Anxiety Disorders (PTSD)

1. Anxiety Disorders(PTSD) Crane 5.2-5.3

2. Anxiety • anx·i·ety • Definition of ANXIETY • a: painful or apprehensive uneasiness of mind usually over an impending or anticipated ill • b: fearful concern or interest • c: a cause of anxiety

3. Anxiety according to the DSM-IV • A. At least 6 months of "excessive anxiety and worry" about a variety of events and situations. Generally, "excessive" can be interpreted as more than would be expected for a particular situation or event. Most people become anxious over certain things, but the intensity of the anxiety typically corresponds to the situation.

4. Anxiety according to the DSM-IV • B. There is significant difficulty in controlling the anxiety and worry. If someone has a very difficult struggle to regain control, relax, or cope with the anxiety and worry, then this requirement is met.

5. Anxiety according to the DSM-IV • C. The presence for most days over the previous six months of 3 or more (only 1 for children) of the following symptoms: • 1. Feeling wound-up, tense, or restless2. Easily becoming fatigued or worn-out3. Concentration problems4. Irritability5. Significant tension in muscles6. Difficulty with sleep

6. Anxiety according to the DSM-IV • D. The symptoms are not part of another mental disorder.

7. Anxiety according to the DSM-IV • E. The symptoms cause "clinically significant distress" or problems functioning in daily life. "Clinically significant" is the part that relies on the perspective of the treatment provider. Some people can have many of the aforementioned symptoms and cope with them well enough to maintain a high level of functioning.

8. Anxiety according to the DSM-IV • F. The condition is not due to a substance or medical issue

13. Article: Are Women Hardwired for Worry? • What other factors might be at play?

14. Article: Cultural Approaches to Anxiety • How does culture change how we view abnormal behavior (anxiety)?

16. PTSD • Post traumatic Stress Disorder, or PTSD, is a psychiatric disorder that can occur following the experience or witnessing of life-threatening events such as military combat, natural disasters, terrorist incidents, serious accidents, or violent personal assaults like rape. • PTSD is marked by clear biological changes as well as psychological symptoms. PTSD is complicated by the fact that it frequently occurs in conjunction with related disorders such as depression, substance abuse, problems of memory and cognition, and other problems of physical and mental health. • The disorder is also associated with impairment of the person's ability to function in social or family life, including occupational instability, marital problems and divorces, family discord, and difficulties in parenting.

17. Symptoms • People who suffer from PTSD often relive the experience through nightmares and flashbacks, have difficulty sleeping, and feel detached or estranged, and these symptoms can be severe enough and last long enough to significantly impair the person's daily life(30 days, specific stressor) • Affective: Anhedonia, emotional numbing • Behavioural: Hypervigilance, passivity, nightmares, flashbacks, exaggerated startle response • Cognitive: Intrusive memories, inability to concentrate, hyperarousal • Somatic: lower back pain, headaches, stomach ache, digestion problems, insomnia, regression

18. Symptoms • Intrusive Symptoms • Intrusive memories "Re-experience" of the trauma • This usually occurs in nightmares • Sometimes comes as a sudden, painful onslaught of emotions that seem to have no cause • Symptoms of Avoidance • Person avoids close emotional ties with family, colleagues and friends • At first, person had diminished emotions and can complete only routine, mechanical activities • Avoid situations that are reminders of the traumatic event because the symptoms may worsen • Symptoms of Hyperarousal • May have trouble concentrating or remembering current information • May develop insomnia • Children may develop stomachaches and headaches, in addition to symptoms of increased arousal • Associated Features • Rid themselves of their "re-experience" by abusing alcohol or other drugs as a "self-medication" • May show poor control over his or her impulses • May be at risk for suicide

19. Prevalence Rate • DSM: 1-14% based on community • DSM: 3-58% of at risk individuals • Twice as prevalent in women

20. PTSD • http://www.minddisorders.com/Ob-Ps/Post-traumatic-stress-disorder.html

21. History • PTSD is not a new disorder. There are written accounts of similar symptoms that go back to ancient times, and there is clear documentation in the historical medical literature starting with the Civil War, when a PTSD-like disorder was known as "Da Costa's Syndrome." (Soldiers Heart) • Careful research and documentation of PTSD began after the Vietnam War. The National Vietnam Veterans Readjustment Study estimated in 1988 that the prevalence of PTSD in that group was 15.2% at that time and that 30% had experienced the disorder at some point since returning from Vietnam. • (READ: VIETNAM VETERANS READJUSTMENT STUDY PDF) • PTSD has been observed in all U.S. veteran populations that have been studied, including World War II, Korean conflict, and Persian Gulf populations, and in United Nations peacekeeping forces deployed to other war zones around the world. • Similar findings of PTSD in military veterans have been found in other countries.  Australian Vietnam veterans experience many of the same symptoms that American Vietnam veterans experience.

22. History • PTSD formally entered into psychiatric nomenclature in the DSM-III (1980). The DSM.-III-R (1987) expanded the definition of the concept of stressors of PTSD, rearranged the symptoms in all the clusters, increased the range of items in both the re-experience and avoidant cluster symptoms, and revised criteria to include items representing PTSD in children • PTSD has most often been studied in soldiers, but clearly many types of natural and civilian catastrophes, criminal assaults, rape, terrorist attacks, and accidents may precipitate it

23. Video Break • Eye to Eye (PTSD)

24. Eitiology • Although the etiology of PTSD is unknown, most investigators believe that a personal predisposition is necessary for symptoms to develop after a traumatic event. Clinically significant symptoms following a traumatic event occur in a minority of persons. Those likely to develop PTSD tend to have a pre-existing depression or anxiety disorder, or a family history of anxiety and neuroticism. • From a biologic perspective, the body's failure to return to its pretraumatic state differentiates PTSD from a simple fear response. In a normal fear response, the immediate sympathetic discharge activates the "fight-or-flight" reaction. Increases in both catecholamines and cortisol occur relative to the severity of the stressor. Cortisol release stimulated by corticotropin-releasing factor via the hypothalamic-pituitary-adrenal (HPA) axis acts in a negative feedback loop to suppress sympathetic activation and cause further release of cortisol.

25. Eitiology • In patients with PTSD, ambient cortisollevels are lower than normal; this state has been attributed to chronic "adrenal exhaustion" from inhibition of the HPA axis by persistent severe anxiety. • However, recent data note that cortisol levels in the immediate aftermath of a motor vehicle wreck were significantly lower in persons who went on to develop PTSD. In a related study, cortisol levels immediately after rape were lower in women with a previous history of rape. Some investigators have hypothesized that the HPA axis and the sympathetic nervous system are disassociated in persons who develop PTSD, which may allow for an uncontrolled catecholamine release that affects formation of memories during the trauma and perhaps exacerbates symptoms when that person is exposed to cues after the trauma.

26. Integrative Analysis Chart on PTSD

27. Treatment

28. Treatment- Learning • Coping • learning skills for coping with anxiety (such as breathing retraining or biofeedback) and negative thoughts ("cognitive restructuring"), • Anger Management • Preparing for stress reactions ("stress inoculation") • Handling future trauma symptoms • Addressing urges to use alcohol or drugs when trauma symptoms occur ("relapse prevention”) • Communicating and relating effectively with people (social skills or marital therapy).

29. Treatment-Bio • Pharmacotherapy (medication) can reduce the anxiety, depression, and insomnia often experienced with PTSD, and in some cases, it may help relieve the distress and emotional numbness caused by trauma memories. • Antidepressants • Tranquilizers (Valium, Xanax) • Several kinds of antidepressant drugs have contributed to patient improvement in most (but not all) clinical trials, and some other classes of drugs have shown promise. At this time, NO particular drug has emerged as a definitive treatment for PTSD. However, medication is clearly useful for symptom relief, which makes it possible for survivors to participate in psychotherapy.

30. Treatment - Cognitive • Cognitive-behavioral therapy involves working with cognitions to change emotions, thoughts, and behaviors. • Four Goals of CBT • Creation of a safe environment • Show that remembering a trauma is not equivalent to experiencing it again • Show that anxiety is alleviated over time • Acknowledge that experiencing PTSD symptoms does not lead to a loss of control • Crisis Intervention therapy is the attempt to prevent the onset of PTSD following a disaster or traumatic event • Testimonial Psychotherapy (Weine, 1998) aims to transcribe the traumatic event for educational or meaningful purpose

31. Treatment - Cognitive • Exposure therapy is one form that is unique to trauma treatment. It uses careful, repeated, detailed imagining of the trauma (exposure) in a safe, controlled context to help the survivor face and gain control of the fear and distress that was overwhelming during the trauma. • Virtual Iraq • In some cases, trauma memories or reminders can be confronted all at once ("flooding"). For other individuals or traumas, it is preferable to work up to the most severe trauma gradually by using relaxation techniques and by starting with less upsetting life stresses or by taking the trauma one piece at a time ("desensitization").

32. Treatment –Cognitive • Eye Movement Desensitization and Reprocessing (EMDR) is a relatively new treatment for traumatic memories that involves elements of exposure therapy and cognitive-behavioral therapy combined with techniques (eye movements, hand taps, sounds) that create an alternation of attention back and forth across the person's midline. • While the theory and research are still evolving for this form of treatment, there is some evidence that the therapeutic element unique to EMDR, attentional alternation, may facilitate the accessing and processing of traumatic material

33. Treatment - Sociocultural • Group Therapy(Friedman and Schnurr, 1996) • Psychoeducational Groups—anger management, social anxiety, conflict resolution • Trauma-focused therapy • Exposure to traumatic memories • Cognitive restructuring • Coping skills development

34. Who is affected by PTSD? • Up to 10% of the population • Strikes more females than males • Can occur with children as well

35. How does Culture affect PTSD? • Do other cultures experience somatic symptoms? • Body Memory Symptoms (Hanscom, 2001)

36. How does Gender affect PTSD • Women are 5x greater risk for PTSD after a violent act or traumatic event • Male Symptoms: • Irritability and impulsiveness • Substance abuse • externalization • Female Symptoms: • Numbing and avoidance • Anxiety and affective disorders • Internalization

37. Can a person suffer from symptoms of PTSD and not have PTSD?

38. Biography • http://www.ncptsd.va.gov/ • http://www.aafp.org/afp/20031215/2401.html • http://www.fbhs.org/PTSD.htm • American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 3d ed. Washington, D.C.: American Psychiatric Association, 1980:232-3