Behavioral consequences of job-related stress among resident physicians: the mediating role of psychological strain

This study examined the correlations among stressors, psychological strain, and behavioral reactions in a national sample of 1785 resident physicians, 27 to 33 years old. Consistent with previous studies of resident physicians, analysis showed that those experiencing high job-related stressors experienced high psychological strain in both their personal and professional lives. Stressors were also correlated with behavioral reactions. Hierarchical regression suggested that psychological strain mediated the relations between two of the stressors and behavioral reactions to some extent. This was consistent with recent research suggesting that psychological reactions may mediate the relations between stressors and outcomes. Further research on both medical residency and the stressing process was suggested.

Resident physician substance use in the United States

A national survey was conducted to determine patterns of drug use among 3000 American resident physicians. Sixty percent (1785) of the residents surveyed responded. This report evaluates the prevalence of drug use among the respondents, when they initiated drug use, and their reasons for current use. Substance use rates are compared with other studies of resident physicians and with a sample of their nonphysician age peers surveyed the same year. Heavy substance use patterns were not observed among resident physicians. They had significantly lower rates of use for most psychoactive substances than their peers in the general population but did report higher rates of past-month use of alcohol and benzodiazepines. A sizable minority began using benzodiazepines and prescription opiates during their residency years-the stage in physicians' training when they first receive prescribing privileges. Current users of benzodiazepines and opiates used these drugs primarily for self-treatment rather than recreation. These two substances are often associated with impairment at later stages in the physician's career.

Snorting benzodiazepines

Two cases of intranasal benzodiazepine use are presented. The methods of preparation and administration of the powder and accounts of the pharmacological effects of the drugs used are described. The pattern of development and progress of the habit and its associated features are delineated. Snorting benzodiazepines appears to be more common than is currently appreciated, and the clinical complications and implications of this habit are discussed.

Is buspirone effective for panic disorder?

Buspirone was compared with imipramine and placebo in the treatment of panic disorder in an 8-week, double-blind controlled study of 52 randomly assigned patients. The side effect profile of buspirone was less disruptive than that of imipramine. Buspirone was not significantly superior to placebo in its antipanic or anxiolytic effects in panic disorder patients.

A double-blind comparison of fluvoxamine, desipramine and placebo in outpatients with depression

1. The efficacy of fluvoxamine is compared to that of desipramine in a multicenter double blind placebo controlled six-week flexible dose trial of 90 outpatients with major depressive disorder. 2. Although overall drug effects were relatively weak, there were trends suggesting separation of both active drugs from placebo at week six. Both drugs were well tolerated. 3. Studies of major depression ought to be designed to last 8-10 weeks in order to demonstrate placebo active drug differences and the stability of such a difference should it occur in the first six weeks.

Cocaine use by senior medical students

The authors studied 589 senior medical students' attitudes about and use of cocaine. Reported use was 36% in the students' lifetimes, 17% in the past year, and 6% in the past month. Overall, these rates were lower than those of an age-matched cohort.

Differentiating anxiety-panic disorders from psychologic dental anxiety

It has always been believed that fear and anxiety of dental treatment was a simple continuum of experience that occurs in mild, moderate, or severe form. Past and present studies that attempt to both trace etiology and measure it reflect this view. The numerous studies that are concerned with methods of management are based on this accepted philosophy regarding the etiology of dental fear and anxiety. To a large extent, this may be true. However, there are some notable exceptions, and it is these cases that present the greatest management problem. Omitting the symptoms of fear and anxiety related to physical illness, drug withdrawal, or major mental illness, they present anxiety as a unidimensional learned problem usually conditioned by externally negative forces or experiences. They postulate that the fear and anxiety seen is due to a variety of factors. The interpretation of the definitions of fear, anxiety, and phobias by many in the profession that are presented in this issue also reflect the view that fear, anxiety, and phobias are learned or conditioned responses. This single-minded view has determined much of our understanding and subsequent management of this problem in dentistry.

The potential role of serotonin reuptake inhibitors in the treatment of obsessive compulsive disorder

The authors examine the role of the serotonergic system in the modulation or genesis of obsessive compulsive disorder and the potential for the use of the new serotonin (5-HT) reuptake inhibitors in its treatment. The data available are still preliminary, but are accumulating rapidly, and appear to hold promise in helping to understand this disorder and treat it more effectively. An overview of the data available is presented to assist in the planning of future research in this subject area. At least six major questions need to be addressed by future work: (1) What are the major hypotheses regarding the involvement of the serotonin system in the modulation or genesis of OCD? (2) Is there a serotonin system defect associated with OCD? (3) Is a serotonin system defect the underlying cause of OCD? (4) Are serotonin reuptake inhibitors effective in the treatment of OCD? (5) Are the effects of the serotonin reuptake inhibitors that are effective in treating OCD mediated via the serotonin system or via another mechanism? and (6) Are these drugs worth pursuing as treatment of OCD?

Panic disorder: the potential role of serotonin reuptake inhibitors

The authors review the role of the serotonergic system in panic disorder and the potential for use of the new serotonin (5-HT) reuptake inhibitors in treating panic disorder. Data currently available are only preliminary but suggest a future potential for this class of drug in the treatment of panic/anxiety disorders. The authors present a succinct and comprehensive overview of the data available, which aims to assist in the planning of future research in this area.

The relative efficacy of buspirone, imipramine and placebo in panic disorder: a preliminary report

There is a need for safe effective alternatives to benzodiazepines in the treatment of panic disorder. Buspirone, a new nonbenzodiazepine anxiolytic, is compared to imipramine and placebo in the treatment of panic disorder in an 8 week double-blind controlled study of 52 randomly assigned patients. Weekly assessments were made using the Hamilton Anxiety Scale, the Sheehan Clinician Rated Anxiety Scale, the Sheehan Patient Rated Anxiety Scale, the Phobia Scale, the Disability Scale, the Hamilton Depression Scale, the Montgomery Asberg Depression Scale, the Investigator Rated Global Improvement Scale and the Patient Rated Global Improvement Scale. Preliminary results of repeated measures Anovas are reported. Imipramine was superior to placebo on many of the outcome measures. Imipramine was superior to buspirone on the Patient Rated Global Improvement Scale and on the Investigator Rated Global Improvement Scale, but not on other measures. Although buspirone appeared to be more effective than placebo, differences were not statistically significant. Some buspirone patients did very well compared to others, suggesting a possible bimodal distribution of response. Patients on buspirone had fewer and less disruptive side effects than those on imipramine.

Urinary catecholamine metabolite and tribulin output during lactate infusion

Urinary output of homovanillic acid and 4-hydroxy-3-methoxymandelic acid was decreased both in patients with panic attacks and in normal controls during lactate infusion, whereas that of tribulin (an endogenous monoamine oxidase inhibitor and benzodiazepine receptor binding inhibitor) was increased. There was no change in urinary excretion of any of these compounds during saline infusion. These findings provide further evidence of a link between tribulin output and stress and anxiety in man and point to its possible in vivo action as a monoamine oxidase inhibitor.

Benzodiazepines in panic disorder and agoraphobia

Benzodiazepines, particularly alprazolam, are quickly becoming the drugs of first choice in the treatment of many cases of panic and agoraphobia. The reason for this choice is that these drugs are safer to use, quicker in onset of action, easier for the physician to prescribe and more pleasant for the patient to take than the alternatives. Although the treatment of panic disorder and agoraphobia has been best studied with the benzodiazepine alprazolam, it now appears likely that other benzodiazepines, for example diazepam, lorazepam and chlorazepam, may also be effective when correctly used. There is no reason at this point to believe that any of the benzodiazepines are unique in this regard. Future research will undoubtedly clarify this observation. In the meantime, it is hoped that some of the guidelines in this paper will help the practicing clinician in the management of his patient with this disabling and neglected disease.

Recent developments in the treatment of panic disorder

The focus of this paper is the treatment of panic disorder with alprazolam. Drug treatments alone are sometimes not sufficient by themselves, to adequately control all of the symptoms or components of this disorder. In the typical case we can identify four targets of treatment: The first target is the biological core of the condition, that is characterized by the unexpected, unprovoked attacks of anxiety. This responds best to medication. The second target is the phobic avoidance behaviour. It appears to be a conditioned or learned complication of the biological core, and appears to follow the laws of learning theory. Unlearning treatments, like behaviour therapy (notably in vivo exposure) are usually necessary to make a full impact against the phobic avoidance behaviour. Thirdly, there is no drug that reverses the psycho-social problems these patients have. Not all of them have such problems, but those that do may need psychotherapy to deal with their conflicts and stresses. Finally, the evidence in several chronic studies, suggest that this is a chronic relapsing disorder in the majority of cases. It is not enough to treat these patients acutely. They must be followed chronically and monitored carefully over many years, if they are to be protected against relapse.

Medical evaluation of panic attacks

Panic disorder with or without agoraphobia is dominated by the occurrence of panic attacks. However, panic attacks are also reported to occur as part of the clinical picture in several medical conditions, notably thyroid disease, hypoglycemia, and pheochromocytoma. The authors examine these conditions, review the relevant literature, and offer an evaluation strategy. Routine screening is not recommended. Panic disorder is also associated with mitral-valve prolapse and temporal lobe seizures. The authors explore the possible consequences of this association and outline an evaluation strategy. Again, routine screening is not recommended.

A case of bupropion-induced seizure

Bupropion is a novel new antidepressant without the undesirable anticholinergic, cardiotoxic, sedative, or sexual side effects of other available antidepressants. However, like many other antidepressants, there is a small risk that patients on bupropion may develop a seizure even at moderate doses and moderate blood levels and even in the absence of any premorbid history or other predisposing factors to epilepsy. The report presents the case of a 25-year-old woman with a 12-year history of agoraphobia and panic attacks treated with bupropion in a research protocol. She was in good physical health, with normal physical and neurological examination, and normal complete blood count, serum mineral analysis-12, and urinalysis laboratory values. She had no premorbid history of epilepsy or neurological illness, nor any other known predisposing factors to epilepsy. On day 28 of the study, immediately after her dose of bupropion was increased from 450 to 600 mg/day, she had a generalized convulsion with tonic and clonic phases, loss of consciousness, and postictal confusion that was reliably witnessed by several observers. The EEG abnormality had cleared 15 days later. Further EEGs after 4 weeks and 10 weeks were normal. Five years later she remains seizure-free, off all antiseizure medication, and without any further complications from this incident. This seizure occurred at a modest blood level of bupropion (83 ng/ml) and at a dose not considered excessive (600 mg/day). Other confounding organic and neurological illness or use of other medication was carefully and systematically ruled out, leaving the bupropion as the most likely explanation for her seizure.(ABSTRACT TRUNCATED AT 250 WORDS)

Immunological response to stress in agoraphobia and panic attacks

The authors studied in vitro immune function as measured by lymphocytic proliferative response to mitogen stimulation in 36 patients with agoraphobia and panic attacks who were participating in a double-blind placebo-controlled psychopharmacological study of anxiety disorder. No significant difference in immune status was observed between panic patients and healthy controls.

Dental anxiety--the development of a measurement model

A more detailed measurement instrument for dental anxiety has been developed. To investigate the dimensionability of the response, two instruments were administered to 452 persons. The first set of items (33) concerned stimuli which might prove fearsome to patients. Some of these were dental specific, others were not. A second instrument (20 items) elicited the anxiety symptoms experienced. By comparing separate Kaiser-Caffrey Alpha Factor Analyses two factors were identified within each instrument. These were labelled "generalized" phobias and "dental specific" phobias; and "endogenous" and "exogenous" (anticipatory) anxiety symptoms. Four scales were constructed using simple summations of highly loaded variables. The scales are quite reliable. Although correlations among the scales proved to be significant they are all quite low, indicating that the four scales give more or less non-redundant information about the patient. The scale had discriminating validity in differentiating between patients who acknowledge experiencing spontaneous panic/anxiety attacks and those who did not. The data confirm that dental fears are relatively independent of other generalized anticipatory fears. The results cast doubt on previously held assumptions regarding the unidimensionality of anxiety. They are consistent with a new classification of anxiety and phobic disorders presented elsewhere. The implications for research and patient management are discussed.