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Unmasking Anxiety with Cognitive Behavioral Therapy

Free essay example:

Unmasking Anxiety with Cognitive Behavioral Therapy

It is not that uncommon that an individual may be late for work. They might begin to rush, and perhaps forget something at home that they needed. They may beat themselves up all day for having put themselves in that position. This scenario reflects typical anxiety. It is a normal reaction to stress by the body, but for some, it can become a chronic disorder. There are many treatments for this disorder, including prescriptions drugs, behavioral therapy, and even homeopathic remedies. Compared to these alternatives, Cognitive Behavioral Therapy (CBT) is the most effective long-term treatment for anxiety.

There is a line between experiencing stress due to a difficult situation, and having a crippling disorder. Individuals with anxiety who wish to be treated must seek psychiatric assistance through self-help programs or doctors. Anxiety is a disorder that is often found hand in hand with depression, both of which can improve with treatment.

Often times, many people do not recognize that there are different classes of anxiety disorders. Five major types of anxiety disorders include Generalized Anxiety Disorder (GAD), Obsessive-Compulsive Disorder (OCD), Panic Disorder, Post-Traumatic Stress Disorder (PSTD), and Social Phobia (SAD), which is also known as Social Anxiety Disorder (NIMH). These types of anxiety range from the most common form of anxiety which is GAD, to Post-Traumatic Stress Disorder, which deals with haunting anxiety that lingers and is triggered by everyday things due to an upsetting experience (NIMH).Many people seeking treatment with any anxiety disorders expect fast results from medication.

Commonly, different drugs are used for different patients. The Behavioural Neurotherapy Clinic (BNC) insists that because of slight abnormalities of neurotransmitters in the brain, anti-depressant medications are useful in treating about 40% of patients seeking treatment for anxiety disorders (BNC). HealthCentral.com presents 104 familiar drugs that are prescribed for anxiety disorders (HealthCentral). Xanax, a familiar drug name is a brand name for a drug called Alprazolam, which is used to treat anxiety and panic disorders (HealthCentral). Xanax is in a class of medications called benzodiazepines which HealthCentral presents as producing, a calming effect by “enhancing the effects” of an unlisted body produced chemical (HealthCentral). Benzodiazepines, while taken by dose can, “…cause a dose-related central nervous system depressant activity varying from mild impairment of task performance to hypnosis” (PDR 2794).These long term side effects can affect the individual negatively.

According to the Johns Hopkins Center website, Benzodiazepines are an effective treatment to ease anxiety. However, more than one third of individuals who take benzodiazepines for anxiety for more than one month become dependant on them. This includes the drugs Alprazolam, Clonazepam, and Diazepam. Brand names for these drugs are Xanax, Klonopin, and Valium (Hopkins). Benzodiazepines are not prescribed long term. This is due to the addictive nature to such drugs which can lose effectiveness over time (Burns, 47). This may lead to short term results from prescription drugs.

Antidepressants have the upper hand against benzodiazepines because they are not addictive. Within three weeks, a human body will become physically dependant on the drug and when they are taken off of it, withdrawal symptoms will occur, as well as extreme anxiety. The effects of both of these may be more extreme than others depending on the dosage taken (Burns 53). “CNS agents of the 1,4 benzodiazepine class presumably exert their effects by binding at stereo specific receptors at several sites within the central nervous system. Their exact mechanism of action is unknown” (PDR 2794).

A well known antidepressant used for the treatment of anxiety is Lexapro Oral, also known generically as Escitalopram Oral. This drug, “works by restoring the balance of certain natural substances (neurotransmitters such as serotonin) in the brain. Escitalopram may improve your feelings of well-being and energy level and decrease nervousness” (HealthCentral). The PDR lists at the bottom of the Patient Information section that even if patients notice improvement within up to a month, they are still advised to attend therapy (PDR 3533). Dr. Burns points out, in When Panic Attacks, that drugs like Lexapro, which are used for both anxiety and depression are known as selective serotonin reuptake inhibitors, or SSRIs. These drugs became popular in the 1980’s (49).

During an eight week study by Forest Laboratories,studies found that adolescents, ages 6-17, experiencing low self-esteem, impaired schoolwork, and difficulty having fun, experienced “significant improvements,” with doses of Lexapro in comparison with children who took placebos. Currently, the FDA has not approved the treatment of depression with Lexapro in pediatric patients (Forest Labs). “Overall premature discontinuation rates (all cases including adverse events) were [19%] for patients receiving LEXAPRO and [15%] for patients receiving placebo” (Frx.com). Though the BNC recognizes that drug therapy may be useful for some patients, they also recognize that CBT is effective for Anxiety Reduction, and may be recommended in addition to other treatment (BNC).

Holistic medication is an alternative therapy to treat anxiety and depression, and often looked highly upon by people who fear the side effects of anti-depressants. Supplements known for their assistance in the ease of anxiety and depression include Kava, L-theanine, Passion Flower, and Valerian (Seredyn).

Evidence claims that toxins in the body can have an effect on mental health. The Behavioural Neurotherapy Clinic states, “Recent research evidence implicates abnormal levels of commensal (usually occurring) gut bacteria that can cause the release of high level of trace amines and toxins, both of which can trigger abnormal neurotransmitter activity in the brain” (BNC). Though intestinal/neurological functions may still not recognized as related to some scientists, the BNC maintains that due to recent studies, Irritable Bowel Syndrome (IBS) may be a large factor in many individuals’ depression or anxiety (BNC). In a meta-analysis of a hundred studies, up to 90% of individuals with IBS had some sort of chronic psychiatric disorder, the majority of which were anxiety/depression (BNC).

Toxins from foods, alcohol, digestive disorders, and radiation among other factors can cause anxiety and depression. Many homeopathic doctors and followers of the natural health field believe in “detox baths” (Busse). While in practice, Dr. Susan Busse recommended many of her patients to take baths with Epsom salts and hydrogen peroxide in a bathtub of water warm enough to create a sauna effect and allow the patient to sweat. During this process, the patient would sweat out the toxins which were being extracted by the Epsom salts and hydrogen peroxide. In turn, her patients experienced an ease of symptoms for their various disorders, including Lyme disease; of which, depression and anxiety are symptoms (Busse).

Though drugs and supplements may assist in calming stress reactions from anxiety and depression for periods of time, studies show that through Cognitive Behavioral Therapy (CBT), sufferers of moderate to extreme anxiety of any type will be able to change their negative thinking patterns to overcome their problem in the long run without any negative side effects, such as from pharmaceutical drugs.

Dr. David Burns, author of When Panic Attacks, and Feeling Good: The New Mood Therapy, began When Panic Attacks, stating that cognitive therapy allows a person to learn to change negative thoughts that cause depression and anxiety. He maintains that by doing so, one can overcome behavioral patterns that distort reason and cloud paradigms. This allows people suffering from anxiety and depression to be relieved of those symptoms. To back up his point he gives an example,

…In a recent landmark study conducted at outpatient clinics at the University of Pennsylvania and Vanderbilt University, 240 patients suffering from episodes of moderate to severe depression were randomly assigned to treatment with CBT [Cognitive Behavioral Therapy], paroxetine (Paxil), or a placebo so the effects of these treatments could be compared in both the short and the long term. The results were recently published in two major papers in the Archives of General Psychiatry, the top psychiatric journal. The findings confirmed, once again, that CBT was at least as effective as the antidepressant in the short term, but more effective in the long term (Burns, 2).

It is also recently documented that pharmaceutical drugs may not be the best answer for treating anxiety and depression, because chemical imbalance in the brain are very publicized theories (Burns 48). However, pills can be the best treatment for psychological problems. For example, if an individual has a stress headache and takes an aspirin and hours later, the headache goes away. The pill did not correct an aspirin shortage in the brain, but it was the simplest way to get rid of the headache (48).

In fact, much new research proposes that genetics play a considerable role in depression and anxiety, not chemical imbalance. The chemical imbalance theory stems back to Hippocrates, the father of modern medicine, who called depression “melancholia” which referred to the condition that had been the product of an unknown black poison created by the gallbladder (48).

Dr. Burns and his colleagues experimented multiple ways to see if depression was a result from a serotonin deficiency in the brain during the 1970’s. His results in one study found that the moods of a group of depressed veterans, whom the doctors had given massive amounts of daily supplements called L-tryptophan, did not improve. L-tryptophan is an amino acid that crosses into the brain quickly and turns into serotonin. The study was published in the Archives of General Psychiatry (49).

In order to most effectively and quickly treat an anxiety disorder, it is helpful for both a patient and their physician to pinpoint the type of anxiety that the individual experiences. This allows the physician to begin a best fit course of CBT for their patient. Thousands of psychologists have been using CBT in their practices for years now. Individuals, without the assistance of a physician in treatment, may find it takes longer to find which CBT techniques work best for them. With different types of anxiety in mind, multiple forms of behavioral therapy must be implemented in order to attack the different triggers of anxiety. Burns extensively explains over forty CBT techniques to overcome anxiety.

An important technique in Dr. Burns’ book is called a Daily Mood Log. Many therapists praise this particular exercise because of its ability to slowly re-adjust thought processes for any type of anxiety disorder. This format, which can be copied from the book onto paper, includes columns to write in negative emotions before and after upsetting events, and spaces to write in the negative thoughts associated with those emotions. Afterwards, the thoughts are countered with logical positive thoughts that expose the negative thoughts for all of their cognitive distortions (76). This type of treatment is the cornerstone to all kinds of behavioral therapy.

Aside from this practice, other exercises uncover Self-Defeating Belief’s (SDBs). The importance of doing so is to figure out what triggers individuals to be upset by their, “psychological vulnerabilities” (99). The two types of SDBs include Individual and Interpersonal SDBs. Individual SDBs have to do with what we think we need to do in order to be worthwhile and love ourselves, and Interpersonal SDBs have to do with how we think we need to be in order to be loved by others (99-100). Many people with SAD have problems stemming from Individual SDBs. Much of their Social Phobia may stem from their insecurities, and their great urge to be perfect, for fear of failure in the eyes of themselves, and quite often loved ones. On the other hand, individuals suffering from PTSD may have problems with more Interpersonal issues such as Perceived Narcissism, where people believe that they will be rejected by loved ones for expressing their feelings (101).  

The technique that Dr. Burns suggests in order to pinpoint SDBs is called the Downward Arrow Technique. In this exercise, an individual takes a SDB from a Daily Mood Log and draws an arrow beneath it.

The arrow is a form of shorthand for questions like these: ‘If this thought were true, why would it be upsetting to me? What would it mean to me?’ When you ask yourself these questions, a new negative thought will pop into your mind. Write it down directly under the arrow, and draw another arrow underneath it. Ask yourself the same kinds of questions again. If you repeat this process several times, you’ll generate a chain of negative thoughts. When you review these thoughts, you can easily pinpoint your Self-Defeating Beliefs (Burns, 101-102).

Pinpointing SDBs is one of the foundation exercises for the rest of an individual’s recovery. From this point, people may then proceed to find the CBT exercises best suited to overcome their SDBs (99).

Dr. Burns gives an example from a therapy session he had with a young man named Rasheed.

I asked Rasheed to put a downward arrow directly underneath his thought and said, ‘Rasheed, we know you’re a top student, so you’ll probably do very well on the test. But let’s assume the opposite. Let’s imagine that you really did flunk the FAA test six months from now. What would that mean to you? Why would it be upsetting?’

He said, ‘Then I’ll look bad in front of my buddies’ (Burns, 102).

The line of questioning continued until the statements, “That would mean I was worthless,” and “Then I could never feel happy again,” were revealed. This marked the end of the Downward Arrow Technique, and began the analysis of Rasheed’s SDB’s. These included Perfectionism, perceived perfectionism, and achievement addiction (105). These beliefs Rasheed had were common for individuals with performance anxiety and achievement addictions. The exercise in turn helped him understand why he was vulnerable to the kind of mood disturbances he had been experiencing (107). From that point, treatment can follow catering to the SDB’s.

To continue, Compassion exercises are exceptionally helpful for those with PTSD who may suffer from extreme guilt. Perfectionists benefit from this treatment too, finding that it is acceptable to make mistakes (133). The idea behind this technique is that we usually criticize ourselves harder when we are upset than we would our friends. A person practicing this exercise can take negative thoughts from their Daily Mood log and focus in on them. Statements like, “I’m a failure,” or “I screwed up so bad, he’ll never forgive me,” should be addressed on paper while practicing alone as a dialogue (139). Exercises such as these produce no long term negative side effects.

Dr. Burns gave a three day workshop in Florida several years ago for a group of psychotherapists. During his workshop he did a compassion exercise with a family therapist named Walter who had been experiencing anxiety and depression for months since his partner of eight years had left him (134). Walter and Dr. Burns created a roll play situation where Dr. Burns played Walter’s good friend Kirk, who had recently been left by his partner of 8 years and was struggling with anxiety and depression. Walter played himself, showing compassion to Kirk. In Walter’s mood log he had written, “Negative Thought: 1. I’ll never be in a loving relationship again.”

On a scale of 1 to 100, he was plagued by this thought by 100%. He then recognized the cognitive distortions from the thought, and countered it with a positive one: “1. There’s no real evidence for this. I’ve been in many loving relationships in the past. I feel like I’ll never have another loving relationship because I’m hurting so much right now. But eventually these feelings will go away and I’ll start connecting just as I’ve always done in the past.” Walter believed this thought 95%, and after countering his negative thought, was only bothered 15% by the original thought (139). These types of exercise teach the individual how to manage their anxiety, which can lead to more permanent results.

CBT exercises are not exclusively found in Dr. Burns’ book. There is a variety of CBT options available throughout the mental health field. Medical journals, books, and through the aid of psychologists or psychiatrists, many more techniques can be obtained.

Something not often considered is that CBT can also benefit the economy. In Britain, this was the conclusion of various studies documented by authors R. Laynard, D. Clark, M. Knapp and G. Mayraz. “Mental illness causes as much of the misery in Britain today as poverty does. It is our great hidden problem—little discussed because of the shame which surrounds it” (Laynard). They pointed out the Exchequer’s (national treasury) expense of 750 pounds a month that an individual collects in capacity benefits due to mental illness such as depression or anxiety (Laynard).

If sufferers of anxiety and depression were treated for their illness, they would take fewer sick days. The authors go on to say, “The difference is twenty days per year. We can again assume that, if a once-sick person is well, his absence is reduced by 60 percent of this figure, that is twelve days a year” (Laynard). Additionally, mentally ill individuals can risk losing their jobs. This can be prevented by treatment.

Additionally, The National Institute for Health and Clinical Excellence (NICE) Guidelines express that unless an individuals condition has only recently arisen or is very mild, patience should have CBT available to them if they indeed choose to do it. These guidelines are not put into action however because of a lack of mental health professionals in the NHS (Laynard).

Furthermore, the authors discuss CBT effectiveness. One chart shows that 82 percent of people who start CBT stick with the treatment, and of that 82 percent, 61 percent recover within four months (Laynard). Studies continue to prove that between CBT and medication for treatment, CBT may be more effective in preventing relapses, and patients may find relief from their mental illnesses for longer periods of time (Laynard).

In conclusion, millions of individuals all over the world experience the debilitating effects of anxiety and depression. The amount of damage the illnesses can do on both, personal and economic levels are astounding. Unlike pharmaceutical drugs and homeopathic supplements, CBT is more effective in long term treatment of anxiety and depression by providing coping skills that drugs do not. CBT does not mask problems that pharmaceutical drugs may end up doing by tinkering with chemicals in the brain. The lack of negative side effects and long term recovery rates makes Cognitive Behavioral Therapy a more effective solution to an ongoing problem facing mankind.  

Works Cited

BioNeurix Corp. Herbal Supplements for Anxiety. 2004-2008. 2 May 2008 <http://seredyn.com/zzherbalsupplementforanxiety.html>.

This source goes into detail about herbal supplements commonly used to treat both chronic and normal anxiety. These supplements are not regulated the same way that pharmaceutical drugs are monitored by the Food and Drug Administration. Valerian is an herb referenced that reduces anxiety and can be taken multiple times a day. This differs from other prescription medications that cannot be taken very often. L-theanine is another supplement that is addressed. The page explains what these supplements are made out of. Valerian consists of valerenic acid. L-theanine is an amino acid. The information also states that it is not habit forming, unlike some prescription drugs. The last supplement that is addressed is Passion Flower. It is stated that it is like Valerian, an extract. However, Passion Flower’s extract is 3-4% vitexin. An important argument is that a supplement with both Valerian and Passion Flower will be more effective than a supplement of either supplement alone. I was able to use this information to support a popular treatment for anxiety and depression that does not always have to be regulated by doctors.

Burns David D., M.D. When Panic Attacks. New York: Broadway Books, 2007. 464.

One of the top selling and critically acclaimed self-help books about drug-free therapy for the treatment of anxiety and depression. Author David D. Burns tackles the issues of the media glorifying prescription drugs in the treatment of anxiety and depression. He explains in detail through statistics and study results that pharmaceutical drugs for these purposes are not proven cures for this line of treatment. He also explains that they may have negative side effects on a user of such drugs. Following this case, Dr. Burns explains in great detail over forty different cognitive behavioral therapy techniques to treat anxiety and depression patients without a prescription. He also gives information on how many other mental health professionals around the country use cognitive behavioral therapy, with or without conjunction of pharmaceutical drugs in the treatment of patients with anxiety and depression. I was able to use this source to my advantage because it described not only the benefits of cognitive behavioral therapy, but to whom it would be useful. It also went into detail about pharmaceutical drugs, and what anxiety and depression were. Overall, this was the most important source which I studied in the process of writing my findings.

Busse, Susan. Personal interview. January 2003.

Dr. Susan Busse had retired from her practice slightly over a year ago now. She is a medical doctor who also used holistic medicine in the treatment of her patients as well as prescription drugs. While she was in practice she both sold supplements such as L-theanine, as well as prescribed prescription drugs. I had gone to see her through the Illinois Northern Lyme Association. The majority of her patients came to her for the treatment of Lyme disease. From early in my treatment until post-treatment she had recommended detox baths to reduce the side effects of Herxheimer reactions. Herxheimer reactions were signs that bacteria was dying in the body and expelling a toxin as they did back into the body which would exacerbate symptoms. This recommendation to her patients also helped with pains, and helped relieve stress and allow patients to think more clearly after the toxins had been sweat out. I was able to use this information in my paper to explain holistic approaches to treating anxiety and depression, that also benefit other health problems.

Forest Laboratories, Inc. Forest Announces Results of Recently Completed Lexapro® Pediatric Depression Clinical Trial. Dec. 19 2007. May 2 2008 <http://www.frx.com/news/PressRelease.aspx?ID=585077>.

A press release from Forest Laboratories, Inc. The findings of a study by the company and reported to the Food and Drug Administration of the ability for adolescents to tolerate Lexapro. The adolescent age range for the study was between 6-17. There were two hundred and sixty four patients that participated in the study. There was only one suicide related event and zero reports of depression worsening in those tested. The source indicates that Lexapro is a newer drug that has been prescribed for more than 5 million patients in the United States. This information was new in 2004. The study provided both Lexapro and placebos to participants. With this information I was able to provide evidence that though drug therapy may not be a proven cure to anxiety and depression, in some cases it is helpful alongside of Cognitive Behavioral Therapy, or stand alone is useful for certain people.  

HealthCentral Network, Inc. Anxiety: Index of Commonly Perscribed Medications. 2004-       2008. 9 April 2008 <http://www.healthsquare.com/nav_indices/anxiety_index.htm>.

This is a listing of prescription medications. This health website provided a hefty list of pharmaceutical drugs often prescribed in the treatment of anxiety disorders. Some of these drugs are also used in the treatment of depression. The list is alphabetical by brand name. General names for the prescription medications were also provided. Online Physicians Desk Reference information was provided in different links. Each drug passage provided general information. It then went on to give informative information on drug usage. Side effects, drug interactions, and drug images were provided. Advertisements and other literature on these pages glorified the use of prescription drugs for the treatment of anxiety and depression. I was able to use this to my advantage in my research by being able to provide information on the abundance of drugs prescribed for the same mental illness that cognitive behavioral therapy was treating. Then I was able to make the correlation that cognitive behavioral therapy was more effective in the long term treatment.

Jacques Duff. Anxiety Disorder and Panic Attacks? 2005. Behavioural Neurotherapy Clinic. 2 May 2008 <http://www.adhd.com.au/anxiety_and_panic_attacks.htm>.

This website was a segment of a larger mental health website hosted by the Behavioural Neurotherapy Clinic. The page focused on explaining that anxiety disorders and panic attacks could be caused by both biochemical and psychological symptoms. A definition of anxiety disorders is provided after the introduction. Triggers of panic attacks and anxiety are discussed in length. Sensations that occur during panic attacks are listed and explained. Aside from positive drug references in the treatment of anxiety and depression, the options and benefits of Cognitive Behavioral Therapy were provided toward the end of the page. This source was useful in providing a statistic of how useful pharmaceutical drugs in the treatment of anxiety and depression are in a percentage of cases. It also provided vital information about new research that proposes that Irritable Bowel Syndrome and other gut related illnesses may play a large part in individuals’ anxiety and depression.

Johns Hopkins Medicine. Treating Anxiety – Avoiding Dependence on Xanax, Klonopin, Valium, and Other Antianxiety Drugs. Nov. 26 2005. 2 May 2008 <http://www.johnshopkinshealthalerts.com/reports/depression_anxiety/59-1.html?CMP=OTC-RSS>.

This is an informative website in association with the Johns Hopkins Research University and hospital in Baltimore, MD. The purpose of this source was to explain to the public of the addictive nature of prescription drugs called Benzodiazepines. Three of the most commonly prescribed benzodiazepines Xanax, Klonopin, and Valium are explained as being capable of easing anxiety for short term treatment. The drug BuSpar is introduced as being new on the market and having fewer negative side effects. The drug is also listed as being less effective for patients being treated for a Panic Disorder. Risk factors of dependency are touched upon in the source. Low doses are recommended to assist prevention of dependency. Also, how to cope with withdrew and alternatives to medication are covered. The site insists that patients should not stop taking their medication without the consultation of their physician, which according to the source should be monitoring patients closely while on these drugs. This source was useful to further explain how simple a drug dependency could occur in patients being treated for extreme anxiety.

Layard, R., D. Clark, M. Knapp, and G. Mayraz. "Cost-benefit analysis of psychological therapy." National Institute Economic Review 202 (Oct 2007): 90(9). Academic OneFile. Gale. Oakton Community College. 29 Mar. 2008 <http://find.galegroup.com/itx/start.do?prodId=AONE>.[1]

The purpose of this study was to provide evidence of positive economic benefits in the treatment of patients with mental illness. The article focuses on the benefits of cognitive behavioral therapy rather than pharmaceutical drug usage. It also glorifies the practice of it, and stresses the importance of seeking assistance for mental illness. The “mental illness” in the article is construed as anxiety and depression, though it does touch on certain other points such as phobias caused by the original illnesses. Results prove that the treatment of mental illness with cognitive behavioral therapy will increase the likelihood that individuals will work more days during the year than they would without treatment. Statistics were provided in tables following the bulk of the written article.  This study was done in Britain. The article benefited my research because it was able to explain that anxiety and depression are not just illnesses that are major problems in the United States. It also was able to explain how treatment through cognitive behavioral therapy could benefit the economy.

National Institute of Mental Health. Anxiety Disorders. 21 March 2008. 29 March 2008 <http://www.nimh.nih.gov/health/topics/anxiety-disorders/index.shtml>.

This is an informative government website with information about different anxiety disorders. The website also includes information on treatment of anxiety disorders. There are five major types of anxiety disorders that are written about in detail: General Anxiety Disorder, Obsessive-Compulsive Disorder, Panic Disorder, Post-Traumatic Stress Disorder, and Social Anxiety Disorder. A description of each type of anxiety disorder was listed. The descriptions were followed by symptoms of each disorder, and treatment information in more specific detail than on the home page where the links are listed. The information provided on the website is beneficial to people who are seeking information about their diagnosed illnesses, or questioning if they do have such an anxiety disorder. The information is written in easy to understand terminology for the convenience of the public. I was provided with more than enough information to provide evidence that anxiety is a taxing mental illness.

Physicians Desk Reference. New York: Thomson PDR, 2006.

This was a more recent edition of a reference book providing information on a wide variety of pharmaceutical drugs. Different colored pages at the front of the book listed drugs by their brand and generic names. I was able to look up drugs in a couple different ways through these colored pages. One was by manufacturer, another by the drug name. Many drugs were oral in listing, but also in the form of injections and sprays. Depending on the drug, product information was listed with tables covering statistics, and organized information in paragraph form. Dosage and administration, as well as side effects, and overdose information was included. I found the side effects and special passages intended to give information to expected and nursing mothers very useful. From them I was able to obtain enough information to express that pharmaceutical drug usage in mental illness cases can be more problematic than helpful.

[1] Even though the citation is not exactly MLA format, the source orders that it be cited as is written here.

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