The following announcement on the FDA approval of Cymbalta for treatment of Generalized Anxiety Disorder (GAD) is important on a number of fronts.

U.S. Regulators Approve Cymbalta(R) for Treatment of Generalised Anxiety Disorder | March 2, 2007 | PRNewswire

U.S. Regulators Approve Cymbalta(R) for Treatment of Generalised Anxiety Disorder

March 2, 2007 - 8:22 AM INDIANAPOLIS, February 26/PRNewswire/ --

The U.S. Food and Drug Administration (FDA) has approved the antidepressant Cymbalta(R) (duloxetine HCl) for the treatment of generalised anxiety disorder (GAD), Eli Lilly and Company (NYSE: LLY) and Boehringer Ingelheim announced today.

The approval is based on the results of three randomized, double-blind, placebo-controlled studies in which the safety and efficacy of duloxetine in the treatment of GAD was studied in more than 800 non-depressed adults. In all studies, duloxetine significantly improved core anxiety symptoms as measured by the Hamilton Anxiety Scale (HAMA), compared with placebo.(i,ii ,iii) In addition, duloxetine patients reported greater improvement in functional impairment associated with the illness, including improved ability to perform everyday activities at work, home, and in social situations.(iv,v)

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First, the studies continue the practice within the FDA of insisting on homogeneous symptoms. Participants in the studies had to have GAD and not depression. While this makes intuitive scientific sense (you exclude other disorders to see if the medication works on the target symptoms of your study, in this case GAD), it does not represent reality. In the real world, we know from epidemiological studies that fully 80% of the population who have any anxiety disorder (including, probably especially GAD) also have concurrent depression or other mental health disorders. This is called comorbidity. Insisting on a homogeneous study population thus excludes most patients who will actually begin taking the drug based upon physician prescription.

Second, it highlights the notion that most mental disorders are defined by high emotional arousal. I call this in my professional book (DBT in Private Practice) the "single factor" theory. Most major mental disorders (mood disorders, anxiety disorders, impulse control disorders, personality disorders, etc.) respond to the SSRI and SNRI class of medications. Their responsiveness to a variety of disorders suggests that our current diagnostic system (that pretends that disorders are separate and discrete phenomena (like the difference between an infection versus a broken bone) simply does not apply in mental health.

Third, it highlights the prevalence and disability that occurs with GAD. It is a disorder that severely impacts individuals ability to lead lives worth living.

The study written about in the Scientific American article below appears to be a "no brainer." Who wouldn't get depressed when their body changes in ways they can't control and they don't want? Of course I'll become depressed that I lose shape and function to my body. Of course having a disease that inflicts pain and disability will not only affect my mood, but cause me significant emotional disability as well.

Appearance related to illness tied to depression | March 2, 2007 | ScientificAmerican.com

Appearance related to illness tied to depression

NEW YORK (Reuters Health) - Appearance and physical disability are risk factors for depression in people afflicted with rheumatoid arthritis, researchers report. With systemic lupus erythematosus, commonly known as just lupus, only appearance seems to predict depression.

Physical deformities, particularly of the hands and feet, can develop with rheumatoid arthritis, whereas skin rashes and other lesions can occur with lupus, Dr. Louise Sharpe, from the University of Sydney in Australia, and colleagues note in the medical journal Arthritis & Rheumatism.

Although few studies have looked at body image concerns, there is evidence that women with these disorders have a poorer body image than unaffected women, the team notes.

The focus of their study was to evaluate the link between physical appearance concerns and psychological distress in patients with lupus and rheumatoid arthritis.

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Remembering Trauma to Beat Anxiety | March 5, 2007 | DrKoop.com

Remembering Trauma to Beat Anxiety

Ivanhoe Newswire

By Lucy Williams, Ivanhoe Health Correspondent

ORLANDO, Fla. (Ivanhoe Newswire) — Posttraumatic stress disorder (PTSD) is a potentially devastating anxiety disorder caused by exposure to traumatic events like combat, rape, assault and disaster. But prolonged exposure therapy could help trauma patients overcome a painful past.

People who suffer from PTSD may re-experience traumatic events, avoid reminders of the event, feel emotionally numb, or exhibit unnecessary outbursts of anger.

Patients who recall their trauma are more likely to overcome PTSD, according to recent research. With prolonged exposure therapy, patients vividly recount a traumatic event until they can confront their past with less emotional response.

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This article establishes the standard of care for Posttraumatic Stress Disorder (PTSD). We have known for years that avoidance and escape of our emotions serves paradoxically to escalate those very feelings we want to stop. Not only is this dynamic applicable in PTSD, it applies to a variety of mental health disorders. In fact, it is a central tenant of Dialectical Behavior Therapy (DBT), which also has been shown effective in the treatment of PTSD because it invites us to be mindful of our painful feelings rather than trying to escape them.

The notion of “unremembered” trauma is more controversial. While some people are able to engage in such incredible denial and repression that they are able to “totally forget” trauma, this really applies only to a very small number of people. Most of us remember vividly the incidents that trouble us. In fact, we can’t get the images, sounds, smells, and contexts out of our head no matter how hard we try. Sometimes people with depression and anxiety are so overwhelmed with their feelings that they presume some horrible incident would be required in their history to produce such sickening symptoms. But that is not the case.

We don’t have to have trauma in our lives to have very debilitating symptoms. Searching for a “cause” for our feelings is not nearly as productive as developing a strategy to overcome our feelings that hurt us. In PTSD the strategy is exposure (re-living the trauma in a safe and guided way, experiencing the feelings without so much of the overwhelm). In depression and anxiety, the treatment is a bit more complex and is discussed in Depressed & Anxious.

A friend of mine recently asked me, “What is the difference between CBT (Cognitive Behavioral Therapy) and DBT (Dialectical Behavior Therapy)?”

Dialectical Behavior Therapy (DBT) is a new form of treatment that assumes that conflict between competing (and frequently contradictory) emotions, wants, demands, and expectations make feelings intense and linger beyond their usefulness.

These competing needs and wants are called “dialectic conflicts” because we want to satisfy both sets of needs or wants, but because they conflict a satisfactory resolution is frequently not possible. DBT helps to identify areas of conflict. Another assumption of DBT is that invalidation of emotions (either by yourself or by others) increases the intensity of emotions. DBT helps you to accept emotions just as they are, and to form new strategies to deal with emotions such that either the environment or you change in ways that make your feelings less intense and more adaptive.

Finally, DBT assumes that high emotional intensity causes us to frequently avoid or escape our emotional experiences (because they are unpleasant). Such avoidance and escape increases emotional intensity over the long run. DBT offers new psychological coping skills to replace avoidance and escape of emotional experience.

In short, DBT is differentiated, both in theory and practice, from CBT, where DBT involves self-management of affect rather than cognitions.

For more information about DBT, please read my FAQ.

Therapists who wish to increase their understanding of Dialectical Behavior Therapy (DBT) as it can be used in private practice settings as a therapeutic orientation to treat acute mental disorders can do so through my book, Dialectical Behavior Therapy in Private Practice, published by New Harbinger Press. The text is 266 pages with almost 300 scientific and professional references to the extant literature. This publication is the first professional book to extend DBT theory and technology beyond the diagnostic and clinical application to suicidal and borderline pathologies, and thus offers a new synthesis of research and theory that can guide patient treatment.

It is with sadness that we see one of the great teachers and researchers in psychology retire. I have had the great fortune to hear many lectures by Dr. Zimbardo over the years. He is sincere, devoted to psychology as a profession and science, and has great emphasis on social action issues (combined with scientific inquiry, which is rare).

His dub of his final lecture (imagine, a professor at Stanford who actually still teaches!) as the Lucifer Effect is important: you and I could easily transform from good-hearted members of society to evil creatures of destruction. What does it take? Only what Zimbardo calls the “bad barrel” (the right environment). Consider the implications: innocent young military personnel sent in to war, police sent in to crime scenes, emergency medical personnel who respond to horror.

The line between good and evil is not as defined as we would like to think. And that is
exactly what Dr. Zimbardo wishes us to ponder.

Zimbardo delivers farewell lecture on evil | March 8, 2007 | The Stanford Daily

Zimbardo delivers farewell lecture on evil

Lauded psych prof. explains “The Lucifer Effect”

March 8, 2007

By Heather Heistand

There was not a single empty seat in the psychology lecture hall yesterday morning as Philip Zimbardo, professor emeritus of psychology, delivered his final Psychology 1 lecture, “The Lucifer Effect” — an event that marked the end of his 50-year teaching career.

Yesterday’s lecture by the “Godfather” of Psychology 1 — an allusion to Zimbardo’s Bronx upbringing — focused on the psychology of evil.

Internationally recognized for his 1971 Stanford Prison Experiment, Zimbardo recently served as the president of the American Psychological Association and is the author of the best-selling introductory psychology textbook, “Psychology and Life,” now in its 18th edition. He is also the director of the new Center for Interdisciplinary Policy Education and Research on Terrorism.

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