Generalized Anxiety Disorder

Generalized Anxiety Disorder

A Booklet

Generalized Anxiety Disorder A Booklet

Copyright Š 2016 by Rachel Bender All rights reserved Including the right of reproduction in whole or part in any form Published by countless of credited authors 189 Miller Avenue Mill Valley, CA 94941

Table of Contents

Part I:

Domination

6–15

Part II:

Restriction

16–25

Part III:

Isolation

26–37

Generalized Anxiety Disorder

The Stigma of Anxiety The symptoms of anxiety have long been familiar to psychiatric nurses and indeed, are common to the human condition. But too often, anxiety can become severely distressful and disruptive, and can become the source of conflict and frustration for clinicians and patients alike. Anxiety, perhaps more than other psychiatric symptoms, is also the victim of stigma and bias, not only from a cultural perspective, but in the professional communities as well. This contributes to a poor understanding of anxiety, difficulties in diagnosis, inadequate assessment, mismanagement of treatment, and can lead to confusion and splitting concerning appropriate pharmacologic intervention. The results are that anxiety remains severely under treated in psychiatric settings.

Anxiety disorders are the most common of all the major groups of mental disorders in the United States. The National Institute of Mental Health (NIMH) has estimated that 6% to 10% of the general population, or as many as 24 million people, currently suffers from an anxiety disorder.1 Estimates are that the lifetime prevalence of anxiety disorders may be as high as 15% of the population.2 Depression, the second most common major mental illness, shares a comorbidity with anxiety and has an overall prevalence of 5% to 18%.3 The diagnostic determination of which condition is the primary problem is often difficult because the two share common symptoms.4 Indeed, between 70% and 90% of depressed patients experience clinically significant anxiety 5 and anxiety may be the only presenting symptom of a depressive disorder.6 Nearly one in seven Americans will develop clinically significant anxiety or depression during their lifetime.7

1 Weissman, M.M. (1988a). Anxiety and alcoholism. Journal of Clinical Psychiatry, 49 (Suppl 10), 17-19.

2 Tollefson, G.D. (1991). Sorting out anxiety and depression. Physicians Assistant, 5, 22-34 3 Hyman, S.E., & Cassem, N.H. (1989). Managing the person with major psychiatric illness. In: E. Rubenstein, D.D. Federmann (Eds.), Sci Am Med., 13, 1-18.

4 Tollefson, G.D. (1991). Sorting out anxiety and depression. Physicians Assistant, 5, 22-34 5 Hamilton, M. (1983). The clinical distinction between anxiety and depression. British Journal of Clinical Pharmacology, 15, 16551695.

6 Blair, D.T., & Ramones, V.A. (1994). Psychopharmacologic treatment of anxiety. Journal of Psychosocial Nursing and Mental Health Services, 32, 49-53.

7 Weissman, M.M. (1988b). The epidemiology of anxiety disorders: Rates, risks and familial patterns. Journal of Psychiatric Research, 22(Suppl 1), 99-114.

6

Domination

Untreated anxiety incurs severe social, financial, and clinical consequences. Untreated anxiety can lead to physical disease and stress-related disorders. Chronic anxiety may lead to depression or substance abuse, both of which are known risk factors for suicide. The suicide attempt rate among untreated patients suffering from an anxiety disorder has been identified at about 15%.1 Economically, there are direct treatment costs related to anxiety and substance abuse as well as the indirect costs such as the over utilization of medical services and lost time from work.2 The social and interpersonal costs of anxiety disorders can be severe with disrupted relationships, stress and abuse in families, loss of employment, and human suffering.

Early and appropriate treatment for anxiety has been shown to be cost effective as the average total medical charges over time per patient are lower after treatment is initiated than before.3 For the general medical/surgical patient, untreated anxiety may prolong hospitalization and complicate or exacerbate physical symptoms.4 Appropriate treatment can significantly reduce the average length of stay for these patients as well.5 During the past two decades, many extraordinary scientific advances have occurred in relation to a better understanding of the biological components of anxiety. This has led to a dramatic improvement in treatment and symptom management, and it would be expected that unrelieved anxiety would diminish.

Instead, evidence indicates that patients continue to experience moderate to severe levels of unrelieved anxiety and that these uncontrolled symptoms continue to exact a high economic and interpersonal toll.

1 Hyman, S.E., & Cassem, N.H. (1989). Managing the person with major psychiatric illness. In: E. Rubenstein, D.D. Federmann (Eds.), Sci Am Med., 13, 1-18.

2 Bonis, J.F., Olendzki, M.C., & Kessler, L. (1985). The offset effect of mental health treatment on ambulatory medical care utilization and charges. Archives in General Psychiatry, 42, 573-580.

3 Holder, H.D., & Those, J.O. (1987). Changes in health care costs and utilization associated with mental health treatment.

Hospital and Community Psychiatry, 38, 1070-1075.

4 Fulop, G., Stram, J.J., Vita, J., Lyons, J.S., & Hammer, J.S. (1987). Impact of psychiatric comorbidity on length of hospital stay in medical-surgical patients, a preliminary report. American Journal of Psychiatry, 144, 878-882.

5 Mumford, E., Schlesinger, H.J., & Glass, G.V. (1984). A new look at evidence about reduced cost of medical utilization following mental health treatment. American Journal of Psychiatry, 141, 1145-1158.

7

Generalized Anxiety Disorder

It is extremely unfortunate that despite the magnitude and prevalence of anxiety, the NIMH reports that only one in five persons suffering from an anxiety disorder will ever seek medical attention and that only 25% of all patients diagnosed with general anxiety disorder are ever treated.1 The rest often see physicians repeatedly with a wide variety of diffuse complaints, or self-medicate with over-the-counter agents, alcohol, or other substances.2 The reasons for this are many and complex. Anxiety, like mental illnesses generally, suffers stigma in both the lay and professional communities. This stigma is the outcome of ignorance of the symptomatology, the nature, and presentation of anxiety. Professional stigma is a result of the lack of appropriate knowledge concerning pharmacologic interventions, the pharmacokinetics of modern anxiolytic agents, and a lack of understanding of modern standards of care regarding the treatment and management of anxiety.3 Professional bias exists against the use of anxiolytic agents in general, and thereby influences appropriate use of these agents. Stigma and professional bias may be directed toward patients who experience disruptive anxiety.

Diagnosis and Etiology Assessment guidelines for anxiety remain rather generic in nature, which leaves room for the varying context and individual differences encountered in each individual patient and in each specific clinical situation. Generally, anxiety should be treated when psychosomatic disorders develop or when symptoms produce acute physiologic or physical disruption.4 Intervention is also indicated when cognitive, social, vocational, or interpersonal impairment occurs; or when significant daily functioning is disrupted. Anxiety should be carefully assessed when symptoms are disproportionate to the risk or severity of the perceived threat or if symptoms persist beyond the existence of the threat or risk.5

1 Weissman, M.M. (1988a). Anxiety and alcoholism. Journal of Clinical Psychiatry, 49 (Suppl 10), 17-19.

2 Blair, D.T., & Hildreth, N.A. (1991). PTSD and the Vietnam veteran: The battle for treatment. Journal of Psychosocial Nursing and Mental Health Services, 29, 15-20.

3 Blair, D.T., & Ramones, V.A. (1994). Psychopharmacologic treatment of anxiety. Journal of Psychosocial Nursing and Mental Health Services, 32, 49-53.

4 American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders, 4th ed. Washington DC; Author.

5 Beck, A.T., & Emery, G. ( 1985). Anxiety disorders and phobias. New York: Basic Books.

8

Domination

During assessment, the professional’s perception tends to be influenced by personal beliefs about the meaning of specific cues and the importance of situations or conditions faced by patients.1 Cultural or social beliefs concerning the role of anxiety in daily functioning and the degree of personal coping can also be important influences of the assessment process.2,3 Erroneous assumptions by the professional concerning causes, course, and display of symptoms may lead to inadequate assessment and, as a result, inadequate intervention. This may result in the under treatment of anxiety, which may be compounded by inadequate knowledge of symptomatic presentation of anxiety; inadequate data collection on assessment; and the influence of personal beliefs, attitudes, and bias concerning anxiety or the nature of pharmacologic intervention.

In many respects, under treatment of anxiety may parallel that of the under management of pain in general medical surgical settings.4 Seers5 found that assessment was not rated by nurses as a high priority in nursing care, yet these nurses significantly and consistently rated patients’ discomfort lower than did the patients. Rankin and Snider6 found that 84% of nurses believed that their patients were receiving adequate PRN pain medication for pain control, yet 67% of these same nurses assessed that their patients suffered moderate pain.

This suggests that the nurses’ perception of moderate relief was an appropriate clinical goal, even though their patients reported significantly higher levels of discomfort.

Treatment Often Delayed Few anxious patients seek early medical help for symptoms, so treatment is often delayed until manifestations become overwhelming or disruptive. Prior to seeking medical intervention, patients may ignore, suppress, deny, or self-treat

1 Fothergill-Bourbonnais, F, & Wilson-Barnett, J. (1992). A comparative study of intensive therapy unit and hospice nurses’ knowledge on pain management. Journal of Advanced Nursing, 17, 362-372.

2 Beck, A.T., & Emery, G. ( 1985). Anxiety disorders and phobias. New York: Basic Books.

3 Blair, D.T., & Ramones, V.A. (1994). Psychopharmacologic treatment of anxiety. Journal of Psychosocial Nursing and Mental Health Services, 32, 49-53.

4 McCaffery, M., & Vourakis, C. (1992). Assessment and relief of pain in chemically dependent patients. Orthopaedic Nursing, 11, 13-27.

5 Seers, K. (1987). Pain, anxiety and recovery in patients under going surgery. Unpublished doctoral thesis. University of London, King’s College, London.

6 Rankin, M.S., & Snider, B. (1984). Nurses perceptions of cancer patients’ pain. Cancer Nursing, 7, 149-155

9

Generalized Anxiety Disorder

symptoms. Many anxious patients visit numerous clinicians before conditions are fully recognized. Diagnosis is complicated by the fact that the distinction between anxiety and related symptoms is not always clear. Determination of the need for intervention depends upon degree of functional impairment and severity of symptoms. Anxiety is a rather personal and subjective sensation and so may be difficult to assess its intensity in patients objectively.

Some suggest that the confusion over complaints and the difficulty in diagnosis may be the result of patients’ considering the diagnosis of anxiety or depression a weakness or lack of character. They may be more comfortable accepting a medical explanation for their symptoms and thereby avoid the idea that complaints are “in their head”.1 Many of these patients may seek medical attention as a coping mechanism. A medical diagnosis allows for a decrease in personal responsibility and challenge and provides support, validation, and attention.2 Nursing Misconceptions There may also be misconceptions by the nurse concerning the honesty or accuracy of the patient’s self-reports, and nurses may believe that complaints of anxiety are psychogenic or indicate malingering.3 It is worse for the unpopular or difficult patient. The irony of the situation is that the longer the patient experiences uncontrolled symptoms, the more likely he or she become irritable, demanding, and preoccupied with the availability and timing of PRN medication.4 Nurses are likely to consider the patient’s reports of symptoms in the context of their own experiences or beliefs about how severe the symptoms a patient may be experiencing. Because nurses are very confident in their ability to judge symptoms and generally report satisfaction in their clinical performance, they may be more suspicious about the honesty or accuracy of the patient and may be wary about reliance upon patients’ self-reports. In light of the evidence to the contrary, it is apparent that nurses may be overconfident about their own clinical competency.1 Watt-Watson2 suggests that the basis for this poor clinical performance and competency is inadequate knowledge about symptoms and pharmacology, and a general failure of nurses to keep up with new standards of treatment or advances concerning psychotropic management. Too often clinical judgment is made without reference to new scientific knowledge and through application of simple inferential strategies or the reliance on traditional beliefs or experience for clinical assessment (Nesbett & Ross, 1980).

PRN PRN, Latin for pre re an ‘ta means literally, “according as circumstances may require.” Herein lies the complexity of the assessment for, the choice of, and the administration of these medications. Assessment and nursing judgment are subject to a myriad of nuances, beliefs, bias, inconsistencies, misunderstandings, and misconceptions. Assessment and judgment certainly must incorporate the knowledge of pharmacology, the signs and symptoms to be treated, and the physiologic responses to these agents; however, stigma and personal bias that could influence adequate assessment and subsequent treatment regimes must be avoided.

1 Roberts, S.J. (1994). Somatization in primary care. Nurse Practitioner, 5, 47-56.

Why can’t I have that? Why 2 Barsky, A. (1988). Hidden reasons some patients visit doctors.do Annals Internal Medicine, 94, 492-498.

I notofseem like the type 2012-03-20 3 Lander. J. (]990). Fallacies and phobias about addiction and pain.

Journal ofwho Addiction, 85,a803-809.Ugh today was like the most stressful day ever. of person can do 2011-02-08 4 Mumford, E., Schlesinger, H.J., & Glass, G.V. (1984).

A new look at evidence about reducedIscost ofItmedical following mental health treatment.on Amerilong-term relationship? startedutilization off innocent enough, I’m behind I’m still messed up. Did everyone forget that? I’m Journal of Psychiatry, 141, 1145-1158. stillcan a volatile force who hasn’t been able to stabilize it because people can sense everything because of my dramatic week off,

for a long time. I’m so scared that I’m never going to find people, or just a person, who is going to make me happy, instead of this terrible isolation I feel wherever I go. The connections I’ve made are fleeting, and I10want something permanent.

that I don’t want to have a long-term relationship with myself? I still want to die sometimes. Actually, a lot of the time.

and then out of nowhere I get a relationship request from Bryce. And those words just really freaked me out. Relationship, commitment, public commentary, and general anxiety. I mean FUCK. I didn’t actually want this to get serious.

Domination

Professional Bias and Cultural Stigma Despite the popularity of BZDs, a certain bias exists in the public and professional communities regarding the use of these agents. When these agents first became popular, they were described as a boon to psychiatric treatment.4 With the discovery of dependency issues, however, BZDs suffered a loss of popularity and, according to the media, became drugs “worse than heroin,”.1 Reactions in the medical community were mixed, with some suggesting that these agents be removed from clinical practice2 while others suggested that BZDs should be sold without prescription.4 Personal beliefs concerning anxiety and the use of anxiolytics can influence assessment, evaluation, and judgment as to when medication is indicated.

Anxiety also may be viewed as a weakness of character. In a national survey, 87% of adults agreed with the statement, “It is better to use willpower to solve problems than it is to use tranquilizers,” and 40% agreed that taking these agents is a sign of weakness.4 In general, mental illness suffers a similar stigma; in particular, anxiety disorders do not command respect and the therapeutic concern that other conditions might.

Much of the stigma surrounding symptoms of anxiety and their treatment is based not only on the nature of the illness, but also on the perceptions and beliefs concerning the use of anti-anxiety agents, particularly BZDs. Understanding the issues of dependence and the use of BZDs may clarify this confusion.

Fear of Manipulation A related source of professional bias is that of manipulation. The schizophrenic patient usually has no difficulty in getting medication to relieve psychotic symptoms. Yet patients complaining of anxiety may have a difficult time in receiving appropriate medication. Anxious patients may appear to be whining, demanding, or manipulative. The more insistent the patient becomes over the availability of anxiolytics, the more firm professionals may become in their refusal to give them. Medications for pain may share a similar bias. The stoic patient may more readily receive medication, and may even be solicited by concerned professionals to take them. Not so the demanding patient. The fear of “being manipulated” by a patient who may be dependent on drugs may become so paramount as to obscure appropriate clinical indications for the proper administration of these agents.

The failure to treat anxiety may cause an adversarial relationship between professionals and patient. The argument whether a patient is having anxiety can never be won. The patient may feel insulted by the implication of being dishonest about his self report, which increases anxiety about receiving relief and this leads to hostility and anger. The argument becomes a power struggle and takes enormous time and energy from both patients and staff, detracts from the treatment focus, destroys the nurse-patient relationship and spoils efforts by -J staff at engagement.

The argument forces the patient to become demanding or manipulative, which, in turn, raises suspicions in the staff. It all ends in a frustrating circle that may lead to noncompliance or discharge from the treatment setting.1

Conclusion Little question remains that medication is the standard for psychiatric treatment of anxiety disorders. And, as economic pressures reduce hospital lengths of stay, the importance of chemical management becomes ever more important. Nurses in psychiatric settings must have a firm knowledge of the indications, characteristics, complications, and side effects of modern anxiolytic agents. The PRN administration of anxiolytics most directly involves the necessity of accurate nursing assessment, judgment, and evaluation. But proper use of medications goes beyond an understanding of the pharmacology of specific agents. Assessment and judgment must transcend professional bias and the influences of cultural stigma. It is vital that nurses be able to self-examine for possible bias concerning anxiety as a legitimate psychiatric symptom and how this may affect patients and appropriate intervention.

1 Lander. this J. (]990).

Fallacies and and phobias aboutand addiction pain. Journal of Addiction, 85, 803-809.

I wanted to be washed stupid end and in like feeling it what people are saying about this. This is actually somewhat 2 Watt-Watson, J. (1987).

Nurses’ of to pain survey. Journal Pain and Symptom 2, 207-211. three weeks when I get boredknowledge and want goissues: backAto out. of And weird stuff,Management, and I know already I need to break up with him.

3 Cohen, F.L. (1980). relief:aPatients’ and purses’now medication choices.

Pain.

265-274. being a loner.

I havePost nosurgical desirepain to have seriousstatus boyfriend I want Which is9,bad, because I just agreed to try this. But I am so 4 Priest,aR.G. (1980). The benzodiazepines: and tomorrow. or even boyfriend at all.

When I saidToday dating, I told himLancaster, out.PA: It’sMPP tooPress. uncomfortable with this. The boy doesn’t even know me, I’d be elusive, so that means I have declare publicly my much too and I HATE BEING USED AS ARM CANDY. I call the commitment to one person? Not my fucking style at all. soon and to shots and now I’m saying I don’t want it! Wow, that wasn’t I’m annoyingly independent, and I’m not going to be be honest so hard I guess. Also note to self, eventually write about dependent on some washer college dropout who happens I cannot how you may not like boys or even girls, but that’s a whole to really like me. I mean, that part is nice, but I know my stand to different argument no one seems to get yet. infatuation will fade. I’m not even infatuated, I’m just think about 11

Generalized Anxiety Disorder

History Generalized anxiety disorder is a relatively recent diagnosis. Before 1980 it was subsumed under the label of anxiety neurosis, a disorder first delineated by Freud in 18941 and characterized by persistent feelings of unattached fearfulness described as free-floating anxiety.1 However, the disorder described by Freud also included the symptom of panic, and when panic disorder was subsequently identified as a separate illness by Klein,2 the part of anxiety neurosis that did not include panic became known as generalized anxiety disorder. This classification was unsatisfactory because there were no features that defined generalized anxiety disorder it became a residual diagnosis for anxiety disorders that had no other diagnosis; and it had substantial overlap with other disorders, known contentiously as comorbidity.3-5 However, the diagnosis of generalized anxiety disorder is now embraced by epidemiologists and clinical psychopharmacologists, although other clinicians, especially those working in primary care, are less enthusiastic. The comorbidity seen in generalized anxiety disorder accounts for a substantial amount of morbidity and disability.6,7 Some clinicians argue that generalized anxiety disorder remains an ill-defined diagnosis, which supports the notion that it was constructed to support the validity of other diagnoses in the anxiety group rather than being a useful homogeneous clinical entity.8 Generalized anxiety disorder was almost excluded from the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)9 classification in 1994, on the grounds that its diagnostic status could be faulted on the grounds of poor reliability. Supporters of this diagnosis argue that, despite its overlap with other disorders, a diagnosis of generalized anxiety disorder is an advance on previous categorizations, and that the criterion that it has a 6-month duration has created a more homogenous disorder. Additionally, the associated social, occupational, and economic burden is similar to that of major depression, and the increasing prevalence of generalized anxiety disorder with advanced age distinguishes it from other anxiety disorders, which suggests that this diagnosis will not be abandoned.

Clinical Features The requirements for the diagnosis of generalized anxiety disorder have changed with time. The symptoms have always included generalized and persistent excessive anxiety10,11 and a combination of various psychological and somatic complaints. These psychological and somatic complaints are given prominence in the WHO’s International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10) criteria, where at least one symptom of autonomic arousal (palpitations, sweating, trembling, or dry mouth) is essential for the diagnosis, together with up to three other symptoms. Three of the symptoms of restlessness, being easily fatigued, difficulty in concentrating, irritability, sleep disturbance, and muscle tension, are necessary for a DSM-IV diagnosis. The additional symptom of worry over minor matters is included in the DSM-IV criteria but is not in ICD-10. This new criterion allows the diagnosis to be made irrespective of any overlap in anxious symptoms, and seems to separate generalized anxiety from other disorders that involve anxious symptoms.12,13 These disorders include hypochondriasis (health anxiety),14 panic disorder,15 medically unexplained symptoms (somatisation disorder),16obsessive-compulsive disorder,17 social anxiety disorder,18 and eating disorders.19 Anxiety is also a common complication of substance misuse disorders, including alcohol misuse,20 and so these too have to be excluded. Because none of the individual symptoms are specific to generalized anxiety disorder, it is therefore necessary to exclude the other anxiety conditions before making the diagnosis. Exclusion of these other disorders is not always easy, especially if the patient has more than one disorder. Two diagnoses can only be made when the specific features of the other disorders can be discriminated reliably.

1 Freud S. On the grounds for detaching a particular syndromeand frombutterflies neurastheniawhen under the description “anxiety neurosis”.

EnglishI’m translation Strachey JT, ed.

2012-05-22 I think an unhealthy obsession. losingin:my fucking Completego psychological worksthis (vol morning.

3). London: IHogarth 1924;him.

85-117I just.... I want to mind. I’m not really anxious that he doesn’t love I couldn’t to my classes don’t Press. about 2 KleinI DF. of two drug-responsive anxiety Psychopharmacologia 1964: 5: 397-408. know, justDelineation couldn’t muster the energy. So I syndromes. make things work for as long me, that’s never been the concern. I’m anxious 3 Hoehn-Saric R, McLeod DR. Generalized anxiety disorder.

N Amlosing 1985; 8:my 73-88. that I can’t seem to handle how to properly skipped, I skipped everything today in fact all in Psychiatric as I canClin without 4 Angst J. Comorbidity of mood disorders: a longitudinal prospective study.

Br J Psychiatry 19%; 168 (suppl): 31-37. now that we don’t live near each attempt to get that research paper done. Then sense of self in the process. communicate 5 Tyrer P.throwing Comorbidity consanguinity?

Br IJ didn’t Psychiatry 19%; 168: 669-71.

I started uporlater.

And then Brigit looks so much like other. It’s really hard for me because I feel like I’m 6 Hunt T, Andrews G. Generalized anxiety disorder and major depressive the National Surveyway of Mental Healthand and Well-Being. want to C, seeSlade Bryce, even though I wanted stoges.

Laurie, it’s harddisorder for meComorbidity to justintalking way way too much, he barely Depress Anxiety 2004; 20: 23-31.

Dilemmas.... look at her because of it. responds. And I would love to actually just talk to 7 Surtees PG. Wainwright NWJ, Khaw KT, Day NE. FunctionalShe’s healthhere status, chronic medical conditions disorders of mood.

J Psychiatry 2003:183: with us tonight him and on the phone, but IBr feel ridiculous that I299-303. want 8 Tyrer P. Neurosis divisible? Lancet 1985; 325: 685-88.

2012-05-23 and tomorrow. I still can’t to call him when I haven’t seen him in only like 9 Brown TA, Barlow Liebowitz MR.about The empirical basis of generalized anxiety disorder.

1994; 151:1272-80.

Minor panic attackDH, in front of Jen math, but believe Laurie died.

It’s soAm J Psychiatry three days.

But honestly, I need it. I need that time.

10 American Psychiatric Association.

Diagnostic Statistical Manual Mental Disorders.

Edition.

Textto revision Washington: American I vaguely recovered.

Life is a joke!!!!!

Didand anything unfairofhow someone so4th good I need know(DSM-IV-TRTM). that everything’s going OK with Psychiatric Association.

2000: 472-76. else happen today? Oh yeah, kept writing that and kind got so sick. I wish him because I care about him. And I want him 11 World Health Organisation.

Pocket Guide to the ICD-10 Classification of Mental and Behavioural Disorders with Glossary and Diagnostic Criteria for Research fucking paper! Finished it!

Victoria was here. I wish she to know what’s going on in my life. It’s such an (DCR-10). Geneva: WHO. Edinburgh: Churchill Livingstone.was 1994:home.

158-60.I wish Julie was nnected, which are literally the best things in the 12 Breslau N, Davis GC. DSM-III generalized anxiety disorder an investigation of more stringent criteria.

Psychiatry Resa1985: 14: 231-38.

2012-07-16 atempirical home instead of here, world, I need more of day-to-day emotional one.

13 Breslau Davis DSM-III generalized disorder an empirical investigation more Restold 1985:about 14: 231-38.

Right nowN,I’m inGC. Santa Monica.

Todayanxiety I went she’s a pain and sheof will getstringent a No, Icriteria. don’t Psychiatry need to be how I’m a huge 14 H, Salkovskis P, Green J, et al.

Prevalence servicestroke implications of health in genitourinary medicine clinics.

Int Jto STD 2004; 15: on 14 theSeivewright Santa Monica College campus with my and heat and die in theanxiety not part of your future, I just need be AIDS told what 519-22. mom and Julie. It seems very nice, and everyone is really that hot Santa Monica you’ve been up to, even if it’s boring or stupid. I 15 Clark DA, Beck AT. Beck JS. Symptom differences in major and generalized disorder. Am because J Psychiatrylooking 1994:151:into smoking, which only made me happier.

I have NOdepression, weather. dysthymia, panic disorder, need present anxiety day information 205-09.

IDEA WHERE IM GOING FOR SCHOOL AT the future is just like staring off the edge of a cliff.

16 Hamilton J. Campos R. Creed F. Anxiety, depression and management of medically unexplained symptoms in medical clinics.

J R Coll Physicians Lond 1996; 30:18THIS POINT. I don’t even know where I could 2012-09-16 get20. in at this point. It makes me sad and it makes Oh god what is wrong with 2012-09-30 17 J. Gamma Obsessive-compulsive syndromes anddoes disorders. ofYou comorbidity withnot bipolar and anxiety Eur Arch meAngst worry, frankly.A,IEndrass want toJ. etdoal.well.

I do I just me? Why thisSignificance keep know, I’m doing great. syndromes.

I miss Bryce even Psychiatry Neurosci 2005;where.

255: 65-71. don’t know Clin where the fuck And what after, happening? Why can’t I though I shouldn’t, I can’t focus on my work for 18 Stein MB, Bailey et al. Comorbidity generalized anxiety disorder and depression in a pediatric primaryknow care sample.

Disord with 2004; andChavira what DA. about Bryce?

He K, actually matters inofthis keepsocial my shit together?

I want anything, and I don’t what’sJ Affect happening 80:163-71. decision because he’s about to attempt to keep his everything with Bryce to be my future. I just don’t. I get horrible anxiety all 19 WH,with Bulikmine CM, Thornton L, Barbarich N, Masters K. Comorbidity of anxietyimportant disorders withthe anorexia bulimia nervosa.

Psychiatry 2215lifeKaye in sync while living in Santa Barbara. fine, a non-issue, timeand that nothing getsAm ridJ of.

I can’t2004; talk161: it out, 21. on earth will happen if I’m in New York? I when I have the time. But What I can’t drink or smoke it off, I can’t sleep, I can’t 20 Helzer JE, Pryzbeck TR. The co-occurrence of alcoholism with other psychiatric disorders in the general population and its impact on treatment.

J Stud Alcohol can’t imagine my life without him now. Unrealistic it’s on my mind ALL THE distract myself. I don’t know what to do. I’m so 219-24.

I’m1988; sure,49:but I really do love him. I still get chills FUCKING TIME. It’s sad and angry and I have no one to talk to and the 12

Domination

When the predecessor to DSM-IV, DSM-III, was introduced in 1980 the duration of symptoms necessary for a diagnosis of generalized anxiety disorder was 1 month and there was a diagnostic hierarchy that excluded the diagnosis if a depressive, phobic, or panic disorder was present.21 This hierarchy was soon recognized to be inappropriate as the concurrent presence of other disorders was the norm rather than the exception22 so the criteria for diagnosis were changed. However, if the symptoms of generalized anxiety disorder occurred only in the course of a mood disorder, the hierarchy still applied. Subsequent enquiry has suggested that the hierarchical relation is not fully representative for all patients, because patients with anxiety and depressive symptoms have greater morbidity than those with a mood disorder alone.23 The duration of symptoms necessary for a diagnosis of generalized anxiety disorder was raised from 1 to 6 months in later editions of DSM and ICD, in recognition of its status as a chronic illness, although there is little difference between patients who have a duration of symptoms of 1-6 months and those who qualify for diagnosis when their symptoms cross the 6-month threshold.24 Assessment Anxiety is a relatively easy symptom to detect in both primary and secondary care settings; the diagnostic difficulty lies in its interpretation. The scope for the use of screening or other instruments to aid the diagnosis or to assess the severity of generalized anxiety disorder is therefore restricted. A simple symptom-based algorithm to aid diagnosis of anxiety disorders has been proposed (figure 1).25 One of the most widely used scales is the Hospital Anxiety and Depression Scale, which includes anxiety and depression sub scales, is both sensitive and specific in identifying pathological anxiety,26,27 and asks questions about symptoms that can distinguish people who have anxiety symptoms associated with other medical conditions. The best-known instrument used in research is the Hamilton Rating Scale for Anxiety28 but this instrument might include too many physical symptoms, is not simple to use, and alternatives are becoming widely employed; some of these are more specific to generalized anxiety disorder than the Hamilton scale.29,30 All these instruments are useful in recording the severity of anxiety quantitatively but are not diagnostic assessments. The formal diagnosis has to be made by clinical or structured interview.30,31 Origin and neurobiology Anxiety is a normal human emotion that has analogues throughout the animal kingdom; to some degree, anxiety is probably of biological value. The higher prevalence of generalized anxietydisorder in women (almost double that of men) suggests an advantage of greater anxiety in the protection of offspring. However, patients with generalized anxiety disorder could have a specific cognitive bias that leads to increased attention to threat-related information and to misinterpretation of ambiguous stimuli as threatening: this bias has been shown to diminish with both cognitive behavioral therapy31 and after selective serotonin reuptake inhibitor (SSRI) treatment.32 In 1977 it was discovered that the benzodiazepines interacted with a specific binding site in the CNS, which suggested that a natural substance (endogenous ligand) associated with benzodiazepines must be present in the brain. This binding site was found to be an integral part of the y-aminobutyric acid A (GABAA) receptor complex, which was isolated and sequenced in 1987.33 GABAAis known to have 19 subunit variants, each encoded by a differentgene; GABAA receptors are divided into eight different classes by sequence differences of the subunits.

The a1 subunit seems to be responsible for the sedative, amnestic, and anticonvulsant properties of benzodiazepines, whereas the a2 subunit appears to be involved in anxiolytic effects. The role of the a3 subunit is unknown. The a5 subunit has high density in the hippocampus and is involved in memory. GABAAreceptor subtype agonists could therefore exert anxiolytic effects with a reduced risk of unwanted side-effects such as sedation.34 Tiihonen and colleagues35 showed decreased binding of a radiotracer ligand for GABAA receptors in the left temporal pole-an area involved in experiencing and controlling fear and anxiety. The GABAA receptor complex is affected by a cluster of genes on chromosome 5,36 but there is no evidence of any chromosomal abnormality specifically associated with generalized anxiety disorder.

There could be abnormalities of serotonergic and noradrenergic neurotransmission in patients with generalized anxiety disorder.36,37 for example, giving metachlorophenylpiperazine (a non-spe-

only person I want to talk to and tell me things are going to watching, themselves? How could you share something so entirely be right never will.Association.

He’s not right for that and he never so. selfish another person?

21 all American Psychiatric Diagnostic and Statistical Manual of willingly Mental Disorders, Thirdwith Edition.

Washington DC: American Psychiatric Association, 1980. will be for just I neverE,have been forcriteria him. We don’t Iawas 22 Boyd JH,me, Burke JD,like Gruenberg et al. Exclusion of DSM-III: studyjust of co-occurrence of hierarchy-free syndromes. Arch Gen Psychiatry 1984; 41: comfort each other.

We’re not good at it.

I debate breaking so curious, I have watched eight close friends in my life suffer with issues 983-89. up Zimmerman with him everyday because I want anxiety these horrible could of addiction withhierarchy drugs and alcohol.

At this point none of 23 M, Chelminski I. Generalized disorder in patients how with major depression: is DSM-IVs correct?

Am J Psychiatry 2003; 160: 504-12. feelings out relationship away. But somebody them areanxiety evendisorder 21 andevidence one of them isNational alreadyComorbidity dead. OneSurvey 24 Kesslerrevolving RC, Brandenburg N, Lane M, ettoal.go Rethinking the they duration requirement for generalized from the won’t and I know this and I love him so much, so without inject a has completely overcome her issues, another is incredibly Replication.

Psychol Med 2005 35: 1073-82 him I’d beDS, even more lost.

It’sDJ, justethard that he isn’tguidelines here for substance dedicated to rebuilding his life. Another doesn’tfrom believe their 25 Baldwin Anderson IM, Nutt al. Evidence-based the pharmacological treatment of anxiety disorders: recommendations the British andAssociation he doesn’t make an effort to try and be there for me. so harmful issues are that severe, that they’ll overcome all of this in time for Psychopharmacology. J Psychopharmacol 2005; 19: 567-96.

And I hate AS, thatSnaith when try to makeAnxiety this clearer, he just Scale. gets Acta intoPsychiatr Scand with1983; willpower.

One doesn’t seem understand the effects 26 Zigmond RP.I The Hospital and Depression 57: 361-70. mad and frustrated.

As always my attempts be honest of Depression the drugsScale. she An does has on her behavior and another 27 Bjelland I, Dahl AA, Haug TT, Neckelmann D. Thetovalidity of the Hospital Anxiety and updated literature review. J Psychosom Res 2002; with acknowledges her addiction issues but isn’t ready to take 52:people 69-77. I care about end with them being offended by what I’ve said. steps towards recovery yet. The last two are so eerily similar 28 Hamilton M. The assessment of anxiety states by rating. Br J Med Psychol 1959; 32: 50-55. in the way thatQuestionnaire.

I don’t think either them wants to 29 Meyer TJ, Miller ML, Metzger RL, Borkovec TD. Development and validation of the Penn State Worry Behav Resof Ther 1990;really 28: 487-95.

2014-01-13 up their habits, but they understand they’llself-report have to put 30 Newman MG, Zuellig AR, Kachiti KE, et al. Preliminary reliability and validity of the give Generalized Anxiety Disorder Questionnaire IV: a revised WILL I EVER REALLY ACCOMPLISH them aside if they want support from anybody who isn’t a diagnostic measure of generalized anxiety disorder. Behav Ther 2002; 28: 215-33.

ANYTHING???

AllMillar I didN,today a parking dealer or adisorder. fellowBehav user. Res Ther 1995; 33: 927-35.

31 Mogg K, Bradley BP, Whitewas J. A gain follow-up study of ticket, cognitive bias in generalised anxiety hide myK, honesty, ton of P,salt, andBP. barely my shit SSRI treatment on cognitive bias in generalised anxiety disorder. Psychopharmacology (Berl) 32 Mogg Baldwin eat DS, aBrodrick Bradley Effectget of short-term done.

Still nothing for my drawing book and I see I struggle with what to do with these people who make my 2004; 176:have 466-70.

Noa tomorrow.

No idea going to happen thatexpression of thelife both impossibly and incredibly satisfying.

A 1987; 33 Schofield PR, Darlison MG,what’s Fujita N, et al. Sequence and with functional GABA A receptor showsdifficult a ligand-gated receptor super-family.

Nature one.328: Oh well, better go to bed so I can wake up early to wiser person would recognize. I still hate the way people talk 221-27 renew my Tomorrow, get out for a bit after for neuropsychiatric drug about Thibault.Pharmacol Well actually, no one 34 Korpi ER,parking.

Sinkkonen ST. GABA-AI’ll receptor subtypes as targets development.

Ther 2006; 109: really 12-32 talks about him class.

And Wednesday in theP, morning, dobenzodiazepine some much receptor binding and distribution anymore.inThere’s an occasional mention from Noey, 35 Tiihonen J, Kuikka J, Rasanen et al. Cerrebral generalized anxiety disorder a fractional analysis.

MolSarah, Psychineeded LA exploring before class.

Yay. Austin, or one of the homies on Facebook, but everyone atry 1997; 2: 463-71. seems to have kind of understood glorifying is over.

Except 36 Nutt DJ, Malizia AL. New insights into the role of the GABAA-benzodiazepine receptor in psychiatric disorder. Br J Psychiatry 2001; 179: 390-96. for Julia. I worry aboutBiol that, she romanticizes him far too 37 Connor KM, Davidson JRT. Generalized anxiety disorder neurobiological and pharmacotherapeutic perspectives.

Psychiatry 1998; 44: 1286-94.

2/14/14 also doesn’t really seem to remember he Biol 38 Germine M, Goddard AW, Woods SW, Charney DS, Heninger GR. Anger and anxiety much. responsesShe to m-chlorophenylpiperazme in generalized anxietywho disorder.

Sometimes when32:I think was, she has this different image in her head that just…well Psychiatry 1992; 457-61.of my life, it all sounds like one bigAbelson awful season a CW show.

Only real, M, theCurtis episodes it neverresponse really existed.

39 JL, Glitz of D, Cameron OG, Lee MA,it’s Bronzo GC. Blunted growth hormone to clonidine in patients with generalized anxiety disorder. never end. some1991; reason I keep getting renewed. I think Arch GenFor Psychiatry 48: 157-62 of Jesse inviting meMC, over thenRC, wanting to shoot upMajor anddepression me Thibault was neverSame the genes, way she describes: confident, Arch 40 Kendler KS, Neale Kessler Heath AC, Eaves LJ. and generalized anxiety disorder. (partly) different 13 environments?

Generalized Anxiety Disorder

cific 5HT1 and 5HT2 agonist) to patients with this illness has been found to increase anxiety.38 Additionally, the reduced growth hormone response to clonidine (an a2 adrenoceptor agonist) seen in patients with generalized anxiety disorder suggests decreased a2 adrenergic receptor sensitivity, although this response was also seen in patients with major depression.39 Genetic studies suggest that generalised anxiety disorder and major depression could have a common genetic basis and that the environment affects their manifestation.40 Advanced genetic studies suggest that heterozygous GABAA y2 subunit knockout mice are less sensitive to benzodiazepines, and display anxiety and hypervigilance, and show decreases in GABAA ligand binding throughout the brain, compared with normal mice.41 Prevalence and Comorbidity The high prevalence of concurrent psychiatric disorders is the most damaging criticism of the diagnosis of generalized anxiety disorder (and many other anxiety disorders). Epiderniological studies in Europe suggest that the illness has a lifetime prevalence of 4.3-5.9% and a probable 12-month prevalence of 1.2-1.9%. Comorbidity with major depression is present in three out of five cases and a similar proportion have other anxiety disorders.42 Only two out of five patients seek treatment for their disorders” and for these patients the rates of full or partial remission in the long term (5 years or more) are fairly disappointing at 38-41%. Comorbidity with personality disorder is a major handicap to recovery.44,45 Comorbid diagnosis is associated with greater social and occupational impairment than generalized anxiety disorder alone and also confers a worse prognosis.45,46 Attempts have been made to regard primary generalized anxiety disorder (i.e., when generalized anxiety disorder is the initial illness that the patient has diagnosed)47,48 as fundamentally different from the secondary equivalent; comorbidity during follow-up is increased for secondary generalized anxiety disorder.49 The association of anxiety with depressive symptoms is the most difficult aspect for the clinician in forming a diagnosis. This combined disorder, which has been called “cothymia”,50 is given separate status in ICD-10 as “mixed anxiety and depressive disorder”, but only when “neither type of symptom is present to the extent that justifies a diagnosis if considered separately”.11 However, even using this restricted definition, mixed anxiety and depressive disorder is by far the most common mental disorder in epiderniological surveys and raises the 1-week prevalence of neurotic disorder to one in eight in men and one in five in women.51 The personality trait neuroticism, or negative affectivity, characterizes the link between anxiety and depression.52 Neuroticism seems to develop early in life and has led to the suggestion that the highly comorbid anxiety and depressive disorders, together with a dependent, avoidant, or obsessional personality, are part of a general neurotic syndrome8,53,54 and should be separated from single disorders that are often self-limiting and have a reasonable outcome. However, even after comorbidity is taken into account, a core generalized anxiety disorder associated with substantial social dysfunction still exists.42,55,56 Generalized anxiety disorder is now accepted as an illness that results in substantial morbidity and leads to poor quality of life.57,58

Outcome Generalized anxiety disorder is typically regarded as a chronic illness. Most patients are still highly affected 6-12 years after diagnosis,44-45 and in one study, personality disorders showed less stability and greater improvement over 2 years than all anxiety disorders.59 Most of these studies were done in affluent countries with wide access to treatment and even here, long-term morbidity remains high. One of the problems in assessment of outcome is determination of the role of concurrent disorders such as hypochondriasis,60 social anxiety disorder,” or avoidant personality

carefree, using drugs because for a reason other and those strangers I meet sick, a desperate entertainer, and struggling. than being uncomfortable within his self or his who need someone like life (both of which I believe are the same thing.) me to reaffirm an image of I joke about being a hot mess when really I’m Hearing her say things like “Gone, but never what girls like me are like. just not sure how to reconstruct the careful forgotten” and somehow STILL bringing him image I’ve made out for myself. I don’t know Psychiatry 1992;to 49:smack 716-22.her. She didn’t even There is no way I will find how much longer I can pretend to be this up Gen makes me want 41 Lesch K-P.old Gene-environment interactions generalized anxiety disorders.who In: Nutt Rickels K,person Stein DJ, without eds. Generalized Disorder.

Symptomatology, know how he was turning this year.in He’s always someone canDJ, put losingAnxiety everyone in the process pathogenesis and management.

Martin Dunitz, 71-87. been on the younger side, little Thibs wasLondon, little for2002;up with all of this. That of telling the truth.

42 Wittchen H-U, Jacobi F. Size and burden of mental disorders in Europe-a critical review and appraisal of 27 studies.

Eur Neuropsychopharmocol 2005; 15: 357a reason. I liked that when he was around I wasn’t person does not exist the76. youngest in the room. I WISH everyone would because I made them up, When I think about what I want going out from 43 Kessler RC, it, McGonagle KA, Zhao he S, etwas al. Differences in theIuse of making psychiatricthings outpatient between the on, US and N Eng J Med 1997; 336: 551-57. forget about stop pretending their happy like upservicesthis point it’sOntario. very unclear.

I have nothing 44 Dyck M, The Kellermourning MB. (2000) Factorsrather predicting thethe course of generalised anxiety disorder.

Br Jdirection.

Psychiatry 2000; 544-19. bestYonkers friend,KA, and be IR, onWarshaw their way. than truth.

I’m pointing in any I’m176: at the center of 45 Tyrerfor P, Seivewright H, public Johnson is T. over.

The Nottingham Study aofnot Neurotic Disorder predictors of 12 year outcome ofIt’s dysthymic, panic and generalised period the general It’s been over a compulsive liar but a compass. hard to figure out whatanxiety it is I Med 2004; 34: 1385-94. yeardisorder. and a Psychol half and people need to move on. I have I don’t like my own story. really want if only because there’s just no way 46 Judd LL, Kessler RC,Not Paulus MP, Zeller PV, Wittchen JL. Comorbidity and as a fundamental featureever of generalized anxiety disorders: results from been trying.

Sort of. really sometimes.

I getHU, Kunovac It’s embarrassing I could really find what I’m looking for.the National Comorbidity Studyin(NCS).

Acta Psychiatr ScandI 1998; 98 (suppl and 393): 6-11. bogged down when he’s my dreams or when awkward most of the In reality, I am that girl. I have a checklist and 47 Winokur G. The concept of secondary depression and its relationship to Comorbidity.

Psychiatr Clin North Am 1990; 13: 567-83. see someone who vaguely looks like him. time completely superficial. until someone fits every box everyone else is a 48 Bruce SE, Yonkers KA, Otto MW, et al. Influence of psychiatric Comorbidity on recovery in generalized anxiety disorder, socialpainful phobia, and panic I am not thinking deepand recurrence distraction, usually an incredibly one. disorder a 12-year prospective study. Am J Psychiatry 2005; 162: 1179-87. here. And the only “There’s a knife stuck in my ribs” type of pain.

12/9/14 thoughts 49 Rogers MP, Warshaw MG, Goisman RM,make et al. Comparing primary andIsecondary generalized anxiety disorder in a long-term naturalistic study of anxiety disorWhen I think of things that truly reason don’t say what I’m Depress Anxiety 1999; 10: 01-07. meders. happy, they are moments I can’t really really thinking is because 3/12/15 50 Tyrer P. The for cothymia: mixed anxiety andhappy depressionI’m as a single diagnosis.

Bran J Psychiatry describe.

Thecase moments I’ve been truly holding on to insane2001; Just 179: lots191-93. of thoughts. Very antsy. Having 51 relationships Jenkins R, Lewis G, et al. The Psychiatric Morbidity Surveyspeople of Great Britain-initial from wanting the Household Survey.

Psychol in areBebbington the onesP,where it National looks like vision that other troublefindings sleeping, to say things to Med 1997; 27: 775-89. a movie, nothing real ever makes me happy. have about me. That I’m people that I can’t seem to say properly. Getting 52 Watson, D, Clark, LA Negative affectivity: the disposition to experience aversive emotional states.

Psychol Bull 1984; 96: 465-90.

I’m in it for the show. Of course I would never strong, confident, funny, my bearings terribly slowly. Trying to move on 53 P, Seivewright H, Johnson T The core elements mixed anxiety-depression personality disorder.

Disord 2003;but 17: tellTyrer anyone that since so often I preach the of neurosis: sarcastic, witty, reliable, (cothymia) fun, andand failing.

Wishing notJ Personality to go backwards, 109-18. exact opposite and will continue to preach the helpful, ridiculous, crazy, to get to a better place. I’m going to New York 54 Khan AA, Jacobsonother KC, Gardner CO,need Prescott CA, Kendler normal, KS. Personality and comorbidity psychiatric disorders.

J Psychiatry 186: 190-96. opposite because people to better depressed, stable,of common on Monday, I’m a littleBrnervous to 2005; go back.

I left 55 Stein DJ. Comorbidity generalized anxiety impact a and implications.

Psychiatry 62 (suppl 11): 29-36.happy. Going back to where and I think I was putinon this Earth fordisorder one real mother, life JofClinthe party, 2001; there so blissfully 56 KesslerI RC, Wittchen HU. other The epidemiology of generalized anxietyher disorder.

Psychiatr Am 2001; 24: 19-40. reason. amKeller hereMB, to help make people feel wise beyond years, a itClin allNorth happened is…a little daunting actually. It’s 57 Massion Warshawwhen MG, Keller MB. Quality life and psychiatric panic disorder and generalized anxiety disorder.

Psychiatry 1993; 150: better.

I’mAO, happier everyone else of is doing drunk,morbidity mature,inchildish, become such a nice placeAminJ mind that in reality 600-07. good. I think in the end, after I help slut, prude, ignorant. On amazingly now, without him, it might be less shiny.

58 Mendlowicz MV, Stein MB. Quality of life in individuals with anxiety disorders.

Am J Psychiatry 2000; 157: 669-82. the people who need it in my world, I’m meant that list is never included 59 Sheaalone.

MT, Yen S. Stability as a distinction between I and Axis II disorders, J Personal 17: 373-86. to be I am a person who does whatAxis I do the things I really am:Dis 2003;4/27/16 60 Jr. The relationship of rarely hypochondriasis to anxiety Hosp Psychiatry 8-17. upon a time, there was a very scared girl. forNoyes otherRpeople.

I actually do anything fordisorders. deeplyGen insecure, scared,1999; 21: Once 61 Brawman Mintzer Lydiard RB, Emmanuel N, et al. Psychiatric comorbiditylonely, in patients with generalized anxietyfear disorder.

Am J Psychiatry 150: 1216-18. myself.

I am hereO,for my family and my friends pessimistic, bitter, She didn’t spiders, heights,1993; or dying, but 62 Turner SM, Beidel, 14DC, Borden JW, Stanley MA, Jacob RG. Social phobia: Axis I and II correlates. J Abnorm Psychol 1991; 100: 102-06.

Domination

63 disorder.62 Avoidant personality disorder itself is very difficult distinguish from andtosodraw the negative could be as muchthat a consequence I’m both outgrowing old fears andtodeveloping freshgeneralized ones all thesocial time.phobia, I decided up a listoutcome of some phenomena I’ve been of generalized of overofthe course mylife,asand indoing so,Ithought itwouldThere helpare givenoaclearer of whybetween Itotallywimped outother overphysical themifdisorders-the association anxiety disorder acting asafraid a precursor these otherofdisorders from the original anxiety disorder. specificidea associations anxiety and Ialso offered atimeline thedisorder exactyears when Iallowed themtokeep meup atnight. atmy fearschronologically likeinthis, I’mwith generalized with thyrotoxicosis is often cited but the anxiety inofthis is often recognized as qualitatively different from otherLooking spontaneous anxieties.

Mortality is raised patients 65 noticing thatfrom theysuicide. have changed over When I wasanxiety a little kid I wasisscared of simple, quotidian thingsalthough such as centipedes; nowofthat anxiety disorder,” but not specifically The cost of time: care for generalized disorder high because of its chronic nature, the cost (mainly consultations with I’mis older they revolve around murkier, morelife-centric stuff like66professional aspirations, social insecurities, andmy statusasorawoman in syndrome is non-psychiatric clinicians) less than that of panic disorder or post-traumatic stress disorder.

The cost of treatment for anxiety with comorbid depression general neurotic aworldthatisn’talwaysawesometowomen.

67 Enjoy,andpleaseexcusemewhileIgohideundermybed. nearly twice that of a single diagnosis of generalized anxiety disorder.

Balloons,1992–1998.

a younganxiety birthday partyremains dissident, I refuseddiagnosis, any andwhich all balloons they around long, and ve never reallydiagnoses been one Some clinicians argue thatAs generalized disorder an ill-defined supportsbecause the notion thatdon’ it wast hang constructed to support theI’validity of other in the anxiety group rather forabrupt goodbyes.

If awell-meaning adulttried toforce aninflatable onAmerican baby-me, IwouldAssociation’ totallyplotz—it wasand likeStatistical theyWANTED than being a useful homogeneous clinical entity.8 Generalized anxiety disorder was almost excluded from the Psychiatric s Diagnostic Manual of Mental Disorders, me 9 to have to grieve for it later when it invariably popped, deflated, or flew away. I would look at other kids at our town street fair and Fourth Edition (DSM-IV) classification in 1994, on the grounds that its diagnostic status could be faulted on the grounds of poor reliability.

Supporters of this diagnosis argue that, its overlap with think, Whytheanxiety hellwould you clamor toon hold ontocategorizations, somethingthat’ sjustthe goingtoleave youheartbroken?

Whatare you,some kindofdespitedisorder. other disorders, a diagnosis of generalized disorder is an advanceknow previous that it has durationtohas created aone more homogenous Additionmasochist?

Well,maybe Ididn’ tactually theword masochistand justthat yet,butcriterion Ididknow thata 6-month Iwasn’tgoing become myself by ally, the associated social, occupational, and economic burden is similar to that of major depression, and the increasing prevalence of generalized anxiety disorder with advanced age distinguishes it from other gettinginlinewiththeotherchumpsfutilelytyingribbonstotheirwristsasif thatwouldmaketheirballoonsstickaroundforgood.Iknew thatif Ithat everthishad onemyself, would loseit,anditwouldbeentirelymyfaultforbeinginsomewayirresponsible(eventhoughthenature anxiety disorders, which suggests diagnosis will notIbe abandoned.

of balloonsisthatthey’reephemeral).

I’ve always felt intense guilt over many frivolous and dumb things. I think this is related to my terror at the thought of being left behind, evenbyadisposableMylarcircle.Insomeof myearliestmemories,myparents,whoweregoingthroughsomeshitatthetime,werenot always thebest atpickinginmepursuit upfromplaces when theysaidalways theywould,andwas Iwasgood oftenthe atkid drinking, standingwith and astrange, I did kind welladult in certain outside ways. I could she was afraid of losing herself of the things of various buildings,her waitingformyIt mom tocomecollectme.

Yes,Isublimated myfear of abandonment intoballoons.Thisfear,likeits having ajustleaked almost hold that were supposed make happened object,to gradually deflatedhappy. intonothing—I gotolderandallthe helium outofalways it,Iguess.

Icanalcohol benormaldown. aroundballoonsnow, beer in a a lot, the promise and expectations of the beginning youguys.Ipromise!Pleasedon’tdisinvitemefromyourbirthdayparties. were crushed swiftly and immediately. It made her feel red plastic I started drinking when I was 14 and for six years probably Sleepovers, 1996–2001. cup. more than at ready a time insane, that nothing was permanent ornot stoic, Whilemy parents weredefinitely stellareverything atpickingmeup fromThe schoolorwent soccerno practice, they knew10todays beatthe inre:without scoopinghaving a drink, or more days getting drunk. could crumble.me up and taking me home whenever I decided I wantedparties to sleep at someone else’sthan house14 during mywithout grade school years. Like manyFor about 3 children,Ilovedhavingfriendsandwantedtobearoundthem alot,soIrepeatedly miscalculated myability handle sleepovers.

Here’ would years, my main focus in to my social life was A)sfinding people a little reproduction of the thought progressions that led me to shakily dial my home phone number from somebody’ s kitchen cordless She wanted to feel full of and instead be full of who had alcohol I could drink and B) finding somewhere sometime nearexperiences midnightoneach failedlove, attempt: of hollow like a tree that had been struck by lightning harmless, to drink alcohol. While I wasn’t really an alcoholic, I was Fearmoments of being the only awakeshe person insatiated, a house full of sleeping peersfun andobsessed having to bewith alonedrinking. in your weirdwasn’t head while everyone else shallow it everyday, so I didn’t twice. There were where felt is dreaming in their Beauty and the Beast sleeping bags, and they’which re probably evenittogether not only hereIbut also indoing the dream, just from think wasfun, a problem. periods of intense lust companionship that seemed high-fi vingand on a ring of Saturn or something amazing and just getting it—how to have how to be effortlessly and appropriately partheart. of afriendship packtime andalsoalways justof liferevealed ingeneral.Why I would aren’tyou abletoaccess thismassheavy-breathed peacefulnessthatthey’re right to her young Passing allsharing with oneshe another insteadtooffor staring atand theceiling,which isinvariablyNow, oneofover thosesix horrible textured onesthatlooks likepeaksof gather years ofominous, consistent I’ve probably the deep fatal flaws those clung lifeown creamof cheese, or maybe little craters on your lonely-ass non-Saturn planet which is actually just this dark,drinking, foreignIhouse? of with had good have purpose. She wasn’t greatwhy at making friends, but Furthermore, didn’tyouhave thegood tastewas tobringadozens sleepingbag aradmore moviebad thingthan onitinstead ofexperiences. uncriticallyaccepting this been oldgreenan oneeclectic fromyourcircle parents?ofYou areverystrange verystupidto andsexually thisisnotyour place,andand maybealso nowhere becauseyouinaresituations assaulted beenis,involved talented at collecting burdens andandpictures badthe atthese simple, partsofthat beingwould apersonwhodocument knowshowtoexist otherpeople. my beliefs. I have vomited, blacked thatwith compromised their stories. Allso for sake of asimple memoir myinviting glorious out,else experienced panic attacks made multiple poor probably never Fear materialize, despite a natural ability andtacitly of goingtothe bathroom and,withyour absence, everyone intheroom,which isbasically halfand of everyone you atthatpoint(noboys,inmypersonalexperience,buthigh allyour girlfriends fromschoolorwherever) toinsult lackofand anything school communication choices withyour friends romantic desire to write. know resembling style (see: green bedroll), your rabid and enthusiastic insistence on discussingIyour favorite animal, the zebra, andon your overall years.

I partners. have fallen asleep alone an outdoor stairwell inabilitytobeamongtherestof them,therealfriends.Atthetime,youdonotyetrealizethateveryonehasthissamefear,albeitinvarying thought in theasmiddle of awords crowd at music festivals.

There had onlysizes ever been one(You person whoan seemed and intensities. weresharing experiencetowiththem afterall!,youand willrealize youwritethese inthe nextdecade, and I have had thenshit youimmediately becomeveryherself sad). with. these were really bad reactions to mixing drinking and various types cut through all the she surrounded of medication.

And often, thewhen initial Though she was only boyparents wasagain? special.

Fear of are16, youshe everknew goingtothis seeyour If yes,the willitpeople bethreehours aftertheappointed pickup timedespite foreveryone, thedesire for andherfamily surehow proceed I could tomakeyousocialization feelnot-terriblebecause brought it’sbeen onsoby long alcohol, andit’sobvious I drink your alone.

He brought uphostess something kindaren’ oftreally magical intoher, a intrying reluctant babysitters have other plans, or at least they did before your lesser-than upbringing, which is now clear to them, totally bulldozed tolerate fearlessness andtheir sheer determination what day?What areyouwillingtotoletget people knowshe aboutyou and your life?

About all your fear? wanted. She wanted him, but the timing was wrong. creating So 41 days ago, I stopped. I didn’t consciously mean to answer to thoseplayers last two questions “nothing” many years during thisdrinking,” period and long afterward I always madeasana result of a vision “quit it just kindstill, ofsohappened There were tooThe many related on the was field and inforthis excuse aboutstomach painbefore rushing intothecarof one of my chantingthesameapologies reprised roughly biweeklyatwhere I start with, myparents, few isIthe part of the an attempt to feel desired byweekend many, shefor was left around 11:30on nights years, sickalone withtheshame of knowing how,incidences. justhoursearlier,(This Ihadbegged and insisted andstory bitched ofI didn’sounding less cool, confident andsindependent by everyone. about how I wasn’t going to do it this time. I always did itband that time. t start feeling comfortable sleeping at people’ houses until I than I’d starteddoingitdrunk,whichmadeitremarkablyeasier,if less memorable.In theto.) interim period, mostly tookabreak fromsleeping onbeen in and intellectual like One of Ithe longest relationships I’ve thefloors of finished awhile. but for outsiders. out of was with a boy who I was really good friends with She had never cried over losingbasements anyonefor before, before any feelings happened. Our friendship came out of him she felt a profound sadness because neither party Chalk,1996–present.

Ican’ttouchtechnically chalk.Thethought of having to,even asIwriteReality this,ismakingmy fingernailslove itchand myteethclamp together.

Why would very deep a mutual a good astand weirdly had really done anything wrong.

Itthat was hersuch anyone be OK with a writing utensil leaves an excruciatingly unpleasant residueconnection, onfor theirhaving hands?and How cantime, anyonealcohol toconsumption, excessive previous actions and her overeager honesty that caused the of course emotional ended particularly of really cheap wine. If we had “a song” it’d be romance to end as quickly as it had begun. up being Drunk in Love, minus the actual being in love part because things with that part never quite clicked. But we remained I drink and smoke excessively. I rely too much on alcohol a little different. pretty after we brokePsychol up, which wasn’t the and now ITA. actGeneralized bizarre onsocial it. I phobia wish Iversus drank less, way less. disorder 63 Widiger avoidant personality a commentary on close three studies.

J Abnorm 1992;maybe 101: 340-43.

Instead1998; of 173: best11-53. idea in hindsight, but it’s hard to lose your boyfriend And the smoking is just escape for inane conversation 64 Harris EC, Barraclough B. an Excess mortality of mental disorder. Br J Psychiatry parties,with it suicidal and best friend in oneattempts fatal blow I lingered and heSurvey. didn’tJ thatSareen makes me want the not so GJG. ironic graphic 65 J, Houlahan T, to Coxclaw BJ, Asmundsson Anxiety disorders associated ideation and suicide in theso National Comorbidity was small really leave me alone either. I started noticing a kind of an teeNerv shirtsMent off Dis of 2005; everyone talking about the latest set of 193: 450-54. groups embarrassing over the 10 months repetitive electronic beats.

It’s the thatburden boresof the 66 Greenberg PE, Sisitsky T, Kessler RC, conversation et al. The economic anxiety disorders in the 1990s. pattern J Clin Psychiatry 1999; 60: 427-35.since we split, I gathered was really only drinking inyears situations where we were meKnerer everyG, time.

The group of boys all have theP.potential 67 Byford S, Johnson T, Seivewright H, Tyrer The Nottingham Study of at Neurotic Disorder predictors of 12 costs. Acta Psychiatr Scandboth 2005; in 112: houses that a group with our mutual friends.

And when I was doing it, to be intelligent and well-rounded.

The intellect, while 224-32. we prayed it was somehow more acceptable for us to still hang out and extensive, only covers the areas of certain musical acts, the prospects of upcoming socializations, and the various would stay talk platonically. empty until I’m in so much pain. I miss my friends. I miss my friends’ effects of prescription and recreational drugs. eleven as friends. I miss possibility.

I don’t know exactly why I fell into this crowd of people. we quickly downed the I miss feeling comfortable in my home and my town.

Before high school I had never thought of any of them cheapest with more than fleeting acknowledgement of their vodka we But I don’t miss being with somebody who made me existence and the occasional bonding over in-class could find. horribly nervous all the time. One day, I’m going to write that activities. But then I was enchanted with the idea of becoming a “party girl.” In my mind this meant having It became epic novel that encapsulates those turbulent two years o my apparent life. It’ll be intense and make for a terrible film adaption. long straight hair, wearing yoga pants and cropped sweatshirt to parties in order to show off my hotness, and early on I 15

Generalized Anxiety Disorder

scrape and grind a stick of it against the sidewalk, or, god forbid, a chalkboard,aka the world’s foremost sensory torture device? My muscles are clenched in fear after typing that sentence. Everything about chalk is wrong. It’s a tactile nightmare.I’msogladIwenttoschoolinatimewheremarkerboardsweremorecommon,becausedoingmathproblems attheboardwashorribleenoughwithoutmyhavingtogetmyfingersalldustyinthatsingularlyrevoltingwaythatfeltlike itwouldneverwashoff.Absolutelyfuckchalk,youguys.It’stheworld’sworst.

PeoplethinkingI’mstupid,1998–present.

IlikeitwhenotherpeoplemispronouncewordsbecauseI’mjustsquirmingforthechancetotellotherswhatLINGUISTICALLY-INHIBITED DUMMY-PEOPLE they are at every turn. Just kidding, that’s not why at all, but oh my god,canyouimagine?Instead,I’mafanof chainsawed-to-piecespronunciationsbecausetheycallthisreallyendearing image to mind, of a person reading a new word in a book and then tentatively testing it out for the first time out loud EVENTHOUGHtheyweren’tsureif theyweresayingitrightsincetheyhadneveractuallyhearditsaidbyahuman voice before. I like that kind of tenacity! Save for, of course, in myself. I know it’s atomic-level dumb to be so vain about somethingsotrivial,butyo!Yourgirlhereisatotalnarcissist,andthat’showwetendtowigglethroughlifewhenwe’renot busyinfrontof reflectivesurfaces.

WhileIthinkit’scutewhenotherpeoplebunglethesyllablesof crepuscularorharpsichord,IrememberhowmortifiedI waswhenmyhighschoolboyfriendpointedoutthatthewordfacetiouswasn’tactuallypronounced“fuh-KETTY-us.”

EversincegradeschoolI’vefeltthispachyderm-size(the“ch”theresoundslikea“k,”bytheby,whichIalsolearnedthe hardway)pressuretodemonstrateintelligenceasmuchaspossibleasoftenaspossible.BeingaroundpeopleIfindinterestingorsmartfeelslikethebiggestprivilegetome,andsometimesIworrythatI’mthreesecondsawayfromslippingup and revealing my true self—the LINGUISTICALLY-INHIBITED DUMMY PERSON I really am—when I’m inimpressivecompany.AndIcan’tevenTALKaboutthetimeswhenIaccidentallymisusewordsandthenIrealizeita minutelater,whenit’stoolatetocorrectmyself withoutcallingmoreattentiontomymistake.Mispronouncingwordsin front of people I like is probably worse than just straight-up wetting myself would be, and I’m not being fuh-ketty-us in theslightest:Iwouldactuallyprefertomisfiremyurinethanmywords.

Havingalienobjectslodgedinmyfeet,1998–present.

Myphysicalreactiontofearisoftenasharpdiscomfortinthesolesof myfeet.Itdoesn’tfeellikeyouraveragestingingor achingorbruising—it’sascratchy,dullsensationof havingtoomuchthere,likesomethingunnaturalhasintrudedupon and disrupted the makeup of my body. I sometimes get this sensation in my mouth, and it makes me bite the insides of mycheeksandbecomeviscerallyawareof myteeth.Thefootsensationaccompanieseveryflareof fear,andIthinkit originatedwithaspectacularlyawfulsplinterIgotatthebeachwhenIwasseven.

I was with my mom walking on a wooden pathway to the shore when I got it lodged all up in my unsuspecting foot.

Imagine a splinter thick and wide like a Scrabble tile, but double the length and sharp on the edges, and you might understand why I didn’t stop screaming for the entire hour it took the First Aid tent to remove the errant wood chip from outta my zone. The nurse, like me, had never seen one that big before, and since his tweezers were hopeless against its horriblegirth,hehadtocarveoutsomeof mysurroundingfoot-skinwithabladeinordertogetitgone.ThingsIdonot recommend: Beingsevenandhavinga sizablechunk of fleshremovedfromyoursolewith a sterilized knifewhen you expectedtobeswimmingorcollectingclamshells.

The next time this fear was realized was also courtesy of the ocean, that most beautiful of total feet-scarring monsters. I had gone a whole twelve years successfully avoiding podiatric invasion, but then I had to go and accidentally kick a sea urchin. My family had just arrived in St. Croix on a vacation to celebrate my grandparents’ 50th anniversary, and after tossing our suitcases on the floor, we dunked our persons into the gorgeous, sequined ocean with relish. I had been in the water for five perfect minutes, but then the business end of my foot met its pointy little match. 12 spiky needles shot into my heel at once. Screaming underwater produces a terrifying and frustrating nothing of a sound, so it felt like ages before my Uncle Jimmy saw me thrashing around and rescued my incapacitated ass. I had to wear crutches, on the beach, for the whole rest of the week because the really fun parts of urchin-related injuries are that a) you can’t remove theneedles,whichIfoundoutafterwaitinginadoctor’sofficeforthreehourstonoavail,andb)puttingpressureonthem inawaylike,oh,say,walking,isexcruciating.Butthedisappointmentof theruinedvacationwasfishfecescomparedto having to wince through life with something else’s biological matter in my feet alongside just my own. UGH IT WAS SOTERRIBLE.AlthoughIhatedsushiatthetime,whenIgothomeIimmediatelysoughtoutsomeuni,orglobsof gooey urchin innards, and ate it in grim revenge. Take that, ya idiot Koosh balls of the sea! In short, stay the hell out of myfeet,EVERYTHING. Driving,2001–present.

Ilearnedtodriveinmydad’swhiteFordExplorerSUVoverthecourseof afewafternoonswhenIwasabout12,which ishowIalsolearnedthatIabsolutelycouldnotdoit.Mybodyseemeddisconnectedfromthesimpleinstructionsitwas given; despite being told ad infinitum not to do so, I drove with two feet on each pedal—one for gas, one for brake. My hands,insteadof indicatingacalm,controlledtenminutesuntiltwoo’clockonthewatchfacethatmydadinstructedme tomentallylayerontopof thesteeringwheel,bothhoveredtentativelyatsix,exceptwheneverIhadtoturn,whenIwould

16

Traditional Treatment jerkthebottomof thewheelawhole90degreestooneside.Iswerved,brakedsoabruptlythatthewholerigseemedto Epidemiology

bucklikeanobduratehorse,anddisregardedthespeedometerentirely.Iunderstoodthatthesethingswereverywrong, but I couldn’t stop doing them, and the inability to command what I perceived as a giant, fast-moving death machine wasterrifyingtome. justafewminutes, Igotout of thecar,vowing thatI’d aneternal passenger fromprevalence thenonout. is 3.1%1.

The lifetime prevalence of After generalized anxiety disorder (GAD) isbe5.1%.

The 1-year 1 immense fear of driving. The maybe-unrelated-but-alThere are plenty of factors to consider when I try to parse my Women are affected about 1.9 times as often as men. associated mood disorders, most-definitely-relevant-because-how-could it-not-be one, theGAD one thatisthefrequently aspiring psychologists amongwith you might the most fun with,substance is that both of my parents were car dealers for a very long time, and my dad actually still is nowother anxietyhave disorders, and adays.

He’s always been astonishinglyabuse. successful at this because he’s a preternaturally talented salesman. He genuinely seemstoneedpeopletobehappy,no,elated,aboutthecarsthey’redriving,andhe’salwayssureof exactlyhowtomake that happen. Because of this passion, they rightfully trust him to show them what’s best for them. Although I tried my hardesttodothesame,tofollowhisconfident,knowledgeableleadintheafternoonswherehe,averycapabledriver,tried Treatment toshowmewhattherightwayof doingthingswas,Icouldn’tmakeithappen,nomatterhowmuchIwantedto.Tothis I say: What the FUCK, brain? Cars are like a part of my family’s genetic makeup; there’s practically motor oil intermingledwithourblood.SowhydoIloathedrivingsomuch?

Initial therapyAfter may consist of thelessons, administration oftime a Ibenzodiazepine forparents 2 to tried 6 weeks my first set of doomed the next, and last, drove a car was when my to goador me buspirone into my permit,months. although I really only had to drive formedications about a few minutes of the first session.

After botching several hydrochloridegetting for several Antidepressant need to be taken 3 to 4 weeks K-turnsandnearlystudent-drivingthetrainingcarrightoff theroad,Iturnedtomyyoungishinstructorandsaid,“Look, before the Ican’tIfactually dothis.I’mare terrifiedof driving, andsince itdoesn’t affectayou eitherwayif IlearnorCognitive not,canyoujusttherapy drive onset of action. used, initially paired benzodiazepine. is also arounduntil thisisthey over?”Ididn’toften reallythink thatmyplea wouldwith fallonreceptive ears,butinsteadof laughingitoff,he said, “Sure. Let’sswitch seats. Wanttohearmydemotape?”Weparked,swapped, hepoppedin theveryHoobastank- and effective for GAD; it may behome better thanand pharmacotherapy.

The of cognitive therapy and Incubus-cover-centric recording, wepatronizedthedrive-thru of acombination Wendy’sinlieuof continuing ouruseless lesson.Ispentthenextfewsessionsthisway,eatingburgersandpretendingtolikethe2dude’sshittymusicsoIdidn’thave todrive,untilthe lastsession,over whenhe triedtotouchwith myboob andImadehim bringmeThere homeimmediately .If Iwaswillmedication improves outcome treatment medication alone. is no well-designed study of ingtoendurebrokenly-strummed acousticHoobastankcoversonrepeatwithmyarmslockedovermychestinorderto 3 ImustREALLYbeafraidof operatingautomotivemachinery.Needlesstosay,Istill outof thepilot’s seat, youknow the long-termstay treatment of GAD. can’tdoit.Infact,partof whyIliveinNewYorkCityissoI’llnever,everhaveto.GodblesstheMTA. Theapocalypse,2003–present.

Have you seen the movie 28 Days Later, starring ultimate sex hottie Cillian Murphy? It portrays a lawless, dystopian inwhichyoucan’tturnyourheadwithoutgettingchompedbyadiseasedex-humanzomboid.ITISSOSCARY, Buspirone world AAAH,MYGOD.Iwatcheditatmyfirstgirlfriend’shouse,andwhenbythetimethecreditsstartedtorollIwasimmobile with horror. I couldn’t turn off the DVD, even after the menu screen popped up. I spent the rest of the night trying nottostareatthewords“SceneSelection”asthebackgroundloopedahackles-raisingprogressionof handsclawingat Among patients with GAD who take 54% havewould significant improvement stormy windowpanes, thinking aboutbuspirone, what our chances of survival be if thoseclinical windows were the ones near mycompared girlfriend’s bed. I also thought about my4inability to hurt other living things (even if the situation called for it) or to run for 5 two seconds wheezing. AsBuspirone my girlfriend slept, I realized that I would never be able to save herefficacy. if society Buspiwith 28% of about patients whowithout take placebo. and benzodiazepines have similar collapsed,andIfeltareal,palpableguiltaboutthatscenario. rone is effective only if taken regularly. Adverse effects-headache, nausea, and dizziness-are mild and TheonlytimeIwasafraidof deathwaswhenIpicturedfightingformylifeinabrutish,anarchicworldwhereeveryone around me was vying to hold on tobuspirone theirs, too, anddoes where, not despiteimpair our desperate efforts, only a few of usperformance, had even the infrequent. Unlike memory, cognitive or remotestbenzodiazepines, chanceof survival.Religious-type doomsdayscenes weretoounrealistic toscareme, butIcouldn’treadabout global warming or the imminent collapse of capitalism without wanting to immediately board up my apartment. driving skills. It has no sedative-hypnotic effects. Buspirone has no potential for dependence, withdrawal publishingmyfirstnovelattheageof 19likeTrumanCapote,2005–2010. symptoms, orNot rebound anxiety after drug withdrawal.

Inwriter, onesoobservational study, I have always hoped that someday I could become a published I am constantly trying to pushbuspirone my words intowas shown theworldandtohaveotherpeopleconsume theminasmanyformatsaspossible.Iwanttodothisforever,andIusedto to be safe to want use the forofficial as long 1 year.

Probably less partof as forever tohave6 started threeyears ago.relapse occurs after buspirone treatment than after Letbenzodiazepines. me explain: When I was 14, my greatest goal was to have my professional and creative timeline match up with the treatment with career of my then icon, Truman Capote, who published his beautiful debut novel, Summer Crossing, when he was 19, and IAnxiety knewthatif IScale workedhardenoughIcouldhavemyownnovelavailableatabookstorenearyoubythetimeIturned The Hamilton 19,too.

ExceptIdidn’t.

Now thatI’vebeen writing foralittle longer, abletoseetrials, theflawscontains inthisplan.I14 know thateverywriter and everycareer The Hamilton Anxiety Scale, often used inI’m clinical symptoms (7my psychic and 7 isdifferent, andcomparing myown progress with others’willalmost alwaysdisappoint meandsnarlup priorities,the first of which should be allotting myself the time necessary to make my writing great—or at least honest. But for a little somatic), each fromof0my tolife,4this points severity.

The for the psychic andto somatic lessrated thanaquarter deadlinefor dominated mylife, andImaximum torturedmyselfscore relentlessly .Everything Iwrotehad beperfect,soIneveractuallycompletedapieceof writing(exceptforsomeseething,self-destructivejournalentriesabout sections is 28what each, and pupa the maximum combined score is 56.

TheWhen average has a total abrainless Iwasfornotbeing abletowritelike Ithought Icould).

Ifinallyperson turned19,bookless andrawscore of less fromanxiety,myfearof beinganythinglessthanaCapote-esqueprodigyhadovertakenallof thejoythatIusedtofindin writing Lookingbackclinically onthisperiod,significant I’msohappythat thedeadlinehaslongsincepassed,andthatIcanjustwrite than 5; a score of fiction.

15 represents anxiety.

1 Kessler RC, McGonagle KA, Zhao S, et al. Lifetime and 12-monthprevalence of DSM-III-R psychiatric disorders in the United States: resultsfrom the National Comorbidity Study. Arch Gen Psychiatry 1994;51:8-19.

2 Barkovec TD, Whisman MA. Psychosocial treatment for generalizedanxiety disorder. In: Mavissakalian MR, Prien RF, eds. Long-TermTreatments of Anxiety Disorders. Washington, DC: American Psychiatric Press; 1996: 171-200. A review of11 randomized controlled trials (RCTs) of the treatment of GAD. 3 Mahe V, Balogh A. Long-term pharmacological treatment ofgeneralized anxiety disorder. Int Clin Psychopharmacol 2000;15:99-105.

4 Gammans RE, Stringfellow JC, Hvizdos AJ, et al. Use ofbuspirone in patients with generalized anxiety disorder and coexistingdepressive symptoms: a meta-analysis of eight randomized, controlled studies. Neuropsychobiology 1992;25:193-201. A meta-analysis of 520 patients ineight double-blind RCTs that assessed the use of buspirone versusplacebo.

5 Pecknold JC, Matas M, Howarth BG, et al. Evaluation ofbuspirone as an antianxiety agent: buspirone and diazepam versus placebo.Can J Psychiatry 1989;34:766771. A double-blind RCT of 119 outpatientswho had GAD. 6 Rakel RE. Long-term buspirone therapy for chronic anxiety: amulticenter international study to determine safety. South MedJ1990;83:194-198. The study compared 264 patients treatedfor 6 months with 424 patients treated for 12 months.

7 Pittler MH, Ernst E. Efficacy of kava extract for treatinganxiety: systematic review and meta-analysis. J Clin Psychopharmacol 2000;20:84-89. A meta-analysis of 198 patients in 3 double-blind RCTs.

17

Generalized Anxiety Disorder

Benzodiazepines withoutworryingthatI’moverthehillatthestill-greenageof 22.R.I.P.,thisfear,Ihopeyourotinhell.

LSD,June30,2007.

IBenzodiazepines wokeupearlyonthemorning of myintroduction toacidwithnoidea wastocome.

Infact, plansfortheday and occasionally are effective, but long-term usewhat carries the risk ofmydependence involved a wholly different first time I had been planning for months: seeing Morrissey, former frontman of the Smiths and current superhero of my heart and life, in concert.

My then-boyfriend, Craig (not his real name), and I were about addiction.

The longer-acting agents least likely toforcause These tohoponthebus toNew YorkCityataround seveninare themorning toqueue 12hoursdependence. soIcouldgetagood spotforinclude the show.

Just before we left, Craig glanced at his email, which brought us the crushing communiqué that the show hadeffects include chlordiazepoxide hydrochloride, diazepam, hydrochloride.

Side beencanceledbecauseMoz’s voiceboxwasmalfunctioning.

I,of and course,flurazepam immediatelytook tobed,wailinginconsolably . sedation, impairment ofmeperformance, transient and After a few hours of trying to coax out of my Morrissey-less hysteria,anterograde Craig suggested amnesia, we make thedisinhibition, day special in another way. We drove to our drug-dealer buddy’s parents’ house, the entire basement of which the dealer naturally ocdepression.

These should be used caution inWe patients history cupied,sharingitwith someagents hulkingreptiles, aPlayStation, andwith afreezer fullof LSD. decidedtowith dropforathe firsttime of substance rightthenandthere.

After afewbecause hoursof trying coaxrisk meback somelesser stateof all-encompassing Morrisseyless Craigsugabuse of tothe of into central nervous system depression andhysteria, addiction.Withdrawal gestedwemakethedayspecialinanotherway.Wedrovetoourdrugdealerbuddy’sparents’house,whereheoccupied, naturally, the entire basement, sharing it only with some hulking reptiles, a PlayStation, and a freezer full of acid. was rarely cause seizures are most likely with short-acting benzodiazepines. BenzodiazepinesItalone raining,sowedecidedtodroprightthenandthereforourfirsttime.Ihaddonemushroomsafewtimesbefore,butonly after thorough consideration and planning, with someone sober hanging out with me in case I needed to be calmed fatal and overdose, but towhen with central nervous depressants, they can be down, plenty of room explorecombined the outside world and other ~the wonders of nature~ safely system while I tripped.

Not in a stinky, windowlessbasementwithaniguanacageinthecornerafterwhatseemedlikethemostcolossaldisappointment lethal. of atleastalltime,andcertainlyneverasimpulsivelyasonthisparticularnight.Whenthedrugswhooshedthroughmy system,Iwantedbadlytogooutside,butnotbymyself intherain.Theguys,conversely,wantedtoplayGuitarHeroand notlistentometalkabouttheSmiths.Isatonthehardcarpetinfrontof theTV,fullyfreakingoutaboutthevastdisconnect betweenthemusicalexperienceIthoughtI’dbehavingthatnightincomparisonwiththetwoplasticmini-guitarshoverAntidepressant ingjustabovemyeyelevelDrugs andhackingupaPrimussong.Iwenttothebathroom,gazedatmyself inthemirrorthrough agalaxyof ratherpermanent-lookingtoothpastespeckles,andsaidaloudandwithENORMOUSdread,“Thisisyou.

YouareAmyRoseandthisiswhatyourwholelifehasbeenbuildingupto:thisshittyacidtrip.Youarewillfullybyyourself inabathroom inorderhave toescape beingforced tolistenwith toGuitar momentbealessonmedications, tousall:DoNOTparticularly Several studies shown benefit theHero.” use Let ofthis antidepressant giveadevastatedMorrisseyacolytetwotabsof acidaftershe’sspentthedaywithhertear-puffedfaceinapillow.It’sgonna end with some fatalistic bathroom monologues about inescapable loneliness, which sheAlthough feels she deserves because of imipramine hydrochloride, in generalized anxiety disorder. benzodiazepines provide BadChoices,plusalsoshewillrefusetocomeoutformadhours,if mycaseisanyindication. greater relief of symptoms during the first 2 weeks of study, antidepressants show equal or better WhenIdidallowmyself toleavetheconfinesof thekindof bathroomwhosecleanlinesswasdictatedbyanaciddealer who wore the same pair of probably-once-they-were-white cargo shorts roughly every day year-round, it was only berelief thereafter. causeCraig promisedmewewereleaving.Iprobablywouldn’thaveleftmytubof despairhadIrealizedthathemeantin aCAR(seeabovemotorvehicle-basedfear,whichwasbadlyexacerbatedbythedrugs)withsomefriendsof hiswhom Ididn’tlike,andwhomhealsohadforgottentotellweweretripping.ThisoversightonlybecamecleartoeveryoneonceI hadrepeatedlyaskedtogetoutinthepouringrainsixishtimesinthefive-minuteridehomeandthenstartedscreaming after the dudes keptKava (rightfully) being like, “Uh, no, what is going on here, why are you so fucking petrified?” We finally Botanicals: Extract got home and ended the day in the same place it had begun so hopefully, except now I felt terrible instead of hopeful andhappy,andthatwaskindof exactlywhatIdidnotneedatthatparticularjunctureof being16andVERYmiserable.

If you’regonnadoacid, don’tdoitimpulsively andafter disappointment, because youmayanxiety endup Kava superior to placebo foraheart-decimating the treatment of TO anxiety; lowers terrifiedinextract adrybathis orshrieking “PULL OVERRIGHT NOW ORI’MGOING DIE”atitsome guysyoubarely by a mean of 10 know over something as small-potatoes as a popular musical video game.

7 Man,Iwassoshakenbyallof this.THANKS points more than,YA placebo on HAM-A scale A LOT, MORRISSEY BIG JERK (ohthe my god just kidding i love you i would love you even if you made me play guitarheroondrugswithyouforaweekstraight) Don’t do acid, kids, but if you’re gonna do acid, don’t do it on a whim after a heart-decimating disappointment, or you mayendupterrifiedinadrybathand/orshrieking“PULLOVERRIGHTNOWORI’MGOINGTODIIIIIE” Referral to barely a Psychiatrist, atsomeguysyou know.It’snotthatPsychologist, funof atime,trust. or Therapist Walking outside atnight,2007–2008.

Consider referral for any patient who wants cognitive therapy. Patients refractory to medical therWhenIwasinmylastyearof highschool,mytacticalstrategyforfumblingmywayhomefrompartieswasheavilyinfluenced bymy constantcompanion andbestafter friend.Shewasterrifiedofof every passingcar, herlogicbe being thatanyperson apyhad or with relapse therapy should referred toIna psychiatrist who the galltorecurrent beoutafterdark inoursmalltownwithdrawal wasdefinitelyalsocapable of kidnapping orraping usorworse. ordertoavoidwhatshepicturedasaconstantbarrageof attacks,shemadeusdiveintowhateverhedgeswereavailable, regardlessof potentialinjuryorthorns,whenevershesomuchassensedanapproachingheadlight.Thefirstfewtimes she made me scramble into the sanctuary of neighborhood bushes, which always got severely damaged as a result of twointoxicatedteenagebodiesstumblingaroundinthem,Irolledmyeyesandtoldhershewasbeingridiculous,butas it turns out, paranoia can be very contagious if you’re stoney bologna (as we so often were). Her skittishness made an impressiononme,andsoonenough,Iwastheoneslammingourbodiesintothelong-sufferingshrubberyof ourroute home,eventhoughnothingsinistereverevencameclosetohappeningtous,oratleast,itdidn’tthen.

18

Restriction

Pharmacotherapy

AyearorsolaterImovedtoNewYork,aplacewithverylittleinthewayof bushestohidein,butplentymoreintheway of actual predators, thanmysuburbeverhad.AlthoughManhattanisa far safercitythan mostmovieswould haveyou believe, Ididexperience manylate-nightinteractions thatIdidn’texactly wantintoabereduction havingwhilewalking homefroma Pharmacologic treatment of generalized anxiety results in you symptoms party, likestreetharassment andsoon—being hisseddisorder atbyastranger whocould potentiallyreallyhurt hasawayof wearing down your nerves.

My new college friends and I traveled 8 in groups a lot that first year, which is always a smart and disability and improved health-related quality ofnight, life.having Studies provide support forprevent the some effiidea for a young person in ANY city after dark.

But one six friends around me totally didn’t dudefromgrabbingmythroatandslammingmeagainstabrickwalloutsideof asubwaystationatdusk,quietlytelling cacy of most (but all)inantidepressants, several benzodiazepines, buspirone, and pregabalin me,not with rage his voice, that he was going to “fucking kill me.” My friends screamed and froze, which is what I had imaginedthatIwoulddoinmydaymaresaboutthisverytypeof situation.Instead,whatIdiddowasdrivealitcigarette9 in the of generalized anxiety disorder (Table 3). into his neck as hard as I could and then,treatment when he ran, chase him down the subway steps until he hopped the turnstile anddisappeared.

TheinstantIcouldn’tseehimanymore,Ibegantofeelagain.Istartedcryingimmediately,mostlybecauseIwasflooded with sadness about having had to hurt someone, which speaks to the ridiculous degree to which young women are conditionedtothinkthateven defendingyour lifeissomething youneedtofeelguiltyabout.

Selective serotonin-reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inAs I sat in my dorm room that night, trying to sort out everything I felt, the real shock of it all wasn’t the attack haphibitors (SNRIs) considered to be first-line forthat generalized penedare inthegenerally firstplace:Iknew thatwomenand girlsare physicallypharmacotherapies harmedbymenallthetime,hence thefear’sexistence in the first place.

The truly impactful part of the experience was that I immediately knew what to do to protect myself, 10,11 anxiety disorder, with response rates inanother the range ofis30 A recent even though myreluctance tohurt livingthing suchto that50%.

I’llstartsobbing if apersonmeta-analysis tellsmehewantstosugmurder me and I have to do something physical to them to prevent that. The actual ~worst-case scenario~ had totally just gested the possibility of but publication reporting in clinical trialsIwould. of these agents the gonedown, Ihadhandledand itverycapably insteadbiases of goinglimp, asI’dimagined Although Istartedfor carrying pepper spray after this to sate my parents, I was never truly afraid of walking around at night again, even alone. Since Ihaven’tbut ruined asingle hedge,concluded a fact,which,devoid context,biases mightmean nothingtodid someone buttoto me,a treatment of then, anxiety, the authors thatofthese probably notelse, lead issomethingof whichIamvery proud.

12 systematic inflation of effect sizes. No SSRI or SNRI has been shown to be superior to any Notspendingenoughtimewithmyparents,2009–present.

When I wentof to college, I anticipated a few years of never having to hang out withofmydrug parents,should save for holidays.

Our other in the treatment anxiety disorder, so and the beplaces based relationship was allgeneralized frayed and fucked up from addictions (theirs) anchoice insistent lack of empathy about the of pain those come from and how hard it must have been for them (mine).

I refused to temper my judgment of their family on cost and onhistories, the patient's prior response or how themuch physician's particular what incredibly young parents theytowere, work they hadfamiliarity both done to getwith sober aand try to make thingsright—anything,really,butmyowncanyonof hurtaboutthewholemess. agent. When SSRIs and SNRIs are used they administered My self-imposed estrangement planfor lastedgeneralized for approximatelyanxiety six monthsdisorder, before I started beingare accosted by fears to the tune of WHAT IF I NEVER SEE THEM AGAIN? The distance between us had created an inverse vortex of the at the same doses those for thefeeling treatment of major depression, with theneed same expectamostas intense loveIused couldremember forthemsince childhood.

Iwassothrownby thisfresh forcloseness that IactuallybeganCALLINGthem.ByCHOICE.Imagine!

I once feared death only in theand context of a global apocalypse, I realized at 18 that myanticipated parents were getting older, tion of time toWhere response (4 to 6 weeks) with the same precautions and adverse andIpanicked.Today,Ilovethemmorethanever.Iwanttocramasmuchof theirlivesintomineasIcan.Isometimes 13 get so freaked out and guilty about projecting this way onto them, though— it makes me feel totally queasy and weird whenIcatchmyself aggressivelypushingtheideathatallof ourtimebequalitytimeonthem,eventhougheffects. allIactually wanttodoislistentomymomtalkaboutherthesisandwhatthedogdidthatdayinsteadof havinganexistentialcrisis.

It’sreallyfun!SeeyouafterIgotextmydadfourtimesinarowrealquick!

The evidence base is growing forforever. the use of SSRIs and SNRIs for the treatment of anxiety House centipedes, alwaysand Have you seen them? If not, don’t go Google a picture unless you hate not wedging a pair of14leggings under the crack disorders, including generalized anxiety disorder, inbecause children and adolescents.

However, these of your bedroom door before you go to sleep at night you accidentally remembered what one looked like and suddenlyneedtocreateaperma-sealbetweenyourself andthemwithwhateverhappenstobeclosesttoyouatthetime, if that’sbe a pair of Lycra-based coverers thatand you somehow think might off hell-bugs.

(They won’t.) What medicationseven should prescribed tolegchildren adolescents onlystave when psychological apawfulthingsthesecentipedesare.No,Idon’tcareawhitthatthey’reharmlesstohumans,don’tyouevenstartwithme rightfailed, now. and only then by experienced behavioral pediatricians or psychiatrists. proaches have ThatIdidn’tdoagoodjobwiththisessay,August,2013.

Inwritingthisbite-sizeencyclopedia(en-FRIGHTs-lopedia?…OK,Idon’tthinkthatpun’sgonnahappen),Iworrythat I have been too cavalier,trials or not cavalier enough, thataIbenefit have not accurately described how it feels toantideprestruly be afraid or how Several randomized, controlled haveand shown a newly marketed intertwined thatfeelingis withanxiety insecurity .Mostof all,of Iworry thatmywriting, hereandelsewhere,isn’tdoing the main job I want it to do, which is to make you (and lots of others,15too, but also you specifically) feel like I could be a sant, vilazodone,good in patients generalized anxiety disorder, but this agent has no known friendtoyou,with orthatsomeone elseislike you.I’mhoping thatI’mwrong.

Inwritingyouthis,I’mactivelytryingtogetovernotonlythatfear,butalsothesameonethatexpelledmefromsleepovers, advantages over hounded generically SSRIs involving withinageneralmeasIavailable triedtocopycat Capote,or andSNRIs. everytimeTrials Ifeltotherwise terrifiedofpatients beingaperson worldwhereexternalhorrorslikechalkandballoonsareinfinitesimalincomparisontothehorrorsmyownbrainsooftentriestoimpose onitself.While parts ofconsistently somefearsnevertruly goaway (oratleasthaven’t formejust yet),part of climbingupthroughmy ized anxiety disorder have not shown efficacy of certain other antidepressants, years of fears is also a gradual ascent past the biting insecurity that I’m less in control of my decisions and other mental

8 Wilson H, Mannix S, Oko-osi H, Revicki DA The impact of medication on health-related quality of life in patients with generalized anxiety disorder. CNS Drugs 2015;29:29-40 9 Ravindran LN, Stein MB. Anxiety disorders:somatic treatment. In:Sadock BJ, Sadock VA, Ruiz P, eds. Kaplan &Sadock comprehensive textbook of psychiatry. 9th ed. Philadelphia:Lippincott Williams &Wilkins, 2009:1906-1914.

10 Reinhold JA, Rickels K Pharmacological treatment for generalized anxiety disorder in adults:an update. Expert Opin Pharmacother 2015;16:1669-1681 11 Kapczinski F, Lima MS, Souza JS, Schmitt R Antidepressants for generalized anxiety disorder. Cochrane Database Syst Rev 2003:CD003592CD003592 12 Roest AM, de Jonge P, Williams CD, de Vries YA, Schoevers RA, Turner EH Reporting bias in clinical trials investigating the efficacy of second-generation antidepressants in the treatment of anxiety disorders:a report of 2 meta-analyses. JAMA Psychiatry 2015;72:500-510 13 Taylor WD Depression in the elderly. N Engl J Med 2014;371:1228-1236 14 Strawn JR, Welge JA, Wehry AM, Keeshin B, Rynn MA Efficacy and tolerability of antidepressants in pediatric anxiety disorders:a systematic review and meta-analysis. Depress Anxiety 2015;32:149-157 15 Gommoll C, Durgam S, Mathews M, A double-blind, randomized, placebo-controlled, fixed-dose phase III study of vilazodone in patients with generalized anxiety disorder. Depress Anxiety 2015;32:451-459

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16a list of some phenomena I’m both outgrowing old fears and fresh onesmarketed all the time. Ivortioxetine, decided to draw up including bupropion anddeveloping the and idea these agents thatI’vebeenafraid of overthecourse of myrecently life,andindoing so,Ithoughtitwouldhelpgiveaclearer of why Itotallyare not recommen 17 wimped outoverthem iftricyclic Ialsoofferedantidepressants atimelineof theexactyears when Iimipramine allowedthemtokeep meupatnight.

Looking The efficacy of such as is similar to that atmyfearschronologicallylikethis,I’mnoticingthattheyhavechangedovertime:WhenIwasalittlekidIwasscaredof of SSRIs, but tricyc simple, quotidian things such as centipedes; now that I’m older they revolve around murkier, more life-centric stuff like antidepressants have a less and favorable safety profile.

Their inawesome treating generalized anxiety diso professional aspirations, social insecurities, my status as a woman in a world that isn’trole always to women.

Enjoy,andpleaseexcusemewhileIgohideundermybed. is currently uncertain, though they may be useful in persons who have had a response to them in th Balloons,1992–1998.

As ayoung partydissident,in Irefused anyandwho allballoons because theydon’t hangaround andI’ve reand maybirthday be considered patients do not have a response tolong, SSRIs ornever SNRIs.

allybeenoneforabruptgoodbyes.If awell-meaningadulttriedtoforceaninflatableonbaby-me,Iwouldtotallyplotz—it was like they WANTED me to have to grieve for it later when it invariably popped, deflated, or flew away. I would look atotherkidsatourtownstreetfairandthink,Whythehellwouldyouclamortoholdontosomethingthat’sjustgoingto leaveyouheartbroken?

Whatareyou,is some kindof masochist?

Well,maybe Ididn’t actually knowthe wordmasochist Referral psychiatrist indicated formyself patients who dowith not a response to SSRIs or SNRIs just yet, but Ito did aknow that I wasn’t going to become one by getting in line thehave other chumps futilely tying ribbons to theirhad wristsadverse as if that would make their balloons stickdrugs aroundthat for good.

I knewnot that ifbeI ever had one myself, I who have effects from these could managed, or when the clinical pic would lose it, and it would be entirely my fault for being in some way irresponsible (even though the nature of balloons isthatthey’reephemeral). complicated by a coexisting condition (such as a substance-use disorder or suicidality).

In such ins I’vealwaysfeltintenseguiltovermanyfrivolousanddumbthings.Ithinkthisisrelatedtomyterroratthethoughtof being left behind, even by a disposable Mylar circle. In some of my earliest memories, my parents, who were going through es, or adjunctive therapies may be prescribed; include buspirone somealternative shitatthetime,were notalwaysthebest atpickingme upfrom placeswhentheythese saidthey would,and Iwasoften (a nonbenzodiaz the kid standing with a strange, kind adult outside of various buildings, waiting for my mom to come collect me. Yes, I sublimatedmyfearof abandonment intoballoons. fear,likethat itsobject, graduallyto deflated intonothing—I gotfor oldergeneralized anxie nonantidepressant azapirone class This of drug appears be effective only and all the helium just leaked out of it, I guess. I can be normal18 around balloons now, you guys. I promise! Please don’t disinviteme from yourfor birthday parties. order and not other anxiety disorders), and quetiapine (not FDA-approved for generalized a 19 Sleepovers,1996–2001. disorder, butwere its definitely use is not similarly supported byschool dataorfrom randomized trials).

Treatment with quetia Whilemyparents stellaratpicking meupfrom soccerpractice, theyknewto beattheready in re: scooping me up and taking me home whenever I decided I wanted to sleep at someone else’s house during my or other atypical antipsychotic agents should be undertaken with due regard to gradeschoolyears.Likemanychildren,Ilovedhavingfriendsandwantedtobearoundthemalot,soIrepeatedlymiscal-the adverse metab culatedmyabilitytohandlesleepovers.Here’salittlereproductionof thethoughtprogressionsthatledmetoshakilydial effects of this drug and kitchen with close of theonpatient's weight, lipid levels, and glycate myhomephone number fromclass somebody’s cordlessmonitoring sometimenearmidnight eachfailedattempt: Fearof beingtheonly awake personinahouse fullof sleeping peersand havingtobeefficacy aloneinyourof weird headwhileevhemoglobin level.

Although limited data have suggested antihistamines such as hydrox eryoneelseisdreamingintheirBeautyandtheBeastsleepingbags,andthey’reprobablyeventogethernotonlyherebut also ingeneralized the dream, just high-fiving on a ring of Saturn or something amazing and just getting it—howbecause to have fun, how for anxiety disorder, these agents are not recommended of their tendency to s tobeeffortlesslyandappropriatelypartof afriendshippackandalsojustof lifeingeneral.Whyaren’tyouabletoaccess 20of staring at the ceiling, which is thismass heavy-breathed peacefulness thatthey’re allsharing withoneanother instead and the absence of longer-term data to support their use. invariably one of those horrible textured ones that looks like peaks of cream cheese, or maybe little craters on your own lonely-assnon-Saturnplanetwhichisactuallyjustthisominous,dark,foreignhouse?Furthermore,whydidn’tyouhave thegoodtastetobringasleepingbagwitharadmoviethingonitinsteadof uncriticallyacceptingthisoldgreenonefrom yourparents?Youareverystrangeandverystupidandthisisnotyourplace,andmaybenowhereis,becauseyouareso Benzodiazepines suchaperson as diazepam andtoclonazepam (both of which are long-acting agents) badatthese simple,simplepartsof being whoknowshow existwithotherpeople.

21 in the and, treatment of generalized disorder, but because of concerns about Fearefficacious of going to the bathroom with your absence, tacitly invitinganxiety everyone else in the room, which is basically half of everyoneyouknowatthatpoint(noboys,inmypersonalexperience,butallyourgirlfriendsfromschoolorwherever) toinsult yourdependence, lackof anythingresembling style(see:greendo bedroll), rabidandenthusiastic insistence ondiscussing and some physicians notyour administer them for generalized anxiety disorder an yourfavoriteanimal,thezebra,andyouroverallinabilitytobeamongtherestof them,therealfriends.Atthetime,youdo notyet realizethatdisorders. everyonehasthisMost samefear, albeitinvaryingguidelines sizesandintensities.

(Youwere sharing anexperiencewith should be used on anxiety prescribing suggest that benzodiazepines themafterall!,youwillrealizeasyouwritethesewordsinthenextdecade,andthenyouimmediatelybecomeverysad). basis (3your to parents 6 months), time that after is inconsistent withtime thefortypically chronic na Fear ofshort-term are you ever going to see again? If ayes, will itframe be three hours the appointed pickup everyone, whenthehostess andher familyaren’tHowever, reallysurehowmany toproceed intryingtomake youfeelthat, not-terrible because generalized anxiety disorder. specialists believe with close monitoring, benz it’s been so long and it’s obvious your reluctant babysitters have other plans, or at least they did before your lesser-than upbringing, which is now clear to them, totally bulldozed their day? What are you willing to let people know about you pines are a reasonable and yourlife?

About allyourfear? option in selected patients (i.e., those without current or past alcohol-use o The answer to those last two questionsfor was “nothing” many yearsagents during thisare period and long afterward still, so I al- with a poor side substance-use problems) whom for preferred ineffective or associated waysmadeanexcuseaboutstomachpainbeforerushingintothecarof oneof myparents,chantingthesameapologies Ireprised roughly biweeklyatarounddata 11:30on weekend nightsconcern foryears,sickregarding withtheshame ofincreased knowinghow,risk justhours profile.

Observational have raised an of dementia associat earlier,IhadbeggedandinsistedandbitchedabouthowIwasn’tgoingtodoitthistime.Ialwaysdiditthattime.Ididn’t 22 Istarteddoingitdrunk,whichmadeitremarkablyeasier,if less startfeeling comfortablebenzodiazepine sleepingatpeople’shouses until long-term use, but it is unclear whether this relationship is causal. Benzodia

16 Kapczinski F, Lima MS, Souza JS, Schmitt R Antidepressants for generalized anxiety disorder. Cochrane Database Syst Rev 2003:CD003592-CD003592 17 Mahableshwarkar AR, Jacobsen PL, Serenko M, Chen Y A randomized, double-blind, fixed-dose study comparing the efficacy and tolerability of vortioxetine 2.5 and 10mg in acute treatment of adults with generalized anxiety disorder. Hum Psychopharmacol 2014;29:64-72 18 Chessick CA, Allen MH, Thase M, Azapirones for generalized anxiety disorder. Cochrane Database Syst Rev 2006:CD006115-CD006115 19 Kreys TJ, Phan SV A literature review of quetiapine for generalized anxiety disorder. Pharmacotherapy 2015;35:175-188 20 Guaiana G, Barbui C, Cipriani A Hydroxyzine for generalised anxiety disorder. Cochrane Database Syst Rev 2010:CD006815-CD006815 21 Ravindran LN, Stein MB The pharmacologic treatment of anxiety disorders:a review of progress. J Clin Psychiatry 2010;71:839-854

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memorable.

Inthe period,Imostly tookabreakfromsleeping floorsof are finished basementsforagents) awhile. such asinterim diazepam and clonazepam (both on ofthewhich long-acting nded. Benzodiazepines 21 Chalk,1996–present. are also efficacious in the treatment of generalized anxiety disorder, but because of conclic I can’t touch chalk. The thought of having to, even as I write this, is making my fingernails itch and my teeth clamp together.Why would anyonebeOKsome withawriting utensilthatdo leaves such anexcruciatingly unpleasant residueontheir and dependence, physicians not administer them for generalized ordercerns about misuse hands?Howcananyonestandtoscrapeandgrindastickof itagainstthesidewalk,or,godforbid,achalkboard,akathe world’s foremost sensoryanxiety torture device?

My muscles are clenched in fear afterguidelines typing that sentence.

Everything about and It’s other disorders.

Most prescribing suggest that benhe pastanxiety disorder chalkiswrong. atactilenightmare.

I’msogladIwent toschool inatimewhere markerboards weremore common, because doing math problems at the board was horrible enough without my having to get my fingers all dusty in that zodiazepines should beway used only a short-term basis (3fuck tochalk, 6 months), time frame singularly revolting thatfelt likeiton would neverwashoff.Absolutely youguys.It’sathe world’s worst. that Peoplethinking I’mstupid, 1998–present. is inconsistent with the typically chronic nature of generalized anxiety disorder. However, IlikeitwhenotherpeoplemispronouncewordsbecauseI’mjustsquirmingforthechancetotellotherswhatLINGUISTICALLY-INHIBITED DUMMY-PEOPLE they arebenzodiazepines at every turn. Just kidding, not why at all, but oh my believe that, with close monitoring, arethat’s a reasonable option or many specialists god,canyouimagine?Instead,I’mafanof chainsawed-to-piecespronunciationsbecausetheycallthisreallyendearing to mind,(i.e., of a person reading a new current word in a book and then tentatively testing itother out for the first time out loud patients those without or past alcohol-use or substance-use cture is in selectedimage EVENTHOUGHtheyweren’tsureif theyweresayingitrightsincetheyhadneveractuallyhearditsaidbyahuman I likepreferred that kind of tenacity!

Save for, of course, in myself.

Iassociated know it’s atomic-level dumb to beside-effect so vain about forbefore. whom agents or how withthrough a poor stanc- problems)voice something sotrivial, butyo!Yourgirl hereisaare totalineffective narcissist,andthat’s wetendtowiggle lifewhenwe’renot busyinfrontof reflectivesurfaces. profile. Observational data have raised concern regarding an increased risk of dementia zepine, WhileIthinkit’scutewhenotherpeoplebunglethesyllables of crepuscularorharpsichord,IrememberhowmortifiedI long-term benzodiazepine use, but is unclear whether this relationship is waswhen myhighschool boyfriendpointedout that22the worditfacetious wasn’tactually pronounced “fuh-KETTY-us.” ety dis-associated with EversincegradeschoolI’vefeltthispachyderm-size(the“ch”theresoundslikea“k,”bytheby,whichIalsolearnedthe hardway)pressureto demonstrate intelligence aswith muchas possibleas oftenaspossible.because Beingaround people Irisk findintershould not be used opioid medications of the of anxietycausal. Benzodiazepines estingorsmartfeelslikethebiggestprivilegetome,andsometimesIworrythatI’mthreesecondsawayfromslippingup and revealing mythe true self—the LINGUISTICALLY-INHIBITED DUMMY PERSON I really am—when I’m and use these agents should minimized in thewords elderly, inIrealize whom apine drug interactions, inimpressive company .Andof Ican’t evenTALK about thetimesbe when Iaccidentallymisuse andthen ita minutenot later,when it’stoowith latetocorrect myself without calling more attention my Mispronouncing wordsin should be used opioid medications because oftolikely themistake. risk of drug benefits. risks such as falls are to outweigh bolic front of people I like is probably worse than just straight-up wetting myself would be, and I’m not being fuh-ketty-us in theslightest: Iwould prefertoagents misfiremyshould urinethanbe myminimized words. interactions, and the useactually of these in the elderly, in ed Benzodiazepines as diazepam and1998–present. clonazepam (both oftowhich are long-acting Havingsuch alienobjects lodged inmy feet, whom risks such as falls are likely outweigh benefits. agents) Myphysicalreactiontofearisoftenasharpdiscomfortinthesolesof myfeet.Itdoesn’t xyzine 21 feel like your average stinging or achingorbruising—it’s ascratchy,dullof sensation of havingtoo muchthere, likesomething unnatural hasintruded upon are also efficacious in the treatment generalized anxiety disorder, but because of conand disrupted the makeup of my body. I sometimes get this sensation in my mouth, and it makes me bite the insides sedate of mycheeks and becomeviscerally awarephysicians of myteeth.Thedo footnot sensation accompanies everyflare ofgeneralized fear,andIthinkit cerns about misuse and dependence, some administer them for originatedwithaspectacularlyawfulsplinterIgotatthebeachwhenIwasseven.

I was with myother mom walking on adisorders. wooden pathway to theprescribing shore when I gotguidelines it lodged all up in my unsuspecting foot. anxiety disorder and Most thatmight benImagine a splinter thickanxiety and wide like a Scrabble tile, but double the length and sharp on thesuggest edges, and you understand why I didn’t stop screaming for the entire hour it took the First Aid tent to remove the errant wood chip from zodiazepines should short-term (3 to months), a were timehopeless frame thatits outta my zone.be Theused nurse,only like me,on hadanever seen one thatbasis big before, and6since his tweezers against are also horriblegirth,hehadtocarveoutsomeof mysurroundingfoot-skinwithabladeinordertogetitgone.ThingsIdonot is inconsistent with the chronic nature offlesh generalized disorder.

However, recommend: Beingtypically sevenandhaving a sizable chunk of removedfromanxiety yoursolewith a sterilized knife when you misuse expectedtobeswimmingorcollectingclamshells. many specialists believe that, with close monitoring, benzodiazepines are a reasonable option The next time this fear was realized was also courtesy of the ocean, that most beautiful of total feet-scarring monsters. I nd other gone a whole yearswithout successfullycurrent avoiding podiatric invasion, but then I had go and accidentally kick a sea in selectedhad patients (i.e.,twelve those or past alcohol-use ortoother substance-use urchin. My family had just arrived in St. Croix on a vacation to celebrate my grandparents’ 50th anniversary, and after nly on a tossing our suitcases on the floor, we dunked our persons into the gorgeous, sequined ocean with relish.

I had been in problems) the forwater whom agents ineffective orfoot associated a poor side-effect for fivepreferred perfect minutes, but thenare the business end of my met its pointywith little match.

12 spiky needles shot ature of into my heel at once.

Screaming underwater produces a terrifying and frustrating nothing of a sound, so it felt like ages profile. Observational datasaw have raised around concern regarding an increased ofcrutches, dementia before my Uncle Jimmy me thrashing and rescued my incapacitated ass. I hadrisk to wear on the zodiazebeach, for the whole rest of the week because the really fun parts of urchin-related injuries are that a) you can’t remove 22 associated with long-term benzodiazepine but isthree unclear relationship is theneedles, whichIfound outafterwaitinginuse, adoctor’s officeitfor hourstowhether noavail,andthis b)putting pressureonthem or other inawaylike,oh,say,walking,isexcruciating.Butthedisappointmentof theruinedvacationwasfishfecescomparedto causal. Benzodiazepines should notsomething be usedelse’s with opioid medications because of the risk of having to wince through life with biological matter in my feet alongside just my own.

UGH IT WAS SOTERRIBLE.AlthoughIhatedsushiatthetime,whenIgothomeIimmediatelysoughtoutsomeuni,orglobsof e-effect gooey urchin and ate in grim revenge. that, yabe idiotminimized Koosh balls of the short, stayin thewhom hell out of drug interactions, andinnards, the use ofitthese agentsTake should in sea! theInelderly, myfeet,EVERYTHING. ted with risks such as falls are likely to outweigh benefits.

Driving,2001–present. azepines

1 2

Ravindran LN, Stein MB The pharmacologic treatment of anxiety disorders:a review of progress. J Clin Psychiatry 2010;71:839-854 Billioti de Gage S, Pariente A, Bégaud B Is there really a link between benzodiazepine use and the risk of dementia? Expert Opin Drug Saf 2015;14:733-747

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Generalized Anxiety Disorder

Ilearnedtodriveinmydad’swhiteFordExplorerSUVoverthecourseof afewafternoonswhenIwasabout12,which ishowIalsolearnedthatIabsolutelycouldnotdoit.Mybodyseemeddisconnectedfromthesimpleinstructionsitwas given; despite being told ad infinitum not to do so, I drove with two feet on each pedal—one for gas, one for brake. My hands,insteadof indicatingacalm,controlledtenminutesuntiltwoo’clockonthewatchfacethatmydadinstructedme tomentallylayerontopof thesteeringwheel,bothhoveredtentativelyatsix,exceptwheneverIhadtoturn,whenIwould jerkthebottomof thewheelawhole90degreestooneside.Iswerved,brakedsoabruptlythatthewholerigseemedto bucklikeanobduratehorse,anddisregardedthespeedometerentirely.Iunderstoodthatthesethingswereverywrong, but I couldn’t stop doing them, and the inability to command what I perceived as a giant, fast-moving death machine wasterrifyingtome.Afterjustafewminutes,Igotoutof thecar,vowingthatI’dbeaneternalpassengerfromthenonout.

There are plenty of factors to consider when I try to parse my immense fear of driving. The maybe-unrelated-but-almost-definitely-relevant-because-how-could it-not-be one, the one that the aspiring psychologists among you might have the most fun with, is that both of my parents were car dealers for a very long time, and my dad actually still is nowadays. He’s always been astonishingly successful at this because he’s a preternaturally talented salesman. He genuinely seemstoneedpeopletobehappy,no,elated,aboutthecarsthey’redriving,andhe’salwayssureof exactlyhowtomake that happen. Because of this passion, they rightfully trust him to show them what’s best for them. Although I tried my hardesttodothesame,tofollowhisconfident,knowledgeableleadintheafternoonswherehe,averycapabledriver,tried toshowmewhattherightwayof doingthingswas,Icouldn’tmakeithappen,nomatterhowmuchIwantedto.Tothis I say: What the FUCK, brain? Cars are like a part of my family’s genetic makeup; there’s practically motor oil intermingledwithourblood.SowhydoIloathedrivingsomuch?

After my first set of doomed lessons, the next, and last, time I drove a car was when my parents tried to goad me into getting my permit, although I really only had to drive for about a few minutes of the first session. After botching several K-turnsandnearlystudent-drivingthetrainingcarrightoff theroad,Iturnedtomyyoungishinstructorandsaid,“Look, Ican’tactuallydothis.I’mterrifiedof driving,andsinceitdoesn’taffectyoueitherwayif Ilearnornot,canyoujustdrive arounduntilthisisover?”Ididn’treallythinkthatmypleawouldfallonreceptiveears,butinsteadof laughingitoff,hesaid, “Sure. Let’sswitch seats.Wanttohearmydemotape?”Weparked,swapped, hepoppedin theveryHoobastank- and Incubus-cover-centrichomerecording,andwepatronizedthedrive-thruof aWendy’sinlieuof continuingouruseless lesson.Ispentthenextfewsessionsthisway,eatingburgersandpretendingtolikethedude’sshittymusicsoIdidn’thave todrive,untilthelastsession,whenhetriedtotouchmyboobandImadehimbringmehomeimmediately.If Iwaswillingtoendurebrokenly-strummedacousticHoobastankcoversonrepeatwithmyarmslockedovermychestinorderto stayoutof thepilot’sseat,youknowImustREALLYbeafraidof operatingautomotivemachinery.Needlesstosay,Istill can’tdoit.Infact,partof whyIliveinNewYorkCityissoI’llnever,everhaveto.GodblesstheMTA. Theapocalypse,2003–present.

Have you seen the movie 28 Days Later, starring ultimate sex hottie Cillian Murphy? It portrays a lawless, dystopian worldinwhichyoucan’tturnyourheadwithoutgettingchompedbyadiseasedex-humanzomboid.ITISSOSCARY, AAAH,MYGOD.Iwatcheditatmyfirstgirlfriend’shouse,andwhenbythetimethecreditsstartedtorollIwasimmobile with horror. I couldn’t turn off the DVD, even after the menu screen popped up. I spent the rest of the night trying nottostareatthewords“SceneSelection”asthebackgroundloopedahackles-raisingprogressionof handsclawingat stormy windowpanes, thinking about what our chances of survival would be if those windows were the ones near my girlfriend’s bed. I also thought about my inability to hurt other living things (even if the situation called for it) or to run for about two seconds without wheezing. As my girlfriend slept, I realized that I would never be able to save her if society collapsed,andIfeltareal,palpableguiltaboutthatscenario.

TheonlytimeIwasafraidof deathwaswhenIpicturedfightingformylifeinabrutish,anarchicworldwhereeveryone around me was vying to hold on to theirs, too, and where, despite our desperate efforts, only a few of us had even the remotestchanceof survival.Religious-typedoomsdayscenesweretoounrealistictoscareme,butIcouldn’treadabout globalwarmingortheimminentcollapseof capitalismwithoutwantingtoimmediatelyboardupmyapartment.

Notpublishingmyfirstnovelattheageof 19likeTrumanCapote,2005–2010.

I have always hoped that someday I could become a published writer, so I am constantly trying to push my words into theworldandtohaveotherpeopleconsumetheminasmanyformatsaspossible.Iwanttodothisforever,andIusedto wanttheofficialpartof forevertohavestartedthreeyearsago.

Let me explain: When I was 14, my greatest goal was to have my professional and creative timeline match up with the career of my then icon, Truman Capote, who published his beautiful debut novel, Summer Crossing, when he was 19, andIknewthatif IworkedhardenoughIcouldhavemyownnovelavailableatabookstorenearyoubythetimeIturned 19,too.ExceptIdidn’t.

NowthatI’vebeenwritingforalittlelonger,I’mabletoseetheflawsinthisplan.Iknowthateverywriterandeverycareer isdifferent,andcomparingmyownprogresswithothers’willalmostalwaysdisappointmeandsnarlupmypriorities,the first of which should be allotting myself the time necessary to make my writing great—or at least honest. But for a little

22 Billioti de Gage S, Pariente A, Bégaud B Is there really a link between benzodiazepine use and the risk of dementia?

Expert Opin Drug Saf 2015;14:733-747

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Ilearnedtodriveinmydad’swhiteFordExplorerSUVoverthecourseof afewafternoonswhenIwasabout12,whichishow IalsolearnedthatIabsolutelycouldnotdoit.Mybodyseemeddisconnectedfromthesimpleinstructionsitwasgiven;despite beingtoldadinfinitumnottodoso,Idrovewithtwofeetoneachpedal—oneforgas,oneforbrake.Myhands,insteadof indicatingacalm,controlledtenminutesuntiltwoo’clockonthewatchfacethatmydadinstructedmetomentallylayerontopof the steeringwheel,bothhoveredtentativelyatsix,exceptwheneverIhadtoturn,whenIwouldjerkthebottomof thewheelawhole 90degreestooneside.Iswerved,brakedsoabruptlythatthewholerigseemedtobucklikeanobduratehorse,anddisregarded thespeedometerentirely.Iunderstoodthatthesethingswereverywrong,butIcouldn’tstopdoingthem,andtheinabilitytocommandwhatIperceivedasagiant,fast-movingdeathmachinewasterrifyingtome.Afterjustafewminutes,Igotoutof thecar, vowingthatI’dbeaneternalpassengerfromthenonout.

Thereareplentyof factorstoconsiderwhenItrytoparsemyimmensefearof driving.Themaybe-unrelated-but-almost-definitely-relevant-because-how-couldit-not-beone,theonethattheaspiringpsychologistsamongyoumighthavethemostfunwith,is thatbothof myparentswerecardealersforaverylongtime,andmydadactuallystillisnowadays.He’salwaysbeenastonishingly successfulatthisbecausehe’sapreternaturallytalentedsalesman.Hegenuinelyseemstoneedpeopletobehappy,no,elated, aboutthecarsthey’redriving,andhe’salwayssureof exactlyhowtomakethathappen.Becauseof thispassion,theyrightfully trusthimtoshowthemwhat’sbestforthem.AlthoughItriedmyhardesttodothesame,tofollowhisconfident,knowledgeable leadintheafternoonswherehe,averycapabledriver,triedtoshowmewhattherightwayof doingthingswas,Icouldn’tmakeit happen,nomatterhowmuchIwantedto.TothisIsay:WhattheFUCK,brain?Carsarelikeapartof myfamily’sgeneticmakeup;there’spracticallymotoroilintermingledwithourblood.SowhydoIloathedrivingsomuch?

Aftermyfirstsetof doomedlessons,thenext,andlast,timeIdroveacarwaswhenmyparentstriedtogoadmeintogettingmy permit,althoughIreallyonlyhadtodriveforaboutafewminutesof thefirstsession.AfterbotchingseveralK-turnsandnearly student-drivingthetrainingcarrightoff theroad,Iturnedtomyyoungishinstructorandsaid,“Look,Ican’tactuallydothis.I’m terrifiedof driving,andsinceitdoesn’taffectyoueitherwayif Ilearnornot,canyoujustdrivearounduntilthisisover?”Ididn’t reallythinkthatmypleawouldfallonreceptiveears,butinsteadof laughingitoff,hesaid,“Sure.Let’sswitchseats.Wanttohear mydemotape?”Weparked,swapped,hepoppedintheveryHoobastank-andIncubus-cover-centrichomerecording,and wepatronizedthedrive-thruof aWendy’sinlieuof continuingouruselesslesson.Ispentthenextfewsessionsthisway,eating burgersandpretendingtolikethedude’sshittymusicsoIdidn’thavetodrive,untilthelastsession,whenhetriedtotouchmyboob andImadehimbringmehomeimmediately.If Iwaswillingtoendurebrokenly-strummedacousticHoobastankcoverson repeatwithmyarmslockedovermychestinordertostayoutof thepilot’sseat,youknowImustREALLYbeafraidof operating automotivemachinery.Needlesstosay,Istillcan’tdoit.Infact,partof whyIliveinNewYorkCityissoI’llnever,everhaveto.God blesstheMTA. Theapocalypse,2003–present.

Haveyouseenthemovie28DaysLater,starringultimatesexhottieCillianMurphy?Itportraysalawless,dystopianworldinwhich youcan’tturnyourheadwithoutgettingchompedbyadiseasedex-humanzomboid.ITISSOSCARY,AAAH,MYGOD.I watcheditatmyfirstgirlfriend’shouse,andwhenbythetimethecreditsstartedtorollIwasimmobilewithhorror.Icouldn’tturn off theDVD,evenafterthemenuscreenpoppedup.Ispenttherestof thenighttryingnottostareatthewords“SceneSelection” asthe background looped ahackles-raisingprogressionof handsclawingatstormy windowpanes,thinkingaboutwhatour chancesof survivalwouldbeif thosewindowsweretheonesnearmygirlfriend’sbed.Ialsothoughtaboutmyinabilitytohurt other living things (even if the situation called for it) or to run for about two seconds without wheezing. As my girlfriend slept, I realizedthatIwouldneverbeabletosaveherif societycollapsed,andIfeltareal,palpableguiltaboutthatscenario.

TheonlytimeIwasafraidof deathwaswhenIpicturedfightingformylifeinabrutish,anarchicworldwhereeveryonearound mewasvyingtoholdontotheirs,too,andwhere,despiteourdesperateefforts,onlyafewof ushadeventheremotestchance of survival.Religious-typedoomsdayscenesweretoounrealistictoscareme,butIcouldn’treadaboutglobalwarmingorthe imminentcollapseof capitalismwithoutwantingtoimmediatelyboardupmyapartment.

Notpublishingmyfirstnovelattheageof 19likeTrumanCapote,2005–2010.

IhavealwayshopedthatsomedayIcouldbecomeapublishedwriter,soIamconstantlytryingtopushmywordsintotheworld

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Restriction Generalized Anxiety Disorder andtohaveotherpeopleconsumethemin asmany formats aspossible.Iwanttodothisforever,andIused towanttheofficialpartof forevertohavestartedthreeyearsago.

Letmeexplain:WhenIwas14,mygreatestgoalwastohavemyprofessionalandcreativetimelinematch upwiththecareerof mythenicon,TrumanCapote,whopublishedhisbeautifuldebutnovel,Summer Crossing,whenhewas19,andIknewthatif IworkedhardenoughIcouldhavemyownnovelavailableat abookstorenearyoubythetimeIturned19,too.ExceptIdidn’t.

NowthatI’vebeenwritingforalittlelonger,I’mabletoseetheflawsinthisplan.Iknowthateverywriter andeverycareerisdifferent,andcomparingmyownprogresswithothers’willalmostalwaysdisappoint meandsnarlupmypriorities,thefirstof whichshouldbeallottingmyself thetimenecessarytomakemy writinggreat—oratleasthonest.Butforalittlelessthanaquarterof mylife,thisdeadlinedominatedmylife, andItorturedmyself relentlessly.EverythingIwrotehadtobeperfect,soIneveractuallycompletedapiece of writing(exceptforsomeseething,self-destructivejournalentriesaboutwhatabrainlesspupaIwasfornot beingabletowritelikeIthoughtIcould).WhenIfinallyturned19,booklessandrawfromanxiety,myfear of beinganythinglessthanaCapote-esqueprodigyhadovertakenallof thejoythatIusedtofindinwriting fiction.Lookingbackonthisperiod,I’msohappythatthedeadlinehaslongsincepassed,andthatIcanjust writewithoutworryingthatI’moverthehillatthestill-greenageof 22.R.I.P.,thisfear,Ihopeyourotinhell.

LSD,June30,2007.

Iwokeupearlyonthemorningof myintroductiontoacidwithnoideawhatwastocome.Infact,myplans forthedayinvolvedawhollydifferentfirsttimeIhadbeenplanningformonths:seeingMorrissey,former frontmanof theSmithsandcurrentsuperheroof myheartandlife,inconcert.Mythen-boyfriend,Craig (nothisrealname),andIwereabouttohoponthebustoNewYorkCityataroundseveninthemorning toqueuefor12hourssoIcouldgetagoodspotfortheshow.Justbeforeweleft,Craigglancedathisemail, whichbroughtusthecrushingcommuniquéthattheshowhadbeencanceledbecauseMoz’svoicebox wasmalfunctioning.I,of course,immediatelytooktobed,wailinginconsolably.

Afterafewhoursof tryingtocoaxmeoutof myMorrissey-lesshysteria,Craigsuggestedwemaketheday specialinanotherway.Wedrovetoourdrug-dealerbuddy’sparents’house,theentirebasementof which thedealernaturallyoccupied,sharingitwithsomehulkingreptiles,aPlayStation,andafreezerfullof LSD. Wedecidedtodropforthefirsttimerightthenandthere.

Afterafewhoursof tryingtocoaxmebackintosomelesserstateof all-encompassingMorrisseylesshysteria,Craigsuggestedwemakethedayspecialinanotherway.Wedrovetoourdrugdealerbuddy’sparents’house,whereheoccupied,naturally,theentirebasement,sharingitonlywithsomehulkingreptiles, aPlayStation,andafreezerfullof acid.Itwasraining,sowedecidedtodroprightthenandthereforourfirst time.Ihaddonemushroomsafewtimesbefore,butonlyafterthoroughconsiderationandplanning,with someonesoberhangingoutwithmeincaseIneededtobecalmeddown,andplentyof roomtoexplore theoutsideworldand~thewondersof nature~safelywhileItripped.Notinastinky,windowlessbasementwithaniguanacageinthecornerafterwhatseemedlikethemostcolossaldisappointmentof atleast alltime,andcertainlyneverasimpulsivelyasonthisparticularnight.Whenthedrugswhooshedthrough my system, I wanted badly to go outside, but not by myself in the rain. The guys, conversely, wanted to playGuitarHeroandnotlistentometalkabouttheSmiths.Isatonthehardcarpetinfrontof theTV,fully freakingoutaboutthevastdisconnectbetweenthemusicalexperienceIthoughtI’dbehavingthatnight incomparisonwiththetwoplasticmini-guitarshoveringjustabovemyeyelevelandhackingupaPrimus song.Iwenttothebathroom,gazedatmyself inthemirrorthroughagalaxyof ratherpermanent-lookingtoothpasteFootnotes speckles,andsaidaloudandwithENORMOUSdread,“Thisisyou.YouareAmyRose andthisiswhatyourwholelifehasbeenbuildingupto:thisshittyacidtrip.Youarewillfullybyyourself ina bathroominordertoescapebeingforcedtolistentoGuitarHero.”Letthismomentbealessontousall: DoNOTgiveadevastatedMorrisseyacolytetwotabsof acidaftershe’sspentthedaywithhertear-puffed

24

in a pillow. It’s gonna end with some fatalistic bathroom monologues about inescapable loneliness, which she feels shedeservesbecauseof BadChoices,plusalsoshewillrefusetocomeoutformadhours,if mycaseisanyindication. face

Restriction

When I did allow myself to leave the confines of the kind of bathroom whose cleanliness was dictated by an acid dealerwhoworethesamepairof probably-once-they-werewhitecargoshortsroughlyeverydayyear-round,itwasonly because Craig promised me we were leaving. I probably wouldn’t have left my tub of despair had I realized that he meantinaCAR(seeabovemotorvehicle-basedfear,which wasbadlyexacerbatedbythedrugs)withsomefriendsof hiswhomIdidn’tlike,andwhomhealsohadforgottento tellweweretripping.ThisoversightonlybecamecleartoeveryoneonceIhadrepeatedlyaskedtogetoutinthepouring rainsixishtimesinthefive-minuteridehomeandthenstartedscreamingafterthedudeskept(rightfully)beinglike,“Uh, no,whatisgoingonhere,whyareyousofuckingpetrified?”

Wefinallygothomeandendedthedayinthesameplaceit hadbegunsohopefully,exceptnowIfeltterribleinsteadof hopefulandhappy,andthatwaskindof exactlywhatIdid notneedatthatparticularjunctureof being16andVERY miserable.If you’regonnadoacid,don’tdoitimpulsivelyand afteraheart-decimatingdisappointment,becauseyoumay end up terrified in a dry bath or shrieking “PULL OVER Footnotes

25

e c b p t o o w a o friend. She was terrified of o o o RIGHTNOWORI’MGOINGTODIE”atsome

guysyoubarelyknowoversomethingas small-potatoesasapopularmusicalvideo game.Man,Iwassoshakenbyallof this.

THANKSALOT,MORRISSEY,YA BIGJERK Don’t do acid, kids, but if you’re gonna do acid, don’t do it on a whim after a heart-decimatingdisappointment,oryou may end up terrified in a dry bath and/ or shrieking “PULL OVER RIGHT NOWORI’MGOINGTODIIIIIE” atsomeguysyoubarelyknow.It’snotthat funof atime,trust.

Walkingoutsideatnight,2007–2008.

WhenIwasinmylastyearof highschool, mytacticalstrategyforfumblingmyway homefrompartieswasheavilyinfluenced by my constant companion and best Restriction Generalized Anxiety Disorder

Footnotes

26

every passing car, her logic being that any person who had the gall to be out after dark in our small town was definitely also capable of kidnapping or raping us or worse. In order to avoid Isolation

a captive of my own mind. the instigator of my

own thoughts. the more i think, the worse it gets. the less i think, the worse it gets. breathe. just breathe. drift. it’ll ease soon.

27

what she pictured as a constant barrage of attacks, Generalized Anxiety Disorder

a captive of my own mind. the instigator of my own thoughts. the more i think, the worse it gets. the less i think, the worse it gets. breathe. just breathe. drift. it’ll ease soon.

she told her she was being ridiculous , 28

but

parano can be very co nta , gious H

e s t e

r g

t

Isolation

it’s strange — in the pit of your stomach. it’s like when you’re swimming and you want to put your feet down but the water is deeper than you thought. you can’t touch the bottom and your heart skips a beat. cuts so deep it’s like they’re never going to heal. pain so real, it’s almost unbearable. i’ve become this… this cut, this wound. all i know is

this same pain; sharp breath, empty eyes, shaky hands. if it’s so painful, why let it continue? unless… maybe it’s all that you know.

29

sk tis ne GeneralizedIsolation Anxiety Disorder

no matter how much i resist, it’ll always be right here desperate to hold me, cover me, break down with me. each day i fight it, “you’re not good for me and you never will be”. but there it is waiting for me

when i

wake up and eager to hold me as i sleep. it takes my breath away. it leaves me speechless.

30

itshss Isolation

a captive of my own mind.

the instigator

of my own thoughts. the more i think, the worse it gets. the less i think, the worse it gets. breathe. just breathe. drift. it’ll ease soon.

31

Generalized Anxiety Disorder

you were created for me and by me. you were created for my seclusion. you were created by venomous defense. you are made of fear and lies. fear of unrequited promises and losing trust so seldom given. you’ve been forming my entire life. stronger and stronger.

32

Isolation

I feel EVER and I feel N

RYTHING NOTHING.

i’m afraid to live to die. what a

e and i’m afraid a way to exist.

depression is when you can’t feel at all. anxiety is when you feel too much.