Ralph Tufano, M.B.A., M.D.

• Professor of Otolaryngology - Head and Neck Surgery

https://www.hopkinsmedicine.org/profiles/results/directory/profile/0015647/ralph-tufano

Things to keep in mind are available in the form of an injection given just under when you have exercise-induced asthma include the skin antiviral vaccines ppt purchase 400 mg albendazole free shipping. Using Medications to Control Asthma People who have been diagnosed with asthma will have a personalized medication plan hiv infection of oral cavity cheap albendazole 400mg fast delivery. The medicine goes into the spacer and then the person inhales the medication through the mouthpiece on the spacer hiv infection male to female order albendazole online pills. This is especially helpful when the person is unable to What to Do Until Help Arrives take deep breaths hiv infection listings discount albendazole 400 mg on-line. This will help the person to remain children younger than 5 years and the elderly. Help the person to are used for people who have trouble using inhalers and sit comfortably (Fig. Assist the person with his or her prescribed quick-relief medication if requested and if permitted by state or local regulations. This sound, known as wheezing, occurs Asthma is a life-long lung disease that affects because air becomes trapped in the lungs. It is important to be prepared to help people with breathing emergencies caused by asthma. Your care could help to save the life of a person Feelings of fear or confusion. Read and follow all instructions printed on the inhaler prior to administering the medication to the person. Nor should these instructions be substituted for directions given by a medical professional in consultation with a site where epinephrine auto-injectors will be used. Consult a health care professional for speciflc advice on the use of epinephrine auto-injectors. It is a life-threatening emergency that must be Arecognized and cared for immediately. Fortunately, some deaths can be prevented if anaphylaxis is recognized immediately and cared for quickly. Allergic Reactions Allergic reactions are caused by the activity of the immune system. When to Call 9-1-1 Some common allergens include bee or insect Call 9-1-1 or the local emergency number if the person: venom, certain antibiotics, pollen, animal dander and Has trouble breathing. Over 12 million people in the United States have food Explains that he or she is subject to severe allergic allergies. Peanuts and tree nuts cause the most What to Do Until Help Arrives cases of fatal and near-fatal allergic reactions to food. Anaphylaxis usually occurs suddenly, within seconds Give care for life-threatening emergencies. The skin or area of the body that comes in contact with the Check a conscious person to determine: substance usually swells and turns red (Fig. Trouble breathing can progress to a blocked airway due { Do you have any allergiesfl Do you have prescribed to swelling of the lips, tongue, throat and larynx (voice medications to take in case of an allergic reactionfl Low blood pressure and shock may accompany { Do you know what triggered the reactionfl Assisting with an Epinephrine Auto-Injector { Notice if the person is drowsy, not alert, confused People who know they are extremely allergic to or exhibiting slurred speech. Two injectable epinephrine { Ask if he or she is experiencing pain during systems are available: the Epi-Pen, which includes breathing. When the auto-injector is removed, handle it carefully and do not touch the needle if it is exposed. If a person is conscious and able to use the auto-injector, help him or her in any way asked. If you know that a person has a prescribed auto-injector and is unable to administer it himor herself, then you may help the person use it where allowed by state or local laws or regulations. Helping the Person Self-Administer an Antihistamine should be followed when assisting someone with Some anaphylaxis kits also contain an their prescribed epinephrine auto-injector. An antihistamine is a type of dose should not be given unless recommended by medication. It lessens the effects of compounds released advanced medical personnel or in extremely by the body during an allergic reaction. It also is important for the person to follow any and signals of anaphylaxis persist after a instructions given by the health care provider. When how to give immediate care and help someone use an activated, it injects the epinephrine. The auto-injector epinephrine auto-injector could mean the difference is activated when it is forcefully pushed against the skin. Check the label to conflrm that the prescription of the auto-injector is for this person. These injuries incur billions of dollars in lost wages, medical expenses, insurance, property damage and other Uindirect costs. Being prepared and following established safety precautions can reduce risk, prevent injuries and save lives. Living on a farm or in the city, having a home Every year in the United States millions of people made of wood or brick, using a speciflc type of heat suffer an unintentional injury. In 2007, nearly in your home and your local climate all affect your 124,000 Americans died from these injuries. For instance, death rates from injury That year, unintentional injury was the leading are higher in rural areas as opposed to metropolitan cause of death for people 1 to 44 years of age; areas. The death rate from injuries is twice as high in of these, motor-vehicle crashes were the number low-income areas as in high-income areas. In 2007, many injuries and fatalities, in both teenagers and American also sustained approximately 34. In 2008, 32 percent of all motor-vehicle deaths nonfatal injuries that required medical attention. It is estimated that a signiflcant number of victims who die as a result of falls, drowning and flres were under the influence of alcohol. These factors include age, gender, geographic location, Reducing Your Risk of Injury economic status and alcohol misuse and abuse. Statistics show that people of certain ages and gender are Nonfatal injury rates remain highest among people injured more often than others. Risks of an injury can be reduced by taking the Gender also is a signiflcant factor in risk of injury. Be alert for and avoid potentially harmful conditions or activities that increase your risk of injury. Take precautions, such as wearing appropriate protective devices, including helmets, padding and eyewear. There have been dramatic improvements in emergency medical systems nationwide over the past decade; however, you are the person who often makes the difference between life and death. In addition to these personal steps, laws and consumer protection regulations have been put in place to reduce or prevent injury. There may Think about the types of possible emergencies that not be time to consider what to do, only time to you may face: react. The steps you have already taken to prevent Number and location of smoke alarms or minimize the effect of the emergency. Gather information from sources extinguisher and flrst aid kit such as insurance companies, your city or county Think about who lives in your home: emergency management offlce and your police, flre Total number of people and number of people or rescue department. Being prepared for an emergency before driver who agrees not to drink on this occasion. See Focus on eyes off the road, your hands off the wheel or your mind Preparedness: Developing a Plan of Action above.

In 1990 hiv infection statistics nyc quality 400mg albendazole, factors of recurrent febrile seizures in pediatric only age at the time of initial febrile seizure was patients in Chiang Mai University Hospital hiv infection of the brain order 400mg albendazole with amex. The mean age at acquired and the medical records were thoroughly onset of febrile seizure was 1 hiv infection immediate symptoms purchase 400 mg albendazole with visa. Cases with incomplete Among 261 cases who presented with frst episode data or data loss hiv infection rates asia order albendazole no prescription, age less than six months and of febrile seizure, 52 cases (19. Simple febrile seizure infection or electrolyte imbalances, prior nonwas diagnosed in 276 cases (82. Mean number of seizure episodes same hospital number with multiple outpatient among 52 cases who presented with frst febrile visits or inpatient admissions was counted as a seizure with recurrence was 3. Mean time of fever before febrile the information collected included clinical seizure was 28. Subsequent Clinical characteristics included age at initial epilepsy was found in 6 out of 335 cases (1. Respiratory tract epilepsy, day-care attendance, maternal alcohol infection and acute gastroenteritis were the most consumption and smoking during pregnancy, frequent concomitant infections. Investigations included complete and without recurrent febrile seizures is shown blood count, urinalysis, chest radiography, stool in Table 3. We excluded 74 patients who already examination, cerebrospinal fuid profle if spinal had previous recurrent febrile seizures prior to tapping was done, serum and body fuid cultures visiting our hospital. In case of signifcant differences between cases with and recurrent febrile seizures, the information of an without recurrent febrile seizures in respect to initial seizure was recorded and number of total mean temperature at admission (p=0. The with positive family history of febrile seizures Student t-test and Chi-square test were used (35. This is also similar to the 2002, Berg described that children who present fndings of Esmaili et al. There are also studies which did main etiology of fever in this study was upper not fnd temperature to be risk of recurrence. Although febrile fnd the duration between fever and seizure as a seizures in childhood are generally benign with signifcant factor to seizure recurrence. Being a retrospective Many studies mentioned that the family history study, information could not be reviewed in every of febrile seizures was an important risk factor aspect. Initial febrile seizures information of and associated with a 50-100 % increase in the 74 out of 335 patients (22. However, we did not fnd seizure higher in children with recurrent febrile seizures, at low temperature or short period between fever compared with those without recurrent febrile and seizure to be risk factors for recurrence of seizures. Most studies about the risk factors of recurrent febrile seizures agreed Conficts of Interest: None that low age at onset of initial febrile seizures increased the risk of recurrent febrile seizures. Febrile seizures: update on diagnosis with those without recurrent febrile seizures. Febrile seizrues: demographic, clinical and etiological profle of children admitted with febrile seizures in a tertiary care hospital. Febrile seizures: factors affecting risk of recurrence in Pakistani children presenting at the Aga Khan University Hospital. Demographic characteristics and predisposing factors of febrile seizures in children admitted to Hospital No. Risk factors for seizure recurrence in children with febrile seizures: a pooled analysis of individual patient data from fve studies. Recurrence rate of febrile convulsion related to the degree of pyrexia during the frst attack. Results: A total of 17 literatures with 2,162 subjects were included in the meta-analysis. The overall quality of the included studies was low, except for 6 high-quality studies. However, this result needs further studies in the future because of the low quality of the included studies. Keywords: Febrile convulsion, recurrence, meta-analysis, diazepam, phenobarbital, ibuprofen Introduction after complex type of febrile seizures is 4. More recurlepsy or sequelae are likely to occur, and rence times, more severe damages in hipposeverely threaten the health of the children. There are two of anti-convulsion drugs such as phenobarbital types of onset types, simple type and complex or sodium valproate, intermittent therapy and type. Data extraction and quality assessment Two investigators cross-checked the results of the literatures, and selected literatures strictly following the inclusion and exclusion criteria. In case of any disagreement between the two investiMaterials and methods gators, the decision was made after thorough Literature search discussion or by a third investigator. The heterogeports; v) literatures with the most complete neity among the results of included studies was data from the same research institutions were examined using fl2 test. Quality assessment of randomized controlled trials Studies, year Allocation Sequence Blinding of Selective Jadad Randomized (reference) Concealment Generation subjects reporting score Uhari 1995 [6] Yes Yes Yes Yes No 3 Cai 1999 [7] Yes Unclear Unclear Yes No 1 Zhang 2001 [8] Yes Unclear Unclear Yes No 1 Yun 2001 [9] Yes Unclear Unclear Yes No 1 Verrotti 2004 [10] Yes Yes Unclear Yes No 3 Pavlidou 2006 [11] Yes Yes Yes Yes No 4 Wang 2009 [12] Yes Unclear Unclear Yes No 1 Hennati 2013 [13] Yes Yes Yes Yes No 4 Wang 2013 [14] Yes Unclear Unclear Yes No 1 Yu 2003 [15] Yes Unclear Unclear Yes No 1 Huang 2006 [16] Yes Unclear Unclear Yes No 1 Mo 2006 [17] Yes Unclear Unclear Yes No 1 Gao 2011 [18] Yes Unclear Unclear Yes No 1 Long 2013 [19] Yes Unclear Unclear Yes No 1 Van 1995 [20] Yes Yes Unclear Yes No 3 Strengell 2009 [21] Yes Yes Yes Yes No 3 Zhang 2014 [22] Yes Unclear Unclear Yes No 1 Note: Unclear-if allocation concealment or random sequence generation or outcome assessment is not reported. The overall the studies, only descriptive analysis was quality of the included studies was low, except for 6 high-quality studies [9, 13, 14, 16, 23, 24] performed. By reviewing titles and abstracts, among studies was great (I2 = 58%), so random 251 literatures were excluded and 56 literaeffects model was used. The heterowhile the other 12 literatures were published in geneity among studies was small (I2 = 8%), so Chinese. There was no heterogeneity among included the follow-up period was 1 to 5 years (Table 1). Among the 5 literatures regarding phenobarbital, only 1 litAnalysis of safety erature [21] reported 4 cases with mild drowsiRegarding the safety of the diazepam, 3 literaness, which disappeared after withdrawal of tures [11, 15, 17] did not report adverse event the drug. Of note, only a few literatures included in the present study have reported safety of the drugs. Because anti-epileptic drugs and antipyretics have high rates of adverse reactions, it is not Figure 5. Therefore, more clinical trials are still tions were reported in the three studies on required before recommending these drugs in ibuprofen. Assessment of publication bias There are still some limitations in the present study. The data placebo-controlled trials should be included, showed that the funnel plot was symmetrical and the implementation of random and blind (Figure 5). Fourth, immediate, short-term and longsimple structure of brain cells in infants, incomterm follow-ups should be recorded separately, plete functional differentiation and axonal and the number of losses of follow-ups should branching, incomplete myelin sheath formabe recorded and analyzed. Lastly, heterogenetion, activity of chemical composition enzymes ity evaluation should be performed, and data of brain tissue, and excitatory and inhibitory should be analyzed in sub-groups with different transmitters [26]. By contrast, the effect of intermittent oral urbanyl is better, but Acknowledgements this is reported in only one study [29] and needs more clinical trials to validate. Preventive treatment of recurrence of febrile convulsion in children with low dose diNone. Intermittent oral diazepam prophylaxis in febrile conpartment of Pediatrics, No. Effectiveness of intermittent diazepam prophyReferences laxis in febrile seizures: long-term prospective controlled study. Childs Nerv Syst 2013; 29: febrile convulsion in children: analysis of 80 2011-2017. Fediazepam to prevent recurrence of febrile conbrile seizures: clinical practice guideline for the vulsion. Guide of China Medicine 2013; 12: long-term management of the child with sim585-586. Phenobarbital for the prezures in the immature rat model enhance hipvention of recurrence of febrile seizures in chilpocampal excitability long term. A guide to barbital for the prevention of recurrence of feinterpreting discordant systematic reviews. J Pediatr 1995; [24] Strengell T, Uhari M, Tarkka R, Uusimaa J, Alen 126: 991-995. A prospective study on for preventing recurrences of febrile seizures: oral diazepam to prevent recurrence of febrile randomized controlled trial. Effect of short course of retention enema with diazepam and ibuprofen oral diazepam on prevention of recurrence of in prevention of febrile convulsion in children.

Complex partial seizures often but not always beginning At present hiv infection flu buy discount albendazole, the following syndromes are established olive leaf antiviral buy albendazole 400 mg with amex, but with motor arrest typically followed by oroalimentary more may be identified in the future: automatism antiviral birth control buy generic albendazole 400mg online. The Benign childhood epilepsy with centrotemporal spike duration is typically >1 min hiv infection europe buy discount albendazole 400mg line. Temporal spikes, sharp waves and/or slow waves, unilatwhich are based mainly on seizure types and other clinical feaeral or bilateral, synchronous but also asynchronous. Inferences regarding anatomic localization may allow better definition of the intracranial distribumust be drawn carefully. Seizure symptomatol(a) a unilateral or bilateral interruption of background activity ogy and, sometimes, additional clinical features often provide and (b) temporal or multilobar low-amplitude fast activity, important clues. The first sign or symptom of a seizure is often rhythmic spikes, or rhythmic slow waves. Intracranial recordings may provide additional reflect its further propagation through the brain. This information regarding the chronologic and spatial evolution sequence, however, can still be of high localizing importance. One must bear in mind that a seizure may start in a clinically silent region, so that the first clinical event occurs only after Amygdalo-Hippocampal (Mesiobasal Limbic spread to a site more or less distant from the locus of initial or Rhinencephalic) Seizures discharge. The following tentative descriptions of syndromes Hippocampal seizures are the most common form; the symprelated to anatomic localizations are based on data which toms are those described in the previous paragraphs except include findings in studies with depth electrodes. Seizures are characterized by rising epigastric discomseizures, complex partial seizures, and secondarily generalized fort, nausea, marked autonomic signs, and other symptoms, seizures, or combinations of these. Frequently, there is a history of febrile seizures, and a family history of seizures is com1 Reproduced, with permission, from Commission on Classification mon. On metabolic imaging studand Terminology of the International League Against Epilepsy. Proposal for revised classification of epilepsies and epileptic synUnilateral or bilateral temporal lobe spikes are common on dromes. Simple partial Lateral Temporal Seizures seizures, particularly partial clonic facial seizures, are comSimple seizures characterized by auditory hallucinations or illumon and may be ipsilateral. If secondary sensory changes sions or dreamy states, visual misperceptions, or language disoroccur, numbness may be a symptom, particularly in the hands. Motor cortex epilepsies are mainly characterized by simple partial seizures, and their localization depends on the side and topography of the area involved. In cases of the lower preFrontal Lobe Epilepsies rolandic area, there may be speech arrest, vocalization or dysphasia, tonic-clonic movements of the face on the contralateral Frontal lobe epilepsies are characterized by simple partial, side, or swallowing. Generalization of the seizure frequently complex partial, secondarily generalized seizures, or combinaoccurs. Seizures often occur several times a day and fremarch or Jacksonian seizures occur, particularly beginning in quently occur during sleep. Status epileptiinvolving the paracentral lobule, tonic movements of the ipsicus is a frequent complication. Complex partial seizures arising from the frontal lobe, among the epileptic syndromes of childhood noted under sympoften with minimal or no postictal confusion. Rapid secondary generalization (more common in rolandic partial epilepsy in both adults and children and is seizures of frontal than of temporal lobe epilepsy). Such epilepsies include those with preand postcentral symptoCingulate matology (perirolandic seizures). Such overlap to adjacent Cingulate seizure patterns are complex partial with complex anatomic regions also occurs in opercular epilepsy. Autonomic signs are In frontal lobe epilepsies, the interictal scalp recordings common, as are changes in mood and affect. Intracranial recordings can sometimes disor initial loss of contact and adversive movements of head and tinguish unilateral from bilateral involvement. Dorsolateral Depending on the methodology, intracranial recordings may Dorsolateral seizure patterns may be tonic or, less commonly, provide additional information regarding the chronologic and clonic with versive eye and head movements and speech arrest. Chapter 18: Classification of the Epilepsies 237 visual seizures involve epileptic discharge in the temporoparietoParietal Lobe Epilepsies occipital junction. The initial signs may also include tonic and/or clonic contraversion of eyes and head or eyes only (oculoclonic Parietal lobe epilepsy syndromes are usually characterized by or oculogyric deviation), palpebral jerks, and forced closure of simple partial and secondarily generalized seizures. Sensation of ocular oscillation or of the whole body may seizures arising in the parietal lobe remain as simple partial occur. The discharge may spread to the temporal lobe, producing seizures, but complex partial seizures may arise out of simple seizure manifestations of either lateral posterior temporal or hippartial seizures and occur with spread beyond the parietal pocampoamygdala seizures. Seizures arising from the parietal lobe have the following in the supracalcarine area, the discharge can spread forward to features: Seizures are predominantly sensory with many charthe suprasylvian convexity or the mesial surface, mimicking acteristics. Positive phenomena consist of tingling and a feelthose of parietal or frontal lobe seizures. Spread to contralateral ing of electricity, which may be confined or may spread in a occipital lobe may be rapid. There may be tongue sensations of crawling, stiffness, and the etiology is unknown. Thus, this category differs or coldness, and facial sensory phenomena may occur bilaterfrom the previous one by the lack of etiologic evidence ally. Parietal lobe Benign neonatal familial convulsions visual phenomena may occur as hallucinations of a formed Benign neonatal convulsions variety. Metamorphopsia with distortions, foreshortenings, Benign myoclonic epilepsy in infancy and elongations may occur and are more frequently observed Childhood absence epilepsy (pyknolepsy) in cases of nondominant hemisphere discharges. Severe vertigo or dis Other generalized idiopathic epilepsies not defined orientation in space may be indicative of inferior parietal lobe above seizures. Seizures in the dominant parietal lobe result in a variety Epilepsies with seizures precipitated by specific of receptive or conductive language disturbances. Seizures of the paracentral lobule have a tendency Salaam Krampfe) to become secondarily generalized. Complex Early infantile epileptic encephalopathy with suppartial seizures may occur with spread beyond the occipital lobe. The clinical seizure manifestadefined above tions usually, but not always, include visual manifestations. Under this heading are included diseases in sia, amaurosis) or, more commonly, positive (sparks or flashes, which seizures are a presenting or predominant phosphenes). Epilepsies and syndromes undetermined whether focal or to the entire visual field. Perceptive illusions, in which the objects generalized appear to be distorted, may occur. Visual hallucinatory seizures are occasionwave sleep ally characterized by complex visual perceptions. In some cases, the scene is dissyndrome) torted or made smaller, and in rare instances, the subject sees his Other undetermined epilepsies not defined own image (heutoscopy). Special syndromes of antecedent illness, but frequently have a family history of 4. The seizures are usually brief and rare, but Febrile convulsions may be frequent early in the course of the disorder. The Isolated seizures or isolated status epilepticus seizure patterns may vary from case to case, but usually Seizures occurring only when there is an acute metaremain constant in the same child. Both seizure types are disorders in which seizure semiology or findings at investigaoften related to sleep. Onset occurs between the ages of tion disclose a localized origin of the seizures. Genetic predisposition is fregenic lesions (anatomic or functional), that is, true focal quent, and there is male predominance. In most waves that are activated by sleep and tend to spread or shift symptomatic localization-related epilepsies, the epileptogenic from side to side.

There is evidence that specifcity may only apply to a subset of anxious cognitions hiv infection symptoms after 2 years order albendazole 400mg free shipping. Jolly and Dykman (1994) reported that some threat cognitions were more related to a general negativity factor hiv infection prophylaxis guidelines generic albendazole 400 mg with mastercard, whereas other cognitions related to physical or health-related threat were more specifc to anxiety quantum antiviral formula generic 400 mg albendazole overnight delivery. Finally antiviral treatment for herpes purchase albendazole line, Riskind (1997) has argued that looming vulnerability, the perception of threat movement, may offer better precision in distinguishing anxiety from depression because it incorporates time and rate of change in its conceptualization of threat appraisal. Although still tentative, it appears that only certain types of threat-related cognitions such as concerns about physical symptoms, health, social evaluation, and impending danger are specifc to anxiety, whereas anxious apprehension or worry may be more evident in both anxiety and depression. Cognitive Specifcity in Anxiety Disorder Subtypes Less research has investigated whether a specifc cognitive content is associated with the anxiety disorder subtypes. Beck and colleagues found that worry was common to anxiety and depression and a strong predictor of negative affect, whereas hopelessness was predictive of low positive affect and panic-related cognitions were clearly specifc to anxiety states (R. In a confrmatory factor analysis of self-reported anxious and depressive selfstatements, self-statements refecting depression/hopelessness and self-statements refecting anxiety/uncertainty about the future had large and signifcant loadings on a general negativity factor (Safren et al. One of the most direct tests of cognitive content-specifcity among anxiety disorder subtypes was reported by Woody, Taylor, McLean, and Koch (1998). They found that patients with panic disorder scored signifcantly higher on a measure of threat-related cognitions that were unique to panic. Summary Over the years numerous studies have shown that automatic thoughts and images of threat, danger, and harm occur with greater frequency and intensity in the anxiety disorders when fear is activated. Consequently there is ample evidence supporting the basic assertion of Hypothesis 6. Whether thoughts of threat and danger are a specifc marker of anxiety has been more equivocal, and whether each anxiety disorder has its own unique cognitive content that distinguishes it from other emotional states has not been subjected to adequate empirical investigation. However, a number of tentative conclusions can be drawn about cognitive content-specifcity in anxiety. Specifcity is more likely when researchers focus on thought content that characterizes each of the disorder subtypes (see Table 3. Moreover, cognitive content-specifcity may be more apparent at higher levels of symptom severity or in clinical groups that present with greater diagnostic homogeneity. Failure to fnd specifcity in the anxiety disorders could refect the inadequacies of the measures employed, especially if self-report questionnaires are used that underrepresent the more specifc forms of cognition associated with the anxiety subtypes. Also, the high rate of comorbidity between anxiety and depression has complicated efforts to investigate level of specifcity in pathognomonic processes. Until then, much remains unknown about the parameters of cognitive content-specifcity in anxiety. Specific themes of threat and danger will provide valuable diagnostic and assessment information for constructing a case formulation of the anxiety disorder. Ineffective Defensive Strategies Highly anxious individuals will exhibit less effective immediate defensive strategies for diminishing anxiety and securing a sense of safety relative to individuals experiencing low levels of anxiety. In addition, highly anxious individuals will evaluate their defensive abilities in threatening situations as less effective than nonanxious individuals. Hypothesis 7 focuses on the fnal consequence of threat mode activation (see Figure 2. It is proposed that fear activation involves an automatic defensive response that is aimed at immediate reduction or avoidance of fear and the reinstatement of safety. This rapid response system is not an effortful intentional coping response but instead a fundamental biologically based adaptational system that is triggered when the organism encounters a potentially life-threatening situation (Ohman & Mineka, 2001). The adaptational value of fear is partly due to its ability to trigger an immediate defensive response. Fear has evolved to deal with situations involving physical danger that are potentially life-threatening and so primitive alarm reactions may be effective for external dangers. However, they are less useful, even counterproductive, for the more abstract, protracted, and internally oriented threats that characterize the anxiety disorders. The second is a more passive, anergic system that involves a stereotypic immobility response. Craske (2003) presented a threat immiEmpirical Status of the Cognitive Model 83 Automatic Behavioral Response f Avoidance f Escape f Immobility Threat Mode Automatic Cognitive Response Activation f Attentional avoidance f Distraction f Thought Suppression Automatic Safety Seeking f Active responses to restore personal safety figure 3. Escape and avoidance responses are so closely associated with subjective fear that their occurrence is taken as an important marker of fear expression (Barlow, 2002). Behavioral, biological, and emotion theories of fear are almost universal in their agreement that an automatic escape and avoidance response is part of fear activation (Barlow, 2002). Various defensive reactions such as withdrawal (fight, escape, avoidance), attentive (freezing) or tonic (unresponsive) immobility, aggressive defense, and defection of attack (appeasement or submission) are associated with fear arousal in all animals including humans as a means of protection against danger (Marks, 1987). Active avoidance of fear stimuli, which has been demonstrated in numerous animal and human aversive conditioning experiments, is known to have reinforcing effects because it is associated with the avoidance of punishment (Gray, 1987; Seligman & Johnston, 1973). It is not surprising that escape and avoidance responding has played a prominent role in learning theories of fear acquisition and persistence (for further discussion, see Barlow, 2002; Craske, 2003; Ohman & Mineka, 2001; LeDoux, 1996; Marks, 1987). Phenomenological studies of the anxiety disorders have found that some form of immediate escape and avoidance is evident in most anxiety states. Escape and avoidance is more prevalent in high levels of state and trait anxiety (Genest, Bowen, Dudley, & Keegan, 1990). In social phobia individuals are more likely to engage in subtle avoidance behaviors like not giving eye contact or looking away while in social evaluative situations (Beidel et al. For the vast majority of anxious patients, behavioral avoidance plays an important role in their daily experience of this negative emotional state. Cognitive Avoidance: An Automatic Defensive Reaction Various cognitive processes have been identifed as part of the automatic avoidance response to threat. Attentional shift away from threat stimuli, distraction, thought suppression, and the initiation of worry are all protective cognitive processes that are aimed at terminating or preventing exposure to threat (Craske, 2003). Ironically, these immediate responses may actually increase accessibility to the very schemas that represent threat (Wells & Matthews, 2006). Moreover, all of these processes involve a mix of automatic and more conscious, effortful processing. In this section we consider evidence for an automatic cognitive avoidance, whereas the more elaborative aspects of distraction, worry, and thought suppression will be discussed as deliberate avoidant coping strategies under Hypothesis 10. As a result it is still unknown whether an automatic attentional avoidance of threat is a universal feature of all high anxiety states. If a delayed automatic attentional avoidance of threat does emerge more consistently across the anxiety disorders, then this process could be a key element in triggering the more conscious, strategic cognitive avoidance responses like distraction, thought suppression, and worry (see also Mathews & Mackintosh, 1998, for similar view). Borkovec and colleagues present compelling evidence that worry functions as a cognitive avoidance reaction to threatening information (Borkovec, 1994; Borkovec, Alcaine, & Behar, 2004; see also Mathews, 1990) that is instigated by the automatic attentional biases for threat. Although worry is predominantly a conscious effortful coping stratEmpirical Status of the Cognitive Model 85 egy with an avoidant function, the initiation of the worry process may be a product of automatic vigilance for threat. Automatic Safety Seeking Safety-seeking behavior is an important class of escape and avoidance behavior that is evident in the persistence of agoraphobia (Rachman, 1984a), panic disorder (D. Various studies have shown that increased use of safety-seeking behaviors is related to the persistence of anxiety and avoidance. White and Barlow (2002) reported that 74% of their patients with panic disorder with agoraphobia engaged in one or more safety behaviors such as carrying a medication bottle, food/drink, bags, bracelets, or other objects. In another study individuals with social phobia exhibited more safety behavior that was associated with increased anxiety and that mediated actual defcits in social performance (Stangier, Heidenreich, & Schermelleh-Engel, 2006). Cognitive models of specifc anxiety disorders and the few studies that have been conducted on safety seeking suggest that this form of response may be important in the pathogenesis of anxiety. However, this research is of limited relevance to Hypothesis 7 because it focuses on safety seeking as a deliberate avoidant coping strategy. Whether there are more immediate automatic aspects of safety seeking that would make it part of the immediate defense response is unknown at this time. Summary There is overwhelming clinical and laboratory evidence for a fairly automatic escape and avoidance response in high anxiety, and this responding is part of a characteristic automatic defensive pattern aimed at protecting the organism against threat and danger. What is less well known is whether the elimination of escape and avoidance responses is necessary for the successful treatment of anxiety states. Much less is known about the more automatic features of cognitive avoidance and safety-seeking behaviors. The research that has been published has examined these topics in terms of conscious deliberate coping strategies aimed at the reduction of anxiety. Thus more research is needed that directly compares the automatic defensive response of high and low anxious individuals in terms of its immediate impact on anxiety level and perceived effectiveness as a direct test of Hypothesis 7. Until this research has been conducted, the empirical status of the cognitive and safety-seeking aspects of Hypothesis 7 is unknown.

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