be huge obstacles in large doses. In order to better work with them, it is first of all important to distinguish a deep respect, excitement and appreciation for the miracle of life from fear and anxiety. As a second important step, one needs to be able to distinguish between fear and anxiety, since the target of a fear is much better defined and clearer than the general uncertainty that is associated with anxiety. From a CFT perspective, however, both manifest with well defined communication patterns (Haverkampf, 2017c, 2017g)

As mentioned previously, fear and anxiety are two distinguishable phenomenological entities. The amount of information available about the threat appears to be a critical deciding factor. Fear is elicited by a defined threat, while one feels anxious when the threat is uncertain or not clearly defined. The distinction is also reflected on a neuro-morphological level. Anxiety is usually associated with activation in ventromedial prefrontal cortex and hippocampus, while fear is correlated with activation in the periaqueductal grey. At the same time, the amygdala seems associated with both.

To test this, Rigoli and colleagues used functional MRIs to record participants’ brain activity while they performed a computer-based task which required to press a button to move an artificial agent to a target position while an artificial predator chased the agent. In the fear condition the predator was visible, while in the anxiety condition the predator was invisible. Ventromedial prefrontal cortex, hippocampus, and amygdala showed increased activity when the predator was invisible compared to visible, while the opposite effect was observed in periaqueductal grey. They also observed that participants with high but not low trait-anxiety showedhippocampal activation with invisible threat at an earlier time stage during the trial. (Rigoli, Ewbank, Dalgleish, & Calder, 2016)

Extinction

A single session of exposure therapy can eliminate fears of objects or situations. Encoding of fear extinction involves many of the same brain areas that are involved in fear acquisition and expression; however, different circuits within the amygdala and prefrontal cortex are involved. Indeed, fear extinction circuits may in fact inhibit fear circuits to dampen fearful responding. (Tovote et al., 2015) The extinction of fear learning involves to an extent a reversal of the flow of information in the pre- and infralimbic ventromedial prefrontal cortex, the central amygdala subnuclei, and the dentate gyrus. and is used in the therapy of posttraumatic stress disorder and fear memories in general. (Izquierdo, Furini, & Myskiw, 2016)

If applied too life itself, exposure can include anything from meditation to going on a date. We expose ourselves to life if we constantly break down barriers and widen our horizon. This can also include information inside of us. For example, someone who is reflecting on a topic or investigating a feeling is also widening the information horizon, transmitting and receiving meaningful information, and thus engaging with life. As with many other fears, exposure to communication can reduce the anxieties and fears connected with life.

Exposure to various forms of communication, as long as they are not intrinsically harmful, can reduce the fears and anxieties associated with them. This also enlarges the activity radius and mental horizon an individual experiences in life. There are specific brain regios that seem to play an elevated role in fear and the effect of exposure in general. Hauner and colleagues studied changes in brain activity as a result of one successful two hour exposure treatment. Before treatment, fear eliciting images excited activity in a network of brain regions, including amygdala, insula, and cingulate cortex, relative to neutral images. Successful therapy dampened responsiveness in this fear-sensitive network while concomitantly heightening prefrontal involvement, which persisted even six months later, but without prefrontal engagement. Additionally, individual differences in the magnitude of visual cortex activations recorded shortly after therapy predicted therapeutic outcomes six months later. (Hauner, Mineka, Voss, & Paller, 2012)

Change

Throughout development, an important process is to arrive at a point where the amount of fear signalled in daily life is at the correct measure where it sustains survival without interfering too much in life. Flexibility of the fear response may be most advantageous during adolescence when living beings in general are prone to explore novel, potentially threatening environments.

Two opposing adolescent fear-related behaviours—diminished extinction of cued fear and suppressed expression of contextual fear—may serve this purpose. Using microprisms to image prefrontal cortical spine maturation across development in mice, Pattwell and colleagues identified a dynamic blasolateral amygdala – hippocampus – medial prefrontal cortex circuit reorganization associated with behavioural shifts. (Pattwell et al., 2016) The same circuit also seems to play a role in social defeat and some of its consequences. (Qi et al., 2018)

The Cortical Neural Network

Emotional states of consciousness, or what are typically called emotional feelings, are traditionally viewed as being innately programmed in subcortical areas of the brain and are often treated as different from cognitive states of consciousness, such as those related to the perception of external stimuli. Ledoux and Brown argued that conscious experiences, regardless of their content, arise from one system in the brain. In this view, what differs in emotional and non-emotional states are the kinds of inputs that are processed by a general cortical network of cognition, a network essential for conscious experiences. Although subcortical circuits are not directly responsible for conscious feelings, they provide nonconscious inputs that coalesce with other kinds of neural signals in the cognitive assembly of conscious emotional experiences. (LeDoux & Brown, 2017) When subjective state words are used to describe behaviours, or brain circuits that control them nonconsciously, the behaviours and circuits take on properties of the subjective state. Subjective state words should be limited to the description of inner experiences, and avoided when referring to circuits underlying nonsubjectively controlled behaviors. (LeDoux, 2017)

Anxiety

Anxiety is an emotion characterized by an unpleasant state of inner turmoil. It is the subjectively unpleasant feelings of dread over anticipated events, such as the feeling of imminent death.  Anxiety is, as mentioned, not the same as fear, which is a response to a real or perceived immediate threat, whereas anxiety involves the expectation of future threat. Anxiety is a feeling of uneasiness and worry, usually generalized and unfocused as an overreaction to a situation that is only subjectively seen as menacing.

As with fear and fear extinction, a brain-wide neuronal network underlies anxiety, with identified local microcircuits within the bed nucleus of the stria terminalis, the lateral septum, the ventral tegmental area (VTA) and the basolateral amygdala. Importantly, there is potential overlap between fear and anxiety circuits. (Tovote et al., 2015)

Biological Approaches

While psychotherapy should be the first line of treatment when it comes to unhelpful fears, there are biological tools that may be of use in more extreme cases of fear. Psychotherapy and medication both work on the information receiving and processing system in the brain.

Memory

Glucocorticoids affect distinct memory processes that can synergistically contribute to a reduction of fear-related symptoms, for example, by both reducing aversive-memory retrieval and enhancing the consolidation of fear-extinction memory (de Quervain et al., 2017). Clinical trials have provided the first evidence that glucocorticoid-based pharmacotherapies aimed at attenuating aversive memories might be helpful in the treatment of fear-related disorders. In particular, the strategy to enhance extinction processes by combining exposure-based psychotherapy with timed glucocorticoid administration seems to be a promising approach to treat fear-related disorders. (de Quervain et al., 2017)

C-Cycloserine

D-cycloserine is a molecule that binds to the NMDA receptor and improves its efficiency. Because D-cycloserine facilitates extinction in rats, Davis and colleagues investigated whether D-cycloserine might facilitate the loss of fear in human patients. It indeed seemed to help reduce fear of heights substantially after seven or eight sessions. (Davis, 2010) The ability of D-cycloserine to improve psychotherapy been replicated in other studies in obsessive- compulsive disorder, social phobia, and panic disorder.

MDMA

MDMA used as an adjunct during psychotherapy sessions has demonstrated effectiveness and acceptable safety in reducing PTSD symptoms in Phase 2 trials, with durable remission of PTSD diagnosis in more than two thirds of participants. MDMA enhances release of monoamines (serotonin, norepinephrine, dopamine), hormones (oxytocin, cortisol), and other downstream signalling molecules (BDNF) to dynamically modulate emotional memory circuits. By reducing activation in the amygdala and insula, and increasing connectivity between the amygdala and hippocampus, MDMA may allow for reprocessing of traumatic memories and emotional engagement with therapeutic processes. (Feduccia & Mithoefer, 2018)

Other Approaches

Transcranial magnetic stimulation (TMS) is a non-invasive procedure that uses magnetic fields to stimulate nerve cells in the brain to improve symptoms of depression, for example. During a repetitive TMS session, an electromagnetic coil is placed against the scalp near the forehead, which is thought to activate regions of the brain that have decreased activity in depression. Liston showed that transcranial magnetic stimulation targeting a human homolog of a rodent fear regulation circuit enhanced extinction learning in healthy human subjects. (Liston, 2018)

Change

The brain processes information, and fortunately we can consciously select information and teach our brain new ways of dealing with information. But this requires taking a close look at our basic values and fundamental interests, which ultimately drive any change. If you feel that something is important to you, you are more likely to spend energy on figuring out a way to effect a change. Knowing why doing something is valuable and important to oneself is an important force in doing something even if one is fearful (as long as there is no real threat of harm from the activity).

Change from Within

In many cases, however, feeling pressure to go through with a feared activity can be counterproductive. As the need to take the elevator, for example, increases, the fear increases as well. The problem is that the activity is seen as a ‘need’ dictated by the outside world. Overcoming a fear should come from an internal need, the fulfilment of a basic value or fundamental interest.

Greater insight into the own needs, values and aspirations can thus be very helpful in confronting the own fears. This explorative process in itself can already be helpful in confronting the fears. It is facilitated through a better internal communication (Haverkampf, 2010c), a better emotional and cognitive communication, which can be trained in a communication-oriented therapy. (Haverkampf, 2010b, 2017a) An easier access to this emotional information can also provide more stability and trust in oneself, which helps whenever fears, whether internal or external, need to be confronted.

Change Without

Changing communication patterns within leads to changes in communication patterns without. This is how better boundaries can be drawn to the outside world, which also makes the world appear safer and more secure. The ability to stand up for one’s needs, values and aspirations and to say ‘No’ as well as ‘Yes’ requires a good connection on the inside, which then makes it possible to work on one’s communication patterns with the world. Better and more effective external communication patterns can make it easier to deal with everyday problems and other people who may hold different opinions.

Good external communication patterns are those which facilitate understanding on both sides, and understanding can reduce fears and anxiety, as thus feeling understood. Meaningful communication can reduce fears and anxiety because it can bring about changes in the communication partners and adjustments in as situation which benefit everyone. However, it can only accomplish this if the internal communication is also working on both sides.

Psychological Approaches

CBT: Fear of Flying

The Fear of flying (FOF) can be a serious problem for individuals who develop this condition and for military and civilian organizations that operate aircraft. People with fear of flying experience intense, persistent fear or anxiety when they consider flying, as well as during flying. They will avoid flying if they can, and the fear, anxiety, and avoidance cause significant distress and impair their ability to function. Take-off, bad weather, and turbulence appear to be the most anxiety provoking aspects of flying. The most extreme manifestations can include panic attacks or vomiting at the mere sight or mention of an aircraft or air travel. Around 60% of people with fear of flying report having some other anxiety disorder.

Krijn and colleagues compared the effectiveness of bibliotherapy (BIB) without therapist contact, individualized virtual reality exposure therapy (VRE) and CBT. Treatment with VRE or CBT was more effective than BIB. Both VRE and CBT showed a decline in FOF on the two main outcome measures. There was no statistically significant difference between those two therapies. However, effect sizes were lower for VRE (small to moderate) than for CBT (moderate). CBT followed by group cognitive-behavioural training showed the largest decrease in subjective anxiety. (Krijn et al., n.d.)

Virtual Exposure

Virtual Reality (VR) is a technological interface that allows users to experience computer-generated environments within a controlled setting. This technology has been increasingly used in the context of mental health treatment and within clinical research.  VR aims to parallel reality and create a world that is both immersive and interactive. Users fully experience VR when they believe that the paradigm accurately simulates the real-world experience that it attempts to recreate. The sense of presence, or “being there” in VR, is facilitated through the use of technology such as head-mounted displays, gesture-sensing gloves, synthesized sounds, and vibrotactile platforms, which allow for the stimulation of multiple senses and active exploration of the virtual environment. Furthermore, some VR paradigms are programmed to react to the actions of the user. This dynamic interaction enables the participant to engage with the VR environment in a more naturalistic and intuitive way. VR’s precise control of sensory cues, particularly for auditory, tactile, and olfactory systems, increases the sense of realism and memory of the virtual environment. (Maples-Keller, Bunnell, Kim, & Rothbaum, 2017)

Fear of Flying (FOF)

In a study by Rothbaum and colleagues, patients with FOF (N = 49) were randomly assigned to virtual reality exposure therapy, standard exposure therapy, or a wait-list control. Treatment consisted of 8 sessions over 6 weeks, with 4 sessions of anxiety management training followed by either exposure to a virtual airplane or exposure to an actual airplane at the airport. The results indicated that virtual reality exposure and standard exposure were both superior to the control group, with no differences between the two approaches. The gains observed in treatment were maintained at a 6-month follow up. (Rothbaum, Hodges, Smith, Lee, & Price, 2000)

Systematic Desentization

Systematic desensitization has become one of the most effective new therapeutic methods. There are clinical series and laboratory experiments demonstrating its success in alleviating fear and anxiety. Both stimulus and response control elements may contribute to the success of desensitization and similar fear modification treatments. (Lang, 2017)

Expressive Therapy

Fagen reported cases and analyses of terminal-cancer pediatric patients that display a variety of music therapy techniques to show how “grief work” is part of a larger therapeutic process. Fagan concluded that the creative life of the child must not be dismissed as secondary in times of illness, that it must share equal importance with other intellectual and physical needs. (Fagen, 1982)

Cognitive Processing Therapy (CPT)

Cognitive processing therapy (CPT) is based on an information processing theory of PTSD and includes education, exposure, and cognitive components. Its effectiveness was shown in smaller sample sizes. (Resick & Schnicke, 1992)

Thoughts and Emotions

The thoughts and emotions we perceive arise in an interconnected system of areas with nerve cells (neurons). Both are types of information, which can lead to change in the individual, whether resulting in changes in state, behaviours or thinking, if the messages are meaningful, that is if they lead to new meaningful information within the context of existing information, whether in memory or anywhere else in the nervous system.

Thoughts and emotions are thus messages representing sets of information being shuttled between different locations in the brain. The sense of this movement of information gives rise to the sense of self, which is not just a metacognitive ability, but the actual awareness of all those information flows. The greatest fear may be the fear that these information flows stop suddenly, which would resemble the death of the self. However, since the information flows continue throughout life, it is a fear of losing the awareness of them.

The emotions in conjunction with the ability to reflect about them help to identify the thoughts, actions, behaviours and situations which make a person feel better. Especially when confronting fears, whether on the inside or on the outside, this information can be helpful. Emotions are not as accessible to rationality because we are not conscious of the large amount of information that goes into them, a process that happens largely in our subconscious, but thinking about situations in the past and connecting emotionally can help to make it easier to identify them.

Meaningfulness

It is only worth facing one’s fears where an action makes sense in the context of one’s values and aspirations. This means using one’s thoughts and feelings to find those things which make one happy and are enjoyable, as well as being in sync with one’s values. This is a first important step in breaking down fears and developing the motivation and initiative to overcome them.

Meaningfulness is a practical concept. If something is meaningful, it can bring about a change in an individual. For example, if something triggers a feeling in a person, it is meaningful, particularly if it changes the affective state of the person. Whether something triggers a new though, a sadness, anger or happiness, it is meaningful. How a message fits into and corresponds with the information already in the nervous system, and other parts of the body, determines whether it is meaningful. If information about a situation, for example, corresponds with a past situation in memory, which is associated with other information and a feeling of sadness, both these thoughts and the sadness can be triggered. But something more happens, than the retrieval of information. The information about the new situation and the existing information have to be reconciled, which is essentially a creative act, leading to new information. There could, for example, be a new insight into oneself or the world, cognitively, emotionally or otherwise. Meaningfulness thus leads to innovation, which is of particular importance when it comes to facing fears, within and without. Anxiety in itself is not an emotion, but underlying it are usually emotions which need to be addressed to resolve the anxiety or panic attacks.

Communication and Fear

How we communicate with others has an influence of the fears we are experiencing. Meaningful helpful communication can reduce fears, if delivered with empathy and understanding, while negative communication or a lack of communication can increase fears. When we face those fears, communicating with someone else or others can be helpful in overcoming the fears.

Patterns and Communication Structures

Whether something is a fear or not depends on how one communicates with oneself and others. It is usually helpful to recognize the emotion of fear, but to see in it the question which it is. When one encounters a tiger in the wild, the fear really presses the question on one, what to do, whether to freeze or run away. Once the question has been answered, fear may also provide the increase in energy to initiate the action, such as running away. In other words, the purpose of the emotion is to get a new communication process going which often involves the non-emotional mind in the form of asking a question.

Questions

Many people who experience fears and anxieties have picked up on the need for answers, but they skip the crucial step of asking the right question. However, without an awareness of the question looking for an answer is futile, which usually increases the sense of helplessness and hopelessness. An employee who experiences anxiety and the workplace and begins to dread everything about it, and as a consequence is heading straight into a burnout, cannot change anything until the question is asked what needs to be changed. In essence, the fear or possible change and the uncertainty which comes with it lets him or her experience anxiety fears, anxiety or even emotional numbness and disconnect, which would end in the moment the question about change is asked. The mind would immediately focus on constructing a new future rather than on the helplessness and hopelessness of the situation.

Questions are so powerful because they change the communication patterns one has with oneself and with others. While they are a communication entity in themselves with message and meaning, the information they contain leads to a change in the information flows in oneself or in others, as long as they possess meaning to the recipient.

Building the Motivation to Overcome One’s Fears

Reconnecting with ourselves should allow us to identify our value and aspirations which can be very effective in building the motivation to overcome fears and even to reduce them. Doing something we feel strongly about might not reduce the nervousness we feel, but it can lower the amount of fear or even transform it into excitement. It is easier to overcome one’s fears if one knows why this is beneficial to oneself and others.

Information Overload

In the complex world we live in our brains can get overloaded with information, a situation that in itself can cause fears. So, an important first step is to untangle the web of complexity by picking out the information that is important to us. Being selective requires knowing what one wants and what one is looking for. This is why getting in touch with one’s values can be so important. They tell us what is important to us and what we should be looking for. Openness is important to find new interests, make better decisions, formulate new plans and aspire to even greater things, but if we do things that are not in sync with our core sense of ourselves as person and our basic values[1], there will be little happiness in these activities.

Relevance

Humans often spend too much resources on information that is not relevant to them or where they cannot change anything. If you cannot change an issue, there is not much sense in wasting mental or physical resources on it. In such a situation, it is more important to deal with your emotions, be they fears, sadness or anger. One way is to find a way to communicate them in a meaningful way. Communicating an emotion helps to resolve it. This could be in the form of talking about it, writing about it, or even making a movie about it.

Selecting Information

The way we select, process and manage information is important in alleviating fears. You may be anxious of something or of a situation, but maybe one reason is that you do not have enough information about it. We live in a world where information is very readily available, so informing oneself is often not that difficult. And if you do not find answers to a question you have, consider if you are asking the right question, one that is helpful to you.

The Right Question

Often, we ask questions that do not really provide us direction or useful answers, so we get lost in ruminations and endless spirals of meaningless thought cascades. Try to split up a question and see if you might not get at least partial answers to the component that is relevant, while leaving the irrelevant part unanswered.

Values and Basic Interests

Any information is helpful if it helps one live according to one’s values and basic interests. Life is going along a path. You cannot know the entire path until you have lived your life, but your values provide a good compass and they help dispel fear whenever it pops up along the way.

Generalisation

Quite often fears generalize in what is called a ‘generalised anxiety’. This can lead to a general fear of life itself. Here it is important to determine which emotions and specific fears are underlying the generalised anxiety.

You may identify something that triggered the anxiety, but the reasons for it can go back a long time. Dealing with some of the underlying issues may require identifying your values and interests. You want to cut down on thoughts and fears that are irrelevant to you and focus constructively on the issue that are relevant to you by finding helpful information.

General Questions

Generalised anxiety occurs often when people feel they have to fix something or find answers or make decisions, when they do not know where to look for them, or even where to start. Take a step back, see the situations for what it is with its relevant and irrelevant components, and measure your options against what you truly need and want. Much in life is noise and irrelevant to one’s path.

Communication to Counter Fear

It helps to be in contact with someone else to make the fears manageable. Facing fears with another may make it easier to deal with your fears and anxieties because you know you do not have to face them alone. When you talk to your neighbour on an airplane, for example, you might not even notice the take-off, and the brief interaction with the stranger reduces the emotional pressure on the inside.


Dr Jonathan Haverkampf, M.D. (Vienna) MLA (Harvard) LL.M. (ULaw) trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. He is the author of several books and over two hundred articles.

Jonathan can be reached by email at jonathanhaverkampf@gmail.com or via the websites www.jonathanhaverkampf.com and www.jonathanhaverkampf.ie.

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[1] One’s sense of self, one’s personality and one’s values usually change little over one’s life span, except for exposure to extreme, and especially traumatic, experiences.

ADHD and Medication (3)

ADHD-and-Medication-3-Christian-Jonathan-Haverkampf-psychiatry-series

ADHD and Medication

Christian Jonathan Haverkampf, M.D.

Attention deficit hyperactivity disorder (ADHD) has become treatable with medication and psychotherapeutic approaches that have become available recently. This article provides a brief overview of some aspects of the medication used for ADHD.

The most widely used group of medication for ADHD comprises the stimulants. Stimulants such as methylphenidate and amphetamine are currently the most common treatment for ADHD. The substance used should fit the particular individual and the particular condition and situation.

Open and transparent communication between clinician and patient is of paramount importance in the case of ADHD for a successful treatment outcome.

Keywords: ADHD, attention deficit hyperactivity disorder, medication, psychiatry

Table of Contents

Keywords: ADHD, attention deficit hyperactivity disorder, medication, psychiatry. 1

Introduction. 5

The Prefrontal Cortex. 5

Substance Abuse. 6

Psychotherapy. 6

Social 6

Diagnosis of ADHD.. 7

Different Types of ADHD.. 7

EEG.. 8

Diagnosis of ADHD in Children. 8

Stability over Time. 9

Adult ADHD.. 10

Baseline assessment. 11

Medication. 11

Long-Term Effect. 12

Anxiety. 12

Tics. 12

Emotional Lability. 13

Smoking. 13

Medication Groups. 13

Methylphenidate. 13

Atomoxetine. 14

Extended Release. 14

Sex. 14

Medication for Children. 14

Consider offering. 15

Medication for Adults. 15

Consider offering. 15

ADHD Type and Medication. 16

Subtype. 16

Sleep. 16

Anxiety. 16

Genotype. 17

Dose Titration. 17

Abuse. 18

Coexisting Conditions. 18

Caution. 18

Psychosis. 19

Bipolar Disorder. 19

Aggression. 20

Seizures. 20

Priapism.. 20

Peripheral Vasculopathy, Including Raynaud’s Phenomenon. 20

Visual Disturbance. 20

Drug Dependence. 20

Pregnancy. 21

Monitoring. 21

Behavior. 21

Height. 21

Weight. 22

Cardiovascular System.. 22

Children and Adolescents. 23

Adults. 23

Tics. 23

Sexual Dysfunction. 23

Seizures. 23

Sleep. 24

Compliance. 24

Psychotherapy. 24

References. 25

Introduction

The use of medications to treat attention deficit hyperactivity disorder (ADHD) has increased. Using a common protocol and data from thirteen countries and one SAR, Raman and colleagues show increases over time but large variations in ADHD medication use in multiple regions across the world. (Raman et al., 2018)

While medication is effective, one needs to keep in mind that most mental health conditions, and particularly ADHD, is caused and maintained not only by neurobiology, but also by psychological, environmental and social patterns. Most patients would thus benefit from a combined approach. Safren and colleagues, for example, studied cognitive-behavioral therapy (CBT) for adults with attention-deficit hyperactivity disorder (ADHD) who have been stabilized on medications but still show clinically significant symptoms. The data showed that CBT for adults with ADHD with residual symptoms can be a feasible, acceptable, and potentially efficacious next-step treatment approach. (Safren et al., 2005)

The most widely used class of medication for ADHD is the group of stimulants, including methylphenidate and other substances. A stimulant is a drug that stimulates the central nervous system, increasing arousal, attention and endurance. For years, it was assumed that stimulants had paradoxical calming effects in ADHD patients, whereas stimulating ‘normal’ individuals and producing locomotor activation in rats. It is now known that low doses of stimulants focus attention and improve executive function in both normal and ADHD subjects. Stimulants are frequently used to treat attention deficit-hyperactivity disorder. Because the medications can be addictive, patients with a history of drug abuse are typically monitored closely or treated with a non-stimulant. It is argued that the risk of addiction in patients diagnosed with ADHD is much lower. On the other hand, well-monitored stimulant treatment may even reduce the risk for alcohol and substance use in adolescent ADHD. (Hammerness, Petty, Faraone, & Biederman, 2017)

The Prefrontal Cortex

At low doses that improve prefrontal cortex-dependent cognitive function and that are devoid of locomotor-activating effects, methylphenidate substantially increases norepinephrine and dopamine efflux within the prefrontal cortex. In contrast, outside the prefrontal cortex these doses of methylphenidate have minimal impact on norepinephrine and dopamine efflux. (Berridge et al., 2006) The prefrontal cortex regulates behavior and attention using representational knowledge, and imaging and neuropsychological studies have shown that the prefrontal cortex is weaker in subjects with ADHD. This cortical area is very sensitive to levels of catecholamines: moderate levels engage postsynaptic α2A-adrenoceptors and D1 receptors and improve prefrontal regulation of behavior and attention, while high levels impair prefrontal function via α1-adrenoceptors and excessive D1 receptor stimulation. Administering low doses of methylphenidate to rats improves the working memory and attentional functions of the prefrontal cortex, while high doses impair working memory and produce a perseverative pattern of errors similar to that seen in patients. The low dose improvement is blocked by either an α2-adrenoceptor or Dl receptor antagonist, suggesting that both norepinephrine and dopamine contribute to the beneficial actions of stimulant medications. (Arnsten, 2006)

Substance Abuse

Chang and colleagues found no indication of increased risks of substance abuse among individuals prescribed stimulant ADHD medication; if anything, the data suggested a long‐term protective effect on substance abuse. (Chang et al., 2014) However, one should still be vigilant towards stimulant misuse and diversion in ADHD patients.

Careful therapeutic monitoring can reduce medical misuse and diversion of controlled medication among adolescents. They appear to be more prevalent among adolescents who misuse their controlled drugs. In a survey study by McCabe and colleagues, misusers were more likely than non-misusers to divert their controlled medications and to abuse other substances. The odds of a positive screening result for drug abuse were substantially higher among medical misusers compared with medical users who used their controlled medications appropriately. The odds of drug abuse did not differ between medical users who used their controlled medications appropriately and nonusers. Most adolescents who used controlled medications took their medications appropriately. (McCabe et al., 2011) In a literature review by Torgersen and colleagues, psychopharmacotherapy did not seem to affect substance use disorder. (Torgersen, Gjervan, & Rasmussen, 2008)

It is is also important to keep in mind the risk of not medicating ADHD. Empirical data indicates that ADHD is a significant risk factor for the development of SUDs and cigarette smoking in both sexes. (Wilens et al., 2011) One would also need to include the risk of self-medication with illegal drugs due to problems that can be caused or maintained by ADHD, such as unemployment or relationship difficulties (Haverkampf, 2017a).

Psychotherapy

Psychotherapy is often very valuable in combination with medication to alleviate the impairments of ADHD. The author has described communication-focused therapy for ADHD elsewhere. (Haverkampf, 2010, 2017d, 2018b) Unfortunately, while the efficacy of stimulants in reducing ADHD symptoms for adults is well documented in meta-analyses, there is a concerning lack of meta-analysis about other treatment interventions (Moriyama, Polanczyk, Terzi, Faria, & Rohde, 2013). Apart from reports using behavioral therapies, there are also several studies on the successful use of psychodynamic techniques

Social

The social and environmental aspects are often underestimated in the case of ADHD. Pfiffner and colleagues evaluated in their study the efficacy of the Child Life and Attention Skills (CLAS) program, a behavioral psychosocial treatment integrated across home and school, for youth with attention-deficit/hyperactivity disorder-inattentive type (ADHD-I). CLAS resulted in greater improvements in teacher-reported inattention, organizational skills, social skills, and global functioning relative to both PFT and TAU at posttreatment. Parents of children in CLAS reported greater improvement in organizational skills than PFT and greater improvements on all outcomes relative to TAU at posttreatment. Differences between CLAS and TAU were maintained at follow-up for most parent-reported measures but were not significant for teacher-reported outcomes. Direct involvement of teachers and children in CLAS appears to amplify effects at school and home and underscores the importance of coordinating parent, teacher, and child treatment components for cross-setting effects on symptoms and impairment associated with ADHD-I. (Pfiffner et al., 2014)

There are also several psychological models that have been helpful in the treatment of adults. Solanto and colleagues assessed the effectiveness of a new manualized group Meta-Cognitive Therapy (MCT) for adults with ADHD that extends the principles and practices of cognitive-behavioral therapy to the development of executive self-management skills in thirty patients. General linear modeling revealed a robust significant posttreatment decline on the CAARS DSM-IV Inattentive symptom scale as well as improvement on the Brown ADD Scales. The findings indicated that participants in the MCT program showed marked improvement with respect to core ADHD symptoms of inattention, as well as executive functioning skills, suggesting that this program has promise as a treatment for meta-cognitive deficits in adults with ADHD. (Solanto, Marks, Mitchell, Wasserstein, & Kofman, 2008)

Charach and colleagues in a review of the literature between 1980 and 2010. The available evidence suggested that underlying prevalence of ADHD varies less than rates of diagnosis and treatment. Patterns of diagnosis and treatment appeared to be associated with such factors as locale, time period, and patient or provider characteristics. The strength of evidence for parent behavior training as the first-line intervention for improved behavior among preschoolers at risk for ADHD was high, while the strength of evidence for methylphenidate for improved behavior among preschoolers was low. Evidence regarding long-term outcomes following interventions for ADHD was sparse among persons of all ages, and therefore inconclusive, with one exception. Primary school–age children, mostly boys with ADHD combined type, showed improvements in symptomatic behavior maintained for 12 to 14 months using pharmacological agents, specifically methylphenidate medication management or atomoxetine. (A Charach et al., 2011)

Diagnosis of ADHD

The clinical interview is the most important pillar in the process of diagnosing ADHD. Reflecting on the interaction with the patients and observing the communication patterns used is very helpful in the diagnosis and in the treatment of ADHD.

There is also the overall problem in the case of ADHD that, while the diagnostic criteria in the diagnostic manuals are quite clear, it may sometimes be diagnosed based on the individual heuristic criteria the therapist has developed over time. Since attention deficit can occur in several disorders and is not as pathognomonic as, for example, feeling depressed or anxious for depression and anxiety, respectively, it takes more complex algorithms to formulate a diagnosis. However, there still seem to be problems, which, however, are not uncommon in psychiatric diagnosis. The accuracy itself even seems to depend on the diagnosis. For some diagnoses, especially psychotic categories, administrative data were generally predictive of true diagnosis. For others, such as anxiety disorders, the data were less satisfactory. (Davis, Sudlow, & Hotopf, 2016)

Different Types of ADHD

ADHD is to a certain degree heterogeneous which can have a n efefct of how well a particular treatment modality or even a specific treatment works. Unfortunately, there are not many clear parameters that can help to optimize treatment. However, in speical circumstances there may be information available that can be helpful in designing a treatment plan.

  1. ADHD, Predominantly Inattentive Presentation (ADHD-I)

Patients have difficulty paying attention. They are easily distracted but do not have significant symptoms of impulsivity or hyperactivity. This is sometimes called attention-deficit disorder (or ADD).

  • ADHD, Predominantly Hyperactive-Impulsive Presentation (ADHD-H)

Patients who have this type of ADHD have symptoms of hyperactivity and feel the need to move constantly. They also struggle with impulse control. Inattention is not a significant issue. This type is seen most often in very young children.

  • ADHD, Combined Presentation (ADHD-C)

Patients with this type of ADHD show significant problems with both hyperactivity/impulsivity and inattention. Children may gradually have less trouble with hyperactivity/impulsivity as they get into their teen years.

In a study by Mullins and colleagues, children with ADHD varied more in the size and direction of their time reproduction errors than control children. Those with ADHD-C demonstrated more intraindividual variability than did those with ADHD-I in the size of their errors. The data provided support for a relationship between sustained attention and time reproduction.(Mullins, Bellgrove, Gill, & Robertson, 2005)

EEG

Arns and colleagues demonstrated in their study that the EEG phenotypes as described by Johnstone, Gunkelman & Lunt are identifiable EEG patterns with good inter-rater reliability. Furthermore, it was also demonstrated that these EEG phenotypes occurred in both ADHD subjects as well as healthy control subjects. The Frontal Slow and Slowed Alpha Peak Frequency and the Low Voltage EEG phenotype discriminated ADHD subjects best from controls (however the difference was not significant). The Frontal Slow group responded to a stimulant with a clinically relevant decreased number of false negative errors on the CPT. The Frontal Slow and Slowed Alpha Peak Frequency phenotypes have different etiologies as evidenced by the treatment response to stimulants. In previous research Slowed Alpha Peak Frequency has most likely erroneously shown up as a frontal theta sub-group. Furthermore, the divergence from normal of the frequency bands pertaining to the various phenotypes is greater in the clinical group than in the controls. Investigating EEG phenotypes provides a promising new way to approach EEG data, explaining much of the variance in EEGs and thereby potentially leading to more specific prospective treatment outcomes. (ARNS, GUNKELMAN, BRETELER, & SPRONK, 2008)

Diagnosis of ADHD in Children

Attention-deficit/hyperactivity disorder (ADHD) is the most common neurobehavioral disorder of childhood and can profoundly affect the academic achievement, well-being, and social interactions of children; the American Academy of Pediatrics first published clinical recommendations for the diagnosis and evaluation of ADHD in children in 2000; recommendations for treatment followed in 2001. (American Academy of Pediatrics, 2000)

Bruchmüller and colleagues sent a case vignette to 1,000 child psychologists, psychiatrists, and social workers and asked them to give a diagnosis. The results were that in the non-ADHD vignettes, 16.7% of therapists diagnosed ADHD. In the boy version of these vignettes, therapists diagnosed ADHD around 2 times more than they did with the girl vignettes. Their study suggested that there may be an overdiagnosis of ADHD and that the patient’s gender influences diagnosis considerably. (Bruchmüller, Margraf, & Schneider, 2012) It is unclear whether the problem is that therapists do not adhere enough to diagnostic manuals and diagnostic criteria, or if there are other factors, such as issues with the diagnostic criteria or diagnostic algorithms. Another explanation could be that a significant amount of information gets lost in the interaction with the patient. Especially, if the time allowed for the meeting is very limited, there is the risk of both over- and underdiagnosis where maybe several other issues are involved, such as trauma, anxiety or depression, for example.

This guideline has been developed to advise on the treatment and management of attention deficit hyperactivity disorder (ADHD). The guideline recommendations have been developed by a multidisciplinary team of healthcare professionals, service users and carers, and guideline methodologists after careful consideration of the best available evidence. It is intended that the guideline will be useful to clinicians and service commissioners in providing and planning high-quality care for people with ADHD while also emphasizing the importance of the experience of care for them and their carers (see Appendix 1 for more details on the scope of the guideline). Although the evidence base is rapidly expanding, there are a number of major gaps; future revisions of this guideline will incorporate new scientific evidence as it develops. The guideline makes a number of research recommendations specifically to address gaps in the evidence base. In the meantime, it is hoped that the guideline will assist clinicians, people with ADHD and their carers by identifying the merits of particular treatment approaches where the evidence from research and clinical experience exists. ((UK, 2018)

While the disorder continues to be viewed as one of inattention and/or hyperactive-impulsive behavior, theories of ADHD are beginning to focus more on poor inhibition and deficient executive functioning (self-regulation) as being central to the disorder. Clinicians should be aware of these problems and the adjustments that need to be made to them when dealing with special populations that were not represented in the field trials used to develop these criteria. (Barkley, 2003)

Kadesjo and Gillberg examined patterns of comorbid/associated diagnoses and associated problems in a population sample of children with and without DSM-III-R attention-deficit hyperactivity disorder (ADHD). Half (N = 409) of a mainstream school population of Swedish 7-year-olds were clinically examined, and parents and teachers were interviewed and completed questionnaires. The children were followed up 2–4 years later. Eighty-seven per cent of children meeting full criteria for ADHD (N = 15) had one or more—and 67% at least two—comorbid diagnoses. The most common comorbidities were oppositional defiant disorder and developmental coordination disorder. Children with subthreshold ADHD (N = 42) also had very high rates of comorbid diagnoses (71% and 36%), whereas those without ADHD (N = 352) had much lower rates (17% and 3%). The rate of associated school adjustment, learning, and behavior problems at follow-up was very high in the ADHD groups. We concluded that pure ADHD is rare even in a general population sample. Thus, studies reporting on ADHD cases without comorbidity probably refer to highly atypical samples. By and large, such studies cannot inform rational clinical decisions. (Kadesjö & Gillberg, 2001)

Stability over Time

Children rarely remain in the HT classification over time; rather, they sometimes desist from ADHD but mostly shift to CT in later years.  In a study on a sample of 118 4- to 6-year-olds who met DSM-IV criteria for ADHD, Lahey and colleagues showed that the number of children who met criteria for ADHD declined over time, but most persisted. Children who met criteria for the combined subtype (CT, n = 83) met criteria for ADHD in more subsequent assessments than children in the predominantly hyperactive-impulsive subtype (HT, n = 23). Thirty-one (37%) of 83 CT children and 6 (50%) of 12 children in the predominantly inattentive subtype (IT) met criteria for a different subtype at least twice in the next 6 assessments. Children of the HT subtype were even more likely to shift to a different subtype over time, with HT children who persisted in ADHD mostly shifting to CT in later assessments. The subtypes exhibited consistently different mean levels of hyperactive-impulsive symptoms during years 2 through 8 that corresponded with their initial subtype classifications, but initial subtype differences in inattention symptoms diminished in later years. Conclusions  In younger children, the CT and IT may be stable enough to segregate groups for research, but they seem too unstable for use in the clinical assessment of individual children. (Lahey, Pelham, Loney, Lee, & Willcutt, 2005) The authors suggested a continuous hyperactivity-impulsivity rating model in the diagnosis.

Adult ADHD

The diagnosis of attention-deficit hyperactivity disorder (ADHD) in adults is a complex procedure which should include retrospective assessment of childhood ADHD symptoms either by patient recall or third party information, diagnostic criteria according to DSM-IV, current adult ADHD psychopathology including symptom severity and pervasiveness, functional impairment, quality of life and comorbidity. The author has discussed the diagnosis of adult ADHD in greater depth elsewhere. (Haverkampf, 2018c)

A valid and reliable assessment should be comprehensive and include the use of symptom rating scales, a clinical interview, neuropsychological testing, and the corroboration of patient reports. Specific diagnostic criteria that are more sensitive and specific to adult functioning are needed. In treatment, pharmacological interventions have the most empirical support, with the stimulants methylphenidate and amphetamine and the antidepressants desipramine and atomoxetine having the highest efficacy rates. Scientific research on psychosocial treatments is lacking, with preliminary evidence supporting the combination of cognitive behavioral therapy and medication. (Davidson, 2008)

The Wender-Utah Rating Scale (WURS) and the Childhood Symptoms Scale by Barkley and Murphy try to make a retrospective assessment of childhood ADHD symptoms. The Connors Adult ADHD Rating Scales (CAARS), the Current Symptoms Scales by Barkley and Murphy (CSS), the Adult Self Report Scale (ASRS) by Adler et al. and Kessler et al. or the Attention Deficit Hyperactivity Disorder—Self Report Scale (ADHD-SR by Rösler et al.) are self-report rating scales focusing mainly on the DSM-IV criteria. The CAARS and the CSS have other report forms too. The Brown ADD Rating Scale (Brown ADD-RS) and the Attention Deficit Hyperactivity Disorder-Other Report Scale (ADHD-OR by Rösler et al.) are instruments for use by clinicians or significant others. Both self-rating scales and observer report scales quantify the ADHD symptoms by use of a Likert scale mostly ranging from 0 to 3. This makes the instruments useful to follow the course of the disease quantitatively. Comprehensive diagnostic interviews not only evaluate diagnostic criteria, but also assess different psychopathological syndrome scores, functional disability measures, indices of pervasiveness and information about comorbid disorders. The most comprehensive procedures are the Brown ADD Diagnostic Form and the Adult Interview (AI) by Barkley and Murphy. An instrument of particular interest is the Wender Reimherr Interview (WRI) which follows a diagnostic algorithm different from DSM-IV. The interview contains only items delineated from adult psychopathology and not derived from symptoms originally designed for use in children. (Rösler et al., 2006)

Baseline assessment

Before starting medication for ADHD, people with ADHD should have a full assessment, possibly through their GP, which should include also:

  • a review to confirm they continue to meet the criteria for ADHD and need treatment
  • a review of mental health and social circumstances, including:
    • presence of coexisting mental health and neurodevelopmental conditions
    • current educational or employment circumstances
    • risk assessment for substance misuse and drug diversion

care needs There should also be a review of physical health, including also:

  • a medical history, taking into account conditions that may be contraindications for specific medicines
  • current medication
  • height and weight (measured and recorded against the normal range for age, height and sex)
  • baseline pulse and blood pressure (measured with an appropriately sized cuff and compared with the normal range for age)
  • a cardiovascular assessment
  • an electrocardiogram (ECG) if the treatment may affect the QT interval.

One should refer for a cardiology opinion before starting medication for ADHD in cases including also:

  • history of congenital heart disease or previous cardiac surgery
  • history of sudden death in a first-degree relative under 40 years suggesting a cardiac disease
  • shortness of breath on exertion compared with peers
  • fainting on exertion or in response to fright or noise
  • palpitations that are rapid, regular and start and stop suddenly (fleeting occasional bumps are usually ectopic and do not need investigation)
  • chest pain suggesting cardiac origin
  • signs of heart failure
  • a murmur heard on cardiac examination
  • blood pressure that is classified as hypertensive for adults

Medication

Stimulants are the classic medication which is used in the treatment of ADHD. If it is used correctly and for the correct indication, it can help patients have a significant improvement in their quality of life.

However, treatment success in the individual and treatment success on average in a large group can diverge significantly. A clinician’s skills in using the medication can play a significant role. In a large Canadian study, Currie and colleagues found little evidence of improvement in either the medium or the long run. Our results are silent on the effects on optimal use of medication for ADHD, but suggest that expanding medication in a community setting had little positive benefit. (Currie, Stabile, & Jones, 2014)

Long-Term Effect

While methylphenidate (MPH) often ameliorates attention-deficit/hyperactivity disorder (ADHD) behavioral dysfunction, it there is little evidence that methylphenidate (MPH) medication leads to long-term-term academic gains in ADHD. In a study by Hale and colleagues, children aged 6 to 16 with ADHD inattentive type (IT; n = 19) and combined type (n = 33)/hyperactive-impulsive type (n = 4) (CT) participated in double-blind placebo-controlled MPH trials with baseline and randomized placebo, low MPH dose, and high MPH dose conditions. Robust cognitive and behavioral MPH response was achieved for children with significant baseline executive working memory (EWM) / self-regulation (SR) impairment, yet response was poor for those with adequate EWM/SR baseline performance. Even for strong MPH responders, the best dose for neuropsychological functioning was typically lower than the best dose for behavior. (Hale et al., 2011)

There is overall little evidence to suggest that the type of treatment in the present affects the severity of ADHD in the future. A study by Molina and colleagues has shown that or intensity of 14 months of treatment for ADHD in childhood (at age 7.0–9.9 years) does not predict functioning 6 to 8 years later. Rather, early ADHD symptom trajectory regardless of treatment type is prognostic. This finding implies that children with behavioral and sociodemographic advantage, with the best response to any treatment, will have the best long-term prognosis. As a group, however, despite initial symptom improvement during treatment that is largely maintained after treatment, children with combined-type ADHD exhibit significant impairment in adolescence. (Molina et al., 2009)

Anxiety

Compared to parent and teacher reports of anxiety, child reported comorbid anxiety shows foremost the largest associations with the neurocognitive dysfunctions observed in children with ADHD. (Bloemsma et al., 2013) In another study, overall rates of individual anxiety disorders, as well as age of onset and severity of illness were not significantly different in the presence of comorbid ADHD. School functioning in children with anxiety disorders was negatively impacted by the presence of comorbid ADHD. Frequency of mental health treatment in children with anxiety disorders was significantly increased in the presence of comorbid ADHD. ADHD had a limited impact on the manifestation of anxiety disorder in children suggesting that ADHD and anxiety disorders are independently expressed. (Hammerness et al., 2010)

Tics

Findings in a study by Gadow and Nolan suggest that the co-occurrence of diagnosed ADHD, chronic multiple tick disorder and anxiety represents a particularly troublesome clinical phenotype, at least in the home setting. Comorbid anxiety disorder was not associated with a less favorable response to immediate release methylphenidate in children with ADHD and chronic multiple disorder, but replication with larger samples is warranted before firm conclusions can be drawn about potential group differences. (Gadow & Nolan, 2011)

Emotional Lability

Emotional lability, or sudden strong shifts in emotion, commonly occurs in youth with attention-deficit/hyperactivity disorder. Although these symptoms are impairing and disruptive, relatively little research has addressed their treatment, likely due to the difficulty of reliable and valid assessment. Promising signals for symptom improvement have come from recent studies using stimulants in adults, children and adolescents. Similarly, neuroimaging studies have begun to identify neurobiological mechanisms underlying stimulants’ impact on emotion regulation capacities. (Posner, Kass, & Hulvershorn, 2014)

Smoking

Individuals suffering from ADHD have a significantly higher risk of cigarette smoking. Stimulant treatment of ADHD may reduce smoking risk. Schoenfelder and colleagues examined the relationship between stimulant treatment of ADHD and cigarette smoking in a meta-analysis. The study revealed a significant association between stimulant treatment and lower smoking rates. the effect was larger in samples with more severe psychopathology. Implications for further research, treatment of ADHD, and smoking prevention are discussed. (Schoenfelder, Faraone, & Kollins, 2014)

Medication Groups

Common stimulants include:

Methylphenidate (Methylphenidate®, Concerta®), a norepinephrine-dopamine reuptake inhibitor

Dextroamphetamine (Dexedrine®), the dextro-enantiomer of amphetamine

Dexmethylphenidate (Focalin®), the active dextro-enantiomer of methylphenidate

Lisdexamfetamine (Vyvanse®), a prodrug containing the dextro-enantiomer of amphetamine

There are also mixed amphetamine salts, such as Adderall®, a 3:1 mix of dextro/levo-enantiomers of amphetamine.

Atomoxetine (Strattera ®) is a norepinephrine (noradrenaline) reuptake inhibitor which is approved for the treatment of attention deficit hyperactivity disorder (ADHD).

There are also some antidepressants that have mild stimulant effects. Further information can be found in the author’s book An Overview of Psychiatric Medication (Haverkampf, 2018a)

Methylphenidate

Methylphenidate is indicated as an integral part of a total treatment program which typically includes other remedial measures (psychological, educational, social) for a stabilizing effect in children with a behavioral syndrome characterized by the following group of developmentally inappropriate symptoms:

  • moderate-to-severe distractibility
  • short attention span
  • hyperactivity
  • emotional lability, an
  • impulsivity.

The diagnosis of this syndrome should not be made with finality when these symptoms are only of comparatively recent origin. Non-localizing neurological signs, learning disability, and abnormal EEG may or may not be present, and a diagnosis of central nervous system dysfunction may or may not be warranted.

Atomoxetine

In pediatric patients with ADHD and comorbid symptoms of depression or anxiety, atomoxetine monotherapy appears to be effective for treating ADHD. (Kratochvil et al., 2005) In the study by Kratochvil and colleagues, anxiety and depressive symptoms also improved, but the absence of a placebo-only arm did not allow the investigators to conclude that these effects are specifically the result of treatment with atomoxetine. Combined atomoxetine and fluoxetine therapy were, however, well tolerated.

Extended Release

When prescribing stimulants for ADHD, one needs to consider modified-release once-daily preparations for the following reasons:

  • convenience
  • improving adherence
  • reducing stigma (because there is no need to take medication at school or in the workplace)
  • reducing problems of storing and administering controlled drugs at school
  • the risk of stimulant misuse and diversion with immediate-release preparations
  • their pharmacokinetic profiles.

Immediate-release preparations may be suitable if more flexible dosing regimens are needed, or during initial titration to determine correct dosing levels.

Sex

ADHD was once thought of as a predominantly male disorder. While this may be true for ADHD in childhood, extant research suggests that the number of women with ADHD may be nearly equal to that of men with the disorder (Faraone et al., 2000). There is accumulating research which clearly indicates subtle but important sex differences exist in the symptom profile, neuropathology and clinical course of ADHD. Compared to males with ADHD, females with ADHD are more prone to have difficulties with inattentive symptoms than hyperactive and impulsive symptoms, and females often receive a diagnosis of ADHD significantly later than do males (Gaub & Carlson, 1997; Gershon, 2002a, 2002b). Emerging evidence suggests differences exist in the neuropathology of ADHD, and there are hormonal factors which may play an important role in understanding ADHD in females. Although research demonstrates females with ADHD differ from males in important ways, little research exists that evaluates differences in treatment response. Given the subtle but important differences in presentation and developmental course of ADHD, it is essential that both clinical practice and research be informed by awareness of these differences in order to better identify and promote improved quality of care to girls and women with ADHD. (Nussbaum, 2012)

Medication for Children

Drug treatment is not indicated for all children with this syndrome. Stimulants are not intended for use in the child who exhibits symptoms secondary to environmental factors and/or primary psychiatric disorders, including psychosis. Appropriate educational placement is essential and psychosocial intervention is generally necessary. When remedial measures alone are insufficient, the decision to prescribe stimulant medication will depend upon the physician’s assessment of the chronicity and severity of the child’s symptoms.

Methylphenidate should not be used in children under 6 years, since safety and efficacy in this age group have not been established.

Consider offering

  1. Methylphenidate as the first line pharmacological treatment,
  2. Lisdexamfetamine for those who have had a 6‑week trial of methylphenidate at an adequate dose and not derived enough benefit in terms of reduced ADHD symptoms and associated impairment,
  3. Dexamfetamine for those whose ADHD symptoms are responding to lisdexamfetamine but who cannot tolerate the longer effect profile,
  4. Atomoxetine or Guanfacine if:
  5. they cannot tolerate methylphenidate or lisdexamfetamine or
  6. their symptoms have not responded to separate 6‑week trials of lisdexamfetamine and methylphenidate, having considered alternative preparations and adequate doses.

Medication for Adults

Consider offering

  1. Lisdexamfetamine or Methylphenidate as first-line pharmacological treatment,
  2. Lisdexamfetamine for those who have had a 6‑week trial of methylphenidate at an adequate dose but have not derived enough benefit in terms of reduced ADHD symptoms and associated impairment,

Methylphenidate for those who have had a 6‑week trial of lisdexamfetamine at an adequate dose but have not derived enough benefit in terms of reduced ADHD symptoms and associated impairment,

  • Dexamfetamine for those whose ADHD symptoms are responding to lisdexamfetamine but who cannot tolerate the longer effect profile,
  • Atomoxetine if:
  • they cannot tolerate lisdexamfetamine or methylphenidate or
  • their symptoms have not responded to separate 6‑week trials of lisdexamfetamine and methylphenidate, having considered alternative preparations and adequate doses.

Do not offer any of the following medication for ADHD without advice from a tertiary ADHD service:

  • guanfacine for adults
  • clonidine for children with ADHD and sleep disturbance, rages or tics
  • atypical antipsychotics in addition to stimulants for people with ADHD and coexisting pervasive aggression, rages or irritability
  • other medication than that listed above.

ADHD Type and Medication

Subtype

In a study by Barbaresi and colleagues, there was no association between DSM-IV subtype and likelihood of a favorable response or of side effects. Dextroamphetamine and methylphenidate were equally likely to be associated with a favorable response, but dextroamphetamine was more likely to be associated with side effects. (Barbaresi et al., 2014)

Sleep

Differences in sleep problems seem to be a function of ADHD subtype, comorbidity, and medication. In a study by Mayes and colleagues, children with ADHD-I alone had the fewest sleep problems and did not differ from controls. Children with ADHD-C had more sleep problems than controls and children with ADHD-I. Comorbid anxiety/depression increased sleep problems, whereas ODD did not. Daytime sleepiness was greatest in ADHD-I and was associated with sleeping more (not less) than normal. Medicated children had greater difficulty falling asleep than unmedicated children. (Mayes et al., 2008) Linear regression analyses by Corkum and colleagues showed that (1) dyssomnias were related to confounding factors (i.e., comorbid oppositional defiant disorder and stimulant medication) rather than ADHD; (2) parasomnias were similar in clinical and nonclinical children; and (3) the DSM-IV combined subtype of ADHD was associated with sleep-related involuntary movements. However, sleep-related involuntary movements were more highly associated with separation anxiety. (CORKUM, MOLDOFSKY, HOGG-JOHNSON, HUMPHRIES, & TANNOCK, 1999)

Anxiety

ADHD co-occurring with internalizing disorders (principally parent-reported anxiety disorders) absent any concurrent disruptive disorder, ADHD co-occurring with ODD/CD (oppositional defiant disorder / conduct disorder) but no anxiety (ADHD + ODD/CD), and ADHD with both anxiety and ODD/CD (ADHD + ANX + ODD/CD) may be sufficiently distinct to warrant classification as ADHD subtypes separate from ADHD without this phenomenology. Jensen and colleagues found evidence of main effects of internalizing and externalizing comorbid disorders. Moderate evidence of interactions of parent-reported anxiety and ODD/CD status were noted on response to treatment, indicating that children with ADHD and anxiety disorders (but no ODD/CD) were likely to respond equally well to behavioral and medication treatments. Children with ADHD-only or ADHD with ODD/CD (but without anxiety disorders) responded best to medication treatments (with or without behavioral treatments), while children with multiple comorbid disorders (anxiety and ODD/CD) responded optimally to combined (medication and behavioral) treatments. (JENSEN et al., 2001)

Genotype

Stein and colleagues studied the relationship between DAT1 3′-untranslated region (3′-UTR) variable number tandem repeats (VNTR) genotypes and dose response to MPH. Children were genotyped for the DAT1 VNTR and evaluated on placebo and three dosage levels of OROS® MPH. Children who were homozygous for the less common, 9-repeat DAT1 3′-UTR genotype displayed a distinct dose–response curve from that of the other genotype groups, with an absence of typical linear improvement when the dose was increased from 18 mg to 36 and 54 mg. (Stein et al., 2005)

In a study by Epstein and colleagues, youths and adults with ADHD showed attenuated activity in fronto‐striatal regions. In addition, adults with ADHD appeared to activate non‐fronto‐striatal regions more than normals. A stimulant medication trial showed that among youths, stimulant medication increased activation in fronto‐striatal and cerebellar regions. In adults with ADHD, increases in activation were observed in the striatum and cerebellum, but not in prefrontal regions. Conclusions: This study extends findings of fronto‐striatal dysfunction to adults with ADHD and highlights the importance of frontostriatal and frontocerebellar circuitry in this disorder, providing evidence of an endophenotype for examining the genetics of ADHD. (Epstein et al., 2007)

Some medication which is licensed for use in childhood may have to be continued off license in adults if there are no better alternatives and the patient has benefitted from it significantly. Psychotherapy may have to be adjusted to external and internal changes that are part of growing up.

Dose Titration

The dose should be titrated against symptoms and adverse effects in line with guidelines until optimized. This means reduced symptoms, positive behavior changes, improvements in education, employment and relationships, with tolerable adverse effects.

During the titration phase, ADHD symptoms, impairment and adverse effects should be recorded at baseline and at each dose change on standard scales, in children also by parents and teachers, and progress reviewed regularly.

Dose titration should be slower and monitoring more frequent if another condition is present, such as

  • neurodevelopmental disorders (for example, autism spectrum disorder, tic disorders, learning disability)
  • mental health conditions (for example, anxiety disorders [including obsessive–compulsive disorder], schizophrenia or bipolar disorder, depression, personality disorder, eating disorder, post-traumatic stress disorder, substance misuse)
  • physical health conditions (for example, cardiac disease, epilepsy or acquired brain injury).
  • Think about using immediate- and modified-release preparations of stimulants to optimize effect (for example, a modified-release preparation of methylphenidate in the morning and an immediate-release preparation of methylphenidate at another time of the day to extend the duration of effect).
  • Addictions

Abuse

One needs to be particularly careful about prescribing stimulants for ADHD if there is a risk of addictions and/or diversion for cognitive enhancement or appetite suppression. One should not offer immediate-release stimulants or modified-release stimulants that can be easily injected or insufflated, if this may be an issue.

Coexisting Conditions

In ADHD the comorbidity for other conditions is quite high, which can play a significant role in treatment. The same medication choices can be offered to people with ADHD and anxiety disorder, tic disorder or autism spectrum disorder as other people with ADHD.

Studies indicate that co-occurrence of clinically significant ADHD and autistic symptoms is common, and that some genes may influence both disorders. However, the DSM basically does not allow for the concurrent diagnosis of ADHD and autism.

Children with the combination of ADHD and motor coordination problems are particularly likely to suffer from an autism spectrum disorder. These co-occurrences of symptoms are important since children with ASD in addition to ADHD symptoms may respond poorly to standard ADHD treatments or have increased side effects. Such children may benefit from additional classes of pharmacologic agents, such as α-agonists, selective serotonin reuptake inhibitors and neuroleptics. They may also benefit from social skills therapy, individual and family psychotherapy, behavioral therapy and other nonpharmacologic interventions. (Reiersen & Todd, 2008)

Caution

Stimulants need to be used with care and caution, and it is important to have as much information about the medical and psychological state of the patient as possible. The following list just gives some examples, but is by no means comprehensive or factually up to date:

  • Some contraindications for methylphenidate are marked anxiety, tension, and agitation are contraindications to Methylphenidate, since the drug may aggravate these symptoms. Methylphenidate is contraindicated also in patients known to be hypersensitive to the drug, in patients with glaucoma, and in patients with motor tics or with a family history or diagnosis of Tourette’s syndrome.
  • Methylphenidate is contraindicated during treatment with monoamine oxidase inhibitors, and within a minimum of 14 days following discontinuation of a monoamine oxidase inhibitor (hypertensive crises may result).
  • Because of possible effects on blood pressure, methylphenidate should be used cautiously with pressor agents.
  • Methylphenidate may decrease the effectiveness of drugs used to treat hypertension. Human pharmacologic studies have shown that racemic methylphenidate may inhibit the metabolism of coumarin anticoagulants, anticonvulsants (e.g., phenobarbital, phenytoin, primidone), and tricyclic drugs (e.g., imipramine, clomipramine, desipramine). Downward dose adjustments of these drugs may be required when given concomitantly with methylphenidate. It may be necessary to adjust the dosage and monitor plasma drug concentration (or, in case of coumarin, coagulation times), when initiating or discontinuing methylphenidate.

Stimulant medications cause a modest increase in average blood pressure (about 2-4 mmHg) and average heart rate (about 3-6 bpm), and individuals may have larger increases. While the mean changes alone would not be expected to have short-term consequences, all patients should be monitored for larger changes in heart rate and blood pressure. Caution is indicated in treating patients whose underlying medical conditions might be compromised by increases in blood pressure or heart rate, such as those with preexisting hypertension, heart failure, recent myocardial infarction, or ventricular arrhythmia.

Psychosis

Psychosis is an important, unpredictable side effect of stimulant medication. In the case of acute psychotic or manic episodes, ADHD medication should be stopped because it can exacerbate or even trigger them under certain conditions. Restarting the ADHD medication after the episode has resolved can be considered, taking into account the individual circumstances, risks and benefits of the ADHD medication. The potential for psychotic side effects are well known, but usually reported as rare. Long acting preparations appear to be a contributory factor to the development of psychotic side effects, while symptoms resolve with discontinuation of treatment. (Shibib & Chalhoub, 2009)

Administration of stimulants may exacerbate symptoms of behavior disturbance and thought disorder in patients with a preexisting psychotic disorder.

Mosholder and colleagues analyzed data from 49 randomized, controlled clinical trials in the pediatric development programs for these products. A total of 11 psychosis/mania adverse events occurred during 743 person-years of double-blind treatment with these drugs, and no comparable adverse events occurred in a total of 420 person-years of placebo exposure in the same trials. The rate per 100 person-years in the pooled active drug group was 1.48. The analysis of spontaneous postmarketing reports yielded >800 reports of adverse events related to psychosis or mania. In about 90% of the cases, there was no reported history of a similar psychiatric condition. Hallucinations involving visual and/or tactile sensations of insects, snakes, or worms were common in cases in children. (Mosholder, Gelperin, Hammad, Phelan, & Johann-Liang, 2009)

Bipolar Disorder

ADHD in combination with bipolar disorder may be associated with more severe symptoms and worse outcomes of both conditions. Prior to initiating treatment with a stimulant, patients with comorbid depressive symptoms should be adequately screened to determine if they are at risk for bipolar disorder; such screening should include a detailed psychiatric history, including a family history of suicide, bipolar disorder, and depression. The frequent coexistence with alcohol and substance abuse may further complicate treatment management. A hierarchical approach is desirable, with mood stabilization preceding the treatment of ADHD symptoms.

Atomoxetine may be effective in the treatment of ADHD symptoms in patients with bipolar disorder, with a modestly increased risk of (hypo)manic switches and destabilization of the mood disorder when utilized in association with mood stabilizers. (Perugi & Vannucchi, 2015)

Aggression

Aggressive behavior or hostility is often observed in children and adolescents with ADHD and has been reported in clinical trials and the post-marketing experience of some medications indicated for the treatment of ADHD. Patients beginning treatment for ADHD should be monitored for the appearance of or worsening of aggressive behavior or hostility.

Seizures

There is some clinical evidence that stimulants may lower the convulsive threshold in patients with prior history of seizures, in patients with prior EEG abnormalities in absence of seizures, and, very rarely, in patients without a history of seizures and no prior EEG evidence of seizures. In the presence of seizures, the drug should be discontinued.

Priapism

Prolonged and painful erections, sometimes requiring surgical intervention, have been reported with methylphenidate products in both pediatric and adult patients. Priapism usually developed after some time on the drug, often subsequent to an increase in dose. Priapism has also appeared during a period of drug withdrawal (drug holidays or during discontinuation). Patients who develop abnormally sustained or frequent and painful erections should seek immediate medical attention.

Peripheral Vasculopathy, Including Raynaud’s Phenomenon

Stimulants are associated with peripheral vasculopathy, including Raynaud’s phenomenon. Signs and symptoms are usually intermittent and mild, although less frequently permanent tissue damage can occur. Signs and symptoms often improve after reduction in dose or discontinuation of the drug. Careful observation for digital changes is necessary during treatment with ADHD stimulants.

Visual Disturbance

Difficulties with accommodation and blurring of vision have been reported with stimulant treatment. However, in a study by Martin and colleagues in children, visual acuity increased significantly in the ADHD group after treatment with a stimulant. Also, more ADHD subjects had subnormal visual field results without stimulants, compared with controls, but with stimulants the difference was no longer significant. (Martin, Aring, Landgren, Hellström, & Andersson Grönlund, 2008)

Drug Dependence

Methylphenidate should be given cautiously to patients with a history of drug dependence or alcoholism. Chronic abusive use can lead to marked tolerance and psychological dependence with varying degrees of abnormal behavior. Psychotic episodes can occur, especially with parenteral abuse. Careful supervision is required during withdrawal from abusive use, since severe depression or another underlying condition may surface.

Pregnancy

The number of pregnancies exposed to ADHD medication has increased similarly to the increase in use of ADHD medication among women of childbearing age. Use of ADHD medication in pregnancy was associated with different indicators of maternal disadvantage and with increased risk of induced abortion and miscarriage.

Haervig and colleagues studied data from the Danish national health registries to identify all recorded pregnancies from 1999 to 2010. From 2003 to the first quarter of 2010, use of ADHD medication during pregnancy increased from 5 to 533 per 100 000 person‐years. Compared with unexposed, women who used ADHD medication during pregnancy were more often younger, single, lower educated, received social security benefits, and used other psychopharmaca. Exposed pregnancies were more likely to result in induced abortions on maternal request, induced abortions on special indication, and miscarriage compared with unexposed pregnancies. (Haervig, Mortensen, Hansen, & Strandberg-Larsen, 2014)

However, ADHD treatment could put both mother and baby at risk. This has to be balanced against the possible risks to the baby of continuing treatment. Although the data remain inadequate, the risk of the latter appears to be quite small overall, at least for methylphenidate, (Besag, 2014) while there is evidence, that the rates of fetal loss both through abortion and through miscarriage are increased with methylphenidate. Discussions about ADHD treatment with women of childbearing age should be balanced, open and honest, acknowledging the lack of information on the possible risks to the offspring of continuing treatment, while also drawing attention to the possible risks to both mother and child of discontinuing treatment. (Besag, 2014)

Monitoring

Medication is an important element of therapeutic strategies for ADHD. While medications for ADHD are generally well‐tolerated, there are common, although less severe, as well as rare but severe adverse events that can occur during treatment with ADHD drugs. Cortese and colleagues reviewed the literature. The review covers monitoring and management strategies of loss of appetite and growth delay, cardiovascular risks, sleep disturbance, tics, substance misuse/abuse, seizures, suicidal thoughts/behaviors and psychotic symptoms. Most AEs during treatment with drugs for ADHD are manageable and most of the times it is not necessary to stop medication, so that patients with ADHD may continue to benefit from the effectiveness of pharmacological treatment. (Cortese et al., 2013)

Behavior

Monitor the behavioral response to medication, and if behavior worsens adjust medication and review the diagnosis.

Height

Growth should be monitored during treatment with stimulants, and patients who are not growing or gaining height or weight as expected may need to have their treatment interrupted.

Research on the issue of growth suppression is lacking, mostly owing to insufficient follow-up on patients’ final heights. However, it has been argued that the rate of height loss seems relatively small and is likely reversible with withdrawal of treatment. (Goldman, 2010)

Weight

Some young adults are misusing prescription stimulants for weight loss. This behavior is associated with other problematic weight loss strategies. Interventions designed to reduce problematic eating behaviors in young adults may wish to assess the misuse of prescription stimulants. (Jeffers, Benotsch, & Koester, 2013) In the study by Jeffers and colleagues, undergraduates who reported using prescription stimulants for weight loss had greater appearance-related motivations for weight loss, greater emotion and stress-related eating, a more compromised appraisal of their ability to cope, lower self-esteem, and were more likely to report engaging in other unhealthy weight loss and eating disordered behaviors.

Weight should be measured at least once at 3 and 6 months after starting treatment in children over 10 years and young people, and at least once every 6 months thereafter. In adults, weight should be measured at least once every 6 months. Monitoring the BMI of adults is in many cases important.

If a child or young person’s height over time is significantly affected by medication (that is, they have not met the height expected for their age), stopping the medication or at least a break in treatment over school holidays to allow ‘catch‑up’ growth may be considered.

Cardiovascular System

Stimulants agents can increase heart rate and blood pressure and cause other cardiovascular symptoms. Since increased BP and HR in general are considered risk factors for cardiovascular morbidity and mortality, heart rate and blood pressure should be monitored closely. Patients who are being considered for treatment with stimulant medications should have a careful history (including assessment for a family history of sudden death or ventricular arrhythmia) and physical exam to assess for the presence of cardiac disease and should receive further cardiac evaluation if findings suggest such disease (e.g., electrocardiogram and echocardiogram).

Statistically significant pre–post increases of SBP, DBP and HR were associated with amphetamine and atomoxetine treatment in children and adolescents with ADHD, while methamphetamine treatment had a statistically significant effect only on SBP in these patients. These increases may be clinically significant for a significant minority of individuals that experience larger increases. (Hennissen et al., 2017)

Among young and middle-aged adults, current or new use of ADHD medications, compared with nonuse or remote use, does not seem associated with an increased risk of serious cardiovascular events. Habel and colleagues examined whether current use of medications prescribed primarily to treat ADHD is associated with increased risk of serious cardiovascular events in young and middle-aged adults. Participants were adults aged 25 through 64 years with dispensed prescriptions for methylphenidate, amphetamine, or atomoxetine at baseline. The sample size was 443 198 users and nonusers. The multivariable-adjusted rate ratio (RR) of serious cardiovascular events for current use vs nonuse of ADHD medications was 0.83. Among new users of ADHD medications, the adjusted RR was 0.77. The adjusted RR for current use vs remote use was 1.03; for new use vs remote use, the adjusted RR was 1.02. (Habel et al., 2011) In the study including data about 1,200,438 children and young adults between the ages of 2 and 24 years and 2,579,104 person-years of follow-up, including 373,667 person-years of current use of ADHD drugs, Habel et al showed no evidence that current use of an ADHD drug was associated with an increased risk of serious cardiovascular events, although the upper limit of the 95% confidence interval indicated that a doubling of the risk could not be ruled out. (Habel et al., 2011)

Children and Adolescents

Sudden death has been reported in association with CNS stimulant treatment at usual doses in children and adolescents with structural cardiac abnormalities or other serious heart problems. Although some serious heart problems alone carry an increased risk of sudden death, stimulant products generally should not be used in children or adolescents with known serious structural cardiac abnormalities, cardiomyopathy, serious heart rhythm abnormalities, or other serious cardiac problems that may place them at increased vulnerability to the sympathomimetic effects of a stimulant drug.

Adults

Sudden death, stroke, and myocardial infarction have been reported in adults taking stimulant drugs at usual doses for ADHD. Although the role of stimulants in these adult cases is also unknown, adults have a greater likelihood than children of having serious structural cardiac abnormalities, cardiomyopathy, serious heart rhythm abnormalities, coronary artery disease, or other serious cardiac problems. Adults with such abnormalities should also generally not be treated with stimulant drugs.

Tics

If a person taking stimulants develops tics, one should consider whether the tics are related to the stimulant (tics naturally wax and wane) and the impairment associated with the tics outweighs the benefits of ADHD treatment. If tics are stimulant related, one may need to reduce the dose or switch the medication.

Sexual Dysfunction

Erectile and ejaculatory dysfunction are potential adverse effects of atomoxetine.

Seizures

If a person with ADHD develops new seizures or a worsening of existing seizures, their ADHD medication needs to be reviewed and any medication that might be contributing to the seizures stopped.

Patients with ADHD seem to be at a higher risk of seizures. However, ADHD medication was associated with lower risk of seizures within individuals while they were dispensed medication, which is not consistent with the hypothesis that ADHD medication increases risk of seizures. Wiggs and colleagues followed a sample of 801,838 patients with ADHD medication. Patients with ADHD were at higher odds for any seizure compared with non-ADHD controls (odds ratio [OR] = 2.33). In adjusted within-individual comparisons, ADHD medication was associated with lower odds of seizures among patients with (OR = 0.71) and without (OR = 0.71) prior seizures. Long-term within-individual comparisons suggested no evidence of an association between medication use and seizures among individuals with (OR = 0.87) and without (OR = 1.01) a seizure history. (Wiggs et al., 2018) Koneski and colleagues evaluated 24 patients ranging from 7 to 16 years of age who took MPH for 6 months. Inclusion criteria were at least two epileptic seizures in the previous 6 months and a diagnosis of ADHD based on DSM-IV criteria. There was an overall improvement in ADHD symptoms in 70.8% of patients, and there was no increase in frequency of epileptic seizures in 22 patients (91.6%). (Koneski, Casella, Agertt, & Ferreira, 2011)

Sleep

Changes in sleep pattern should always be asked for, the timing and dose of the medication adjusted. Immediate release methamphetamine should usually not be administered after 4pm.

Compliance

Experiences of adverse effects are a frequent explanation for discontinuation among youth. Despite impaired functioning during adolescence, many discontinue medication treatment. Beliefs and attitudes may differ widely. Some families understand that ADHD is a neurobiological condition and accept that medication is indicated, for others, such treatment is unacceptable. Converging evidence describes negative perceptions of the burden associated with medication use as well as concerns about potential short- and long-term adverse effects. Ways to improve shared decision making among practitioners, parents and youth, and to monitor effectiveness, safety and new onset of concurrent difficulties are likely to optimize outcomes. (Alice Charach & Fernandez, 2013).

Psychotherapy

Psychotherapy should always be part of a comprehensive treatment plan for ADHD. Communication-Focused Therapy® (CFT) as it was developed by the author focuses on internal and external communication patterns which has shown to be helpful in ADHD. (Haverkampf, 2017b, 2017d, 2017c)


Dr Jonathan Haverkampf, M.D. MLA (Harvard) LL.M. trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. The author can be reached by email at jonathanhaverkampf@gmail.com or on the websites www.jonathanhaverkampf.com and www.jonathanhaverkampf.ie.

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Haverkampf, C. J. (2010). Communication and Therapy (3rd ed.). Dublin: Psychiatry Psychotherapy Communication Publishing Ltd.

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Haverkampf, C. J. (2018b). Communication-Focused Therapy (CFT) – Specific Diagnoses (Vol II) (2nd ed.). Dublin: Psychiatry Psychotherapy Communication Publishing Ltd.

Haverkampf, C. J. (2018c). The Diagnosis of ADHD in Adults.

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Mayes, S. D., Calhoun, S. L., Bixler, E. O., Vgontzas, A. N., Mahr, F., Hillwig-Garcia, J., … Parvin, M. (2008). ADHD Subtypes and Comorbid Anxiety, Depression, and Oppositional-Defiant Disorder: Differences in Sleep Problems. Journal of Pediatric Psychology, 34(3), 328–337. https://doi.org/10.1093/jpepsy/jsn083

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This article is solely a basis for academic discussion and no medical advice can be given in this article, nor should anything herein be construed as advice. Always consult a professional if you believe you might suffer from a physical or mental health condition. Neither author nor publisher can assume any responsibility for using the information herein.

Trademarks belong to their respective owners. Communication-Focused Therapy, the CFT logo with waves and leaves, Dr Jonathan Haverkampf, Journal of Psychiatry Psychotherapy and Communication, and Ask Dr Jonathan are registered trademarks.

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Psychotherapeutic Technique A Brief Overview (6)

When patients come to see a therapist, they often have a long list of things that do not work for them in their lives. It is easy to overlook that one of the hardest steps towards health has been taken, stepping into the office of a therapist. Psychotherapeutic Technique is then largely about helping the patient find his or her path and to have the courage to follow it. Empathy, common sense, and a good dose of optimism are helpful in this line of work, as is thinking about what is happening and has happened in the life of the patient, how they relate to themselves and the world, and that in the end everything should make sense to the head and to the heart.

Keywords: psychotherapy, psychotherapeutic technique

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Psychotherapeutic Technique A Brief Overview (6) Ch Jonathan Haverkampf

Depression and Medication (3)

Depression is the medical condition with one of the highest prevalence rates, but also one of the costliest ones in terms of human suffering, missed work hours, higher mortality and the higher incidence of physical illnesses. First-line treatment is usually a combination of medication and psychotherapy. In milder cases, psychotherapy alone may be sufficient, while in very severe cases, psychotherapy may not be possible. Antidepressants from a number of functional families are available, with the serotonin reuptake inhibitors (SSRIs) being the mostly used ones, followed by the serotonin and norepinephrine reuptake inhibitors (SNRIs) and antidepressants from other groups. In cases of treatment resistance, an increase in the dose, or if this is not possible a switch to a different group of antidepressants may be necessary. Rarely is a combination therapy needed. Selection of an antidepressant depends on the specific symptoms, such as insomnia or reduced activity, the patient’s current situation, including pregnancy or a requirement for alertness on the job, and many other factors, including past episodes of depression and the medication history.

Keywords: depression, medication, psychiatry

 

 

For the article click here:

Depression and Medication (3) Ch Jonathan Haverkampf

 


Dr Jonathan Haverkampf, M.D. MLA (Harvard) LL.M. trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. He also has advanced degrees in management and law. The author can be reached by email at jonathanhaverkampf@gmail.com or on the website www.jonathanhaverkampf.ie.

This article is solely a basis for academic discussion and no medical advice can be given in this article, nor should anything herein be construed as advice. Always consult a professional if you believe you might suffer from a physical or mental health condition. Neither author nor publisher can assume any responsibility for using the information herein.

Trademarks belong to their respective owners. No checks have been made. 

© 2012-2017 Christian Jonathan Haverkampf. All Rights Reserved

Unauthorized reproduction and/or publication in any form is prohibited.

An Overview of Psychiatric Medication (3)

This article gives a brief overview of the main groups of psychiatric medication.

 

Keywords: medication, psychiatry

 

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A Brief Overview of Psychiatric Medication (3) Ch Jonathan Haverkampf

 

 

This article is solely a basis for academic discussion and no medical advice can be given in this article, nor should anything herein be construed as advice. Always consult a professional if you believe you might suffer from a physical or mental health condition. Neither author nor publisher can assume any responsibility for using the information herein.

Trademarks belong to their respective owners. No checks have been made.

 

© 2012-2017 Christian Jonathan Haverkampf. All Rights Reserved

Unauthorized reproduction and/or publication in any form is prohibited.

Bipolar Disorder and Medication (2)

Bipolar disorder is a condition affecting an individual’s affective states (mood). The different flavors of bipolar disorder have in common that there are alterations in mood between above ‘normal’ (hypomania, mania) and normal or below normal (melancholia, depression). The other important mood disorders are the various types of depression, while mania without episodes of depressions is a rarity. The first line treatment of choice in cases of bipolar disorder is medication. However, in the long run psychotherapy has shown to be successful in making the condition more manageable for individuals suffering from it. This article presents the different types of medication used for bipolar disorder.

Keywords: bipolar disorder, medication, therapy

For the full article please click on the following link:

Bipolar Disorder and Medication (2)

Psychotherapeutic Technique: A Brief Overview

Psychotherapeutic Technique A Brief Overview (3) Ch Jonathan Haverkampf

 

Psychotherapeutic Technique: A Brief Overview

Dr Jonathan Haverkampf, M.D.

 

Introduction

When patients come to see a therapist, they often have a long list of things that do not work for them in their lives. It is easy to overlook that one of the hardest steps towards health has been taken, stepping into the office of a therapist. Psychotherapeutic Technique is then largely about helping the patient find his or her path and to have the courage to follow it. Empathy, common sense, and a good dose of optimism are helpful in this line of work, as is thinking about what is happening and has happened in the life of the patient, how they relate to themselves and the world, and that in the end everything should make sense to the head and to the heart.

The reasoning mind plays a greater role in psychotherapy than it is given credit for. Many mental health conditions arise because of what we think we have to achieve, because we think there are no alternative options or because we think we have failed. If one’s thoughts can make one feel worse, it also makes sense to look to one’s thoughts to make oneself feel better. However, the goal is not to engage in endless loops of thinking about unanswerable questions but to engage with one’s thoughts by asking whether they make sense or not.

 

Making Sense

In the best-case scenario, a patient engages in a process of ‘making sense’ with the help of the therapist. This does not just mean using logic, but seeing one’s thoughts within the context of one’s values and aspirations on one side, and one’s experiences and interactions with other people on the other side. In the end, the objectives and goals of one’s thoughts have to make sense within the context of one’s values. This ultimately leads to stable and persistent happiness and mental well-being.

Let us look at an example, which applies to many people. If one of my values is to provide a safe environment for my family, thinking about how to make more money can lead to greater happiness (and less stress), if I am aware that I am thinking about earning money to be able to buy a house that can offer my family a greater sense of security. If I see money as an end in itself, on the other hand, it can lead to an obsession, which may become endless, because I lose sight of when I have reached my goal.

In other words, life becomes easier once we see our actions and interactions with other people as something that ultimately makes sense for us. One does not need to have a specific outcome in mind. A feeling of significance to oneself is already a good starting point. Many people lack even this general feeling in most of their daily lives, which can lead to emotional disengagement, burnout, depression anxiety, panic attacks, heightened OCD, and so forth. Therapy has to bring ‘sense’ and meaning into the equation again.

 

Guided Self-Help

Much of what can happen in therapy depends on the expectations of the patient. It determines how much he or she will participate in therapy and contribute to the process in general. This makes it worthwhile to point out early to the basic working in principle in therapy, that the therapist can help patients help themselves, but should under normal circumstances not tell them what to do.

 

The Search for Meaning

Therapy is about meaning, helping a patient find relevance in things, which also asks patients to look at their fundamental values and basic interests. Following one’s values and basic interests leads to happiness and not knowing them to such conditions as anxiety and burnout. Many people in today’s busy and increasingly complex world lose their ability to see relevance in the world and in what they do. Helping people to reconnect the world as they perceive it with what they value is an important aspect of therapy. It requires the ability to communicate with oneself and between the inside and outside worlds.

 

The Therapeutic Relationship

Therapy is an exchange of information, which ultimately should help the patient to lead a happier and more fulfilling life, as well as be free from any symptoms that interfere with these goals. The motivation for it should come for a need for the feedback and information that is provided in therapy. The therapeutic relationship is the bundle of channels along which the therapeutic communication takes place.

Observation

The therapist should be able to see how patients deal with information and interact with themselves and the world around them. Better communication with oneself and others can lead to the patient feeling safer, developing greater abilities of introspection and reflection and facilitating a healthier communication with oneself and the environment. All this requires that the therapist has an understanding of the dynamics of interactions in general and of the interactions of the patient in specific, the mutual flow of information and the values, aspirations and interests everyone holds.

Empathy and Interest

Therapeutic work requires empathy and an honest and true interest in the patient and his or her inner worlds. The therapist should also have an interest for the own inner worlds and how they are are influenced by the communication of the patient. In psychoanalysis, the concepts of transference and counter-transference are used here.

Reason

Mostly therapy is about leading the patient with questions and comments to find new perspectives, open up to new information and process information in new ways. The epiphanies should take place in the patient, while the therapist can create the setting in which they take place. The motivation, ownership and integration into the own person that takes place in them is important for the success of therapy.

 

Values, Interests and Aspirations

The psychodynamic process helps to shift through derivative values and non-derivative values to get to the fundamental values which everyone holds. Here are the things which are really important to the individual, whose pursuit makes happy and life worth living for. To compromise these values causes great suffering and a loss of direction.

 

Self-Connectedness

The information to be gained from inside one’s body can be tremendous if one is willing to listen to it. We produce a lot of information in our body, which, though it requires the environment to interact with, is in many ways a very complicated self-contained system. The parallel information processing power of the nervous system and the networks of cells of the rest of the body, connected by chemical and electric pathways, is very large. Even information coming in from the outside world has to pass through cellular networks to reach higher brain centers.

Self-connectedness means being aware that the information reaching the brain is made up of information that is largely influenced by the information processed in our bodies. It requires becoming aware of the shear infinity of information sources our brain is processing, and not just the sentence one may see on a computer screen at work. This awareness is important to deal with anxiety, OCD, burnout, depression, psychosis and a host of other conditions. It does not mean one has to process all this information consciously, just that the processes are stable, while the sources and the information may change. Our values as a result of these processes change little, while our experiences on the summer vacation may be vastly different from year to year.

 

Time

To many patients, time has become convoluted. They do not know what to do with their past, are afraid to think about their feature, and are caught between past and present which deprives them of the present. Making sense of the relationship between the present, the past and the future establishes the bridges that can anchor them in the present moment. Awareness, feelings, feedback and communication are important factors in this process.

Thinking about values and interests helps to rebuild a future, but this might confront the patient with ‘bad decisions’ in the past. The best way to deal with this is through acceptance and integration. This means the past has to be accepted and to a certain extent embraced, which is an important process in therapy.

 

Questions

The most important communication tool one has in psychotherapy is to ask questions. In Socratic questioning the question can lead to insights for both, the patient and the therapist. However, to ask questions that bring greater insight requires having a sense of the type of answers that will be useful to allowing the patient greater awareness, insight and connectedness. The type of answers may often not be apparent early in therapy. However, they should be related to greater happiness, and thus a knowledge of the patient’s values, interests and aspirations.

 

Meaningful Communication

One needs to have faith that the interaction between therapist and patient will reveal the information that provides the course in treatment. And this will always happen if there is meaningful communication, which means that something new is communicated every time information travels between the two partners in the interaction. Information can be little gestures or a twitch on the forehand which signal emotions or thought processes, words that can be understood by the other person and in general every signal that can be sent and received by therapist and patient. This requirement is easy to satisfy, if there is a minimal openness to engage in a therapeutic process.

 

Types of Intervention

An intervention should create greater awareness, insight and connectedness in the patient. A few examples follow.

Questioning

“I want to be in control in social situations.”

“What does it mean to be in control in social situations?”

“I would feel free, I would not think anymore so much, I would not analyze so much what other people think.”

 

Assembling

The next step is to put together the information from the client that reaches the therapist.

“So, you are telling me that you …”

 

The Logic Test

The logical test is a result from assembling the information. Here contradictions can become clear, or spots that have not been thought about at all. These do not make up the world we imagine, but are the things that have to be overcome to get closer to one’s wished states.

 

Imagining

Imagining is that step in which people project their wishes, needs and aspirations into their inner world using building blocks they know from the real world. It is here where we build the world we compare the real world with. This comparison motivates us to change our world, but it can also raise emotions, such as fear or happiness. As emotions have influence over the worlds we imagine, so the worlds we imagine have influence over our emotions.

Our vision of the future plays an especially important role, because it can provide motivation and a sense of direction, as long as it is congruent with the person’s underlying values, aspirations and interests.

“Can you imagine what it would be like not to feel socially anxious anymore?”

 

Bridging real and imagined world

This requires looking at the changes that may have to be made in the present world to get closer to the imagined world. These thoughts should then lead to behavior changes that get the patient closer to where he/she wants to be.

 

Creating new communication pattern

Change also means we have to communicate with the world in new ways. This grows out of the rediscovered values and interests, the feedback and dynamics in the work with the therapist and the life of the patient outside the therapy. Over time, the new communication patterns should solidify as the patient is reinforced by better interactions with the environment.

 

Conclusion

Psychotherapy is both, creative and supportive work. It requires a keen eye for the process and the dynamics unfolding within a session. Working with the patient on communication patterns, interaction dynamics, uncovering values and basic interests often goes a long way towards a successful therapy.

 

 

Dr Jonathan Haverkampf, M.D. MLA (Harvard) LL.M. trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. The author can be reached by email at jonathanhaverkampf@gmail.com or on the websites www.jonathanhaverkampf.com and www.jonathanhaverkampf.ie.

This article is solely a basis for academic discussion and no medical advice can be given in this article, nor should anything herein be construed as advice. Always consult a professional if you believe you might suffer from a physical or mental health condition. Trademarks belong to their respective owners. No checks have been made.

© 2012-2017 Christian Jonathan Haverkampf. All Rights Reserved.

 

Anxiety and Panic Attacks

 

 

Anxiety and Panic Attacks (2)

Dr Jonathan Haverkampf, M.D.

 

 

Anxieties can cause incredible suffering, especially in combination with panic attacks, which are usually a short-lived but more intense form of anxiety.

 

Anxiety Disorders

Anxiety disorders are a group of mental disorders characterized by feelings of anxiety and fear. [1] Anxiety is a worry about future events and fear is a reaction to current events. These feelings may cause physical symptoms, such as a fast heart rate and shakiness. There are a number of anxiety disorders: including generalized anxiety disorder, specific phobia, social anxiety disorder, separation anxiety disorder, agoraphobia, panic disorder, and selective mutism. Often the same individual has more than one anxiety disorders, but in many cases, there might only be one type.

 

Panic Attack

The first panic attack can occur as from nowhere and the sudden sense of imminent death or literally going crazy usually comes as an enormous and sudden shock. In many cases, it has five stages:

  1. An ominous feeling of an imminent panic attack. A heightened sense of self-consciousness with beginning hyperventilation and other symptoms.
  2. The sense that there is no way to avert the full-blown panic attack.
  3. The panic attack with hyperventilation, heart palpitations, the sense of imminent doom and/or death.
  4. Alternations in the intensity of the panic attack, leading to a decline after about ten minutes.
  5. A post-panic phase in which there is a sense of exhaustion and sometimes elation that it is over.

Since the first panic attack often occurs in adolescence or young adulthood, the individual might not know what a panic attack is. In older people, panic attacks often lead to visits to the hospital emergency admission.

 

Invisibility

A feature of many anxieties and panic attacks is that they go largely unnoticed by the environment. Anxieties and panic attacks can lead to the inability to leave the house and interfere with almost every sphere of life, professional, social, and one’s relationships. When anxiety reaches into all areas of life and no longer seems specific to certain situations and locations, we call it ‘generalized’. It is then the pure form of a disturbing feeling that no longer is attached to specific object, but ‘floats freely’.

 

Loss of Control

Anxiety and Panic Attacks do not seem to be so much a fear that something happens to the world, but that one loses control somehow. Often patients mention the sense of loss of control. But it is important to turn this around. The question is why is there such a need for control in the first place? It is because there is probably a loss of something stabilizing on the inside. After all, patients usually describe the sense of losing control over themselves. This is also what maintains the vicious cycle of fear of fear, felling anxious that the anxiety might mean a total loss of control. It is important to mention that I have never seen a single case, in which someone was seriously harmed who suffered from this fear of losing control. But the feeling is there and it needs to be looked at more closely.

 

A Signal of Change

But anxieties are actually something quite interesting because they signal a necessary change if someone is willing to go a new route. The necessity for a more global change lies already in the definition of anxiety. It is not a fear of something specific, but of uncertainty itself. Communication which binds humans together is no longer felt as something really stable.

 

Fear of Imminent Death: Somatic (Body) Reaction

Panic attacks often trigger thoughts of an imminent death, such as not being able to breathe anymore or a heart attack. They frequently go along with bodily ‘fear’ reactions, such as heart palpitations and dizziness. In general, there is a general sense of a loss of control over one’s body and even one’s mind, which further worsens the panic attack. Often panic attacks start in adolescence and young adulthood and frequently they are triggered by relationship events and social situations. But if they remain untreated, they can spread out and become ‘generalized’. They can reach a point where they even occur when someone is at home lying in back or after waking up at night. In the extreme, this can lead to a situation in which a patient is not only house but also bed bound.

 

Certainty and Security

Under the surface of the symptoms of anxiety and panic attacks there often is a fear of losing a fundamental feeling of losing of certainty and security in one’s life. As babies and small children learn to rely on their interactions with others, especially primary caretakers, to meet their needs, they build up a sense of safety in regard to the world around them and a secure sense of self. As we figure out the ‘rules of daily life’ as children we learn to be reasonably in the world. Things might still be unpredictable at times, but in a caring and supportive environment surprises are seen as a fact of life that one might not be able to control, but one can learn from them and the world moves on anyway, for oneself and for everyone else.

However, if this process does not work properly for a number of reasons, a greater sense of uncertainty and a greater susceptibility to anxiety develops, especially if anxieties, OCD, panic attacks and other conditions of elevated anxiousness vis-à-vis the world and other people run in the family.

Society has developed a number of ways to deal with anxiety and reduce uncertainty. Many human endeavours aim to provide a greater sense of safety. Laws and scientific progress deal with both, uncertainty in people and uncertainty in the natural world. However, in generalized anxiety and panic attacks, it is less a certainty in the outside world than in the inside world which is really what individuals with anxiety strive for, and it is here that therapy needs to begin.

 

Meaningful Relationships

Meaningful social interactions and meaningful relationships are effective against anxiety, where it is the quality rather than the quantity which counts. The reason is that meaningful communication reconnects the individual with others, but it also aids in self-regulation and gives the individual a greater sense of being effective in taking care of oneself through the interactions with others.

 

Values and Interests

The other important element is finding not only the strength in oneself but also the direction to proceed in the life. Often there are many paths that can be taken, which confuses people and causes anxiety. Without a sense of one’s trues values, interests and aspirations it is more difficult to make the relevant decisions in life that lead to greater happiness. If one’s sense for one’s own values and fundamental interests and aspirations is compromised because of a loss of connection with one’s thinking and emotional self, stress, anxiety and burnout can ensue. It is like running in place without getting anywhere, while having a strong desire to get somewhere.

True values, part biology, part social learning from other human beings, means a fundamental belief that acting according to these values and interests and attaining one’s aspiration will really mean happiness in the long run. In anxiety, these values and fundamental interests are out of sync with our lives.

 

Inner Conflicts

Anxiety is caused by inner conflicts, which in the cognitive behavioural therapy tradition are assumed to be conscious or ‘near-conscious’, while the psychodynamic or psychoanalytic psychotherapy traditions see most of it in the domain of the unconscious. This largely explains the differences in treatment times between the two approaches, but on a theoretical level both can actually complement each other quite well. Fundamentally the causes are difficulties in communicating one’s underlying needs and wishes in a way that subjectively strengthens rather than weakens a relationship out of a fear of further loss. This also makes the internal conflicts persist. Our communication with the people in our lives has an impact on how we talk to ourselves, because they provide crucial feedback to us. When our social interactions become meaningless, our sense of shaping our world in a way that makes us feel secure and happy suffers.

 

Self-Talk

When I refer to ‘talking to oneself’ I do not mean literally talking to oneself in the street but bouncing back and forth thoughts in one’s head, observing one’s thought process and reflecting on it. This requires the exchange of highly complex information in even more complex webs of networks of nerve cells in the brain. Since our brain is a highly complex network of ever smaller networks of nerve cells it allows the brain to process information in parallel. This is the reason why we can ‘listen’ to our own thoughts. Brain cells are in contact with other brain cells and they can alter the properties of their own connections depending on the information they transmit. Medication can alter certain types of transmissions in this system, but if we want to be more specific, we have to expose ourselves to meaningful information which the brain can use to refigure itself. This is essentially what psychotherapy does. As many empirical studies have shown, psychotherapy can bring about changes in connectivity and activation of the brain, which in turn can have a lasting effect on certain conditions, such as anxieties and panic attacks.

 

Three Steps

The first step is to become aware of situations that trigger anxieties and panic attacks, such as relationship problems or work-related stress. But these problems might not always be obvious, and they might not even explain the anxiety. Problems in a relationship or shyness in social situations are normally not the ultimate explanation for anxiety or panic attacks. We need to analyse in the specific case why losing a relationship causes such threatening fears as anxieties or panic attacks suggest. Sometimes it is worthwhile taking a look into one’s past and reconstruct how an individual dealt with his or her environment as a child or adolescent and how the environment dealt with the individual. At other times it may be important to ‘dissect’ the thought patterns in the here and now and to try to find out what they could mean. “If I leave the house I might have to figure out what I really want to do in life. “If this relationship breaks up I might have to figure out what I need and what I want, who I am, who I want to be with …” and so on. This step is about better understanding one’s needs, values and aspirations, and thus oneself.

The second step is to determine if the current approach, such as avoidance or negation, is the best strategy. It always never is. But this does not mean that one has to radically alter one’s current lifestyle or social life, though in special cases it might. The actual life we have starts in our head, so it is first and foremost about determining the questions that matter and how to approach them. This is actually easier than most people think, because it is not so much about having certain answers but about learning how to think and communicate in novel ways. Change usually means widening one’s mental repertoire, not narrowing it. The more effective tools are in our toolbox and the more meaningful information we have access to, the better will be our answers and decisions.

The third step is to act according to this novel information. This might sound like a tall order in the face of fears, anxieties and panic attacks, but once someone reaches this stage, the hurdles are often diminished or gone altogether. The fears usually disappear during the first and the second step. The reason is that we are usually more afraid of an uncertain ill-defined event than a certain defined event. When you are facing a threatening event, the uncertainty about an unlikely ill-defined outcome can be more painful than the certainty about a certain well-defined event. The certainty of death does not disturb people nearly as much as not knowing how they will die.

 

Happiness

The goal is not absolute certainty in life but the attainment of happiness. Anxiety does not necessarily mean a shift in the balance between happiness and writing a meaningful story for one’s life, rather, it often is a wake-up call for us to re-evaluate who we are and what we really want in life to make us happier.

 

Most people want to lead lives which feel true to themselves for the simple reason that they believe it will make them happy. The only certainty that really helps against anxiety is the certainty that one follows one’s own path. To help a patient reach this path and follow it with confidence is an important objective of psychotherapy and counselling.

 

 

 

 

References

[1] Diagnostic and Statistical Manual of Mental Disorders. American Psychiatric Association (5th ed.). Arlington: American Psychiatric Publishing. 2013. pp. 189–195. ISBN 978-0890425558.

 

 

 

Dr Jonathan Haverkampf, M.D. MLA (Harvard) LL.M. trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. The author can be reached by email at jonathanhaverkampf@gmail.com or on the websites www.jonathanhaverkampf.com and www.jonathanhaverkampf.ie.

This article is solely a basis for academic discussion and no medical advice can be given in this article, nor should anything herein be construed as advice. Always consult a professional if you believe you might suffer from a physical or mental health condition. Trademarks belong to their respective owners. No checks have been made.

© 2012-2017 Christian Jonathan Haverkampf. All Rights Reserved.