Anxiety Disorders (PTSD)

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Anxiety Disorders(PTSD)

• Crane 5.2-5.3

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Anxiety

• anxiety
• 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

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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.

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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.

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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

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Anxiety according to the DSM-IV

• D. The symptoms are not part of another mental
  disorder.

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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.

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Anxiety according to the DSM-IV

• F. The condition is not due to a substance or
  medical issue

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Article Are Women Hardwired for Worry?

• What other factors might be at play?

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Article Cultural Approaches to Anxiety

• How does culture change how we view abnormal
  behavior (anxiety)?

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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.

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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

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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

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Prevalence Rate

• DSM 1-14 based on community
• DSM 3-58 of at risk individuals
• Twice as prevalent in women

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PTSD

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

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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.

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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

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Video Break

• Eye to Eye (PTSD)

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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.

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Eitiology

• In patients with PTSD, ambient cortisol levels
  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.

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Integrative Analysis Chart on PTSD
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Treatment
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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).

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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.

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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

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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").

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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

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Treatment - Sociocultural

• Group Therapy (Friedman and Schnurr, 1996)
• Psychoeducational Groupsanger management, social
  anxiety, conflict resolution
• Trauma-focused therapy
• Exposure to traumatic memories
• Cognitive restructuring
• Coping skills development

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Who is affected by PTSD?

• Up to 10 of the population
• Strikes more females than males
• Can occur with children as well

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How does Culture affect PTSD?

• Do other cultures experience somatic symptoms?
• Body Memory Symptoms (Hanscom, 2001)

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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

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Can a person suffer from symptoms of PTSD and not
have PTSD?
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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, 1980232-3